Feline Quality of Life
Jacky Reid BVMS PhD DVA DipECVAA MRCVS
Professor of Veterinary Anaesthesia

Agenda• The importance of measurement• What is quality of life?
• The challenges• Producing a scientifically robust instrument• Examples

“I often say that when you can measure what you are
speaking about, and express it in numbers, you know
something about it; but when you cannot measure it,when you cannot express it in numbers, your knowledge
is of a meagre and unsatisfactory kind”
PLA, vol. 1, Electrical Units of Measurement, 1883

Lord Kelvin (1824-1907)

Measurement is the key to understanding‘…people with chronic pain reported that most if not all
aspects of their lives are significantly affected bychronic pain, particularly enjoyment of life in general,
emotional well-being, fatigue, weakness, and sleeprelated problems…’
Turk et al (2008) Pain, 137 (2008) 276-285

Measuring QOL has become a major focus in the measurement of chronic pain
in people

‘Quality of life is the subjective evaluation by the individual of its circumstances and theextent to which these meet its expectations, which results in an affective (emotional)
response to those circumstances’Wiseman-Orr et al., 2004
Health – related quality of life (HRQL) is concerned with those aspects of QOL that change asa result of ill health and the treatment of disease‘There is no fundamental difference between man and thehigher animals in their mental faculties .... animals, like man,
manifestly feel pleasure and pain, happiness, and misery’
DarwinNon – verbal behaviour is a form of self-report
Anand & Craig, 1996

This Photo by Unknown Authors islicensed under CC BY-NC-ND

Owner reported behavioural changes associated with chronic and painfulorthopaedic conditions in dogs & catsOwner reported behavioural changes associated with chronicand painful orthopaedic conditions in dogs
> 50% of dog
ownersActivity
Mobility
Agility
Daytime sleeping/rest
Atittude/demeanor
Stamina
Progressive change
Playfulness
Pain vocalising
Facial expression
Consistency
Sociability family members
Keeness to exercise
PostureDrinking

> 30%

< 25%

Activity pattern *Restlessness
Compulsive behaviour
Sociability non familyNight-time sleeping *Animal interactions
Scent marking
Attention seeking
Grooming *CuriosityAggression
Anxiety/fearfulness
Obedience
Weight change
Excitability
Specific toileting
AppetiteInterest in food/appetite
PantingPurring/unusual vocalisation
Clinginess

FDA Guidance of Industry: Patient Reported
Outcome Measures - on the subject of non-verbal
populations‘We discourage proxy-reported outcome
measures for this population (i.e., reports bysomeone who is not the patient responding
as if that person were the patient). For
patients who cannot respond for themselves(e.g., infant patients), we encourageobserver reports that include only those
events or behaviors that can be observed’Whenever we ask a question we risk a biased response• Try to choose the ‘right’ answer• Please the vet• Minimises guilt• Fear of vet suggesting euthanasia over treatment• Excuse for euthanasia

Minimise respondent bias

Scientifically robust measurement scales – key properties
1. Validity:• Content
Items cover all aspects
Established through methodology
Assessed by experts• Criterion
Comparison with ‘gold standard’• Construct - Series of tests
Factor analysis – statistical analysis – groups related items –domains/factors - factor structureFormulate & test hypotheses relating to the construct – ‘known
groups’2. Reliability: ability of a scale to give repeatable results
Inter-observer, intra-observer (test - retest)
3. Responsiveness: ability to measure change when change occurs

Health care - ability of a scale to measure a clinically significant
change over time
Interpretable

Psychometric approach to instrument design
Phase 1
Identify pool of items (questions) from respondents
Phase 2a) Select suitable itemsb) Expert validationc) Incorporate items into instrument
layout, response options, instructions, delivery
Phase 3a) Determine scoring systemb) Field test to evaluate psychometric properties
validity, reliability & responsiveness1. Noble CE, Wiseman-Orr LM, Scott ME, Nolan AM, Reid J. Development, initial validation andreliability testing of a web-based, generic feline health-related quality-of-life instrument.
Journal of feline medicine and surgery. 2019 Feb;21(2):84-94.
2. Streiner DN, Norman GR, Cairney J. Health measurement scales: a practical guide to theirdevelopment and use. Aust NZJ Public Health. 2016.

Pre - testThis Photo by Unknown Author is licensed
under CC BY-NC-ND

Measuring health – related quality of life
HRQL instruments• Structured questionnaires for owner completion with formal scoring methodology• Single item score• Profile of scores• Generic• Disease-specificGeneric
Measure the impact of anything that affects QOL• Chronic pain
• Chronic disease• Lifestyle• Wide application• Only option if more than one condition exists

Disease – specific• Restricted application• More sensitive?

40/41 cats had 1-7
co-morbidities

Disease specific HRQL tools
Rush et al., Cardiacdisease
J Vet Cardiol. 2015;17(1): S341-8

Noli et al., skindisease Vet
Dermatology 2016;
27: 247-258

Benito et al.,degenerative joint
disease. J Feline MedSurg. 2012; 14(12):863-70.

Lynch et al., Cancer. Vet
Comp Oncol. 2011;9(3): 172-82

Freeman et al., cardiac
disease. J Am Vet Med
Assoc 2012; 240: 1188–1193.

Niessen et al., Diabetes
mellitus. J Vet Intern
Med. 2010; 24(5):1098-105

Validity?
Reliability?
Responsiveness?
Interpretability?

Generic HRQL instruments for the cat
Instrument

Items

Domains

Validation

Key informants

Reference

Cat HEalth & Wellbeing(CHEW)

33

8 – mobility, emotion,energy, engagement,eyes, coat, appetiteand fitness

Not in sick cats

Owners whose catswere healthy
according to them

Freeman et al.,Journal of Feline
Medicine and Surgery
18, 689–701.

Feline QOL Tool16

2 – healthy behaviours& clinical signs

Not in sick cats

Owners whose catswere healthy
according to them

Tatlock et al., The
Veterinary Journal.
2017 Oct 1;228:22-32.

General Health QOL
Measure16

4 - general health,eating, behavior andmanagement

Cats with CKD only

Owners of young catsthat were healthyaccording to theowner & vetassessment for oldhealthy cats

Bijsmans et al., Vet
Intern Med
2016;30:183–191

VetMetrica

20

3 – vitality, comfort,
emotional wellbeing(EWB)

Healthy & sick cats

Vet reported healthstatus – healthy & sickcats

Noble et al.,. Journalof feline medicine andsurgery. 2019
Feb;21(2):84-94.

Measures on a continuum

Functional limitation
Holistic - measures how the animal feels

Causal variables

Indicator variables
Happy or
Depressed

Environment

Doing the things
it normally does

Nutrition

Quality of Life

So how do wemeasure ananimal’s feelings?

Socialrelationships

Active orlethargic

Playful orstiff

Health status

This Photo by Unknown Author
is licensed under CC BY-NC-ND

• Generic HRQL instrument delivered online – computer, tablet or phone• Structured questionnaire completed by the owner in ~ 5min• 20 questions for the owner• Owner scores each question on a 0 – 6 scale• Instantaneous computation of a profile of scores in Vitality, Comfort and EWB• Instantaneous reporting to the vet (and owner)• Measures emotional as well as physical healthHow it works in practicehttps://vimeo.com/257478523Alert

R & D database

Host server• Automatically generates profileof scores via establishedalgorithm

Pet owner• Completes questionnaire
for pet on-line

Vitality

Vet in practice
Comfort

Owner output

Emotional
wellbeing

Host server
Logs Pet owner into system• Owner demographic details• Pet details• Frequency of questionnaires(e-mail reminders)• Automatic generation of e-mail• Login details• Secure password

So does it possess the key
properties?
Is it Valid, Reliable, andResponsive to clinicalchange?

Cats that are healthy will have higher HRQL scores than those that are sick• Plots of scores for threedomains of HRQL in 36
healthy cats and 58 sickcats• Vitality, comfort andemotional wellbeing

The HRQL profile of catswill decrease as thenumber of co-morbidities
increase
The Pearson Correlation
coefficients were -0.64, -0.63
and -0.50 for Vitality, comfort andEWB respectively.

Reliability – Intrarater – test retest• 48 owners of healthycats• 2 assessments 14 daysapart
• Intra class correlation(ICC)• Vitality 0.64
• Comfort 0.72
• EWB 0.85

This Photo by Unknown Author is licensed under CC BY-NC-ND

Interpretability
Cat with a common chronic condition undergoing treatment• 0 – 6 transformed
to 0 – 100• 50 = average healthycat.
• 44.8 is the threshold
above which 70% ofhealthy cats will score

Minimum Important Difference (MID)…… the smallest difference in score in the domain of interest which
patients perceive as beneficial and which would mandate, in theabsence of troublesome side effects and excessive cost, a change in thepatient’s management

MIDVitality = 5
Comfort = 7.5
EWB = 5

Minimum Important Difference

MIDVitality = 5
Comfort = 7.5
EWB = 5

Responsiveness••••21 obese cats on a weight loss programme
5 assessments
Clinically significant improvement
in all 3 domains over time

Build a body of evidence supporting its validity in a variety of
populations and circumstances.

Cats with mild OA
will have higher
HRQL scores thanthose withmoderate/severe
diseaseApplications in practice• Routine monitoring of health status• Allows continuous assessment over time
• Measures health improvement or decline• Alerts - early warning system• Gives owner confidence between visits• Makes the owner a partner in their cat’s healthcare• Clinical monitoring• Efficacy of treatment• Obesity, OA, CKD• Identification of humane endpoints

This Photo by Unknown Author islicensed under CC BY-SA

End of life decision making

2/1/18

16/1/18

Latest assessment (27 – March – 2018)

30/1/18

13/2/18

27/2/18

13/3/18

27/3/18

Thank you ………
Andrea Nolan
Marian Scott
Lesley Wiseman – Orr
Cory Noble

All vets & owners who have contributed to the development ofthe VetMetrica HRQL instrument
Dr Barr Hadar, Ontario Veterinary College, University of Guelph

Feeling no pain!