OVERVIEW

March 2015

• The Pet Wellness Report (PWR) is a veterinary Health RiskAssessment (HRA) that was developed for use in a wellnessexam setting for dogs and cats.

• In December 2014, the American AmericanAnimal Hospital Association (AAHA) selectedthe PWR as AAHA’s exclusive Preferred BusinessProvider for Health Risk Assessments in veteri -nary medicine. AAHA accredited hospitals are traditionallyat the forefront of advancing new approaches to medicalcare for companion animals and the recommendationemphasizes the importance of enhancing the pet ownerperception of value for the veterinary wellness exam.

• The PWR features a client-completed, online questionnaireused to gather pet lifestyle and health observations whichcan optionally be combined with basic or comprehensivediagnostic screening (Table 1). These components are usedto generate a pet-specific health risk summary report forthe pet owner. Client collaboration through the HRA processmakes this PWR-enhanced exam a more engaginginteraction than a conventional wellness visit.

• Incorporating the Pet Wellness Report into the wellnessvisit, the principal tool of preventive veterinary health care,

Robert Lavan, MS, DVM, MPVM, DACVPM, Zoetis Inc.Joyce A. Login, DVM, Zoetis Inc.Dennis J. Chmiel Jr., DVM, MBA, Zoetis Inc.

A HEALTH RISK ASSESSMENT (HRA)CLINICAL TRIAL:Medical, Perceptual, and Financial Impacts of Combining the Pet Wellness Report® with Canine & Feline Wellness Exams

provides enhanced medical, perceptual, and financialbenefits to this routine companion animal service.

• This eight-month prospective, observational study wasperformed, starting in April 2013, at 19 primary care veteri -nary practices. Each hospital was asked to administer thePet Wellness Report as a part of a wellness visit to 24canine and 6 feline patients with a total enrollment of 449dogs and 114 cats.

• Study outcomes that were measured included:1. Identification of new medical diagnoses 2. The degree of pet owner compliance with

veterinarian recommendations 3. Pet owner and veterinary perceptions of

satisfaction following the inclusion of the PWR 4. Economic impact to the practice

Medical Impact of the PWR• After the PWR-enhanced exam was performed, veteri nar ians

identified newly diagnosed medical conditions in 36%(162/449) of dogs and 28% (32/114) of cats. These pets wereconsidered clinically healthy at their last veterinary visit, lessthan 90 days prior. Animals that were not found healthy atthe last veterinary visit were excluded from the study.

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acknowledge that the pet owner is the lifestyleexpert of their pet. Currently, there are fewcommunication tools that allow veterinaryteams to quickly quantify the owner’s at-homeobservations. In a short examination period,time spent obtaining a history can be limited,and important clues to the pet’s well-being maybe missed. The HRA bolsters the veterinaryprovider’s understanding of patient lifestyle andpet owner observations of their pet (i.e.,through the HRA questionnaire) as well asunderlying immune and metabolic functions(i.e., when incorporating optional wellnessdiagnostics). Veterinarians can then assimilateinformation from each layer of the evaluation(i.e., HRA questionnaire, history, physical exam,and wellness diagnostics) to more quickly arriveat diagnoses and offer more patient-specificrecommendations for maintaining or improvingthat pet’s quality of life (Table 1).

Unfortunately, many pet owners (especially catowners) use veterinary services sporadically for

C ompanion animal medicine may need toshift away from the traditional reactive,illness-focused model of veterinary health

care towards a more sustainable, wellness-centered approach (Chmiel et al, 2014). Thismoves veterinarians primarily from problemsolving to problem preventing, and encouragespet owners to establish healthier lifestyle habitsfor their pets and engage with their veterinarianmore frequently and meaningfully. The industryshift emphasizes prevention, early detection ofdisease, and timely treatment intervention (i.e.,the opposite of “wait and see”). This moreproactive approach to prevention, detection,and treatment, extended throughout the pet’slifetime is the basis for the Zoetis Lifelong CareInitiative (Ackerman et al, 2013). Lifelong Careoffers a thoughtful pathway to pet, pet owner,and practice wellness. The Health Risk Assess -ment (HRA) process effectively promotes thisLifelong Care approach.

While veterinarians are experts in the medicalcare of companion animals, we should

INTRODUCTION

• Pet owner compliance was measured as the frequency thata pet owner acted on a veterinarian recommendation duringthe two-week period following the PWR. In this study,compliance with treatment recommendations for newdiagnoses averaged 48% but was widely variable betweenpractices, ranging from 14% to 100%.

Financial Impact of the PWR• Hospital records were examined two weeks after the final

PWR was completed by the last pet owner. Veterinarypractices averaged $619 in total additional revenue fromproducts or services related to treating the new medicaldiagnoses from the pets that had participated in the PWR.

• Average per-patient practice revenue derived from treatingmedical diagnoses (n = 96) within the two-week post-PWRstudy window was $126.80 for dogs and $124.29 for cats.

Veterinarian and Client Perception of the PWR• In post-clinical trial surveys of participating veterinarians (n

= 53), approximately 60% said that the PWR-enhancedexam provided superior value to the pet, veterinarian, andthe practice compared to a conventional wellness exam, andmore than 80% of these responding veterinarians said itprovided superior value to the client versus a conventionalwellness exam.

• More than half of veterinarians in post-trial surveys said thatthe PWR-enhanced wellness exam was more likely to

improve client satisfaction, generate new clinic revenue, anddetect subclinical disease compared to a conventionalroutine visit.

• 90% of pet owners (n = 288) who completed a perceptionof care survey after the PWR-enhanced exam said theywere satisfied or very satisfied with the PWR experience.More than 70% said it provided an improved quality of carewhen compared to a conventional exam, and more than80% said they would recommend the PWR to a friend.

Summary• The AAHA-recommended Pet Wellness Report (PWR) is the

first broadly available, standardized HRA service process forcompanion animal veterinary medicine. The HRA is notintended to be a stand-alone diagnostic tool; rather, it ismeant to enhance dog and cat wellness evaluations.

• The clinical trial confirmed that combining the PWR Health Risk Assessment process with a routine wellness exam can be an important contributor to the clinical and economic success of the practice and a positive factor in veterinary and pet owner perception of value.

• Information on the Pet Wellness Report can be found atwww.petwellnessreport.com and by searching Health RiskAssessment, Lifelong Care supplements, or PreferredBusiness Provider at www.aaha.org.

The Zoetis LifelongCare Initiative is theextension of aproactive health careapproach throughoutthe pet’s lifetime,providing a thoughtfulpathway to pet, petowner, and practicewellness. The HealthRisk Assessment (HRA)process effectivelypromotes this LifelongCare approach.

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acute care or vaccinations (Volk et al, 2011).Veterinary practices that emphasize preventivehealth care need to persuade clients to becomeregular consumers of veterinary care throughouttheir pets’ lifetime rather than as-needed usersfor purposes of treating disease or injury(Cavanaugh, 2013). The PWR can enhance thewellness visit, the principal tool of preventivehealth care, beyond what is normally offered incompanion animal practice today. By activelyengaging the client in the wellness visit throughthe completion of the Health Risk Assessment,the PWR process provides an oppor tunity forclient contribution and education related totheir pet’s lifestyle and for prompting additionaldialogue between veterinarian and pet owner.

Pet Wellness Report questionnaire responseshelp identify risks in several areas of pet healthor lifestyle, including cancer, heart disease,dental disease, nutrition, and safety. The PWRtechnology platform can combine these

responses with the results of basic orcomprehensive wellness laboratory screeningwhen included as part of the HRA process.Zoetis 2013 market research (n = 151) shows thatonly a small percentage (12%) of veterinarianswere recommending comprehensive laboratoryblood screening (i.e., CBC, clinical chemistry,urinalysis, T4, +/- blood or fecal parasitescreening, +/- FeLV & FIV) during routinewellness visits.

The questionnaire findings and laboratoryscreening results are used to prepare a patient-specific Pet Wellness Report (PWR) that isgiven to the client. The PWR allows theattending veterinarian to digitally incorporatepersonalized notations which communicateadditional interpretation and recommendationsrelated to the patient’s health. The pet ownercan continue to access and refer to these PWRresults and recommendations later atwww.petwellnessreport.com, improving theclarity of communication from the PWR-enhanced wellness visit. Using a collaborativeapproach involving the client and veterinarian, aPWR-enhanced exam becomes a more robustwellness service than the conventionalpreventive care visit.

Information gathering from the pet ownerduring the conventional preventive care visit isoften the more cursory, on-the-spot patienthistory, and diagnostics are usually limited tobasic parasite screening (41% of annual wellnessvisits according to data on file, Pet WellnessReport Pricing Solutions Study, 2013 Zoetis Inc.).Providing the client with a personalized, easy toread report summarizing the additional layers ofHRA evaluation increases the value ofthe exam experience for the petowner, enhances communication withthe veterinarian and may improvecompliance with treatmentrecommendations. Survey data showsthat nearly 80% of pet owners wantwritten as well as verbal post-examinstructions (AAHA, 2003), and thatwritten information is stronglycorrelated with increased adherenceto treatment instructions (AAHA, 2009).

Data demonstrate that pet owners remainwilling to spend money on their pets. However,

Conventional Wellness Exam• Patient history• Physical exam• ±Basic parasite screening

Pet Wellness Report (PWR)Enhanced Wellness Exam• Health Risk Assessment (HRA) questionnaire• Patient history• Physical exam• ±Comprehensive laboratory screening

- Hematologic panel- 25-Analyte metabolic panel- Urinalysis- T4 assay

• ±Parasite screening• Personalized risk summary report for client

Table 1.

Comparing the ConventionalWellness Exam with the

Pet Wellness Report Enhanced Wellness Exam

The pet owner can continue toaccess and refer to these resultsand recommendations later atwww.petwellnessreport.com,improving the clarity ofcommunication from the annualwellness visit.

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there is a gross disparity between pet ownerspending on pet products compared to spend -ing on veterinary care. Since 1994, domestic petindustry sales have steadily climbed, with thesales of animal-oriented products and servicesseemingly immune to the recent U.S. economicrecession (APPA Pet Industry Market Size &Ownership Statistics, U.S. Pet Industry SpendingFigures & Future Outlook, 2014). Despite thisgrowth, there has been a prolonged trend ofdeclining veterinary-patient visits and adeclining number of active veterinary clientsbeginning before the recent economic recession(Volk et al, 2011). Regular wellness visits havenever been more important in companionanimal medicine.

Attention to these market changes is finallyincreasing. New canine and feline preventivehealth care guidelines (AAHA-AVMA Task Force,2011) were developed to be used during regularwellness exams, which has increased thelikelihood of recognizing disease and otherhealth risks at an early stage. AAHA hasdeveloped Pet, Canine, and Feline LifestyleAssessment forms (AAHA Lifestyle AssessmentForms, 2014) to focus veterinary health caretoward the HRA concept through the identifica -tion of a variety of pet lifestyle issues. AAHAalso supports Partners for Healthy Pets (PHP),which was formed by numerous veteri naryindustry stakeholders to provide guidance toveterinarians on how to increase preventive care

visits for pets (www.partnersforhealthypets.org). The goal of PHP is to ensure that pets canenjoy a longer, healthier life with their petowners through the prevention and earlydetection of diseases.

The Health Risk Assessment clinical trialdescribed in this report evaluated the impact ofthe PWR from several standpoints:• Medical – ability to recognize previously

undiagnosed morbidities and empower clientcompliance with recommendations• Perception – the value of the PWR-enhanced

exam compared to the conventional wellnessexam as perceived by participatingveterinarians and pet owners• Financial – new revenue resulting from treat -

ing new health issues (two weeks post-PWR)

It is proposed that this more complete HealthRisk Assessment process will better identifymodifiable health risks and reveal subclinicalmedical conditions not uncovered in the typicalwellness exam process (Goetzel et al, 2011; Kneslet al, 2013; Lavan et al, 2014). The findings fromthis more proactive approach to wellness careare proposed to provide additional revenue-generating opportunities for the practice.Further, the pet owner–veterinary teamcollaboration and communication arising fromthis enhanced evaluation is expected to improvepet owner perception of value for the veterinarywellness exam.

INTRODUCTION

The American AnimalHospital Association(AAHA) has recom -mended the PetWellness Report byendorsing it as theonly AAHA PreferredBusiness Provider inthe Health RiskAssessment category.

MATERIALS andMETHODS

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Study Design

Nineteen companion animal practices in NewJersey, New York, and Ohio participated in

this prospective, observational clinical trialconducted from April to November, 2013. Eachpractice invited approximately 30 clients topresent a canine or feline pet for a wellnessexam augmented by the Pet Wellness Report(PWR), with a goal of enrolling 24 dogs and 6cats per practice. In order to compare theannual wellness visit with the PWR-enhancedvisit, all invited patients had received the routineannual wellness exam at the same practice 60to 90 days prior to their enrollment in the study.The maximum 90-day interval between theconventional wellness exam and the PetWellness Report enhanced exam was expectedto be short enough so pet owners couldcompare the two wellness visit approaches withminimal recall bias. Only patients that werefound to be clinically healthy at the earlier examwere included in the trial. This inclusion criterionwas to select the healthiest of the healthyanimals. Any patients found to have medicalproblems at the conventional wellness visit wereexcluded from this study. This inclusion criterionmay have produced a selection bias by reducingthe number of new health findings that couldhave been detected from the PWR-enhanced wellness visit.

Use of The Pet Wellness ReportThe PWR can be completed before or after thewellness visit, and with or without wellnessdiagnostics. The PWR-enhanced exam processin this clinical trial combined an online HRAquestionnaire completed by the pet owner withcomprehensive laboratory screening. Pet ownerscompleted the HRA questionnaire after thewellness visit and diagnostic sample collection.The laboratory analysis consisted of a completeblood count (CBC), 25-analyte metabolic panel,heartworm antigen, urinalysis, and totalthyroxine (T4) assay, with tick-borne parasitescreening as a discretionary option for dogsdepending on the veterinarian’s recommenda -tion (Table 1). Pet owner visibility to the PWRresults occurred approximately 48 hours afterthe wellness examination and could includepersonalized comments and/or recommenda -tions from the veterinarian in the report. This

online report was accessed by the pet ownerand veterinarian through a password protectedwebsite (www.petwellnessreport.com). Petowners were not charged for the PWR HRAquestionnaire, the associated blood and urinelaboratory screening, or the personalized PWRpatient report.

All clients were asked to complete a post-PWRperception of care survey, which includedquestions comparing the initial conventionalwellness exam and the subsequent PWR-enhanced wellness exam. At the conclusion ofthe trial, participating veterinarians completedtheir own perception of care survey comparingthe conventional wellness exam with theirexperiences participating in the PWR processwith their clients.

Data Mining the Medical RecordsMedical records were examined to identify thenumber and type of new (previously undiag -nosed) health conditions identified in the PWR-enhanced exams. The case veterinarian had tospecifically identify concerns, risks or medicalfindings in the medical record for their inclusionas new health conditions. New medical findingsseen by the study administrators but notidentified within the medical record by the caseveterinarian were not included as tabulatedfindings.

The total revenue generated was assessed fromthe charges recorded in the medical record thatwere incurred when pet owners agreed toveterinary recommendations. Treatmentcompliance was defined as a revenue-generating procedure agreed to by the client inresponse to a recommendation made by theattending veterinarian for any newly diagnosedcondition(s). Charges associated with thesetreatments, services or product sales performedwithin two weeks of the PWR-enhanced examswere captured for analysis. Charges thatoccurred after the post-PWR two-week windowwere not researched.

ResultsThe patient population enrolled in the study waswell distributed among age groupings (i.e., 1-4years, 4-8 years and >8 years for dogs; 1-10years and >10 years for cats), providing a goodrepresentation of juvenile, adult, and senior

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MATERIALS andMETHODS dogs and cats. None of the three canine age

groups had a population that was less than 30%of the total, and the number of cats in the twofeline age groups were closely divided innumber. Compliance with the study protocolwas very good, however 14 dogs (3%) and 7 cats(6%) received lab work without completing thePWR Health Risk Assessment questionnaire. Atotal of 473 dogs and 123 cats participated inthe study with full data sets gathered from 449dogs and 114 cats. Revenue data from resultingdiagnostic or therapeutic interventions wereobtained for 78 dogs and 15 cats. A post-trialperception of care survey was completed by 288(51.2%) of participating clients and 53 attendingveterinarians.

Medical Impact of PWR-EnhancedWellness ExamThe rate and type of new medical diagnoses fordogs and cats enrolled in the trial are shown inTable 2. Dogs had an overall rate of new

diagnoses of 36% (162/449) across 19 clinicsthat enrolled 21-26 dogs. The number of newhealth findings ranged from 10% (2/21) to 73%(16/22) across study sites. In some cases, dogshad more than one new morbidity diagnosed(i.e., 194 new health findings for 162 dogs),whereas no cat had more than one newdiagnosis per individual. New diagnoses weremore commonly found as dogs aged, with those≥8 years having a 44% incidence of new healthfindings (69/156) versus 32% (51/158) in the 4-8year age group and 31% (42/135) in the 1-4 yeargroup. An assortment of new morbidities wereidentified in canine patients that had beenconsidered clinically normal at the wellnessexam performed within the previous 60-90days. Hypothyroidism (either untreated orunder-medicated), proteinuria, urinary tractinfections, and dental conditions were amongthe most common diagnoses in all three agegroups. A positive Lyme test was the mostfrequent new diagnosis in dogs in the 1-4 year

Medical Impact:The PWR-enhancedexam revealed new (previouslyundiagnosed)medical findings in36% (162/449) ofdogs and 28%(32/114) of cats.

Table 2.

New medical diagnoses identified for canine and feline patients with the Pet Wellness Report Enhanced Wellness Exam

Incidence ofnew medical

Age block diagnoses* Most common new diagnosis (n)Canine patients (n = 449)1.0-4.0 yrs 31% (42/135) Lyme positive (9); crystalluria (7);

proteinuria (5); UTI (4); broken or retained teeth (4); hypothyroidism† (4); all others (≤3)

4.1-8.0 yrs 32% (51/158) hypothyroidism† (7); proteinuria (7); UTI (7); Lyme positive (6); dental disease (4); all others (≤4)

≥8.1 yrs 44% (69/156) hypothyroidism† (14); UTI (10); proteinuria (9); dental disease (10); renal disease (7); all others (≤6)

All ages 36% (162/449)

Feline patients (n = 114)1.0-10.0 yrs 26% (16/61) proteinuria (3); eosinophilia (3); all others (≤2)

>10.1 yrs 30% (16/53) renal disease (4); hyperthyroidism† ±hypertension (3); all others (≤ 2)

All ages 28% (32/114)*Incidence refers to the number of dogs that had new (one or more) medical diagnoses.†Either untreated or under-medicated. UTI = urinary tract infection.

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group and the fourth most common new healthfinding in the 4-8 year old group, behindhypothyroidism, proteinuria and UTI.

Overall, cats had a rate of new diagnoses of 28%(32/114) across 19 clinics that enrolled 4-7 cats.The number of new health findings in catsranged from 0% (0/6) to 66% (4/6) acrossstudy sites. The rate of a new diagnosis in eachage block averaged 26% (16/61) in the 1-10 yearblock and 30% (16/53) in the >10 year groups,respectively. No single morbidity predominatedin either feline age group (Table 2). It seemslikely that the incidence of new health findingsfor dogs and cats would continue to increase asthe time period from the last normal wellnesscheckup was extended beyond the 60-90 dayinterval in this study.

PWR-Enhanced Exam TreatmentCompliance In most cases, when new medical diagnosesoccurred, the attending veterinarian made atreatment recommendation. Treatmentcompliance was measured as the percentage ofpet owners that accepted one or more of theveterinary recommendations and agreed to payfor a recommended service and/or productwithin the two-week post-PWR service process.Between clinics, pet owner compliance withthese recommendations varied between 14%and 100%. Combined treatment compliance for

all 19 practices averaged 48% (78/161) in caninecases and 47% (15/32) in feline cases.

Financial Impact of PWR-EnhancedWellness ExamWithin the immediate two-week post-PWRperiod, total revenue derived from the servicesor products associated with newly diagnosedmorbidities for the 19 clinics averaged $619.00per clinic. The total amount spent to treat newfindings by all pet owners in the PWR clinicaltrial at a given clinic ranged from $58.50 to$2,101.93. Average revenue for all patients with anew medical diagnosis, whether treated or not(n = 193), was $60.91. Average per-patientrevenue for new health findings that weretreated (n = 96) was $126.80 for dogs and$124.29 for cats.

In many cases, the two-week study intervalbetween the PWR visit and medical record datamining was not enough time for the pet ownerto be contacted by the clinic, for the pet ownerto respond to a clinic request for a discussion,or for the clinic to schedule and execute therecommended treatment. This time limitationcut short our ability to capture the full economicbenefit that resulted from the PWR experience,thus probably resulting in an underestimation ofthe economic benefit seen in the day-to-day useof the PWR in clinical practice.

Figure 1 – Veterinarian responses on their experience with the PWR

Veterinary Perception of the PWR-Enhanced Wellness Exam

Ability to improve owner compliance

Ability to improve owner satisfaction

Ability to detect subclinical disease

Ability to generate new clinic revenue

0% 20%

Not Likely Less Likely Same More Likely Much More Likely

40% 60% 80% 100%

49.1%

34.0%

35.8%

34.8% 54.7% 7.5%

47%

60%

59%

62%

More Likely + Much More Likely

52.8% 5.7%

56.6% 3.8%

41.5% 5.7%

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MATERIALS andMETHODS

Veterinarian Perception of PWR-Enhanced Wellness Exam Veterinarians were asked eight questions abouttheir PWR experience upon completing all 30PWR-enhanced office visits (Figures 1 and 2). Atthe time of their responses, the veterinarians (n= 53) were unaware of the aggregated medical,financial and pet owner perception findings forthe clinical trial. More than half (58.5%) of theresponding veterinarians believed the PWR wasmore likely or much more likely to generate newclinic revenue. More than 60 percent believed

Figure 2 – Veterinarian responses on the value of the PWR

Veterinary Perception of the PWR-Enhanced Wellness Exam

the PWR was more likely or much more likely toimprove client satisfaction (60.4%) and detectsubclinical disease (62.2%). Almost half (47.2%)believed the PWR improved pet ownercompliance.

When asked about the value of the PWR, morethan half of the veterinarians surveyed said thatthe PWR-enhanced exam provided superiorvalue compared to the conventional wellnessexam for all stakeholders involved: pet (62.3%),pet owner (80.8%), veterinarian (57.7%), andclinic/hospital (58.5%).

Pet Owner Perception of the PWR-Enhanced Wellness ExamFigure 3 – Pet owner responses on their experience with the PWR

34.0%

15.4%

32.7% 42.3% 15.4%

35.8% 47.2% 11.3%

73.1% 7.7%

62%

81%

58%

59%

45.3% 17.0%Value to the pet

Value to the pet owner

Value to you (the veterinarian)

Value to the clinic/hospital

Not Valuable Less Valuable Same More Valuable Very Valuable

More Valuable + Very Valuable

0% 20% 40% 60% 80% 100%

Much Less Less Same More Much More

71%

71%

82%

83%

77%

More + Much More

Feels engaged with pet’s care

Improved quality of care

More likely to identify health problems

Provides a more thorough evaluation

Provided value to the pet’s health

0% 20% 40% 60% 80% 100%

28.0% 45.1% 26.2%

27.7% 40.4% 30.9%

16.9% 45.4% 36.6%

16.2% 45.5% 37.3%

21.9% 46.3% 31.1%

Clients agreed orstrongly agreed that,because of the PWR,they felt betterinformed about theirpet (86.3%) and betterable to discuss healthcare with theirveterinarian (75.7%).

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Figure 4 – Pet owner responses on the value of the PWR

Client Perception of the PWR-Enhanced Wellness ExamThe pet owners received an online link to ashort perception of care survey after receivingaccess to their completed Pet Wellness Report.The survey was completed by 51% (n = 288/570) of pet owners (Figures 3, 4, 5 and 6).Compared to the conventional wellness examexperience 60-90 days prior, the PWR-enhanced exam provided more or much morevalue to the pet’s health according to 77.4% ofclients surveyed. Clients reported that the PWRwas more or much more valuable in providingimproved quality of care (71.3%), identifyinghealth problems (81.6%), and in providing amore thorough evaluation (82.8%). Clientsagreed or strongly agreed that, because of thePWR, they felt better informed about their pet(86.3%) and better able to discuss health carewith their veterinarian (75.7%). Clients felt moreor much more engaged in their pet's health care(71.3%) and 90.5% of pet owners indicated thatthey were satisfied or very satisfied with thePWR experience (Figure 3 and 5). Finally, thelarge majority of pet owners (81.6%) wouldrecommend PWR to a friend (Figure 6).

The fact that pet owners were not charged forthe PWR questionnaire, the repeat history andphysical exam, and associated lab work mayhave influenced the pet owner assessment ofvalue (Figure 3: “more valuable to my pet’shealth”). However, responses to other questionson the pet owner perception of care survey areexpected to be less affected (Figures 3 and 4:“more thorough exam”, “feel better informed”).

Pet Owner Perception of the PWR-Enhanced Wellness Exam

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

76%

86%

Better able to discusshealthcare with veterinarian

Feels better informed

0% 20% 40% 60% 80% 100%

21.5% 44.7% 31.0%

11.6% 52.5% 33.8%

Agree + Strongly Agree

Pet Owner Perception of Care Survey“In completing the first (“standard”) office visit with the Pet Wellness Report

office visit (second visit), please indicate your level of satisfaction with the Pet Wellness Report.”

“I would recommend the Pet Wellness Report to a friend.”

0

20

40

60

80

100

160

120

140

2.1% 0.0%

7.4%

38.0%

52.5%

Coun

t

Dissatisfied Neutral Satisfied VerySatisfied

VeryDissatisfied

Figure 5 – Pet owner satisfaction with the PWR

90%of pet owners

indicate that theywere satisfied or very

satisfied with the Pet Wellness

Report experience(n=288)

Pet Owner Perception of Care SurveyFigure 6 – Pet owner satisfaction with the PWR

82%of pet owners

indicated that theyagree or strongly agree

with the statement after completing the

PWR experience(n=288)

0

20

40

60

80

100

160

120

140

2.1%0.4%

15.8%

49.6%

32.0%

Coun

t

Disagree NeitherAgree norDisagree

Agree StronglyAgree

Strongly Disagree

The PWR-enhancedexam revealed new(previously undiag -nosed) medicalfindings in 36%(162/449) of dogs and28% (32/114) of cats.

DISCUSSION

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The high incidence of new medical diagnosesarising from the PWR-enhanced exam is note -worthy because all canine and feline patientshad received a clean bill of health from thesame practice within the previous 60-90 days.Nevertheless, 36% of dogs and 28% of cats hada subsequent new morbidity diagnosed duringthe PWR process (Table 2).

New health findings in this observational studymay have been the result of:1. Newly acquired disease in the interval since

the pet was last examined 2. Existing subclinical disease at initial exam

progressing to clinical disease by PWR exam3. History or physical exam discoveries missed

or misinterpreted at the earlier visit 4. New information obtained through the Health

Risk Assessmenta. PWR HRA questionnaire b. PWR comprehensive wellness diagnostic

screening

Dogs in the older age groups had an incre -mentally higher incidence of new diagnoses. Forexample, dogs older than 8 years of age had a44% incidence in new medical findings,compared to an incidence of 31% in dogs 1-4years of age. Multiple cases of positive Lymeresults, hypothyroidism, and abnormalities onurinalysis and/or oral examination wererecorded. Without testing, many morbiditiesmay have remained subclinical (e.g., proteinuria,crystalluria, hypothyroidism) or may haveeventually led to clinical disease. In cats, theincidence of new diagnoses between the twoage blocks was very similar: 1-10 year (26%) and>10 year (30%).

This study reported new health findingsidentified by clinicians in the patient’s medicalrecord. It is important to note that nearly all ofthese findings reported by participatingveterinarians were identified from the PWRcomprehensive laboratory analysis and/orsubsequent physical exam. The case veterinar -ians in this study rarely used the medical recordto record new or potentially new health findingsidentified in the HRA question naire. During datacollection, the study administrators could oftensee pet owner comments in the PWR HRA that

suggested early warning signs for disease andpotentially modifiable lifestyle risks. Forexample, 23% of cat owners noted one or moresigns of oral disease (Addendum A). This is aperfect opportunity to discuss optimal oralhealth and possibly additional dental care.Twelve percent of cat owners noted that theirpets demonstrated stiffness or lameness athome. Cats are less likely to show any signs ofweakness at the veterinary office visit and thismay be the only clue that the pet is developingarthritis. Similarly, 39% of dog owners indicatedthat they were late or completely missed dosesof heartworm medication. This is an educationmoment to discuss heartworm disease andreview the pet owners’ purchase history ofheartworm prophylaxis medications. About 1/3of dog owners indicated that their dog had oneor more signs of skin disease, which could befurther investigated with a skin scraping, allergytest or fungal exam. Any such findings notadded to the patient medical record by the caseveterinarians were not included in the study’sanalytics.

To our knowledge, veterinary medical educationdoes not currently include training on theutilization and interpretation of HRA question -naires in clinical practice. Furthermore, Zoetisdid not provide any training for the veterinar -ians in this study on how to best utilize the PetWellness Report Health Risk Assessment (PWRHRA). This unfamiliarity with the questionnaireaspect of the Health Risk Assessment processmay have biased the study veterinarians toemphasize the findings from wellness diag -nostics and the subsequent physical exam, whilegiving less attention to the responses in theHRA questionnaire.

The value of an HRA questionnaire in thepatient health care evaluation process has beenwell documented in human medicine (Goetzel et al, 2011) and is now being recognized inveterinary medicine. The veterinary health carevalue has been demonstrated in two retro -spective studies (Knesl et al, 2013; Lavan et al,2014) utilizing the Pet Wellness Report. Bothstudies provide interesting insights on the use ofa Health Risk Assessment questionnaire duringannual wellness visits for dogs and cats. Datafrom routine wellness exams were analyzed for7,827 canine cases and 1,197 feline cases at 264

Medical Impact of PWR-EnhancedWellness Exam

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Table 3.

A Comparison of Pet Owner Responses to Questions in the Pet Wellness Report for Dogs and Cats.

PWR Question with YES response Dog1 Cat2

Is your pet overweight?18% 22%

(1337/7333) (264/1197)

Does your pet have stiffness/lameness?27% 11%

(2083/7823) (135/1197)

Does your pet have signs of oral disease?30% 28%

(2315/7827) (331/1197)

Does your pet have contact with other 67% 34% dogs (canine) or go outside (feline)? (329/494) (410/1197)

Do you give your pet medications 89% 33%to prevent heartworm disease? (6939/7827) (390/1191)

primary care U.S. veterinary practices over a 5.5-year period. In these patients the PWR HRAquestionnaire identified health concerns in 77%of dogs and 68% of cats from several riskassessment categories: cancer, heart disease,dental disease, nutrition, and safety. Thesepotential health risks were recognized by petowners with pets of all ages. Lifestyle concernswere self-reported in 42.5% of cats 0-3 years ofage, compared to 82.4% of cats 13+ years of age(Lavan et al, 2014). In dogs 0-3 years of age,60.7% had self-reported lifestyle concernscompared to 93.7% in the 13+ year age group(Knesl et al, 2013).

Data from the retrospective canine study usingthe PWR (Knesl et al, 2013) demonstrated thekinds of actionable information that veteri -narians are being given by pet owners. Forexample, 29% of dog owners self-reported thattheir dogs were off schedule or had missedheartworm preventive dosing, 27% reportedtheir dogs having signs of stiffness or lameness,and 30% reported noticing warning signs of oraldisease (Table 3). Similar actionable informationwas provided by cat owners in the retrospectivefeline study (Lavan et al, 2014). Through thefeline HRA questionnaire, 10% of cat ownersreported their cat having changes in litter boxhabits, 28% noticed warning signs of oraldisease, and 27% noticed hairballs or chronicvomiting. Table 3 highlights examples of HRAquestionnaire findings from these retrospectivestudies.

The value of the HRA questionnaire stems fromthe important lifestyle and observationalinformation relevant to the health of the pet andfamily. The findings from both retrospectivestudies suggest that all pets can benefit fromthe additional health evaluation provided by thePWR HRA questionnaire, regardless of their age.

The HRA questionnaire offers manyopportunities to discover modifiable lifestylehabits and create opportunities for veterinaryintervention to ensure that the healthy-lookingpatient truly is and remains healthy. Additionaltime and practice with the HRA process,especially how to use the information gleanedfrom the questionnaire, can potentially yieldeven more medical findings, provide an evengreater financial impact to the practice, and

create even higher perceptions of value for petowners and veterinarians.

PWR-Enhanced Exam TreatmentComplianceAs might be expected, participating practicesreported a wide difference in the rate of clientcompliance (i.e., 14% to 100%) with treatmentrecommendations for newly diagnosed medicalconditions. This disparity in range may havebeen influenced by pet owner–veterinarianrelationship dynamics including:1. the client-perceived trust in the case

veterinarian 2. the client’s ability to financially afford

follow-up services, and 3. the veterinarian’s ability to explain the diag -

nosis and/or translate the importance of themedical recommendation to the pet owner.

The measurement of compliance with veterinaryrecommendations was negatively influenced bythe narrow time period within which compliancewas measured in this prospective study. Thetwo-week cutoff for collecting data at the endof the trial likely resulted in understating theaverage per-practice treatment compliance rateand associated revenue. In future studies, aperiod of eight weeks (or longer) might be amore realistic interval in which to assess petowner compliance for veterinary recommenda -tions resulting from newly found medical issues.

1Knesl et at, 2013 2Lavan et al, 2014

DISCUSSION

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Approximately half of the clients in this PWRclinical trial accepted veterinary recommenda -tions for treating a newly diagnosed condition(i.e., 48% for dogs; 47% for cats). This should beconsidered a favorable response rate fortreating new morbidities compared to what hasbeen previously reported in other veterinarycompliance studies (AAHA, 2003; AAHA, 2009).A large-scale survey of companion animalpractices found that compliance varies byprocedure (AAHA, 2003). Compliance tends tobe high for intermittent preventive or diagnosticprocedures such as vaccinations (87%) andheartworm testing (83%) but much lower forrecommendations related to treating a chroniccondition such as dental care or therapeuticdiets (35% and 21%, respectively). Writtenrecommendations have been shown to improvecompliance (AAHA, 2009). Providing the clientwith easy-to-read, patient-specific health carecontent such as that created by the PetWellness Report would be expected to remindand encourage clients to consider theveterinarian’s treatment recommendations.

Financial Impact of PWR-EnhancedWellness ExamNew clinic income generated by the Pet WellnessReport represents an otherwise unrealized sourceof practice revenue. This revenue was notgenerated during the conventional wellness visitthat the pet had received 60-90 days prior to thePWR-enhanced wellness exam. In applying thePWR process to 24 dogs and 6 cats, each clinicgenerated an average of $619.00 (range $59.00 -$2,102) in treating new health findings. This is anaverage of $126.80 for dogs and $124.29 for catsthat had a new medical diagnosis that was treated.Some pet owners may have scheduled and/or paidfor follow-up diagnostic and/or treatmentprocedures beyond the two-week window of thestudy. The estimation of clinic revenue may beincompletely captured by this limitation in thefollow-up.

Note that the PWR questionnaire and compre -hensive lab work were offered complementary topet owners in this clinical trial. Thus, any directrevenue potential of selling the questionnaire orlab work is not contributing to the financial impactfor practices participating in this study. In addition,

improved utilization of questionnaire responses bythe veterinarian may identify additional healthissues of concern to the pet owner, with anopportunity to affect patient health outcomes andimpact incremental clinic revenue.

Veterinarian Perception of Care Impactof PWR-Enhanced Wellness ExamIn the post-trial survey, more than half ofparticipating veterinarians indicated that thePWR-enhanced exam was superior to aconventional exam service in three areas thatare central to the conduct of clinical practice:client satisfaction, generating new revenue, anddetection of subclinical disease (Figure 1). Thefavorable impact on client perception of care asjudged by veterinarians is complemented by thepet owners belief that they were better able todiscuss health care with their veterinarian(Figure 4). Without awareness to aggregatedtrial results and pet owner responses, 47% ofveterinarians expected the PWR to improveclient compliance (Figure 1). Coincidentally thisresult is consistent with the percentage ofclients who complied with their veterinarians’treatment recommendations for newlydiagnosed conditions (i.e., 48% for dogs; 47%for cats) in this study.

In their value assessments (Figure 2), veterinar -ians overwhelmingly (81%) said that the PWRprovided more or much more value to theirclients compared to a conventional exam. Thisoutcome was especially encouraging becausethe principal objective of the AAHA-AVMApreventive health care guidelines is to make thewellness exam the principal focus of primarycompanion animal practice (AAHA-AVMA, 2011),which now relies heavily on acute care services.

While the PWR leverages technology topromote client centricity and preventive care, italso includes an interactive veterinary-facinganalytics tool. The veterinary team can seeevery patient’s PWR HRA questionnaire andPWR diagnostic test results for analysis. As well,the veterinary team can:1. communicate with pet owners through the

analytics portion of the tool2. group and explore patients with similar health

risks or analyte abnormalities

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3. identify widespread health carecommunication gaps within the practice suchas with heartworm prevention compliance

The analytics tool can also be valuable when aclinic develops a periodic (e.g., monthly orseasonal) wellness program and wants toidentify patients that could benefit from aparticular medical focus such as dental care orweight management.

Client Perception of Care Impact ofPWR-Enhanced Wellness ExamThe American Animal Hospital Associationanalyzed veterinary hospital financial perform -ance between 2011 and 2012 (Cavanaugh, 2013).In this State of the Industry report AAHArecognized that a select group of veterinaryhospitals experienced an exceptional level ofgrowth despite a depressed overall U.S.economy. While the average growth in revenuewas 5.6% for more than 4,000 U.S. veterinaryhospitals, approximately 25% of study hospitalsexceeded 10% and some even >20% growth(labeled as Growers). Five major factors weredetermined to be critical for driving Growersuccess including: • Strengthening client relationships (i.e., client-

centricity) • Driving regular preventive care visits • Leveraging technology in the practice to

embed client centricity and preventive care • Setting goals and measuring business

progress • Communicating the value of higher standards

The single most important factor differentiatingthese Growers from the Decliners (i.e., thosewith negative revenue growth) was the clientrelationship focus. This client-centricity wasdetermined to be the first key to growth.Practices that focused on engaging clients weremore than twice as likely to be Growers asDecliners. Believing their growth wasindependent of the economy, these Growerveterinary teams were able to communicate thevalue of their services in language clients couldunderstand.

Grower success habits align well with an HRAprocess like the PWR, which reinforces all five

drivers of success. By design, the PWR canstrengthen client relationships by engaging andeducating the pet owner through a sharedprocess of discovery.

In this PWR clinical trial, the clients confirmedthis enhanced perception of value with 71%feeling more or much more engaged with theirpet’s care when the PWR was included with theexam (Figure 3). Three out of four (76%) eitheragreed or strongly agreed that they were betterable to discuss their pet’s health care with theirveterinarian (Figure 4) and 86% agreed orstrongly agreed that they felt better informedwith the Pet Wellness Report (Figure 4). Thesepet owners perceived superior engagement andeducational value when the HRA process wasincluded in the wellness care visit.

PWR study findings demonstrated furtherevidence for this enhanced value with the PWRexperience (Figures 3, 4, 5 and 6): • 71% of pet owners felt it improved the quality

of care their pet received• 82% felt the veterinarian was more or much

more likely to identify health problems• 83% felt the veterinarian was able to provide a

more or much more thorough evaluation oftheir pet

• 77% felt it brought value to their pet’s health,when compared with an annual wellness visitthat did not include a health risk assessment,comprehensive lab work and a pet-specificwritten health report.

Maybe most revealing, 82% said they wouldrecommend the PWR to a friend (Figure 6). Ifclients see more value in the wellness exam, itmay motivate them to become more regularconsumers of preventive pet health care for thelifetime of their pet.

Practices that focusedon engaging clientswere more than twiceas likely to be Growersas Decliners.

By design, the PWRcan strengthen clientrelationships byengaging andeducating the petowner through ashared process ofdiscovery.

SUMMARY

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SummaryThe PWR can be used to engage, educate, andempower the pet owner to take a morecollaborative and proactive role in supportingthe wellness care of their pet. It can be a forcemultiplier in preventive pet health care becauseit offers several enhancements and distinctadvantages over a conventional wellness exam(Table 1).

• The PWR collects clinically relevant clientinput in the form of a standardizedquestionnaire, an assessment tool that goesbeyond what a typical patient history providesin the usual amount of time available for acanine or feline wellness exam.

• The PWR can also include comprehensivelaboratory screening that contains severaltests often omitted from a basic wellnessdiagnostic workup.

• The client receives an easy-to-read,customized Health Risk Assessment report for their pet.

In this clinical trial, the PWR-enhanced examrevealed new diagnostic findings in more than athird of patients that were found to be clinicallynormal by the same practice within thepreceding three months, generating approxi -mately $125 per patient in new product andservice revenue for treating new medicaldiagnoses. In the survey of trial participants,both veterinarians and clients were unambigu -ous in affirming the benefits and value of thePWR. The trial confirmed that the PWR can be

an important contributor to the clinical andeconomic success of the practice and a positivefactor in client perception of value.

This link between good medicine and goodbusiness was emphasized by Dr. MichaelCavanaugh in the March 2013, American AnimalHospital Association (AAHA) State of theIndustry presentation. Cavanaugh remarked,“Growing revenue is a sign of creating valuethrough the delivery of high quality patient care.And when a practice grows revenue, it is able toinvest in itself, which in turn leads to improvedpatient care” (Cavanaugh, 2013). The AmericanAnimal Hospital Association has recommendedthe Pet Wellness Report by endorsing it as theonly AAHA Preferred Business Provider in theHealth Risk Assessment category.

The PWR HRA process is a service tool that iswell-suited to promote the beliefs and habitsnecessary for veterinarians with a wellness focusto consistently excel within the current economyand with modern-day pet owner valueexpectations. We propose that repeating thePWR HRA process every 6-12 months, wouldprovide more Lifelong Care (Ackerman et al,2013) opportunities for the pet, pet owner, and practice.

The PWR can beused to engage,educate, andempower the petowner to take amore collaborativeand proactive role insupporting thewellness care oftheir pet.

REFERENCES Ackerman L, Ball E, Brunt J, et al. The ZoetisLifelong Care Initiative: Putting the promise intopractice. North American Veterinary Conference(NAVC) Clinician’s Brief. http://www.cliniciansbrief.com/article/zoetis-lifelong-care-initiative-putting-promise-practice. PublishedJuly 2013. Accessed February 25, 2015.

American Animal Hospital Association. The pathto high-quality care: Practical tips for improvingcompliance. Lakewood, CO: American AnimalHospital Association; 2003.

American Animal Hospital Association.Compliance: Taking quality care to the next level.Lakewood, CO: American Animal HospitalAssociation; 2009.

American Animal Hospital Association-AmericanVeterinary Medical Association PreventiveHealthcare Guidelines Task Force. Developmentof new canine and feline preventive healthcareguidelines designed to improve pet health. J AmAnim Hosp Assoc 2011;47:306-311.

AAHA Lifestyle Assessment Forms (pet, canine,feline). American Animal Hospital Association(AAHA) Web site. https://www.aahanet.org/Library/Flea_and_Tick.aspx. PublishedDecember 12, 2013. Accessed February 25, 2015.

APPA Pet Industry Market Size & OwnershipStatistics, U.S. Pet Industry Spending Figures &Future Outlook. http://www.americanpetproducts.org/press_industrytrends.asp.Accessed February 25, 2015.

Cavanaugh, M. AAHA State of the VeterinaryProfession. https://www.aaha.org/public_documents/professional/resources/aaha_state_of_the_industry_2013_white_paper.pdf.Published March 2013. Accessed February 25,2015.

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Chmiel D, Cavanaugh M, McFarland JM, Gannon T. Wellness: A Necessary Focus. AAHA Web Conference Dec. 8-21, 2014.https://www.aaha.org/professional/education/web_conference.aspx?key=51B53CA9-82D7-4A63-8D1B-C88CE3EF6CAD#gsc.tab=0.Accessed Dec 10, 2014.

Goetzel RZ, Staely P, Ogden L, et al. AFramework for Patient-Centered Health RiskAssessments: Providing Health Promotion andDisease Prevention Services to MedicareBeneficiaries. Atlanta, GA: US Department ofHealth and Human Services, Centers for DiseaseControl and Prevention; 2011.http://www.cdc.gov/policy/ohsc/hra/. AccessedFebruary 25, 2015.

Knesl O, Lavan R, Horter D, et al. Pet WellnessReport. Canine Health Risk Assessment - AReview of 7,827 Cases. Technical Bulletin, Zoetis.May, 2013.

Lavan R, Knesl O, Holzhauer J, et al. PetWellness Report. A Feline Health Risk Assess -ment (A review of 1,197 cases). TechnicalBulletin, Zoetis. March, 2014.

Volk JO, Felsted KE, Thomas JG, et al. Executivesummary of the Bayer veterinary care usagestudy. J Am Vet Med Assoc 2011;238:1275-1282.

Data on file, Pet Wellness Report PricingSolutions Pricing Study, 2013 Zoetis Inc.

Acknowledgments

The authors acknowledge the contribution ofMark Dana of Scientific Communications, LLC, in the preparation of this report. Additionalcontri bution acknowledgments include: Deb Amodie of Zoetis Outcomes Research fordata analysis, Dr. Amy Pavlock, consultant asstudy co-director, and Dr. Heather Loenser,consultant editor.

ADDENDUM A

All trademarks are the property of Zoetis Inc., its affiliates and/or its licensors. All other trademarks are the property of their respective owners.PWR-00079 ©2015 Zoetis Inc. All rights reserved. March 2015.

Pet Owner Responses to Selected Health Risk Assessment Questions in the Pet Wellness Report Clinical Trial

As a clinician, what would you do with this pet lifestyle and observational information provided by the pet owner?

CANINE Questions from the PWR Pet owners that said Percentage“YES’ to question

Dog shows one or more heart disease warning signs 34/465 7%

Pet owner has been late or missed doses of heartworm medication 180/465 39%

Dog has one or more signs of oral disease 133/465 29%

Dog demonstrates one or more signs of arthritis 79/465 17%

Dog demonstrates one or more skin signs of allergic disease 142/465 31%

FELINE Questions from the PWR Pet owners that said Percentage“YES” to question

Cat regularly spends time outside 24/124 19%

Does your cat ever go outside? 39/124 31%

Cat shows one or more heart disease warning signs 11/124 9%

Cat shows one or more oral disease warning signs 28/124 23%

Cat demonstrates one or more signs of arthritis 15/124 12%

Cat demonstrates one or more skin signs of allergic disease 11/124 9%

Pet Owner is concerned about fleas/ticks infesting their cat (31/124) 25%

Pet Owner currently uses flea/tick medications on their cat (59/124) 48%