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Performance indicators and prescribing antimicrobials
  1. Anne Fawcett and
  2. Thomas Gottlieb

Abstract

T-HIS series gives readers the opportunity to consider and contribute to discussion of some of the ethical dilemmas that can arise in veterinary practice. Each month, a case scenario is presented, followed by discussion of some of the issues involved. In addition, a possible way forward is suggested; however, there is rarely a cut-and-dried answer in such cases, and readers may wish to suggest an alternative approach. This month’s dilemma, ‘Performance indicators and prescribing antimicrobials’, was submitted and is discussed by Anne Fawcett and Thomas Gottlieb. Readers with comments to contribute are invited to send them as soon as possible, so that they can be considered for publication in the next issue. The series is being coordinated by Steven McCulloch, a practising vet with a PhD in the ethics of veterinary policy. It aims to provide a framework that will help practitioners find solutions when facing similar dilemmas.

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Anne Fawcett teaches professional practice and veterinary ethics at the University of Sydney, Australia. She works in companion animal practice and has an interest in infectious diseases. She is a diplomate of the European College of Animal Welfare and Behaviour Medicine and co-wrote ‘Veterinary Ethics: Navigating Tough Cases’ with Siobhan Mullan.

Thomas Gottlieb is a specialist in microbiology and infectious diseases at Concord Repatriation General Hospital in Sydney, Australia, and a clinical associate professor at the University of Sydney. He is also a past president of the Australasian Society for Infectious Diseases and Australian Society for Antimicrobials.

Performance indicators and prescribing antimicrobials

You work in a practice that monitors the performance of vets, to increase practice profitability. It is a well-equipped practice with a high standard of care. One key performance indicator introduced recently is average amount invoiced per consultation. You notice that since this indicator was introduced, a colleague has been prescribing antimicrobials in cases where you feel that antimicrobials are not warranted, and where the choice of antimicrobial is inappropriate. For example, he has on several occasions prescribed combination antimicrobial therapy when this is not indicated, where you think he would not have done previously. Nonetheless, the situation has had the desired effect for management - he has increased his average amount invoiced per consultation and received a bonus. What should you do?

Issues to consider

Measuring employee performance and rewarding high or improved performance aims to motivate employees and increase practice profitability. However, where vets are rewarded for invoicing more, this creates a perceived and actual conflict between the interests of the patient (to be subjected only to appropriate diagnostic and treatment interventions), the interests of the client and/ or insurer (in paying only for appropriate diagnostic and treatment interventions), and the interests of the vet (of which there may be m any, including personal remuneration).

Of course, in recommending the best standard of care for animals, there may be a confluence of interests. For instance, consider when the primary interests (high standard of veterinary care) and secondary interests (remuneration) of the vet are in alignment (Cappola and Fitzgerald 2015). However, the scenario demonstrates that the system as it stands is open to abuse and, indeed, potentially rewards it. Specifically, it is rewarding and promoting non-prudent use of antimicrobials.

Use of antimicrobials where they are not indicated, or inappropriate antimicrobial selection, are drivers of antimicrobial resistance, with negative implications for both human and animal health (One Health). As argued by Stuart Levy, the paradox of antimicrobials is that current misuse reduces potential future treatment options (Levy 2002). It is contrary to the principles of antimicrobial stewardship, which rely on societal and personal reduction of inappropriate antimicrobial use to improve patient outcomes and reduce adverse consequences of antimicrobial use, including antimicrobial resistance, toxicity and unnecessary costs (MacDougall and Polk 2005).

Possible way forward

There is an expectation that professionals do not pursue selfinterest at the expense of their clients or patients. For example, Richard and Daniel Susskind write that: ‘We want to trust professionals, to see them as upright people whose motives often seem noble, and for them to be the embodiments of honesty, probity and integrity. We expect that they will act in good faith, and put the interests of those they help ahead of their own’ (Susskind and Susskind 2015).

Virtue ethics is an approach which, like the account above, focuses on virtues or character traits of professionals. It assumes that ethical decisions follow from virtuous character traits, such as compassion, trustworthiness, discernment, integrity and conscientiousness (Mullan and Fawcett 2017). A trustworthy professional would be expected to declare and manage conflicts of interest. It could be argued that prescribing any treatment that one profits from, whether this is pharmacological or surgical, represents a potential conflict of interest that should be declared and managed. Clients of the practice should be informed that employees receive a commission for services rendered.

Antimicrobial prescribing should be based on developed guidelines and not be influenced by profit to the practice

In the ‘Tragedy of the Commons’, Garret Hardin outlines how pursuit of perceived rational self-interest-grazing the maximum number of cattle on common land - led to the depletion of a resource, to the detriment of all (Hardin 1968). Similarly, failure to reduce use of antimicrobials depletes a common resource.

Is it reasonable to rely on the virtues of individuals, or should we build virtuous systems to limit conflict and exposure to temptation?

To reduce their misuse, antimicrobials should be excluded from calculations used to determine the average amount invoiced. In fact, if such analyses are performed, the conscientious veterinary team would use this information to examine antimicrobial use trends in the practice and reward employees for prudent antimicrobial use. For example, antimicrobial prescription based on guidelines developed by professional societies for indica-tions, selection and duration of antimicrobial use could be measured.

Any thoughts?

Readers with views to contribute on ‘Performance indicators and prescribing antimicrobials’ should e-mail them to inpractice@bva-edit.co.uk so that they can be considered for publication in the next issue. The deadline for receipt of comments is Friday September 22, 2017. Please limit contributions to 200 words.

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