Chris Duke, DVM, and Kathleen Williston
Bienville Animal Medical Center, Ocean Springs, Mississippi
The Heartworm Hotline column is presented in partnership between Today’s Veterinary Practice and the American Heartworm Society (heartwormsociety.org). The goal of the column is to communicate practical and timely information on prevention, diagnosis, and treatment of heartworm disease, as well as highlight current topics related to heartworm research and findings in veterinary medicine.
Heartworm disease is one of the most important diseases threatening companion animals. According to the American Heartworm Society (AHS), disease caused by Dirofilaria immitis has been diagnosed in all 50 states, and, as most veterinarians and veterinary technicians are aware, it can affect both dogs and cats. Veterinary professionals have a wealth of effective, Food and Drug Administration–approved products, including oral, topical, and injectable formulations, that make heartworm disease preventable. One goal of veterinarians and technicians should be to ensure that every pet is protected from heartworm disease for 12 months each year. The key to realizing this goal is effective client education.
MAKING HEARTWORM PREVENTION A PRIORITY
Given the veterinary profession’s understanding of the importance of heartworm prevention, it’s easy to overestimate how seriously clients take this disease. Our practice, along with 46 other veterinary practices, recently participated in a client compliance survey. While we expected that most of our dogs and at least half of our cats would be receiving year-round heartworm prevention, the survey showed that just 58% of dogs and 30% of cats met this profile. Moreover, on average, the survey showed that dogs received heartworm preventives just 4.7 months of the year and cats only 3 months annually. Our profession—and our clients—can do much better.
Each client represents an opportunity for heartworm education or reeducation. The discussion can come about naturally, within the course of any preventive care annual or semiannual visit. In our practice, all puppies and kittens begin receiving heartworm prevention at the time of their second visit. Although there are similarities and differences in heartworm lifecycles (Figure 1), testing procedures, preventive products, and treatment methods between dogs and cats, what is most important is to simply start the discussion.
COSTS OF PREVENTION
Heartworm prevention is not just an investment in an effective medication for the pet; it is an insurance policy against a preventable, potentially lethal disease. For an average-sized dog (20–30 lb), prevention costs around $50 for 6 months, or $100 a year. For small dogs and cats, the cost is even lower. On average, the cost of heartworm prevention is a just a fraction of the cost of heartworm treatment for dogs (Figure 2)—even without consideration of the health risks associated with heartworm infection in dogs. Meanwhile, there is no approved adulticide product for cats, making heartworm prevention essentially priceless.
Another way to frame the discussion of cost of prevention is as follows: If you break the $100 per year cost down to a daily figure, it is $0.28 per day. On a monthly basis, that amounts to approximately $8.40. The value is unquestionable.
THE HEARTWORM CONVERSATION
In the world of marketing, there is a principle called the “Rule of 7,” which refers to the premise that consumers must hear a message approximately 7 times before they will buy or accept a product or service. A single voice—technician or veterinarian—explaining the importance of heartworm prevention is not sufficient. However, not every repetition of the message needs to be verbal. Posters, brochures, videos, and social media posts can all be used to support the message.
The waiting room is a prime area to begin the education process. Display heartworm brochures so clients can read about the disease before they even enter the examination room. Posters and videos in the waiting area are also useful.
Once the client and pet are in the examination room, the veterinary technician takes the lead in discussing heartworm prevention. This discussion should not be overly technical, but rather a common-sense approach to explaining a life-threatening disease, and it can fit into the intake process. In our practice, the technician asks questions about diet, weight trends, lifestyle changes, and parasite prevention. We use a series of exam stickers (Figure 3) to make recording this information easier.
One simple way to begin the heartworm prevention conversation is for the technician to simply ask clients if they have ever seen mosquitoes around their home. If the client says yes—and in almost every instance they will—the technician can explain that the mosquito is the vector in the transmission of heartworm disease. We tell clients, “We can’t kill every mosquito around your home, but we can prevent against the heartworm larvae that any given mosquito can infect your pet with.”
The veterinarian can then restate the practice’s heartworm and flea control recommendations while summarizing the findings from the intake discussion. If an annual heartworm test is conducted during the visit, both the veterinarian and technician can again reinforce the importance of prevention, as well as explain why the test is needed even if the pet is receiving year-round prevention. In our practice, if the results of the heartworm test are positive, the veterinarian will discuss those results.
At checkout, the receptionist can provide one last point of heartworm education, supporting the recommendations of the veterinarian and technician and explaining the value of the recommended products the client is purchasing. Consistent positive affirmation of heartworm prevention, from pet intake to pet discharge, is powerful. By keeping the “Rule of 7” in mind, the veterinary team can remind themselves of the value of repetition.
Some clients refuse to purchase heartworm prevention products—sometimes because of cost and sometimes for other reasons. Pet owners may rationalize that their pets are at low risk because they live indoors or have limited time outside. Others mistakenly believe that a holistic approach will be effective. Still others are concerned about the safety of heartworm preventives. Every one of these objections presents an educational opportunity. Veterinarians can share stories of heartworm cases with tragic outcomes—or display an infected heart in a jar of formalin to prove the reality of heartworms. Although our practice’s philosophy leans toward positive education, both approaches can work.
If heartworm prevention or a heartworm test is declined, this should be noted in the clinic record. If the pet later becomes infected, the opportunity for reeducation is always there.
For the Veterinary Practice
Every time a heartworm prevention product is sold, it should be linked to a refill reminder to be e-mailed, texted, or delivered via traditional postal service. A simple reminder is one of a practice’s strongest compliance enhancers.
In our practice, annual heartworm tests are commonly performed in conjunction with annual examinations, but resale or renewal opportunities for prevention products often coincide with semiannual visits at 6-month intervals. In some veterinary clinics, a team member calls the client with a reminder on a given date. Regardless of the products stocked or the communication method used, the main objective is to compel the client to return to the clinic for more heartworm preventives—and to use them
Free and convenient resources are available. All the major pharmaceutical manufacturers that sell heartworm preventives provide incentives, discounts, or rebates to help market their products. These offers can be used to help educate your clients and distribute the product.
Once your clients have purchased heartworm medication, they must be encouraged to administer it. Enhancing client compliance at home is as important as getting clients to the clinic. Consider two useful approaches:
- Clients who use a smartphone can add a reminder to alert them when their pet requires dosing. The app used by our practice generically reminds clients that heartworm and flea prevention should be administered on the first of the month, whether a monthly, every-3-months, or every-6-months product is used.
- Clients can use their at-home calendar to remind them when doses are due or can use the check-off panels on the prescription boxes if applicable.
It is important to improve compliance on heartworm prevention with an electronic or more traditional reminder system within the comfort zone of the client.
Finding and telling stories One of the most effective client education tools is the real-life stories of other pet owners and pets the practice has seen (Box 1).
BOX 1. A Tale of Two Heartworm-Positive Cases
A principle of adult learning is the use of narrative: people learn through stories. In our clinic, telling stories of past patients is one of the most effective ways to emphasize the importance of heartworm prevention, testing, and treatment. Owners who are concerned about adopting a heartworm-positive rescue dog might be inspired to learn about Maya. Those who are questioning the importance of year-round prevention or whose buying history indicates lapses in compliance likewise may benefit from hearing how Rock’s unfortunate outcome might have been averted.
Maya was a 4-year-old mixed-breed rescue dog. When she was spayed at a local shelter, she was tested for heartworms and diagnosed with asymptomatic heartworms. She was then referred to our hospital for treatment. The hospital staff promptly started her on a course of doxycycline for 30 days and a monthly dose of ivermectin, following the AHS heartworm treatment protocol. Maya was placed in foster care for the next 2 months, then brought back for melarsomine therapy. She completed the treatment without complications. Shortly after treatment ended, a foster group asked to have her shipped from the Gulf Coast to Connecticut. Maya is now happily settled in her new home, with a new veterinarian. She is now receiving year-round heartworm prevention to avoid a repeat episode.
Rock was a 10-year-old neutered male bulldog whose owners had discontinued use of heartworm prevention. At diagnosis of heartworm infection, he presented clinically with heavy, labored breathing, pale gums, and ascites on his abdomen and had been anorectic for 3 days. The staff worked valiantly to improve his condition through supportive IV fluids, antibiotics, and other drugs; however, after watching Rock’s condition deteriorate over 3 days in the hospital, the owner elected to have him euthanized. It was too late for Rock to be helped. This outcome was preventable.
There are many ways to share anecdotes such as these. Tell stories of successful heartworm treatment and rescue dog turnarounds on your Facebook page (if the owner/foster volunteer consents). Feature stories on your clinic website. Share them on Twitter. The goal is to turn these compelling stories into messages that reinforce the importance of heartworm prevention, testing, and treatment.
The AHS offers members and nonmembers many nonbranded client education materials at heartwormsociety.org. Brochures, videos, infographics, and heartworm preventive waivers are among the numerous tools available to help busy practitioners.
Clients desiring links to informational websites may be directed to heartwormsociety.org, avma.org/public/PetCare/Pages/Heartworm-Disease.aspx, or capcvet.org. PetMD.com also has a very practical, informative page on heartworm disease and prevention.
Educating and re-educating clients about heartworm disease can be challenging. A team approach to heartworm education not only helps lighten the load but also ensures the message breaks through.