Client perceptions improve with collaborative care when managing dogs with cancer: a Collaborative Care Coalition study

Samantha L. Morello Center for Veterinary Business and Entrepreneurship, College of Veterinary Medicine, Cornell University, Ithaca, NY

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 DVM, DACVS-LA
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Elizabeth A. Maxwell University of Florida, College of Veterinary Medicine, Gainesville, FL

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 DVM, MS, DACVS-SA
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Kimberly Ness Trone Research and Consulting LLC, High Point, NC

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Tom Minsel Trone Research and Consulting LLC, High Point, NC

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Kai-Biu Shiu Trone Research and Consulting LLC, High Point, NC

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 BVMS, MRCVS, DACVIM

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Abstract

OBJECTIVE

Collaboration between primary care veterinarians (pcVets) and veterinary oncologists is common for dogs diagnosed with cancer, but no data exist that explore dog owner utilization and perceptions of collaborative care. The objectives were to describe dog owner perceptions of the value of collaborative veterinary cancer care and identify drivers of a positive collaborative care experience between the pcVet and oncologic specialists.

SAMPLE

890 US dog owners who had pets diagnosed with cancer in the past 3 years.

PROCEDURES

Online contextual survey. Data were analyzed using group comparisons and multiple regression analysis. Significance was set at P < .05.

RESULTS

76% of clients sought specialty care following cancer diagnosis in their dog. Seventy percent of owners across all income brackets indicated that referral to a specialist was a very good value based on money spent and outcomes. Delayed referral resulted in lower client satisfaction scores for pcVets. Top predictors of client satisfaction with pcVets were as follows: responsiveness to questions, staying involved with their dog’s care, and willingness to work with other veterinarians and specialists. For specialists, top predictors were as follows: providing accurate cost estimates, cancer knowledge, and effectiveness of care. Client perceptions of pcVets were 6 times more likely to improve following referral to a specialist. All were significant predictors of owner advocacy (P < .0001).

CLINICAL RELEVANCE

Dog owners perceived early collaboration between pcVets and specialists favorably, fostering client satisfaction and positive perceptions of the value for service provided for dogs diagnosed with cancer.

Abstract

OBJECTIVE

Collaboration between primary care veterinarians (pcVets) and veterinary oncologists is common for dogs diagnosed with cancer, but no data exist that explore dog owner utilization and perceptions of collaborative care. The objectives were to describe dog owner perceptions of the value of collaborative veterinary cancer care and identify drivers of a positive collaborative care experience between the pcVet and oncologic specialists.

SAMPLE

890 US dog owners who had pets diagnosed with cancer in the past 3 years.

PROCEDURES

Online contextual survey. Data were analyzed using group comparisons and multiple regression analysis. Significance was set at P < .05.

RESULTS

76% of clients sought specialty care following cancer diagnosis in their dog. Seventy percent of owners across all income brackets indicated that referral to a specialist was a very good value based on money spent and outcomes. Delayed referral resulted in lower client satisfaction scores for pcVets. Top predictors of client satisfaction with pcVets were as follows: responsiveness to questions, staying involved with their dog’s care, and willingness to work with other veterinarians and specialists. For specialists, top predictors were as follows: providing accurate cost estimates, cancer knowledge, and effectiveness of care. Client perceptions of pcVets were 6 times more likely to improve following referral to a specialist. All were significant predictors of owner advocacy (P < .0001).

CLINICAL RELEVANCE

Dog owners perceived early collaboration between pcVets and specialists favorably, fostering client satisfaction and positive perceptions of the value for service provided for dogs diagnosed with cancer.

Introduction

Over 77 million dogs reside in homes in the US,1 and it is estimated that between 1 in 3 and 1 in 4 dogs will be diagnosed with cancer at some point in their lives.2,3 Cancer is most prevalent in older dogs and remains a leading cause of death in those over 10 years of age.4 The 2022 Gallup-sponsored Take CHARGE Canine Cancer Survey identified a 2.8% incidence of dogs newly diagnosed with cancer in the US, 4.6 times higher than the incidence of diagnosis in people.5 Due to the prevalence of the disease and size of the population served, demand for oncologic care is tremendous and expected to continue to grow. Over the last 25 years, veterinary cancer care has transformed with the development of a broader range of treatment capabilities and an increase in accessibility of specialty services and treatment centers.6 While the decision to pursue treatment is based on a complex interaction of factors including prognosis, cost, quality of life, availability of facilities, and individual preferences, early detection and intervention may be key to improving outcomes.79 This latter point highlights the critical role that primary care veterinarians (pcVets) play in the overall management of cancer in a canine population.

Recent evidence demonstrates up to 90% of dog owners seeking veterinary services, with most visits occurring at the primary care level.10 The relationship built between a pet owner and pcVet is arguably the most important to a pet’s overall health and necessitates mutual trust and respect. These relationships may be tested by financial and emotional stressors, such as the realization of a cancer diagnosis. Cancer adds another layer of complexity to veterinary care, typically through referral to an oncologic specialist. The addition of a new doctor to the medical team to provide specialized care requires additional time and financial investment for the owner and introduces more complex treatment strategies. Logistically, financially, and emotionally, a cancer diagnosis can therefore lead to an overwhelming experience for a dog owner. Collaborative care in veterinary medicine is the involvement of multiple providers working together and with an owner to manage a pet’s diagnosis and ongoing treatment. Cancer care may be intensive and prolonged with no guaranteed success, and therefore the collaborative relationships developed between a pcVet and the specialist represent an important area of communication and coordination to minimize stress and maximize client compliance and satisfaction, with a goal of improving quality of life and optimizing outcomes.

The American Animal Hospital Association provides guidelines detailing situations in which referral or consultation should be considered and the manner of communication that should be upheld to best serve the client and patient.11 In contrast to human oncologic care, guidelines for referral to veterinary oncologists by pcVets following a diagnosis of cancer are less clear and are influenced by a variety of objective and subjective factors.12,13 In Canada, only 56% of pcVets report referring clients for specialty care following common cancer diagnoses13; among multiple factors evaluated in this study, referral was influenced by perceived patient health status, client finances, and pcVet confidence in the referral clinic. There is a small body of literature demonstrating the value of communication between a pcVet and specialists in the referral and collaborative process for both general patient care and specialty oncologic care.1416 Similarly, there is limited but powerful objective evidence that supports the value of communication between clients and veterinarians.16,17 This includes some qualitative work evaluating perceptions of clients accessing specialty oncologic care, indicating that thorough and frequent availability and established relationships were deeply valued.16 Financial conversations represent another critical element of the overall process of client engagement.18 These findings all highlight ways to improve access to and functionality of collaborative care models, providing value for clients and their pets. Gaining more insight into the validity of these determinants would be helpful in creating the most effective framework for recommending collaborative cancer care.

Collaborative care has been investigated and discussed in a variety of specialties in human medicine, including oncology.19,20 Despite the simultaneous need for, and benefits of, expanding access to collaborative cancer care, there is no current evidence defining the clients’ perspective on its use in veterinary medicine. There is also no objective evidence outlining how clients value access to referral oncologic care following a diagnosis of cancer. The objectives of this study were to (1) define dog owner perceptions of the value of collaborative veterinary care when treating a dog for cancer and (2) identify drivers of a positive dog owner experience related to collaborative care between the pcVet and a veterinary oncologic specialist.

Materials and Methods

Study population

The study group consisted of a listserv with > 23,000 dog owners registered on the Puppy Up Foundation’s database (Puppy Up Foundation) and an additional sample of 614 dog owners accessed from a commercially available database (EMI Research Solutions). Respondents were selected to provide a nationally representative sample with no oversampling in 1 geographic area. An invitation and link to the survey were also provided via online social media platforms including the Puppy Up Foundation’s Facebook page and the Collaborative Care Coalition’s Facebook and Instagram pages. The invitation requested that only 1 participant/household fill out the survey. Inclusion criteria for respondents included (1) having, or having had, a dog (and not another species of animal) that was diagnosed with cancer within the last 3 years and (2) being the primary or co–decision-maker regarding the dog’s healthcare. Participants not meeting these criteria were excluded from survey logic flow. For the purposes of this study, an “oncology referral experience” was defined as involvement with any specialist a dog owner was referred to for a suspected or confirmed cancer diagnosis. Specialists primarily included oncologists as well as neurologists, surgeons, and internists. Research was conducted by Trone Research and Consulting LLC on behalf of the Collaborative Care Coalition and VCA Pet Cancer Care.

Survey

The online survey consisted of an 82-item questionnaire; the survey was deployed, and data were collected using a proprietary survey infrastructure panel developed and moderated by Trone Research and Consulting. The survey link was disseminated with an accompanying introductory letter, which explained the purpose of the survey without revealing the service provider (blinded study). Participation was voluntary and anonymous, and participants were provided an incentive, which included a small donation to the Puppy Up Foundation on their behalf. The survey was designed to solicit information in the following general areas: (1) dog owner demographics, (2) collaboration behaviors, (3) collaboration attitudes, (4) satisfaction, and (5) expenditures. The survey was available between March 25, 2021, and May 3, 2021; the study population was prompted for participation 6 times during this period. The survey was approved as exempt from review by the Institutional Review Board at the University of Florida.

Data analysis

Prior to analysis, response data were processed and cleaned using deduplication and examining for excessive commonalities in responses among participants. Data were examined overall and grouped by various demographic factors (generational cohort, gender, race or ethnicity, and income cohort) to identify differences in client perceptions. Net promoter score (NPS) was calculated as originally described.21 Briefly, respondents were asked a question about how likely they were to recommend either their pcVet or specialist, with answer choices along a possible scale from 0 to 10. The percentage of respondents providing detractor scores (0 to 6) was then subtracted from the percentage of respondents providing promoter scores (9 and 10) to create a final NPS to be used as a gauge for client advocacy. Comparisons were performed using χ2 analyses on group proportions including demographics, collaboration segment, spending segment, income level, performance factors, and attitudinal factors. To mitigate the risk of type 1 errors on group comparisons, especially when performing multiple comparisons on client advocacy data, the Benjamini-Hochberg procedure was used to control the false discovery rate and P values were adjusted as indicated.

To identify the factors that were predictive of client advocacy for pcVets as well as for oncologic specialists, 46 variables were evaluated that comprised demographics, dog factors, cost factors, pcVet/specialist performance factors, attitudinal factors, and reasons for not proceeding with specialty care. A series of multiple regression analyses were conducted using a corroborative multistage methodology involving generalized linear models, maximum R2 improvement, and stepwise-type regression model selection methods. This approach was taken to corroborate the factors retained in the analysis across multiple models, mitigate multicollinearity, and optimize the subsets of variables retained. All statistical analyses were run using SAS statistical computing software (version 9.4; SAS Institute).

Results

Dog owner and dog demographics

A total of 890 questionnaires were completed voluntarily by dog owners who met the inclusion criteria. Among respondents, 40.6% (362/890) identified themselves as Millennials. Twenty-nine percent (261/890) and 30% (267/890), respectively, identified themselves as Generation X and Baby Boomers. Of those reporting race or ethnicity, a majority were white (78.7% [700/890]), with small numbers of Hispanic or Latino/a (5.8% [52/890]), Black/African American (4.8% [43/890]), Asian (2.5% [22/890]), Native American (1% [9/890]), Caribbean (0.8% [7/890]), or other races (2.6% [23%]) also represented; an additional 3.8% (34/890) of respondents preferred not to answer. Regarding gender, 54.7% (477/872) identified as women and 45.3% (395/872) as men.

Respondents reported living in a variety of geographic classifications; 34.1% (304/890) lived in small cities or urban communities, 28.8% (256/890) in the suburbs, 20.8% (185/890) in rural communities, and 16.3% (145/890) in a major metro area. Specific geographic location (ie, state or region) was not assessed. Most pet owners (57.6% [473/821]) reported household incomes < $100K/y and 25.2% (207/821) reported incomes between $100K and $149K/y, with the remaining 17.2% (141/821) earning > $150K annually.

At the time of cancer diagnosis, most owners reported that their dogs were between 5 and 10 years of age (48% [428/890]), with an additional 24.7% (220/890) over the age of 10. Specific cancer diagnosis was not identified but was rated by the owner as mild (13% [116/890]), moderate (42% [372/890]), or severe (45% [402/890]). Most owners rated the quality of life of their pet as good or very good (79% [707/890]) prior to receiving a diagnosis of cancer. These questions were asked on the basis of prior evidence that age, quality of life, and perceptions regarding severity of diagnosis influenced decision to pursue referral and treatment.10

Collaboration segment

Most clients (76% [678/890]) whose dogs were diagnosed with cancer sought specialty care following diagnosis; the majority of these were the result of referral (79.5% [539/678]), with the remainder (20.5% [139/678]) pursuing specialty care without referral (Figure 1). Among the latter group, most clients (106/139) reported maintaining a collaborative relationship between the specialist and pcVet throughout their dog’s cancer treatment despite lack of initial referral. Among those who did not seek specialty care, few (15.6% [33/212]) were offered referral and declined; the remaining subset of clients were neither offered referral nor sought referral on their own (179/212). In total, 64% (572/890) of respondents received a referral to a specialist following a diagnosis of cancer.

Figure 1
Figure 1

Flow chart representing collaboration path between primary care veterinarians (pcVets) and specialists following cancer diagnosis among survey respondents (n = 890). Data are further segmented by generation. Both percent and number (n) of each group selecting to pursue care are represented.

Citation: Journal of the American Veterinary Medical Association 261, 7; 10.2460/javma.23.01.0046

Differences were observed by generation, gender, and income bracket affecting the likelihood for clients to pursue specialty oncologic care. Younger generations were more likely to pursue specialty treatment (P = .0001), with 88% of Millennial clients, 72% of Generation X clients, and 57% of Boomer-generation clients reporting seeking specialty care. Men were more likely to see specialists as compared with women (85% vs 65%, respectively; P = .0001). Income level was also significantly correlated with the decision to pursue care with an oncologic specialist, with increasing income brackets being associated with an increased likelihood of seeking specialty care as follows: < $50K, 66%; $50K to $99,999, 71%; $100K to $149,999, 81%; and > $150K, 84% (P = .0001). Finally, clients with dogs < 10 years of age were more likely to pursue specialty care (81% vs 59%; P = .0001).

Client satisfaction

Clients were asked separate questions about to what degree they were likely to recommend their pcVet or oncologic specialist to another dog owner; from these questions, an NPS was calculated to gauge customer satisfaction and degree of client advocacy. Client advocacy (NPS) for the pcVet was not different between those who saw a specialist and those who did not (P = .36) but was significantly higher (+40 vs +4; P = .01) among those who saw a specialist and received referrals following a diagnosis of cancer for their dogs compared with clients who received no referrals and sought specialty care on their own. NPS scores were high for specialists regardless of whether the client had been referred (+42; 517/890) or sought the specialist out on their own (+50; 50/890). When scores were evaluated on the basis of time to referral, delayed referral was associated with lower levels of advocacy (P = .0001). Specifically, NPS score for pcVets was +40 (417/890) among clients who received a referral within 1 to 3 visits and was +23 (113/890) among those who received a referral after 4 or more visits (Figure 2). There was no difference in client advocacy scores for pcVets or specialists between male and female clients (P = .44 and .84, respectively).

Figure 2
Figure 2

Client advocacy scores as measured by net promoter score (NPS) for pcVets (n = 801) and specialists (678) based on time to referral following a diagnosis of cancer in their dog. NPS was generated on the basis of the question, “How likely would you be to recommend the pcVet/specialist to another dog owner?”

Citation: Journal of the American Veterinary Medical Association 261, 7; 10.2460/javma.23.01.0046

Drivers of client advocacy

A multivariable model was used to evaluate the top drivers for client advocacy for both pcVets and specialists among all respondents (Tables 1 and 2). Broadly, categories evaluated included demographics, dog factors, cost factors, pcVet/specialist performance factors, attitudinal factors, and reasons for not proceeding with specialty care. The 3 key drivers of client advocacy for pcVets among all respondents were found to be responsiveness to questions, staying involved with your dog’s care, and willingness to work with veterinarians and specialists (r2 = 0.5619; P < .0001; Table 1). These 3 factors explained 91% of the model. The top 3 drivers of client advocacy for specialists were providing accurate cost estimates for treatment options, cancer knowledge, and effectiveness in treating/caring for your dog (r2 = 0.5556; P < .0001; Table 2). These variables explained 87% of the model.

Table 1

Factors driving pcVet advocacy. Variables are listed in descending order of factor coefficient of determination (partial R2) to illustrate strength of incremental individual effect on the advocacy model. The top 3 variables were validated via a separate non-stepwise maximum R2 multiple linear regression model selection method.

Variable Partial R2 Model R2 F value PR > F
Responsiveness to questions 0.4458 0.4458 583.14 <.0001
Staying involved with your dog’s care 0.0834 0.5291 128.18 <.0001
Willingness to work with other veterinarians and specialists 0.0374 0.5665 62.37 <.0001
Cancer knowledge 0.0202 0.5868 35.33 <.0001
Effectiveness in treating/caring for your dog 0.0108 0.5975 19.29 <.0001
Provides accurate cost estimates for treatment options 0.0079 0.6054 14.46 0.0002
Likelihood of proceeding with treatment at price cited as “bargain” 0.0068 0.6122 12.57 0.0004
Ease of communication 0.0035 0.6148 6.63 0.0102
Size of dog when suspected/diagnosed cancer 0.0026 0.6183 4.79 0.0289
$ typically spent on care/well-being of dog 0.0024 0.6207 4.44 0.0355
Maximum R2 selecting 3 variables Parameter estimate F value PR > F
Intercept -1.16454 14.65 0.0001
Responsiveness to questions 0.69646 80.28 <.0001
Staying involved with your dog’s care 0.59295 65.53 <.0001
Willingness to work with other veterinarians and specialists 0.53107 61.66 <.0001

Adjusted R2 = 0.5619

Table 2

Factors driving specialist advocacy. Variables are listed in descending order of factor coefficient of determination (partial R2) to illustrate strength of incremental individual effect on the advocacy model. The top 3 variables were validated via a separate non-stepwise maximum R2 multiple linear regression model selection method.

Variable Partial R2 Model R2 F value PR > F
Provides accurate cost estimates for treatment options 0.4295 0.4295 466.09 < .0001
Ease of communication 0.1052 0.5347 139.68 < .0001
Cancer knowledge 0.0345 0.5692 49.45 < .0001
Effectiveness in treating/caring for your dog 0.025 0.5942 37.96 < .0001
Likelihood of proceeding with treatment at price cited as a “bargain” 0.0146 0.6088 22.94 < .0001
Willingness to work with other veterinarians and specialists 0.0132 0.622 21.46 < .0001
Provides cost saving treatment options 0.0064 0.6284 10.53 .0012
Staying involved with your dog’s care 0.0047 0.6331 7.8 .0054
Size of dog when suspected/diagnosed cancer 0.0033 0.6364 5.49 .0195
I take my dog to the veterinarian routinely for checkups 0.0034 0.6398 5.82 .0161
Likelihood of proceeding with treatment at price cited as “getting expensive” 0.0024 0.6422 4.1 .0434
Maximum R2 selecting 3 variables Parameter estimate F value PR > F
Intercept –1.53422 17.46 < .0001
Provides accurate cost estimates for treatment options 0.68471 102.95 < .0001
Cancer knowledge 0.67259 73.97 < .0001
Effectiveness in treating/caring for your dog 0.57209 69.71 < .0001

Adjusted R2 = 0.5556

To determine whether drivers of client advocacy among a nonwhite respondent population were different from a predominantly white population, the procedures were repeated only examining respondents who identified as a race or ethnicity other than white. Top drivers of client advocacy for pcVets among the nonwhite segment of respondents (n = 143) included responsiveness to questions, ease of communication, and providing multiple treatment options (r2 = 0.5426; P = .0003, P = .0012, and P = .001, respectively). Key drivers for client advocacy of specialists included cancer knowledge, willingness to work with other veterinarians and specialists, and providing accurate cost estimates for treatment options (r2 = 0.5635; P < .0001 and P = .0002, respectively).

Value of services

Owners were asked to self-report an estimated value spent on primary and specialty care services related to their dogs’ cancer diagnosis. Respondents estimated a mean of $1,811 (n = 802; range, < $100 to > $10,000) spent on visits, tests, and therapy with the pcVet and $3,215 in visits, tests, and therapy (678; range, < $100 to > $10,000) with the oncologic specialist. To provide a baseline comparison, respondents were also asked how much, on average, they spent on the annual care and well-being of their dog and reported a mean of $2,180 in annual expenses (n = 890; range, < $100 to > $10,000). Clients who received an earlier referral for specialist care (1 to 3 visits) were just as likely to be in the top 25% of spenders as those who experienced delayed referral (P = .38).

Overall, the value of specialty oncologic care for money spent and the result for the dog were assigned the top 2 highest rating scores on a 6-point Likert scale by 70% (678/890) of respondents. There was no difference by gender (P = .64), generation (P = .1), race or ethnicity (P = .1), or collaboration segment (P = .55). A simple effect of income was present in which higher household incomes were associated with higher levels of NPS-defined client advocacy (P = .006). However, even within the lowest income brackets, most respondents reported high levels of satisfaction (< $50K, 54%, n = 120; $50K to $99,999, 59%, n = 217).

Discussion

This survey provided novel insights into the perceptions and behaviors of dog owners regarding collaborative care following the diagnosis of cancer in their dog. Within our sample population, a large majority of respondents chose to pursue specialty oncologic care following cancer diagnosis, largely through referral but also through independent means. We found that early referral and collaboration between the pcVet and oncologic specialist resulted in improved client satisfaction for both groups of veterinarians, demonstrating the importance of collaborative cancer care. Overall, such collaborative efforts were perceived as a good value for the cost of service, regardless of the clients own financial situation, suggesting that stereotypes about socioeconomic status may be misleading. Finally, we identified specific factors that can improve the likelihood of client satisfaction with a pcVet or veterinary oncologic specialist during cancer care, providing valuable and specific insights for practitioners to improve the quality of clinical service.

This study utilized voluntary, anonymous survey methodology with participant screening to identify an eligible population of clientele who owned dogs that had received a diagnosis of cancer within the past 3 years to evaluate their experiences with collaborative cancer care. The demographics of respondents were broadly representative of age, race, ethnicity, geography, and economic status. It is possible, and even likely, that there was a response bias associated with those choosing to respond to a voluntary survey on dog cancer. However, given the lack of a control (or nonresponding) population, no definitive demographic comparisons or conclusions can be drawn that define this study cohort. While the level of evidence gathered from cross-sectional analyses is noted to be less powerful through observational sampling in comparison to, for example, a case-controlled or longitudinal methodology, the data generated here are useful to reflect the range of clientele that may engage with veterinary services in various practices and areas of the US but should be interpreted with this limitation in mind.

Seventy six percent of respondents made the choice to pursue care with an oncologic specialist after receiving a cancer diagnosis; most of these visits were a result of referral from the pcVet, yet a notable proportion (20.5%) sought out specialty services on their own, having not received any referral by their pcVet. Overall, 64% of clients received referral for specialty oncologic care, representing a smaller proportion of clients than ultimately pursued care and a higher proportion than has been previously reported receiving referral for treatment following a diagnosis of lymphoma or osteosarcoma.13 These findings present 2 critical pieces of knowledge: first, that the prevalence of collaborative oncologic care has grown in the 10 years since the previous report was published, but second, that the needs of clientele still may not be met at the current rates of referral. Many clients sought specialty care on their own, without referral, suggesting an opportunity for collaborative cancer care that remains underutilized at the level of the pcVet.

Among the large population of respondents who pursued specialty oncologic care, referral was associated with greater client satisfaction with the pcVet compared with no referral, demonstrating the relationship-building value of collaboration. Efficient, versus delayed, referral also proved beneficial for client advocacy. Various factors have been identified as influencing the decision to refer a client for oncologic care, including patient health status, client financial status, confidence in the referral center, and how worthwhile practitioners considered treatment for the condition diagnosed.13 As individual relationships and animal health are core to any veterinary-client relationship, it would be myopic to suggest that the decision to refer functions as the main driver for client satisfaction during oncologic care. However, efficient referral improved client satisfaction among a population who largely sought specialty care, even at the lower income brackets. A reevaluation of factors used in decision-making for referral by some pcVets may therefore be beneficial to optimize both client satisfaction and patient health, particularly if the result may increase access to specialty care options for cancer patients.

Multivariable modeling was used to determine the most impactful drivers of patient advocacy scores among pcVets and specialists. For the pcVet, factors related to communication and collaboration were found to be the most highly predictive of client satisfaction, including responsiveness to questions, continued involvement with the pet’s care, and willingness to collaborate. For specialists, key drivers included cancer knowledge, willingness to collaborate, and providing accurate cost estimates. Recent literature corroborates the value of communication between veterinarians and clients as well as between pcVets and specialists.14,17 In another study16 of clients receiving oncologic care at a tertiary referral facility, the importance of answering questions and communicating medical knowledge in an understandable manner were highlighted. While corroborative with the results of the current study, many of these findings are also intuitive in a healthcare setting. Creating specific and targeted recommendations utilizing the knowledge generated here may be useful for veterinarians and veterinary trainees—including students, interns, and residents—to provide guidelines and even formal education for optimizing client-centric collaborative care for those receiving a cancer diagnosis. Even after referral, clients seek to maintain ongoing and consistent involvement of their pcVet in the dog’s cancer journey. This highlights the value of the original client-pcVet relationship as a critical anchor point from which a successful collaborative care initiative can be built.

Through multivariable regression, we were able to define different drivers of client advocacy among a population of respondents who did not identify as white. While some of these factors overlapped with those identified for respondents overall, the majority of which were white, the emphasis placed on communication and collaboration by the nonwhite population highlighted a critical area for consideration. Compared with the US population, a smaller proportion of veterinarians overall is racially and ethnically diverse, with 88% of veterinarians identifying as white.22 An even smaller proportion of specialists are thought to represent diverse racial and ethnic groups.23,24 In human medicine, studies have shown that patient satisfaction and outcomes are both improved when there is concordance between providers and patience with respect to their racial, ethnic, and language backgrounds.25,26 Cultural competency, trust, communication practices, and implicit or even explicit biases are all factors that may affect the veterinarian-client relationship when a lack of diversity exists within provider populations compared with the owners whose animals they treat. It is possible that these discrepancies are part of the causal elements driving the comparatively lower advocacy scores observed in this study, suggesting a broader and more universal need to expand the diversity of the oncologic and collaborative workforce in veterinary medicine.

Most clients in this study rated the value for money of specialty oncologic care as a high value; while scores varied by personal income, most respondents in even the lowest income brackets reported high levels of satisfaction. This finding points to a previous report13 that client finances can affect the likelihood of referral for specialty care by a pcVet. It is unclear to what extent veterinarians consistently have accurate or explicit knowledge of the finances of an individual client; therefore, referral decisions may be influenced by assumptions or biases adopted by the veterinarian or based on heuristics or implicitly held beliefs. It is true that, on an individual client basis, veterinarians may be inclined to make treatment recommendations tailored to previous financial behaviors exhibited by the client; however, a diagnosis of cancer may not fall in line with prior medical experiences or ailments and may therefore provide an alternative paradigm for client behavior. Identified among the key drivers of advocacy for pcVets and specialists in this study were providing accurate cost estimates and options for care. Combined with an overall high rating of value for services provided and higher advocacy scores among clients receiving referral, these data suggest that best practices for both the pcVet and specialist include offering referral as well as the full range of specialty care options, regardless of the clients perceived or actual financial situation. Finally, the mean expenditures reported by clients in this study were lower than the typical cost of specialist surgery or chemotherapy services. This finding may reflect a perception or recall error or may reflect a higher proportion of dog owners that did not pursue extensive specialty care—a decision possibly influenced by the type or severity of cancer diagnosed, which was not evaluated in this study. Therefore, in addition to collaborative care of cancer patients, pcVets and specialists may both serve their clients most effectively by having working knowledge of estimates for care in each other’s practice environment to counsel clients accurately and thoughtfully.

Despite objective findings from a varied national sample of dog owners, this study was not without limitations. Specific cancer diagnoses were not elicited by the survey data; therefore, assessment of variations in client behavior by various individual pathologies could not be assessed. The use of the Puppy Up Foundation database may have facilitated a biased response population, including mainly individuals who had a positive experience with cancer care to belong to a veterinary cancer nonprofit organization’s mailing list. An attempt to counteract this effect was made by purchasing a commercial listserv of dog owners who may or may not have had previous experience with oncologic care. In fact, most respondents (n = 614) were derived from this sample population, likely minimizing any implicit favorable response bias among those solicited from the Puppy Up Foundation list (120). Though a nationally representative sample was obtained, responses were not recorded with geographical identification; therefore, regionality to patterns in owner demographics, perceptions, or behaviors could not be assessed. Finally, it is important to note that this study was conducted in the spring of 2021, coinciding with the COVID-19 pandemic and a national trend toward increased utilization of veterinary services at all levels, including greater levels of pet ownership and spending. It is possible that shifting climates around the veterinary profession, as well as variations in the economy, could alter the behaviors and perceptions of owners, particularly regarding seeking specialty care.

In conclusion, following a cancer diagnosis in their dog, early referral and collaboration between a pcVet and specialist foster a high degree of client satisfaction and clients perceive good value for the money spent on the oncologic care of their dog. Furthermore, the necessity and influence of a pcVet was not lost for the client, even following referral for specialty care, highlighting the fundamental role pcVets play in a client’s veterinary experience and the added value of collaborative care. As the veterinary profession continues to strain under the demand for services by an increasing number of pet owners, as cancer diagnoses become more common in a larger population of dogs and the availability of oncologic specialists grows in number and location, collaborative cancer care will be increasingly utilized as an effective and valuable approach to servicing our clients and their pets.

Acknowledgments

This study was funded by VCA Pet Cancer Care on behalf of the Collaborative Care Coalition.

The authors declare that there were no conflicts of interest.

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