Heartworm prevention: Clients can’t comply if they don’t know that they shouldWhile we may feel like we’ve talked about heartworm disease over and over again, we must keep educating clients about how to protect their pets. September 5, 2019 By Charles Johnson, DVM, MBA, and Karen Padgett, DVMCanin heartworm is a devastating disease, but it is also preventable. So why are so many dog owners choosing to leave their pets unprotected? If you think clients are making a conscious choice against using a heartworm preventative, think again. They’re also not tired of hearing about the disease. In fact, when asked, many of them say they do not even remember discussing it with their veterinarian at their last visit to the clinic. Lack of compliance isn’t the only factor leading to the spread of canine heartworm disease; however, it is a consideration veterinarians and their staff can mitigate. And new research seems to support that. In a recent study,1 dog owners shared their knowledge of heartworm disease and the action they take to prevent it. The results were surprising. The number one takeaway is that dog owners aren’t giving preventatives consistently because they often don’t know they should. Or they think they are providing heartworm protection when they are only fighting against external parasites. This means the number of dogs unprotected against the disease is higher than many believe. The results also revealed owners fall into four distinct categories based on usage.2 Three of those categories are no surprise to veterinarians: 25 percent are consistent users—dogs receive eight to 12 doses of prevention in a year;3 18 percent are inconsistent users—dogs receive one to eight doses per year; and 30 percent are active nonusers—dogs whose owners are actively choosing not to provide heartworm prevention. An autopsied heart shows the devastating consequence of not administering a heartworm preventative to dogs. However, 27 percent of respondents fall into a fourth group you may have likely never considered. The study refers to them as confused nonusers. These are well-meaning pet owners who think they are giving their dog heartworm prevention, but are, in fact, only providing flea and/or tick protection. This segment of pets has no heartworm protection at all. From your clients’ perspectives, 70 percent think they are using heartworm preventative. Unfortunately, the number to remember—the one we as a profession really need to fix—is that only one out of four dogs receives heartworm preventative consistently. So how can we positively increase the number of dogs getting heartworm prevention when they should? Remember, clients want your advice The study showed respondents believe veterinarians are vital to pet care and the products they use. Specifically, it found: 82 percent rely on you to determine what to purchase; 81 percent are likely to seek your recommendation or approval; 76 percent will give their pet whatever you recommend; and 68 percent say their veterinarian’s recommendation is a very important factor in their purchase decision. That’s great news, but clients, unfortunately, often don’t retain the information they’re given. In fact, it’s not the case the confused pet owners received bad information during a visit to their veterinarian—it’s just that they simply forgot what they heard. Or they got confused and consulted Dr. Google or a friend who provided bad information. Think about it from this perspective: visiting a clinic is stressful. For one, the pet might be anxious and not acting as it normally would. Secondly, if there is a medical issue, clients are trying to remember the details and symptoms they want to share with the veterinarian. This is a less-than-ideal situation for adult learning or retention of the information you and your staff present. It could also be they are saying “no” or “not now” to a medication because they need time to process information. If the appointment was for a health problem, fixing that issue often takes priority over other recommendations, in the client’s eyes. No information equals no preventative Image Courtesy Ceva Animal Health Too often, we don’t start a heartworm conversation because we think the client already understands the disease. Moreover, when the pet owner has declined a monthly preventative in the past, we assume they will say no again. More often, we think they are tired of hearing about heartworm disease when really, we are the ones who are tired of talking about it. Active nonusers reported statistically fewer discussions with their veterinary team about heartworm prevention and received fewer brand-specific recommendations than user groups did. As such, it is vital we take time to understand—from the owner’s perspective—why they aren’t using a preventative or why they don’t use one every month. We need to take active listening to a new level. It is so easy to listen to respond, rather than listening to understand. That understanding is key to determining the perceptions and barriers you must overcome. There should be no blame directed toward either party for this breakdown in communication. These are complex conversations held with time constraints under often complicated circumstances. Instead, veterinarians must embrace the belief that high-quality and frequent communication are critical to stopping the spread of this disease. But it is a heartworm preventative, isn’t it? Too often, we don’t start a heartworm conversation because we think the client already understands the disease. Another of the study’s results showed owners in the confused nonuser category were certain their brand of choice protected against heartworm disease, too. Even when asked to get the package and read the indications, they still said it prevented heartworm disease. If their product of choice didn’t come from your hospital and you didn’t write a prescription, your client is likely in the confused nonuser group. To be certain you know what their pet is receiving—and what it isn’t—ask clients to bring all their pet’s medications to their appointment. That allows you to see with your own eyes where the gaps are. If they forget, ask for the brand name of what they are using, and find out when they last administered it and how. These answers will help you get the information you need. Other prevention difficulties The survey identified three additional usage barriers that get in the way of dog owners purchasing and using preventatives on a consistent basis. They are: 1) Perception of risk (i.e. a perceived low risk of heartworm disease because of where they live, or a perceived high risk of drug side effects) 2) Ease of use, meaning the requirement of a prescription and other perceived hassles with obtaining medication 3) Cost, which was by far the biggest barrier for the active nonuser segment Interestingly, other factors (e.g. forgetting to buy or give the heartworm preventative or apathy) did not emerge as strong impediments to address. Consistent users received or recalled starkly different information from their veterinarians than did the other groups of users and nonusers. Let’s look at each barrier more closely: Making the risk real: A lack of perceived risk is a key reason why owners don’t administer heartworm preventatives. Maybe you’re in a region of the country that has not had significant issues in the past. Perhaps the owner thinks that because their dog is an indoor dog, it’s not at risk. Or maybe the owner knows mosquitoes carry the disease, but they think there isn’t a risk of transmission during the winter. Don’t all mosquitoes die during winter months? No mosquitoes means no problem, right? (Don’t we wish!) Owners who fear side effects more than the disease need support, too. While we know the risks are low for an adverse event, those concerns are very real and scary for your client. It’s important to take the time to determine where the fear is coming from to help make them understand heartworm preventatives are safe. Where do you start? Help pet owners see the risk in their community, at their park, and in their own backyard. Ensure clients know that if there is a heartworm-positive dog within a mile and a half, their pet is at risk because mosquitoes can travel that far Rather than ask if the dog is an indoor or an outdoor pet, ask how much time it spends outside to help discuss the risk And let them know it’s a myth they don’t need to use a preventative in the winter. Regardless of where you live in the U.S., mosquitoes don’t die off during the winter. Due to microclimates and warmer temperatures in general, it’s easier than ever for them to survive in colder months. It’s critical owners understand a monthly preventative isn’t about the mosquito. It’s about preventing the worms from growing in the circulatory system (and, of course, year-round protection against intestinal parasites, as well). Many clients aren’t aware infected mosquitoes are found in more places than ever before. This is due in part to more dogs traveling with owners. Plus, recent natural disasters have led to the relocation of many heartworm-positive dogs. For practitioners, it is easy to fall into a trap of believing the risk is low. So, we drop the conversation when we get pushback from the client. However, that is a mistake. Low prevalence doesn’t equal no prevalence. If there has been even a single heartworm-positive dog visiting your community, your canine population is at risk. Make it hassle-free: The second challenge centers on ensuring heartworm prevention is easy and hassle-free for your clients, and especially for those inconsistent users and nonusers. Spend time training your staff what to do when they receive outside prescription requests. Ask if clients are shopping those other outlets due to cost or convenience. If it’s cost-related, offer a price match or a generic. If it’s a matter of convenience, offer to mail it to them at no charge or encourage them to order it through your online store. And set up protocols so the pet owner doesn’t even need to think about it. Reminder calls, postcards, and an auto-ship program to deliver the medication just in time are a few ways to make giving preventatives routine. Tackle the cost issue: Finally, for many dog owners, and especially those in the inconsistent users and active nonusers segments, cost is a key barrier; a significant percentage of those dog owners report they would give a preventative every month if it cost less. In today’s competitive environment, there are great generic options at your disposal. Make sure you carry a low-cost option for clients in need of them. Heartworm prevention starts in the clinic There are many ways clients talk themselves out of giving these products to their pets. Believe it or not, these same factors can sway even veterinarians and hospital staff from recommending these products. While we may feel like we’ve talked about heartworm disease over and over again, we must keep educating clients about how to protect their pet. And even after you have presented a compelling and influential case, don’t be discouraged if a client says no. You will likely get this response many times before the client agrees to your recommendation for heartworm prevention. Don’t get discouraged. No veterinarian wants to tell a pet owner, “Well, there was something we could have done to prevent this from happening, but I didn’t want to push the conversation.” Our clients trust us to help them provide the best care possible so their pets can live a long, happy, and pain-free life. Nobody wants to part with a beloved pet before its time. The needless suffering that accompanies heartworm disease can be prevented. Improving discussions about heartworm Asking open-ended questions takes practice, but working to make that skill second nature will help draw out better information from your client. Here are a few to consider: What do you know about how heartworm disease is spread? Where do you think heartworm is found in the U.S.? How are you working to prevent your dog from getting heartworm disease? What do you know about products for your dog that kill and repel mosquitoes? How would your dog’s quality of life decline if he contracted heartworm disease? What are the activities you would miss doing with your dog if he had decreased heart or lung capacity? It seems like you’re not concerned about heartworm disease. Can you tell me more? How much do you know about the mosquito’s ability to live year-round? If a client says they are giving a preventative, but didn’t get the product or a prescription from you, ask the following: How do you get your heartworm medication? How is it working for you? When and how did you administer it to your dog? How many doses of the preventative did you give this year and when was it given? Charles (Chuck) Johnson, DVM, MBA, is senior director of U.S. veterinary services and pharmacovigilance at Ceva Animal Health. He has more than 30 years’ veterinary practice experience. Dr. Johnson earned his bachelor of science degrees (animal and poultry science) and DVM from the University of Florida. His experience as a practice owner stimulated a deeper interest in business and he earned an MBA from University of Wisconsin-Madison. Johnson has been active in business education for the veterinary industry, and is a member of the executive board of the University of Florida, College of Veterinary Medicine. He can be contacted at firstname.lastname@example.org. Karen Padgett, DVM, is a graduate of the University of Georgia College of Veterinary Medicine and practiced small-animal medicine in Charlotte, N.C. She’s since held leadership and executive positions in the animal health industry, including numerous roles at Hill’s Pet Nutrition, followed by Ceva Animal Health, where she served as chief operating officer of the U.S. companion animal group. Dr. Padgett is president of Unfenced Animal Health, an animal health marketing business offering market research, technical writing, business planning, and branding to help national and global animal health companies better service the veterinary profession and improve pet health. She can be contacted at email@example.com. References 1 Ceva partnered with Unfenced Animal Health and True North Market Insight for this research project and found very enlightening facts along the way. The study’s goal was to understand pet owners’ knowledge about heartworm prevention. By analyzing reasons why preventatives were or were not given, Ceva hoped to gain insight veterinarians could use in-hospital to increase the number of dogs receiving a preventative. To learn more, visit bit.ly/2WzdLvB. 2 Consistent users are those who receive a great deal of communication and support from their veterinarian and the hospital staff. Through frequent and clear communication, the team at the veterinary hospital has reinforced adherence to a prevention plan. For inconsistent users and nonusers, there is a clear lack of engagement with the veterinarian and a failure in communication or a total absence of a discussion about the disease and how it can be prevented. 3 For consistency, the research counted ProHeart 6 injections as six doses.