Veterinary Medicine Database | Methodology
The V-GRADE pathway assesses the quality of available evidence and issues a grade (V-GRADE) that communicates the strength of consensus-generated therapeutic recommendations for the use of a specific medicine, for a particular indication, in a defined patient type.
V-GRADE aims to support clinicians through informed choices about effective medical care for their patients through consensus-derived therapeutic recommendations, especially where the available evidence base appears either random or limited. Additionally, the pathway defines the evidence base required to execute high-quality medicine when treating any species (i.e. universal elements of safe medicine supply) and identifies gaps in our available knowledge base requiring further investigation at the species level.
Unfortunately, the veterinary profession has not decided upon the evidence base and data structure needed to identify the safe, effective, informed use of veterinary drugs in specific clinical situations outside the drug marketing authorisation process. Without agreed standards such as V-GRADE and a systematic approach to qualifying our therapeutic recommendations, the scientific community can not determine whether we are providing the best care possible. Without standardised evidence review, knowledge gaps remain and may be given little attention by clinicians and researchers. Furthermore, there is little way to formally assess the implications of hidden knowledge gaps to patient outcomes and audit these against treatment goals, especially when our patients are unusual and our understanding of their conditions is ealy in its understanding unclear.
One vital aim of this project is to reduce unnecessary confusion arising from multiple systems for grading evidence and recommendations. The scope of species, physiology, disease, knowledge, and evidence for veterinary staff in clinical practice can be vast. Therefore, we have designed the V-GRADE pathway so veterinary analysts can apply it to all therapeutic situations. We continue to modify and iterate the pathway following the advice of all colleagues but mainly through consensus-derived support from the EBM community. We welcome all communication and collaboration from within the veterinary profession.
V-GRADE builds and maintains a defined, stable, scaleable knowledge base through systematic evidence analysis coupled with evidence synthesis regardless of the drug, species, or indication. The V-GRADE Pathway employs an evidence matrix and a systematic multi-stream evidence analysis pathway to generate a specific V-GRADE Rating from an Average Matrix Score (AMS). Together, these
act as powerful collaborative tools for grading the quality of evidence when making therapeutic recommendations.
The V-GRADE (Delphi Review) Pathway offers our profession a simple type of "Mini-Meta-Analysis", a bespoke method of synthesising evidence and summarising the results of wide-ranging information sources. This initiative has commenced with a calibration and validation exercise. We invite you to join us in this.
Introduction to our Methodology
The VCI administration team registers an active substance through the creation of a set of monograph templates for the active substance and a similar filing structure within the reference manager database that mirrors the key monograph data fields.
(Active substances are medicines recognised and classified by WHO using the ATCC and ATCVC systems).
Monograph templates contain all the necessary data fields for pharmacology review, dosing review, evidence analysis and the development of therapeutic recommendations.
The filing structure within the reference manager database allows the organised storage of references covering the core data fields within the monograph series.
During our calibration and validation phase, VCI has registered example active substances employed in treating various conditions and species types. Working with as diverse a monograph type and evidence range as possible helps create a robust, scalable system with which we can strategically grade the quality of the evidence behind any therapeutic recommendations made.
Examples of active substances with extensive use in treating our major pet species (cats and dogs) include Gabapentin, Meloxicam, Omeprazole, Paracetamol, and Pimobendan. Consequently, these medicines have a substantial evidence base. However, other active substances frequently used in treating minor pet species, like rabbits, have a significantly smaller base of supporting evidence than when these medicines are used for our major pet species. Typical examples within rabbit therapeutics include Cisapride, Alfaxalone, Bupivacaine, Buprenorphine, Butorphanol, Fenbendazole, Meloxicam, Medetomidine, Lidocaine, Paracetamol, and Propofol.
VCI is developing a series of monographs with a narrow evidence base through the natural construction of both rabbit and hedgehog formularies. We balance this by analysing the same active substances in major pet species.
Please visit our Veterinary Medicine Database for an overview of the active substances we have under development.
The pharmacology data for each active substance is subdivided into the following sections General Pharmacology, Precautions, Toxicology, Literature Review, Resources, and Collaboration Information; Examples of Pharmacology Monographs include:
Dosing information, by species, is displayed for each active substance; Examples of Species Dosing Monographs include:
Evidence Analysis Monographs
The product of every V-Grade Analysis is presented via our desktop platform. Each V-GRADE Analysis Monograph includes the information behind each analysis stream's matrix score ( Suitability, Safety and Efficacy) and details of the experts in the Delphi survey, which has validated it.
Every V-Grade Analysis is drug, species, and indication-specific. Access to each V-GRADE analysis is via the grade icon assigned to each indication; Examples of V-GRADE Analysis Monographs include:
Gabapentin | Canine | Analgesia (Canine | V-GRADE Analysis | Indication 1)
Medetomidine | Rabbit | Medetomidine-Butorphanol+Ketamine (Rabbit | V-GRADE Analysis | Indication 1)
Gabapentin | Feline | Analgesia (Feline | V-GRADE Analysis | Indication 1)
Gabapentin | Rabbit | Analgesia (Rabbit | V-GRADE Analysis | Indication 1)
Meloxicam | Canine | Acute Pain ( Canine | V-GRADE Analysis | Indication 1)
Paracetamol | Canine | Analgesia (Canine | V-GRADE Analysis | Indication 1)
Therapeutic Recommendation Monographs
Once the V-GRADE analysis is complete, the Delphi panel continues to work with the author to present consensus-based therapeutic recommendations for the clinical use of the medicine (in this species, for this indication); Examples of Therapeutic Recommendation Monographs include:
Gabapentin | Canine | Analgesia (Canine | Therapeutic Guidelines | Indication 1)
Medetomidine | Rabbit | Medetomidine-Butorphanol+Ketamine | Rabbit | Therapeutic Guidelines | Indication 1)
The Evidence Development Team
The evidence development team working on any given monograph are called a "Monograph Study Group". A study group consists of an admin team, various authors and editors, and a series of Delphi panels (10-20 suitable experts.) In addition, smaller study groups cover species-specific dosing monographs.
A suitable person can apply to join any of our study groups. An eligible person is a registered vet or veterinary nurse, or a colleague outside of the veterinary profession with a professional qualification relating to our project; the admin team will respond to this application, grant access to collaborator resources and explain the conditions associated with collaborator status.
Study group access is via links on a parent monograph collaboration page. In addition, you can apply to join any study group by emailing us directly via the email link on the header bar of every desktop browser page.
During our pilot period, the Veterinary Consensus Initiative will approach many suitable individuals directly with a request for them to partake in an evidence review.
Colleagues who join study groups become formal collaborators when any Delphi review in which they partake is completed. All collaborators will be granted free access to VCI services for two years during our inception period. After this period, VCI will review the terms of collaboration. VCI anticipate that a rolling two-year collaborator status will be granted for an additional contribution.
Literature Review Guide
1 | Permitted Evidence
Only papers published in peer-reviewed journals or journal supplements are permitted evidence.
Information unsupported by a journal citation is expert opinion ascribed to the monograph author, as the inclusion of such material is a consequence of their judgment.
2 | Journal Access
Online Journals: RCVS Knowledge provides access to Open Athens services (Royal College of Veterinary Surgeons | Knowledge | Library and Information Services).
Physical Journals: The British Library provides our access to physical journals where online access is unavailable (The British Library | Thorpe Arch, West Yorkshire).
3 | Search Engines Employed
Three search engines are used to interrogate journal databases during this calibration-validation phase.
PubMed: MEDLINE is the most significant component of PubMed and consists primarily of citations from journals selected for MEDLINE; articles indexed with MeSH (Medical Subject Headings) and curated with funding, genetic, chemical and other metadata [https://pubmed.ncbi.nlm.nih.gov/advanced/]
Cabi VetMed Resource: - Key records on all aspects of veterinary medicine, CAB Reviews and the Animal Health and Production Compendium (AHPC) [https://www.cabi.org/vetmedresource/advancedbibliographicsearch/]
Wherever possible, papers identified by these search engines are captured as PDF files and stored within the reference manager database in the appropriate folders.
If you collaborate with us in developing the evidence base behind our recommendations for any form of clinical practice, you will be invited to join the reference manager study group associated with your monograph series.
During our calibration and validation development phase, We employ Zotero (https://www.zotero.org) reference management to store, verify and allow collaborative access to the references we cite. Zotero is a free easy-to-use reference manager. It will enable authors, editors, and Delphi experts to develop a monograph together, build a collaborative bibliography, and distribute reference material as necessary.
VCI Database: The VCI database contains metadata and, where possible, copies of journal papers employed in analysing every active substance.
Access: Only active members of the monograph study group can access the reference manager and store journal references relevant to the monograph. The whole study group works together, populating the evidence base to be as complete as possible.
Deletions: Only a member of the VCI admin team will delete files and folders from the reference manager database. All material uploaded to the reference manager that is not a journal reference is automatically removed by the admin team,
File Structure: Our storage folders are arranged by active substance, and access is made available by active substance. Wherever possible, Our reference manager file structure mirrors our monograph data field structure. The preference settings of our reference database are bespoke and designed to support the V-GRADE Evidence Analysis process and respect journal copyright.
The easiest way to understand our evidence analysis and evidence development processes is to collaborate in the creation of a monograph and, in so doing, become part of a monograph study group.
VCI is an organisation founded upon evidence analysis. Consequently, the VCI evidence analysis process is dynamic and never-ending. All members of the study group perform this analysis. As a result, the evidence used by VCI to support its Veterinary Medicine Database is constantly amended and improved.
All study group members have access to the reference database and are responsible for correctly maintaining reference storage and filing structures derived from journal metadata for colleagues' benefit. All citations and bibliography lists within a monograph rely upon reference manager software accurately downloading the citation data contained within these files. Therefore, collaborators must file references within the correct reference manager files. In many cases, journal metadata will appear in multiple files.
Formal evidence analysis and review are essential at FIVE specific monograph development points listed below.
1 | Primary Dose Monograph Construction
The first evidence review sweep is the author's literature review while writing the first monograph draft. In this sweep, the author files the core references used to construct the information presented in the draft monograph so that co-authors, editors and future reviewing teams can independently scrutinise it and either validate or amend the data.
We cover how the evidence is analysed and used to construct dosing recommendations below, in section 6 | Primary Dose Monograph Construction
2) The V-GRADE Analysis
The second evidence review sweep is during the authors initial V-GRADE determination..The process of grade determination is a specific analysis of the evidence gathered to populate the monograph..
We cover how the editor reviews the evidence supporting the authors dosing recommendations below, in section 7 | The V-GRADE Analysis
3) Therapeutic Recommendations
The fourth evidence review sweep is by the author during the process of defining the therapeutic recommendations for the use of the active substance.
. We cover how the authors proposes therapeutic recommendations in section 8 | Therapeutic Recommendations
4 | Editing
The fourth evidence review sweep is during the monograph's editing phase.
We cover how the evidence is analysed and used to construct dosing recommendations below, in section 9 | Editing
The fifth evidence review sweep is by the Delphi panel during the process of validating the edited dosing, V-GRADE and therapeutic recommendations
We cover how the editor reviews the evidence supporting the authors dosing recommendations below, in section 10 | Delphi Validation
The author performs a comprehensive literature search as described above and files all references located within the main active substance folder so that co-authors, editors and future reviewing teams and teams working on dosing in other species can independently view these references.
The author may work with co-authors the develop the draft monograph. Where there are co-authors, they share access to all reference material and have an equal ability to add additional material to the reference database.
The process of grade determination is a specific analysis of the evidence gathered to populate the monograph.. The author and their team interrogate the journals in the reference manger database to determine if and how it supports the specific indication, of the specific active substance, in the given patient type. All relevant papers are further filed within three indication subgroup files in Zotero. (Suitability, safe dosing and efficacy).
Once a grade is calculated, it is independently agreed upon with the editor, who also reviews how that evidence has been analysed. The editor has an opportunity to review and amend it.