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Integration of Nutrition into Clinical Practice

Sean J. Delaney, Andrea J. Fascetti, Jennifer A. Larsen, and Paul Brentson

Introduction

While some veterinarians enjoy the various complex aspects of owning and managing a clinical practice, many more take on these roles out of necessity rather than preference. In either case, this results in many clinical approaches being at least partially viewed through a "fiscal filter." Although this filter should not be fine enough to strain out appropriate medical decisions, it certainly requires that the economics associated with certain medical practices be considered. Therefore, this introductory chapter will discuss the "business" of nutrition in clinical practice, as an understanding of these basics will enable the practitioner to afford to implement the knowledge contained in the rest of this textbook.

Average Revenue from Food Sales and the Potential

In 2017, the average food revenue was static compared to 2015 at 3.5% of total veterinary practice revenue in the United States (range 2.8-4.3%; AAHA 2019). At the same time, average total revenue earned by practices in 2017 was US$1?271?402. The therapeutic food revenue-to-expense ratio has remained fairly static over time at 1.3, and is consistent across practice types (with regard to number of full-time clinicians, revenue level, years at current location, and American Animal Hospital Association [AAHA] member status). Practices with higher ratios may be managing expenses more efficiently (including consideration of costs related to inventory control) or have higher markups. Lower ratios may reflect undercharging relative to the cost of managing food inventory. Revenue from therapeutic diet sales, while relatively significant on average, can be higher, as practices that focus more on the large compliance gap with therapeutic food recommendations (this gap includes both veterinarians who do not actively recommend medically needed foods and clients who do not choose to feed them) can easily double gross profits from food sales with minimal additional effort or expenditures.

Theoretically, there is much opportunity for growth in revenues and profits if practices can successfully identify and correct barriers to care both for wellness and for chronic and acute disease management (Volk et al. 2011). In large part, the longevity and success of any given practice model will depend on the ability to remain flexible and responsive to changing client demographics, the impacts of the economic climate, and the continued growth in internet resources for both information and products. For some clients, the accessibility and cost of veterinary care and products are a challenge, and the practitioner must effectively communicate the value of services and facilitate convenience in order not just to achieve compliance, but also to maximize both medical outcomes and revenue (Box 1.1). In fact, profits could be increased more than fivefold based on the low compliance found in a study by the AAHA, which includes sales of therapeutic pet foods (AAHA 2003).

Box 1.1 Dietary Recommendations to Maximize Patient Outcome and Ensure Practice Sustainability

Few recommendations hold as much weight with clients about what to feed their animal companion as a veterinarian's recommendation. Many pet food companies are aware of this and invest heavily in the veterinary community, vying for the veterinarian's awareness of their products and, ideally, for their recommendation. Unfortunately, the resulting influx of generous support is increasingly viewed by some as creating a conflict of interest for veterinarians and resulting in a bias in dietary recommendations. This perception is increased by veterinarians who have limited recommendations beyond the products, brands, and/or companies they stock. Therefore, the goal of this chapter is to assist the veterinarian in methods to ensure they can afford to provide the best medical care for their patients and clients by fully integrating nutrition into their clinical practice.

Strategies to Increase Product Sales

Recommending an Effective Therapeutic Food

The surest way to increase compliance and therapeutic pet food sales is to recommend an effective one. This sounds simple enough, but can be quite challenging in practice. To start, one must make the correct diagnosis and select a food that can produce measurable improvement in the animal companion's condition or disease management. For example, clients feeding a "weight loss" food that does not result in weight loss are likely to stop feeding the ineffectual food. Similarly, trying to sell food that an animal companion will not eat is unlikely to be successful. Therefore, establishing expectations, performing a nutritional assessment to guide more informed food recommendations, monitoring the patient response, and providing a variety of options are vital for client compliance.

Establishing Expectations

Many clients choose not to start feeding a recommended therapeutic food, or choose to stop feeding one, because they do not clearly understand what is expected from the food. Expectations are built on the client's understanding of the purpose and mechanism of the food. For example, clients who understand that higher dietary phosphorus can cause progression of chronic kidney disease, and that most dietary phosphorus comes from protein-rich ingredients, are more likely to feed an appropriately lower protein- or phosphorus-containing food. Not surprisingly, human patients have better retention of medical information when verbal information is accompanied with written information (Langdon et al. 2002). Therefore, in the veterinary setting, client handouts can be a very useful adjunct to verbal client education. Equally helpful can be reinforcement of key points by veterinary staff at checkout or discharge. Veterinary staff can play an instrumental role in drafting these materials, as they are often aware of common questions and issues that should be addressed. Staff involvement is expected to enhance their investment in effective transmission of this information to clients, and helps maintain a unified approach to communication.

Performing a Nutritional Assessment

An evaluation of the patient's medical status as well as lifestyle, life stage, weight trends, body composition, appetite, and diet history is a critical step to inform a confident food recommendation. The process of collecting this information, and assessing it in the context of the patient's clinical presentation, provides valuable data to the healthcare team. In some cases this may help achieve a diagnosis, while in other cases a specific treatment plan can be more confidently justified. For example, the clinician may need to discuss specific risk factors in the case of clients who feed raw meat to their omnivore or carnivore. Similarly, a different approach may need to be considered for a feline patient with recurrent constipation that has only ever eaten foods with high fiber content.

Monitoring Patient Response

Although therapeutic foods can be quite effective, not all foods work for every patient. A food's failure may be simply due to a patient being unwilling to eat the food. Therefore, monitoring both acceptance and response to a newly recommended food is crucial to improving compliance. Initially, the greatest risk to compliance is food refusal. Often this can be managed with appropriate recommendations for transitioning to the new food, as well as planned and periodic follow-up in the form of an email, phone call, or in-person office visit to address any issues that arise. Follow-up is equally important to reinforce the importance of the dietary recommendation. Recommendations that have no follow-up are more likely to be perceived as not being as crucial or important. Finally, checking on progress provides an opportunity to discuss and select an alternative but still appropriate food if the first recommendation is not successful. At times there can be a reluctance to perform follow-up since it often is "nonbillable" time; however, follow-up can be tiered or bundled, and veterinary support staff can be leveraged to assist. Many outbound calls can be conducted by veterinary staff, with elevation to veterinarians as needed. This "triaging" of sorts can increase efficiency, and often is welcomed by staff members who feel both entrusted and empowered.

Providing a Variety of Options

Since no food will work in every situation, it is important to have additional options for the client. A ready and specific alternative recommendation should reduce the likelihood that the client may choose a food by themselves, resulting in the potential for an inappropriate food to be selected and the possible loss of a medically justified sale. The tendency to stock only one "house brand" - while convenient from an inventory management perspective - decreases the ability to readily offer alternatives and can lead to a perception that there is only one option, or, worse yet, that the recommendation is made solely on the basis that the particular brand is all the veterinarian sells. Certainly, carrying every therapeutic food available (which now number in the hundreds for small animals) is not...