Risk Assessment
Nan Boss, DVM
Best Friends Veterinary Center, Grafton, WI, USA
2.7.1 Summary
None of us has unlimited time and money to discuss or investigate every possible disease for every patient. When making a personalized care plan for any dog or cat, you will need to prioritize. When educating a client or screening for diseases, spend more time and effort on those problems that are most likely to be found and/or that have the highest risk for harm. When diagnosing and treating diseases, the same holds true – rule in or out what is common first. Assessing risk accurately and using that assessment to inform medical care for your patients is a skill that can be developed and improved.
2.7.2 Terms Defined
Risk: An exposure to danger, harm or loss.
Risk Assessment: A process for evaluating potential risk.
Wellness care is all about reducing risk. We vaccinate to reduce the risk for contagious diseases, we prescribe heartworm preventives to reduce the risk for parasites, and so on.
Some health risks are nearly universal, such as exposure to contagious diseases and parasites. Others are specific to a pet's species, sex, age, location (city versus rural as well as region of the country), lifestyle or breed. All of these factors must be taken into account when developing a healthcare plan for a particular patient, whether in sickness or in health.
In ill patients, our risk analysis helps to guide us toward the most likely diagnoses so that we can diagnose and treat the pet appropriately. For example, if a Boston terrier is presented for vomiting, you might consider the usual rule‐outs such as foreign body, infectious or metabolic causes, or garbage ingestion. In this scenario, you would also want to consider pyloric stenosis, a reported genetic problem in the Boston terrier breed.
Risk assessment also guides our client education efforts. You wouldn't spend much time educating clients about a disease you only see a few times a year, or one a particular patient is unlikely to ever encounter. You'd spend those valuable few minutes you have with clients at wellness visits to talk about common things. You would want to incorporate the most common topics into a broad educational plan.
A simple way to do this is to choose one or two topics to focus on per visit, so you can educate every client about them. Examples would be dental care or obesity. Once that broader, more general topic has been covered, you can choose a risk or two to go over that is specific for the individual client or pet. What is likely to harm the patient and how might we prevent or treat the problem?
2.7.3 Determining Risk
There are many factors that can be used to determine and prioritize risk, so that you can offer specific laboratory tests or discuss the most important topics with your client.
2.7.4 How Common Is It?
In other words, what is the likely prevalence of each risk?
1 Most common
2 Somewhat common
3 Not very common
Sometimes this is easy to determine, but what is statistically likely in one patient may be uncommon in another. Common causes of death or injury in an indoor and an outdoor cat, for example, are completely different. You need to have a signalment, history and background information on a patient, as well as exam findings, to judge risk accurately. The answers to these questions will often determine how likely certain diseases are, what level of understanding the pet's guardian has about care for the pet, and in what direction you need to steer your healthcare plan.
When did the owner acquire the pet and from whom?
Where does the pet go and what does it do?
What does it eat and how much?
What type of care does the pet get at home? Does the owner brush its teeth? Clean its ears? Administer preventive medications regularly and on time?
Some diseases are high risk for a great many dogs and cats. Universal or high‐risk conditions for most pets would include:
dental disease – 80% of pets over age 3 years
obesity – over 50% and climbing every year
risk due to age – a small percentage of young apparently healthy patients will have a disease diagnosed on screening bloodwork whereas a significantly larger percentage of those of senior age will do so. Risks for cancer, heart disease, endocrine disorders, and metabolic problems increase with time. Furthermore, almost all pets will eventually develop arthritis if they live long enough.
With species and breed come other lists of disorders that need to be ranked as common or uncommon, including genetically related diseases. For example, the risk for cardiac issues in a Cavalier King Charles spaniel is virtually 100% if they live long enough, and gastric dilation‐volvulus (GDV) risk is significantly higher in Great Danes than shih tzus.
Moderate‐risk conditions would include orthopedic disorders such as cranial cruciate ligament disease, hip dysplasia or medial patellar luxation, and many ear, eye or skin problems, among others. The actual amount of risk will vary greatly from patient to patient, depending on age, breed, lifestyle, and many other factors. Diabetes mellitus, for example, is a high‐risk disease in an obese cat eating a high‐carbohydrate diet but a lower risk in a normal‐weight cat eating a low‐carb diet.
Low‐risk conditions include many rare genetic disorders or cancers that we barely even consider when diagnosing or screening for diseases. Yet, for an individual patient the rare condition may turn out to be pertinent and worth considering or talking about. Uncommon in a Labrador retriever may be common in a toy poodle or vice versa. A disease uncommon in your part of the country may be much more likely if your patient was recently living or traveling somewhere else. There is no list of common or uncommon conditions that applies to everyone (see Recommended Reading for tools that can be useful in determining how common risks are for particular patients).
When teaching clients about pet healthcare or offering screening tests, another set of criteria comes into play.
2.7.5 How Serious Is the Problem?
The second way to prioritize risk is by seriousness of problem – a higher risk for death or illness.
1 Diseases and problems that could be fatal.
2 Diseases or problems which could cause pain, suffering or chronic damage.
