Why we NEED an Equine Wellness Institute

We need, and it is time for, an equine wellness institute.

Unfortunately for the equine, our current "best practices" in care and keeping are built on recent tradition, and not level 1 evidence. Let's give veterinary medicine, and you, the help we all need to give your horse a better quality of life through research on wellness!

Level 1 Evidence: Read the description of Level 1 Evidence below. This is the type of research that is LIKELY RELIABLE folks. LIKELY!  Why do we do this with human medicine, strive for this? Because we know that current, popular, recent opinion is not adequate medicine, that is why. We can, and will, do better with human medicine as a result of such studies. The question is, how do we bring more quality to equine research?

Is it better to look at the research performed with humans to guide development of medicine for a species we don't use these standards with, or is it better to just keep building on the popular ideas of "care" we have developed over recent time?

I would assert that we must develop a more comprehensive basis for comparative treatments in equines that is guided by the goal of maximizing life-long wellness. We are so far behind in some medical approaches with horses that we are still using principals that were removed from human medicine long ago. No other species suffers from the intellectual joke that a rim of metal at the bottom of their limb represents medical care under any circumstance. But because the equine industry started with that faulty premise, they seem to be stuck with it, to the extent that they keep suggesting more and more ways to goof around with this idea to "help" equines recover from health crises such as laminitis. But does it ever help relative to a control group ... ie those that don't have metal rims at the bottom of their legs? Only appropriate research, not biased research, will yield the quality of data needed to answer that question and advance our "best practices."

Much of any recovery an equine is doing in response to an acute laminitic episode is probably despite our current standards of "care," not because of them. But who cares what I think??.....let's get to work and test this hypothesis! Give me a wellness institute so that we have a baseline to measure whether or not our popular notions offer any true aid to the domesticated equine.

Based on the concepts advanced in human medicine in the last 100 years, we are so far off the mark with hoof and whole body care, that it is almost beyond belief. 

Level 1 (likely reliable) Evidence - representing research results addressing clinical outcomes and meeting an extensive set of quality criteria which minimizes bias.

Levels of evidence for conclusions derived from individual studies https://dynamed.ebscohost.com/content/LOE

  • DynaMed criteria for level 1 (likely reliable) evidence for interventional conclusion (conclusions that an intervention does or does not change an outcome)  
    1. Full-text report available in English (or language well understood by participating editor)
    2. Clinical outcome (also called patient-oriented outcomes)
    3. Population, intervention, comparison, and outcome in the study is representative of expected clinical practice
    4. Random allocation method (i.e. not assigned by date of birth, day of presentation, “every other”)
    5. Blinding of all persons (patient, treating clinician, outcome assessor) if possible
    6. Follow-up (endpoint assessment) of at least 80% of study entrants AND adequate such that losses to follow-up could not materially change the results
    7. Accounting for dropouts (even if not included in analysis)
    8. Confidence intervals do not include both presence and absence of clinically meaningful differences
    9. Consistency of findings across measures of similar outcomes
    10. In cases of randomized parallel-group trials 
      • Allocation concealment
      • Intention-to-treat analysis comparing groups according to randomization
    11. In cases of randomized crossover trials 
      • Trial conducted in patients with condition not expected to change spontaneously during course of trial
      • Random allocation method for order of assignment
      • Washout period between interventions long enough to avoid carryover effects between interventions
      • Adequate duration of intervention and assessment period to represent outcome being measured
      • Analysis of paired data
      • Analysis not suggesting period effects (i.e. effect resulting for order of intervention), or period effects if present not materially changing results
    12. In cases of early trial termination 
      • Stopping decision made by independent monitoring board without competing interests
      • Interim analysis preplanned
      • Statistical stopping rule accounts for multiple assessments (lower p value threshold) for early termination benefit
      • Clinically significant differences with absolute benefit/harm warranting early termination
      • For classification of level of evidence for a specific outcome (which may be different than outcome used for stopping decision), outcome has sufficient statistical results such that trial continuation would be unlikely to change these results
    13. No other factors contributing to substantial bias, such as 
      • Differences in management between groups other than the intervention being studied
      • Differential loss to follow-up
      • Posthoc analysis
      • Subgroup analysis
      • Baseline differences between groups
      • Unclear how missing data are accounted for if possible 
  • DynaMed criteria for level 1 (likely reliable) evidence for a diagnostic conclusion 
    1. Full-text report available in English (or language well understood by participating editor)
    2. Patient sample represents patients for whom testing would be appropriate (i.e. diagnostic uncertainty)
    3. Reliable reference standard
    4. Test under investigation is representative of how test would be conducted in clinical practice
    5. Reference standard and test under investigation each applied to all study subjects (with and without diagnosis)
    6. Test under investigation conducted blinded to and independent of reference standard results
    7. Reference standard conducted blinded to and independent of study test results
    8. Adequate follow-up and accounting for subjects
    9. Confidence intervals do not include both presence and absence of clinically meaningful differences
    10. Test studied in independent validation cohort (i.e. a cohort that is independent from the derivation of the test or specific cutoff value being investigated)
    11. No other factors contributing substantial bias
  • DynaMed criteria for level 1 (likely reliable) evidence for prognostic conclusion
    1. Full-text report available in English (or language well understood by participating editor)
    2. Inception cohort study
    3. Prospective follow-up
    4. Representative sample at a similar course in the disease
    5. Follow-up sufficiently long and complete
    6. Systematic (unbiased) evaluation of outcomes
    7. Adjustments for important confounding factors
    8. Confidence intervals do not include both presence and absence of clinically meaningful differences
    9. Additional criteria for prediction rules 
      • Validation in relevant population
      • Validation in sample independent from derivation cohort
    10. No other factors contributing to substantial bias

Levels of evidence for conclusions regarding a body of evidence:

  • DynaMed criteria for level 1 (likely reliable) evidence for conclusions from a systematic review:
    1. Full-text report available in English (or language well understood by participating editor)
    2. Clinical outcome (also called patient-oriented outcomes)
    3. Systematic search
    4. Explicit inclusion criteria that do not appear to inappropriately exclude important evidence
    5. Systematic selection of included studies
    6. Key factors analyzed from included studies are representative of expected clinical practice
      • For interventional conclusions key factors are population, intervention, comparison, and outcome
      • For diagnostic conclusions key factors are population, test under investigation, and reference standard
      • For prognostic conclusions key factors are population and outcome
    7. Evaluation of study quality sufficient to determine if individual studies meet level 1 evidence criteria
    8. Consistency of findings across studies (whether or not meta-analysis performed)
    9. Consistency of findings across measures of similar outcomes
    10. Additional criteria if meta-analysis 
      • Studies are clinically appropriate for pooled analysis (reasonably similar populations, interventions, methodology, and outcomes)
      • Meta-analysis not limited by statistically significant heterogeneity
    11. Conclusion based on 1 or more primary studies meeting Level 1 evidence criteria
    12. Confidence intervals do not include both presence and absence of clinically meaningful differences
    13. No strong suspicion of publication bias
    14. No other factors contributing substantial bias, such as subgroup analysis or indirect comparisons
  • DynaMed criteria for level 1 (likely reliable) evidence for conclusions from a synthesis of systematic literature surveillance:
    1. Conclusions are consistent with 1 or more primary studies meeting Level 1 evidence criteria
    2. Key factors analyzed from included studies are representative of expected clinical practice
      • For interventional conclusions key factors are population, intervention, comparison, and outcome
      • For diagnostic conclusions key factors are population, test under investigation, and reference standard
      • For prognostic conclusions key factors are population and outcome
    3. MEDLINE search conducted to exclude conflicting evidence (to supplement systematic literature surveillance)
    4. Consistency of findings across studies
    5. Consistency of findings across measures of similar outcomes
    6. No strong suspicion of publication bias