The Big Pet Diabetes Survey

13 Pages·2017·2.12 MB·English

veterinary
sciences
Article
The Big Pet Diabetes Survey: Perceived Frequency
and Triggers for Euthanasia
StijnJ.M.Niessen1,2,*,KatarinaHazuchova1,SonyaL.Powney3,JavierGuitian4,
AntoniusP.M.Niessen5,PaulD.Pion6,JamesA.Shaw2andDavidB.Church1
1 DiabeticRemissionClinic,DepartmentofClinicalScienceandServices,RoyalVeterinaryCollege,
HawksheadLane,NorthMymms,HertfordshireAL97TA,UK;[email protected](K.H.);
[email protected](D.B.C.)
2 InstituteofCellularMedicine,MedicalSchoolNewcastle,FramlingtonPlace,Newcastle-upon-TyneNE2
4HH,TyneandWear,UK;[email protected]
3 E-MediaUnit,RoyalVeterinaryCollege,HawksheadLane,NorthMymms,HertfordshireAL97TA,UK;
[email protected]
4 VeterinaryEpidemiologyandPublicHealthGroup,RoyalVeterinaryCollege,HawksheadLane,
NorthMymms,HertfordshireAL97TA,UK;[email protected]
5 TwanConsultancy,Romerstraat24,5911HVVenlo,TheNetherlands;[email protected]
6 VeterinaryInformationNetwork,777WestCovellBlvd,Davis,CA9561,USA;[email protected]
* Correspondence:[email protected];Tel.:[phone]
AcademicEditor:PatrickButaye
Received:17January2017;Accepted:10May2017;Published:14May2017
Abstract: Currentpetdiabetesmellitus(DM)treatmentnecessitatestheactivedailyinvolvement
ofownersandcanbecostly. Thecurrentstudyaimedtoinvestigatetheownerpopulationwhich
optsforeuthanasiainsteadofDMtreatment. Asurveywasdesignedusingmultiplefeedbacksteps
and made available online to veterinarians world-wide. A total of 1192 veterinarians completed
thesurveyandsuggestedamedianonein10diabeticpetsareeuthanasedatdiagnosis;afurther
medianonein10withinoneyearbecauseoflackofsuccessorcompliance. Perceivedmostimportant
motivatingfactorsincluded“presenceconcurrentdisease”(45%respondents);“costs”(44%);“animal
age”(37%);“problemsobtainingadequatecontrol”(35%);“petwelfare”(35%);and“impactowner’s
lifestyle” (32%). Cats in Canadian (odds ratio (OR) 2.7), Australian (OR 2.3), rural (OR 1.6) and
mixed(OR1.7)practicesweremorelikelytobeeuthanasedbecauseofDMdiagnosis,whilecats
presentedtoreferral/universitywerelesslikelytobeeuthanased(OR0.6). Dogsweremorelikely
tobeeuthanasedbecauseofDMinCanadian(OR1.8),rural(OR1.8)andmixed(OR1.6)practices.
ThesurveyresultssuggestthatbenefitexistsinimprovedDMeducationwithemphasisonofferinga
choiceoftreatmentstylesrangingfromintenseandexpensivetohands-offandcheap.
Keywords: diabetesmellitus;survey;euthanasia;qualityoflife;insulininjections
1. Introduction
Owners’activeparticipationinthetreatmentisessentialforsuccessfulmanagementofdiabetes
mellitus (DM) in companion animals. The disease and the treatment commitments are likely to
haveconsiderableimpactonowners’dailyroutinesandqualityoflife(QoL)andmightrepresenta
significanttemporal,financialandemotionalburden. Severalareasofeverydaylifethatarenegatively
influencedbyDManditstreatmenthavebeenidentifiedinarecentsurveyconcerningtheQoLof
diabeticcatsanddogsandtheirowners[1,2]. Owners’perceptionofsubstantialimpairmentinone
ormoreoftheseareascouldpotentiallyleadtotreatmentcessationandsimilarconcernscouldeven
promptthedecisiontodeclinetreatmentatthetimeofdiagnosis. However,theabovementionedQoL
Vet.Sci.2017,4,27;doi:10.3390/vetsci4020027 www.mdpi.com/journal/vetsci
Vet.Sci.2017,4,27 2of13
surveyreflectstheviewsonlyofthosewhohadalreadyacceptedandinitiatedthetreatmentandthe
assumptionthatownerswhodeclineoropttoceasetreatmentsharethesameconcernsmightnotbe
correct. Rationaleofthelattergroupisnotwelldocumented.
EpidemiologicdataregardingDMandsurvivalofdogsandcatswithDMarelimited[3,4]and
onlyafewstudiesconcerningdiabeticcatstreatedatuniversityteachinghospitals(UTHs)provide
someinsightstofactorsassociatedwithmortality[5–7]. However,noneofthestudieshaveassessed
thereasonsforownerstodeclineorceasetreatment. Moreover,mostinformationstemsfromUTHs
andlargescalestudiesconcerningtreatmentofDMinprivatepracticearelacking.
Theaimofthisstudywastodocumenttheperceivedfrequencyofeuthanasiaamongcatsand
dogswithDMatthetimeofdiagnosisandwithinthefirstmonthandfirstyearoftreatment,investigate
thepossibleinfluenceofdemographicfactorsonthedecisiontodeclineorceasetreatmentofDMas
wellasidentifytheowner’sreasonsformakingthisdecisionandcomplianceissues. Toobtainthis
information,theBigPetDiabetesSurveywasdesignedandperformedamongveterinaryclinicians.
Atthesametime,thisapproachallowedassessmentofcurrentDMtreatmenthabitsandexperiences
ofparticipatingclinicians.
2. MaterialsandMethods
2.1. DesignofSurvey
QualitativeresearchwasconductedaspartofthedesignphaseoftheBigPetDiabetesSurvey.
ToensureallitemswereDM-treatment-centredandofspecificvaliditytoclinicians,diabeticpetsand
theirowners,detaileddiscussionswereconductedwith65veterinarysurgeonsand36nurses(bothin
primarypracticeandinreferralpractice,bothintheUKandUSA),aswellasaclinicalepidemiologist.
Thisinitialphaseresultedintheformulationoffivedemographicquestionsand36specificDM
treatmentquestions,includingquantificationofthenumberofpetsbeingdeniedtreatment,reasons
forsuchdenial,treatmenthabitsandsuccessratesoftheparticipatingclinician,aswellasperceived
concernsofclientandcliniciansurroundingDMtreatment. Allquestionsrequiredtherespondentto
chooseonemultiplechoicequestionansweroranumericanswer. Afreecommentssectionattheend
ofthesurveyprovidedtheopportunityforadditionalcomments.
The second phase consisted of the Big Pet Diabetes Survey being digitalised and publicised
onlineusingasoftwarepackage(QuestionmarkPerceptionManager,Questionmark,London,UK).
Aninitialtrialwasconductedamongst20veterinarysurgeonsand10veterinarynursesinorderto
identifyareasofconfusionandassessthequestions’truevalidity. Feedbackwasusedtofine-tuneand
finalisethequestionsandanswercategories,beforesubsequentapplicationofthefinalonlineversion
(Supplement1)inthelargerveterinarycliniciancommunity(thirdphase). Thepresenteddatawere
voluntarilyprovidedbyveterinariansinthefullknowledgethatthisinformationfacilitatedthestudy
ofdiabeticpetsandtheirowners;thestudywasapprovedbytheRoyalVeterinaryCollege’sethics
andwelfarecommittee.
2.2. RecruitmentofRespondents
The final digitalised Big Pet Diabetes Survey was made available online using the Uniform
Resource Locator (URL) www.rvc.ac.uk/diabetesvet. Recruitment of respondents was conducted
in 2008 and 2009, parallel with and through the same channels as the diabetic pet owner survey
recruitmentasdescribedpreviously[1,2].
2.3. StatisticalAnalysis
Descriptivestatisticswereobtainedforallvariablesusingproportionofobservationsindifferent
categories for categorical variables, mean and standard deviation (SD) for normally distributed
quantitative variables and median and interquartile range (IQR) for non-normally distributed
quantitative variables. Data regarding the diabetes treatment decision questions were analysed
Vet.Sci.2017,4,27 3of13
throughunivariateanalysisusingthenon-parametricKruskall–Wallistestforquestionsintheformat
“outof10cats/dogs/owners,howmany...”. Multivariateanalysiswasperformedtoassessthesame
relationships while adjusting for potential confounding effects by selected demographical factors.
Forthepurposeofreportingtheresults,thecategory“practicetypeI”includesmixedand100%small
animalpractices,and“practicetypeII”includesreferral/university,charityandprivatepractices.
ContinentalEurope,suburban,100%smallanimalandprivatepractices,aswellaspracticeswith
<20%ofcats/animalsinsuredservedasreferencecategory. Oncethevariablestobeincludedinthe
modelwereidentified,ordinallogisticregressionwasused.
Inviewofthelowfrequencyofanswersindicatingfourormoreforquestionsintheformat“out
of10cats/dogs/owners,howmany...”andtheresultsoftestingforparallellines(testingforequal
slopecoefficientsacrossoutcomevariables),answersoptionswerere-groupedintofivecategories,
specifically: 0,1,2,3andgreaterorequalto4. Assessmentofthemultivariateanalysismodelwas
donebytestingforparallellines;themodelwasdeemedappropriateifp>0.05.
All statistical analyses were performed using a statistical software package (SPSS 17.0 for
Windows,SPSSInc.,Chicago,IL,USA)andp≤0.05deemedsignificant.
3. Results
A total of 1192 veterinarians completed the survey. The majority of respondents worked in
suburbanandurbanareasoftheUSAandUKandIreland. Mostofthecliniciansworkedin100%
smallanimalprivatepracticesettings,servingapredominantlyuninsuredpatientpopulationand
diagnosedDMinlessthansixcatsandlessthansixdogseachyear(Table1).
Table 1. Country of origin of 1192 responding veterinary clinicians and breakdown according to
variousdemographicalparameters.
CountryorRegion Numberof Practice Practice %Catsand
Location DMDiagnoses/Year
PracticingClinician Respondents(%) TypeI TypeII DogsInsured
Rural95 Private732 Cats:
(11.8%) SA715 (91.2%) <6:330(40.9%)
Urban192 (89.3%) Charity9 <20%insured 6–10:282(34.9%)
(23.8%) Mixed62 (1.1%) 789(98%) >10:195(24.2%)
USA 807(67.8%)
Suburban (7.7%) Referral/Uni >20%insured Dogs:
509(63.1%) Other20 37(4.6%) 16(2%) <6:492(61.3%)
Other11 (2.5%) Other25 6–10:195(24.3%)
(1.4%) (3.1%) >10:115(14.3%)
Rural26 Private129 Cats:
(15.5%) SA139 (77.2%) <6:90(53.6%)
Urban72 (83.2%) Charity20 <20%insured 6–10:47(28.0%)
(42.9%) Mixed26 (12%) 59(35.1%) >10:31(18.5%)
UKandIreland 168(14.1%)
Suburban67 (15.6%) Referral/Uni >20%insured Dogs:
(39.9%) Other2 15(9%) 109(64.9%) <6:97(58.1%)
Other3 (1.2%) Other3 6–10:43(25.7%)
(1.8%) (1.8%) >10:27(16.2%)
Rural10 Private82 Cats:
(10.8%) (88.2%) <6:36(38.7%)
SA80(86%)
Urban27 Charity3 <20%insured 6–10:36(38.7%)
Mixed11
(29.0%) (3.2%) 90(96.8%) >10:21(22.6%)
Canada 93(7.8%) (11.8%)
Suburban54 Referral/Uni >20%insured Dogs:
Other2
(58%) 4(4.3%) 3(3.2%) <6:67(72.8%)
(2.2%)
Other2 Other4 6–10:19(20.4%)
(2.2%) (4.3%) >10:6(6.5%)
Rural13 Private68 Cats:
(14.1%) SA73 (73.1%) <6:48(51.6%)
Urban46 (78.5%) Charity2 <20%insured 6–10:32(34.4%)
(50%) Mixed16 (2.2%) 85(92.4%) >10:13(14.0%)
ContinentalEurope 93(7.8%)
Suburban32 (17.2%) Referral/Uni >20%insured Dogs:
(34.8%) Other4 21(22.6%) 7(7.6%) <6:69(74.2%)
Other1 (4.3%) Other2 6–10:14(15.1%)
(1.1%) (2.2%) >10:10(10.8%)
Cats:
Rural3 Private24
<6:13(44.8%)
(10.3%) SA27 (82.8%)
<20%insured 6–10:11(37.9%)
Urban7 (93.1%) Charity1
29(100%) >10:5(17.2%)
Australia 29(2.4%) (24.1%) Mixed2 (3.4%)
>20%insured Dogs:
Suburban19 (6.9%) Referral/Uni
0(0%) <6:19(65.5%)
(65.5%) Other0(0%) 4(13.8%)
6–10:3(10.3%)
Other0(0%) Other0(0%)
>10:7(24.1%)
DM–DiabetesMellitus;SA—100%smallanimalpractice;Uni—referraloruniversitypractice.
AsummaryoftheirDMtreatmenthabitsisprovidedinTable2.
Vet.Sci.2017,4,27 4of13
Table2.Descriptionofclinicians’DMtreatmenthabits.
Value
Parameter Unit
Cats Dogs
Proportionofcliniciansprescribing Number(percentage)
980of1182(82.9%) 946of1132(83.6%)
twicedailyinsulininjections ofclinicians
U/kgBW/injection:
Startinginsulindose 0.45±0.31 0.60±0.52
mean±SD
Numberofcats/dogsstartedonnew Mediannumberof
9of10(6–10) 7of10(3–9)
dietatdiagnosis cats/dogs(IQR)
Numberofcats/dogsstartedonoral Mediannumberof
0of10(0–0) 0of10(0–0)
hypoglycaemicdrugsatdiagnosis cats/dogs(IQR)
BW—bodyweight;SD—standarddeviation;IQR—interquartilerange.
A total of 946 (93.2%) and 984 (95.3%) of the clinicians, respectively, reported they would
“certainly”treattheirowncatordogwithinsulininjectionsshouldtheirpetbediagnosedwithDM.
The proportions of cats and dogs euthanased at the time of DM diagnosis, those euthanased
becauseofinjectionissuesorthoseceasingthetreatmentwithin1monthand1yearofDMdiagnosis
aregiveninTable3.
Table3.AnswerstoquestionsaboutmaintreatmentdecisionsinregardstoDM(euthanasiaatthetime
ofdiagnosis,at1monthand1year).
“Typically,inthispractice,outoftencatsor
dogsnewlydiagnosedwithdiabetes Cats:Median Dogs:Median
QuestionNumber
mellitus,....”(secondpartofthequestion (IQR) (IQR)
continuedbelow)
“... howmanyareeuthanasedonrequestof
C1/D1 1(0–2) 1(0–1)
theownerattimeofdiagnosis?”
“... howmanyareeuthanasedonrequestof
C2/D2 theownerbecauseofnotwantingtotreatwith 1(0–1) 0(0–1)
insulininjectionsattimeofdiagnosis?”
“... andstartedoninsulininjections,inhow
manyisinsulintreatmentsubsequently
C3/D3 0(0–1) 0(0–1)
stoppedwithin1monthbecauseoflackof
successorcompliance?”
“... andstartedoninsulininjections,inhow
manyisinsulintreatmentsubsequently
C4/D4 1(0–2) 1(0–2)
stoppedwithin1yearbecauseoflackof
successorcompliance?”
IQR—interquartilerange.
Theopinionofthemajorityofclinicians(percentageofcliniciansinbrackets)wasthatowners
were“probably”(41.8%)or“definitely”(26.7%)morelikelytooptforinsulininjectiontherapywhen
animals were insured. Clinicians (percentage of clinicians in brackets) also assumed that owners
were“probably”(31.2%)or“definitely”(57.5%)morelikelytooptforinsulininjectionswhenthey
themselvesorclosefamilyorfriendswerediabetic.
Factorsconsideredbyclinicians(percentageofcliniciansinbrackets)tobeof“greatimportance”
intheowner’sdecisionmakingtoeuthanasediabeticanimals, stopthetreatmentornotstartDM
treatmentinthefirstplacewere(indecreasingorder)“concurrentdisease”(45%);“costs”(44%);“age
oftheanimal”(37%);“problemsobtainingadequatecontrol”(35%);“welfareofthepet”(35%);“too
muchimpactonowner’slifestyle”(32%);and“injectionproblems”(17%)(Figure1).
Vet. Sci. 2017, 4, 27 5 of 12
Vet. Sci. 2017, 4, 27 5 of 12
animals were insured. Clinicians (percentage of clinicians in brackets) also assumed that owners were
animals were insured. Clinicians (percentage of clinicians in brackets) also assumed that owners were
“probably” (31.2%) or “definitely” (57.5%) more likely to opt for insulin injections when they
“probably” (31.2%) or “definitely” (57.5%) more likely to opt for insulin injections when they
themselves or close family or friends were diabetic.
themselves or close family or friends were diabetic.
Factors considered by clinicians (percentage of clinicians in brackets) to be of “great importance”
Factors considered by clinicians (percentage of clinicians in brackets) to be of “great importance”
in the owner’s decision making to euthanase diabetic animals, stop the treatment or not start DM
in the owner’s decision making to euthanase diabetic animals, stop the treatment or not start DM
treatment in the first place were (in decreasing order) “concurrent disease” (45%); “costs” (44%); “age
treatment in the first place were (in decreasing order) “concurrent disease” (45%); “costs” (44%); “age
of the animal” (37%); “problems obtaining adequate control” (35%); “welfare of the pet” (35%); “too
Voeft .thScei. a2n01i7m,4a,l2”7 (37%); “problems obtaining adequate control” (35%); “welfare of the pet” (35%);5 “otfo1o3
much impact on owner’s lifestyle” (32%); and “injection problems” (17%) (Figure 1).
much impact on owner’s lifestyle” (32%); and “injection problems” (17%) (Figure 1).

FFiigguurree 11.. CClliinniicciiaannss’’ aannsswweerrss ttoo tthhee ssuurrvveeyy qquueesstitoionn ““IfI fddiaiabbeteitci cananimimalasl saraer eeueuthtahnaansaesde/dtr/etaretmatemnet nist
Figure 1. Clinicians’ answers to the survey question “If diabetic animals are euthanased/treatment is
sistosptoppepde/ndo/tn sotatrstteadrt, ehdo,who iwmpimorptaonrtta anrtea trheet hfoellfoowlloinwgi nfagctfoarcsto?”rs F?a”cFtoarcsto irnsdiincdatiecdat ebdy bnyumnubmerbs eorns oXn-
stopped/not started, how important are the following factors?” Factors indicated by numbers on X-
Xax-aisx; is1;. 1c.osctoss; t2s.; w2.ewlfaerlefa oref opfetp; e3t.; t3o.ot omoumchu cimhpimacpta ocnt olnifelsifteyslety olef oofwonwern; e4r.; 4in.jeinctjieocnti opnropbrloebmlesm; 5s.;
axis; 1. costs; 2. welfare of pet; 3. too much impact on lifestyle of owner; 4. injection problems; 5.
p5.rpobrolebmlesm osbotbaitnaiinnign gadaedqeuqautaet ecocnotnrtorlo; l6;.6 c.ocnoncucurrrernent tddisieseaassee; ;77. .AAggee ooff tthhee aanniimmaall;; 88.. ootthheerr ((aaddddiittiioonnaall
problems obtaining adequate control; 6. concurrent disease; 7. Age of the animal; 8. other (additional
iissssuueess rreeppoorrtteedd bbyy tthhee rreessppoonnddeennttss aanndd rraatteedd aaccccoorrddiinngg ttoo iimmppoorrttaannccee))..
issues reported by the respondents and rated according to importance).
The most commonly encountered compliance issues considered to be “of great importance” by
TThhee mmoosstt ccoommmmoonnllyy eennccoouunntteerreedd ccoommpplliiaannccee iissssuueess ccoonnssiiddeerreedd ttoo bbee ““ooff ggrreeaatt iimmppoorrttaannccee”” bbyy
the clinicians (percentage of clinicians in brackets) were “owner does not stick to feeding protocol”
tthhee cclliinniicciiaannss ((ppeerrcceennttaaggee ooff cclliinniicciiaannss iinn bbrraacckkeettss)) wweerree ““oowwnneerr ddooeess nnoott ssttiicckk ttoo ffeeeeddiinngg pprroottooccooll””
(28%); “owner having injection difficulties” (17%); “cat causing injection difficulties” (15%);
((2288%%));; ““oowwnnererh ahvainvginign jeicntjieocntidoinffi cduiflftiiecus”lt(i1e7s”% )(;1“7c%at);c a“ucsaint gcianujescintigo nidnijfeficctiuolnti esd”if(f1ic5u%lt)i;e“si”n je(c1t5io%n)s;
“injections not given at right times” (12%); “inappropriate insulin storage” (9%); and “dog causing
“niontjegcitvioennsa ntorti gghivtetnim aet sr”ig(h12t %tim);e“si”n a(1p2p%ro)p; “riiantaepipnrsouplriniatseto irnasgueli”n( 9st%or)a;gaen”d (“9%do)g; acnadu s“idnoggi ncajeucstiinogn
injection difficulties” (8%) (Figure 2).
idnijfeficctuioltni edsi”ff(i8c%ul)ti(eFsi”g u(8r%e2) )(.Figure 2).

Figure 2. Clinicians’ answers to the survey question "According to you how important are the
FFiigguurree 22.. CClilniniciicaianns’sa’ nasnwsweresrtso tthoe tshuer vseuyrvqeuye sqtiuones"tAiocnc o"rAdcincgortdoiynogu thoo wyoium phoorwta nimtapreortthaenfto lalroew tinhge
following compliance issues encountered in your practice?” Compliance issues indicated by numbers
fcoolmlopwliianngc ceoimsspuleisanecnec oisusnuteesr eedncionuynotuerrepdr ainc tyicoeu?r” pCroamctipclei?a”n cCeoimsspuleiasninced iicsasuteeds binydnicuamtebde brsyo nnuXm-baexriss:
on X-axis: 1. owner having injection difficulties; 2. cat causing injection difficulties; 3. dog causing
1o.n oXw-anxeirs:h 1a. voinwgneinrj ehcatvioinngd iinffijeccutilotine sd;i2ff.iccualtticeasu; s2i.n cgatin cjaecutsiionng dinifjfiecctuioltnie sd;if3f.icduoltgiesc;a u3.s idnoggi ncajeucstiinong
injection difficulties; 4. inappropriate insulin storage; 5. injections not given at right times; 6. owner
idnijfeficctuiolnti edsi;f4fi.ciunlatipeps;r 4o.p irniaatpepirnospurliiantes tionrsauglein; 5s.toinrajegceti; o5n. sinnjoecttgioivnesn naott rgigivhetnt iamt ersig;h6.t otiwmnees;r 6d.o oewsnneort
sticktofeedingprotocol;7.other(additionalissuesreportedbytherespondentsandratedaccordingto

importance).
Basedontheirexperience,clinicians(percentageofcliniciansinbrackets)considered“QoLofthe
animal”(60%);“costsoftreatment”(52%);“havingtoinjecttheiranimal”(48%);“lifestylechangesthe
ownerhastomake”(38%);“hypoglycaemia”(23%);and“diabeticketoacidosis(DKA)”(7%)tobeof
“greatconcern”forownersofdiabeticcatsanddogs(Figure3).
Vet. Sci. 2017, 4, 27 6 of 12
Vet. Sci. 2017, 4, 27 6 of 12
does not stick to feeding protocol; 7. other (additional issues reported by the respondents and rated
does not stick to feeding protocol; 7. other (additional issues reported by the respondents and rated
according to importance).
according to importance).
Based on their experience, clinicians (percentage of clinicians in brackets) considered “QoL of
Based on their experience, clinicians (percentage of clinicians in brackets) considered “QoL of
the animal” (60%); “costs of treatment” (52%); “having to inject their animal” (48%); “lifestyle changes
the animal” (60%); “costs of treatment” (52%); “having to inject their animal” (48%); “lifestyle changes
the owner has to make” (38%); “hypoglycaemia” (23%); and “diabetic ketoacidosis (DKA)” (7%) to
Vthete.S ociw.2n01e7r, 4h,a2s7 to make” (38%); “hypoglycaemia” (23%); and “diabetic ketoacidosis (DKA)” (76%o)f 1to3
be of “great concern” for owners of diabetic cats and dogs (Figure 3).
be of “great concern” for owners of diabetic cats and dogs (Figure 3).

FFiigguurree3 3.. CClliinniicciiaannss’’ aannsswweerrss ttoo tthhee ssuurrvveeyy qquueessttiioonn ““AAccccoorrddiinngg ttoo yyoouu,, hhooww mmuucchh aarree oowwnneerrss ooff
Figure 3. Clinicians’ answers to the survey question “According to you, how much are owners of
ddiaiabbeettiicca annimimaalslsc coonncceerrnneeddb byyt htheef ofolllolowwininggi sisssuueess??””::1 1.. hhyyppooggllyyccaaeemmiiaa;; 22.. ddiiaabbeettiicc kkeettooaacciiddoossiiss;; 33..
diabetic animals concerned by the following issues?”: 1. hypoglycaemia; 2. diabetic ketoacidosis; 3.
hhaavvininggt otoi ninjejeccttt htheeirira annimimaal;l;4 4..c coossttsso offt rtreeaatmtmeenntt;;5 5..q quuaaliltityyo offl ilfifeeo offt htheea annimimaal;l;6 6..l ilfiefesstytylelec chhaannggeess
having to inject their animal; 4. costs of treatment; 5. quality of life of the animal; 6. lifestyle changes
ththaattt htheeo owwnneerrh haasst otom maakkee..
that the owner has to make.
FFoorr tthhee cclilniniciciiaannss tthheemmsseellvveess,, ““QQooLL ooff tthhee aanniimmaall”” ((6633%%)) wwaass aallssoo tthheem moossttc coommmmoonnllyy ssttaatteedd
For the clinicians themselves, “QoL of the animal” (63%) was also the most commonly stated
fffaaaccctttooorrr o oofff “ ““gggrrreeeaaattt c ccooonnnccceeerrrnnn”””,,, f ffooollllloloowwweeeddd b bbyyy “ ““hhhyyypppoooggglllyyycccaaaeeemmmiiiaaa””” (((444666%%%))),,, “““dddiiiffffiffiicccuuullltttiiieeesss i iinnn g ggeeettttttiiinnnggg t tthhheee o oowwwnnneeerrr o oonnn
bbooaarrddw wiitthht thhee ttrreeaattmmeenntt””( (4444%%)),,“ “DDKKAA”” ((4433%%)),, ““ddiifffificcuullttiieess iinn oobbttaaiinniinngg rraappiidd aanndd aaddeeqquuaattee ccoonnttrrooll””
board with the treatment” (44%), “DKA” (43%), “difficulties in obtaining rapid and adequate control”
(((444222%%%))) a aannnddd “ ““cccooosssttstss o oofff t trtrreeeaaattmtmmeeennntt”t”” ( (1(11333%%%))) ( (F(FFiigigguuurreree4 44)).)..

Figure 4. Clinicians’ answers to the survey question “How much do the following issues worry you
FFiigguurree 44.. CClliinniicciiaannss’’ aannsswweerrsst otot hthees usurvrveyeyq uquesetsiotinon“ H“Howowm mucuhchd odtoh ethfeo lfloolwloiwnginigss iusessuewso wrroyryryo uyoaus
as a vet?”: 1. hypoglycaemia; 2. diabetic ketoacidosis; 3. costs; 4. quality of life of the animal; 5.
aasv eat ?v”e:t1?.”h: y1p. ohgylypcoagelmyciaae;m2.idai; a2b.e tdiciakbeettoiac ckideotosiasc;i3d.ocsoiss;t s3;.4 .coqsutasl;i t4y. oqfuliafleitoyf tohfe laifnei mofa lt;h5e. dainffiimcuallt;i e5s.
difficulties in obtaining rapid and adequate control; 6. difficulties of getting the owner on board with
idnifofbictuailntiiensg inra opbidtaainnidnagd reaqpuidat aencdon atdroelq;u6a.tdei fcfiocnutlrtoiel;s 6o.f dgiefftticinuglttihese oofw gneettrionng bthoea rodwwniethr othne btoreaartdm wenitth.
the treatment.
the treatment.
IInnffoorrmmaattiioonn aabboouutt cclliinniicciaiannss’ ’vvieiwews sini nrergeagradr dtot tohteh QeoQLo aLchaicehvieedv ebdy boywonwerns earnsda tnhdeitrh peeirtsp aest swaesll
Information about clinicians’ views in regard to the QoL achieved by owners and their pets as well
wase lilnafosrimnfaotiromna atbioonuta fbroequutefnrecqyu oefn ccoymopfliccoamtiopnlsic sautciohn ass shuycphoagslyhcyaepmogialy acnade mDKiaAa nisd pDroKvAideids pinr oTvaibdlee d4.
as information about frequency of complications such as hypoglycaemia and DKA is provided in Table 4.
in Table4.
Vet.Sci.2017,4,27 7of13
Table4.AnswerstoquestionsaboutqualityoflifeandfrequencyofcomplicationsofDM.Questions
C6/D6aswellasquestion9relatestoowners’qualityoflifeanddifficultiesfittingintwicedaily
injections,respectively.Inquestion9,catanddogownerswerenotaddressedseparately.
“Typically,inthispractice,outoftencatsor
dogsnewlydiagnosedwithdiabetesmellitus Cats(CatOwners): Dogs(DogOwners):
QuestionNumber
(ortheirowners),....”(secondpartofthe Median(IQR) Median(IQR)
questioncontinuedbelow)
“... howmanyachieveasatisfactoryqualityof
C5/D5 lifeaccordingtotheowneroncetreatmentwith 8(7–9) 8(7–9)
insulininjectionshasbeenstarted?”
“... howmanyoftheownerseventuallyhavea
C6/D6 satisfactoryqualityoflifeandnotfeellimitedin 8(6–9) 8(6–9)
lifestylebecauseofdailyinsulininjections?”
“... howmanysufferfromanapparent
hypoglycaemiccrisis(suggestiveclinicalsignsOR
C7/D7 2(1–4) 2(1–3)
recordedbloodglucose)atsomestageduring
treatment?“
“... howmanywillsufferfromanepisodeof
C8/D8 keto-acidosis(DKA)afterinsulintreatmenthas 1(0–2) 1(0–2)
beeninitiated?“
“...howmanyoftheownersreporthaving
difficultiesfittinginatwicedailyinjection
9 2(1–4)
treatmentinsteadofaoncedailyinjection
treatment?”a
IQR—interquartilerange.
3.1. ResultsofUnivariateAnalysis
The variables “country”, “location of the practice” and “practice type I” were found to be
significantly associated with the answers to questions D/C 1 (“frequency of euthanasia of newly
diagnoseddiabeticdogs/catsattimeofdiagnosis”)andD/C2(“frequencyofeuthanasiaofnewly
diagnoseddiabeticdogs/catsattimeofdiagnosisbecauseofnotwantingtoinject”),and“practicetype
II”wasassociatedwiththeanswerstoquestionC2. “PracticetypeI”wasassociatedwiththeanswers
toquestionsD/C3and4. Additionally,“practicelocation”and“practicetypeII”wereassociated
withtheanswerstoquestionD3,while“%insured”wasassociatedwiththeanswerstoquestionD4.
TheresultsofunivariateanalysisareprovidedinSupplement2.
3.2. ResultsofMultivariateAnalysis
ResultsofmultivariateanalysiscanbeseeninTables5and6.
Vet.Sci.2017,4,27 8of13
Table5.ResultsofmultivariateanalysisforquestionsC1,C2,D1andD2.
FrequencyEuthanasia FrequencyEuthanasiaNewly FrequencyEuthanasiaNewly
FrequencyEuthanasiaNewly
NewlyDiagnosedDiabetic DiagnosedDiabeticcats—Not DiagnosedDiabeticDogs—Not
DiagnosedDiabeticDogsD1
Factor Cats(C1) WantingtoInjectC2 WantingtoInjectD2
p-value OR(95%CI) p-value OR(95%CI) p-value OR(95%CI) p-value OR(95%CI)
0.72
UKandIreland 0.331 0.75(0.42–1.34) 0.188 0.67(0.38–1.21) 0.290 0.828 0.93(0.51–1.72)
(0.40–1.32)
0.79
Country USA 0.383 0.83(0.54–1.27) 0.349 0.81(0.53–1.25) 0.294 0.835 0.95(0.61–1.50)
(0.51–1.23)
2.36
Canada 0.001 2.68(1.53–4.67) 0.050 1.75(1–3.08) 0.003 0.014 2.06(1.15–3.68)
(1.34–4.16)
1.28
Australia 0.038 2.26(1.04–4.88) 0.32 2.38(1.08–5.27) 0.537 0.105 1.97(0.87–4.46)
(0.58–2.83)
Cont.Europea – a – a – a – a
2.17
Rural 0.010 1.6(1.12–2.28) 0.001 1.81(1.26–2.59) 0.000 0.000 2.17(1.51–3.13)
(1.51–3.12)
Location
1.13
Urban 0.339 1.14(0.87–1.47) 0.63 1.29(0.99–1.68) 0.385 0.300 1.16(0.88–1.53)
(0.86–1.47)
Sub-urbana – a – a – a – a
1.00
Mixed 0.009 1.69(1.14–2.50) 0.02 1.59(1.07–2.35) 0.987 0.312 1.23(0.82–1.85)
PracticetypeI (0.67–1.51)
SAa – a – a – a – a
0.54
Referral/Uni 0.032 0.6(0.37–0.96) 0.439 0.83(0.52–1.33) 0.015 0.560 0.86(0.53–1.41)
(0.33–0.89)
PracticetypeII
1.69
Charity 0.424 1.3(0.68–2.5) 0.101 1.72(0.90–3.31) 0.129 0.597 1.2(0.61–2.37)
(0.86–3.33)
Private – a – a – a – a
1.00
>20% 0.693 1.11(0.67–1.82) 0.809 0.94(0.57–1.56) 0.988 0.562 0.86(0.51–1.45)
%insured (0.59–1.68)
<20%a – a – a – a – a
CI—confidenceinterval;aReferencecategory;Bold:Statisticallysignificantassociation(p≤0.05).
Vet.Sci.2017,4,27 9of13
Table6.ResultsofmultivariateanalysisforquestionsC3,C4,D3andD4.
FrequencyTreatment FrequencyTreatmentStopped FrequencyTreatmentStopped FrequencyTreatmentStopped
Factor StoppedCats<1MonthC3 Dogs<1MonthD3 Cats<1YearC4 Dogs<1YearD4
p-value OR(95%CI) p-value OR(95%CI) p-value OR(95%CI) p-value OR(95%CI)
0.48b 0.74
UKandIreland 0.017 0.47(0.26–0.88) 0.026 0.307 0.136 0.64(0.36–1.15)
(0.25–0.92) (0.41–1.32)
1.12
Country USA 0.033 0.61(0.28–0.94) 0.148 0.71(0.44–1.13) 0.614 0.490 0.86(0.56–1.32)
(0.73–1.71)
1.30
Canada 0.017 0.47(0.43–0.51) 0.630 0.86(0.61–1.11) 0.350 0.969 1.01(0.45–1.48)
(0.79–1.81)
1.03
Australia 0.318 0.65(0.68–2.03) 0.623 0.80(0.33–1.94) 0.939 0.767 1.13(0.51–2.49)
(0.48–2.23)
Cont.Europea – a – a – a – a
0.98
Rural 0.766 1.06(0.72–1.56) 0.061 1.45(0.98–2.14) 0.892 0.260 1.23(0.86–1.76)
(0.69–1.39)
Location
0.91
Urban 0.786 0.96(0.72–1.28) 0.322 1.16(0.86–1.57) 0.451 0.440 1.11(0.85–1.44)
(0.70–1.17)
Sub-urbana – a – a – a – a
1.64
Mixed 0.155 1.35(0.89–2.05) 0.149 1.37(0.89–2.09) 0.012 0.01 1.67(1.13–1.47)
PracticetypeI (1.12–2.41)
SAa – a – a – a – a
1.59
Referral/Uni 0.404 1.23(0.75–2.01) 0.367 0.78(0.45–1.34) 0.045 0.232 1.32(0.84–2.09)
(1.01–2.49)
PracticetypeII
2.05
Charity 0.023 2.18(1.11–4.27) 0.002 2.93(1.49–5.78) 0.028 0.047 1.92(1.01–3.66)
(1.08–3.87)
Privatea – a – a – a – a
1.00
>20% 0.556 1.18(0.68–2.03) 0.588 1.17(0.66–2.08) 0.991 0.195 0.72(0.43–1.19)
%insured (0.61–1.65)
<20%a – a – a – a – a
CI—confidenceinterval;aReferencecategory;Bold:Statisticallysignificantassociation(p<0.05).
Vet.Sci.2017,4,27 10of13
“Percentage insured” (with a 20% cut-off) was found not to be significantly associated with
answerstoanyofthefourassessedquestions(D/C1,2,3,4). CatspresentedtopracticesinCanada
(oddsratio(OR)2.7)andAustralia(OR2.3)aswellasinrural(OR1.6)andmixed(OR1.7)practices
weremorelikelytobeeuthanasedbecauseofDMdiagnosis,whilecatspresentedtoreferralcentresor
UTHwereatlowerrisk(OR0.6). DogsweremorelikelytobeeuthanasedbecauseofDMinCanada
(OR1.8)andiftheywerepresentedtorural(OR1.8)andmixed(OR1.6)practices. Catsanddogs
presentedtopracticesinCanada(ORforcats2.4,ORfordogs2.1)andtoruralpractices(ORforboth
catsanddogs2.2)wereathigherrisktobeeuthanizedonownerrequestbecauseofnotwantingto
treatwithinsulininjections;theriskwaslowerforcatspresentedtoreferralcentresoruniversities
(OR0.54). TreatmentofDMwaslesslikelytobeceasedwithinthefirstmonthofdiagnosisbecause
oflackofsuccessorcomplianceincatspresentedtopracticesinCanada(OR0.5),USA(OR0.6)and
UKandIreland(OR0.5)andindogsinUKandIreland(OR0.5). Ontheotherhand,bothcatsand
dogsweremorelikelytohaveDMtreatmentstoppedwithin1month(ORforcats2.2,ORfordogs2.9)
andwithin1year(ORforcats2.0,ORfordogs1.9)ofDMdiagnosisifpresentedtocharitypractices.
Beingpresentedtoamixedpracticeincreasedtheriskfortreatmentcessationwithin1yearinboth
cats(OR1.6)anddogs(OR1.7). Theriskoftreatmentcessationwithin1yearofDMdiagnosiswas
alsohigherforcatspresentedtoreferraloruniversityhospitals(OR1.6).
4. Discussion
TheBigPetDiabetesSurveyisthefirstofitskindtodocumentperceptionsofveterinarianson
frequencyandreasonsforeuthanasiaofdiabeticcatsanddogsatthetimeofdiagnosisandwithinthe
firstyearoftreatment. Furthermore,thestudyalsoobtainedinformationaboutDMtreatmenthabits
aswellasclinician’sandperceivedowner’sconcerns.
Thestudyrevealedthataccordingtotheinterviewedpopulationofveterinarians,amedianofone
in10catsanddogswithDMwereeuthanasedonrequestoftheowneratthetimeofdiagnosisandin
anothermedianofonein10catsanddogs,treatmentwasstoppedwithinoneyearbecauseoflackof
responseorcompliance. AlthoughthefrequencyofeuthanasiawithinthefirstmonthofDMdiagnosis
inthisstudy(0–1of10catsanddogs)wascomparabletopreviousreportsincats(mortalityrates
of11%–17%withinfirst3–4weeks)[5,7],higherfigureswerereportedinalargeSwedishinsurance
studyconcerningdiabeticdogs[3]. Inthelatterinvestigation,30%ofdogswereeuthanasedattime
ofdiagnosisandanother15%within30days. Mortalityrateswithin1yearofDMdiagnosiswere
foundtobe35%–40%incats[4,5,7]and60%indogsintheabovementionedSwedishstudy[3],which
ishigherthaninthepresentinvestigation. Thismightbeattributabletodemographicandtemporal
differences,previousstudiesconcerningcatspresentedtoUTHsintheUSAandSwitzerland[5–7]and
primary-careveterinarypracticesintheUK[4]anddiabeticdogsinSweden[3].
Inhindsight,theremighthavebeenadvantagetore-phrasingtheeuthanasia-questionstostate
“outof20”insteadof“outof10”,allowingformoredetailedassessmentofthemostcommonanswers,
whichweremostlyaroundtheoneoutof10. Comparisonofthecurrentdatawithotherstudiesor
extrapolationtootherdiabeticpetpopulationsshouldthereforebeperformedwithcaution,especially
inviewofthedemonstratedinteractingdemographiccharacteristics. Higherproportionsofeuthanasia
cases or treatment cessations were reported to occur amongst newly diagnosed cats and dogs in
CanadaandAustralia, inrural, mixedandcharitypractices, andalowerproportioninreferralor
UTH.Thesefindingscouldrelatetodifferingclientperceptionsandexpectationsorattitudesamongst
differentcountriesandpracticetypes,aswellaspossiblydifferingeconomicfactors. Additionally,
resultsofourstudycouldalsoimplythatshouldagreaterproportionofrespondentshaveoriginated
fromoutsidetheUSA,UKandIrelandorContinentalEurope,and/orfromrural,charityandmixed
practices,adifferentpicturemightwellhavebeenrecorded,withatrendtowardsmoreeuthanasiaand
casesofprematurecessationoftreatment. Educationalprogrammesfocussedonofferingavarietyof
DMmanagementstyles(rangingfromintenseandexpensivetorelativelyhands-off)mightpositively
affecttheseincreasedeuthanasiarates, althoughthecurrentdatasetdoesnotprovidedirectproof