Treatment complexity and caregiver burden are linked in owners of dogs with allergic/atopic dermatitis

Abstract

Background

Skin disease severity and treatment plan complexity are both related to owner experience of caregiver burden; however, to date they have not been examined simultaneously in owners of dogs with atopic or other chronic allergic dermatitis.

Hypotheses/Objectives

We expected to replicate and extend previous work by showing that caregiver burden is linked to treatment complexity and disease severity in this population. Moreover, we hypothesized that a relationship between burden and treatment complexity would be present in both subjective (owner report of experience) and objective (number of weekly treatments) measures, and that these relationships would exist independent of skin disease severity.

Participants

Eighty‐six owners of dogs with atopic or other chronic allergic dermatitis recruited through social media dog allergy groups.

Methods and materials

Cross‐sectional online assessments were completed for caregiver burden, treatment plan complexity and skin disease severity.

Results

Caregiver burden was correlated with skin disease severity (r = 0.40) and both subjective (r = 0.37) and objective (r =0.30) measures of treatment complexity (P < 0.01 for all). Relationships between caregiver burden and treatment complexity remained significant after accounting for skin disease severity.

Conclusions and clinical importance

Greater treatment plan complexity is associated with higher caregiver burden in owners of dogs with atopic or other chronic allergic dermatitis. The independence of this relationship highlights the importance of simplicity in effective treatment planning.

Short abstract

Background – Skin disease severity and treatment plan complexity are both related to owner experience of caregiver burden; however, to date they have not been examined simultaneously in owners of dogs with atopic or other chronic allergic dermatitis. Hypotheses/Objectives – We expected to replicate and extend previous work by showing that caregiver burden is linked to treatment complexity and disease severity in this population. Moreover, we hypothesized that a relationship between burden and treatment complexity would be present in both subjective (owner report of experience) and objective (number of weekly treatments) measures, and that these relationships would exist independent of skin disease severity. Conclusions and clinical importance – Greater treatment plan complexity is associated with higher caregiver burden in owners of dogs with atopic or other chronic allergic dermatitis. The independence of this relationship highlights the importance of simplicity in effective treatment planning.

Introduction

Accumulating evidence suggests that chronic disease in a companion animal is linked to caregiver burden for the owner. ¹ , ² Higher burden in the owner is, in turn, related to stress and burnout for the veterinarian via “burden transfer” ³ and contributes to owner consideration of euthanasia. ⁴ Owner reports of treatment plan complexity ² and severity of clinical signs ⁵ both predict burden in general veterinary client samples. Recent work in a canine veterinary dermatology sample demonstrated that greater severity of skin disease in the dog correlated with higher caregiver burden for the owner, ⁶ and that when skin disease was well‐controlled, burden in owners of a dog with dermatological disease did not differ from that of owners with a healthy dog. ⁶ Together, findings suggest that dermatological treatment that is effective yet simple would lead to reduced owner distress, potentially impacting upon owners’ decisions about the companion animal and translating to lower stress for the veterinarian. Treatments for atopic and other chronic allergic dermatitis range in complexity from a single monthly (or less frequent) injection, ⁷ to more complex multimodal interventions requiring combinations of oral, injectable and topical treatments, ⁸ making this an ideal population in which to examine these relationships.

This study was undertaken to first replicate previous work by showing that caregiver burden in owners of dogs with atopic or other chronic allergic dermatitis is linked to treatment complexity and disease severity. Extending past work, we sought to show that the relationship with treatment plan complexity would be present in not only the owner’s subjective report of difficulty, but also in an objective measure – frequency of skin disease treatments. A final goal was to demonstrate that these relationships would be present after accounting for severity of skin disease, suggesting an independent contribution of treatment complexity to caregiver burden.

Methods and materials

Procedure

This study was approved by the local Institutional Review Board and conducted/reported in accordance with STROBE ⁹ criteria for cross‐sectional studies. Data were collected in the period 2–29 March 2020 using an advertisement posted in social media groups for owners of dogs with allergies (n = 14,865), inviting followers caring for a dog with a skin condition to share their experience. The advertisement included a link to an online Qualtrics protocol (Appendix S1). Following informed consent, the protocol opened. Participants could opt into a draw for one of three US$50 gift cards for an online retailer.

Participants and power analysis

Participants were required to be (i) English‐speaking, (ii) ≥18 years of age and (iii) reporting on a dog with skin disease. Total number of responses was 151 (~1% response rate). Participants with incomplete measures were removed (n = 42), as were those describing a dog without allergic or atopic dermatitis (n = 23) for a final analytic sample of 86. The required sample size was determined based on research suggesting medium effects for the relationship between caregiver burden and treatment complexity ² and skin disease severity. ⁶ With significance level (α) set at P = 0.05 and power (1–β = 0.8) for a medium effect (δ = 0.5), 86 participants was sufficient to detect the hypothesized relationships.

Measures

Zarit burden interview (ZBI ¹⁰ )

An adapted 18 item ZBI validated for companion animal owner use ¹ measured caregiver burden with questions such as “Do you feel strained when you are around your pet?” Likert‐type responses [0 (never) to 4 (nearly always)] were summed for a total. Past work suggests that a score of 18 indicates meaningful caregiver burden. ¹¹ Sample internal consistency was α = 0.87.

Skin disease severity

Owners reported severity of skin disease using a previously validated measure; ¹² responses on this single item question range from 0 (not at all) to 3 (very much).

Treatment plan complexity

Subjective and objective measures of treatment plan complexity were used. Subjective measurement relied on treatment plan‐related items from the Pet Owner Adherence Scale (POAS), including “It is simple to follow my dog’s medication and/or treatment recommendations.” ¹³ POAS items 4, 5, 7, 10, 11, 12 and 15 were rated [1 (strongly disagree) to 5 (strongly agree)] and reverse‐scored as indicated (α = 0.61). Objective data were gathered by asking participants to indicate the number of individual treatments used to manage their dog’s skin condition (i.e. oral medication, injections, quick topical treatments, intense topical treatments, and other) and the number of weekly treatments was then summed.

Demographic information

Participants reported their age, gender, education and income, and the dog’s diagnosis, treatment and treatment provider type.

Statistical analyses

Descriptive statistics (means/standard deviations for continuous, frequencies for categorical data) were conducted. Nonparametric tests were utilized, given the categorical skin disease severity variable. Relationships between caregiver burden, skin disease severity and treatment plan complexity were evaluated using Spearman bivariate correlation coefficients. Spearman partial correlations were used to examine the relationships between burden and treatment complexity after accounting for skin disease severity. Statistical significance was set at P < 0.05 and held to Bonferroni–Holm sequential rejection. Analyses were conducted using SPSS 26.0 (IBM Corp; Armonk, NY, USA).

Results

Table 1 presents sample characteristics and Supplemental Table S1 for breakdown of treatment types in the sample. Table 2 provides descriptive statistics and correlations for primary variables. Mean ZBI = 19.29 indicates clinically meaningful caregiver burden. Most dogs (>80%) had moderate to severe skin disease. Significant correlations were observed between caregiver burden and disease severity (r = 0.40; P < 0.01) as well as subjective (r = 0.37; P < 0.01) and objective (r = 0.30; P < 0.01) treatment complexity. Relationships between caregiver burden and treatment complexity, both subjective (r = 0.31; P < 0.01) and objective (r = 0.31; P < 0.05), remained significant after accounting for skin disease severity.

Table 1.

Sample demographic characteristics of owners of dogs with atopic or other chronic allergic dermatitis

	Total sample, n = 86
Gender (n, %female)	86 (100.0)
Age (M/SD)	43.51 (13.09)
Education (n, %)
Pre‐high school	3 (3.5)
High school	18 (20.9)
College	48 (55.8)
Advanced degree	15 (17.4)
Declined to answer	2 (2.3)
Annual income (n, %)
<US$25,000	5 (5.8)
US$25–75,000	29 (33.7)
>US$75,000	36 (41.8)
Declined to answer	16 (18.6)
Diagnosis (n, %)
Allergic dermatitis (undetermined/unknown)	45 (52.3)
Atopic dermatitis	19 (22.1)
Both	22 (25.6)
First opinion type (n, %)
General practitioner	55 (64.0)
Referral clinician	24 (27.9)
Holistic adviser	1 (1.2)
None	6 (7.0)

Table 2.

Descriptive statistics for primary measures and correlations between caregiver burden and treatment complexity

	Total sample, n = 86	r	Partial r
Caregiver burden
Zarit burden interview‐adapted (M, SD)	19.29 (10.02);
	Range 0–63	–	–
Disease severity (n/%)
Not at all severe	1 (1.2)
A little	15 (17.4)	0.40**	–
Quite a bit	46 (53.5)
Very much	24 (27.9)
Subjective treatment complexity
Pet owner adherence scale items (M/SD)	17.79 (4.24);	0.37**	0.31**
	Range 9–36
Objective treatment complexity
Frequency of weekly skin disease	23.50 (12.77);	0.30**	0.25*
Treatments (M/SD)	Range 0–72.23

M mean; SD standard deviation; r correlation with caregiver burden.

Range of weekly treatments is not a whole number as injections given less frequently than weekly result in numbers < 1.

Partial r represents this correlation after controlling for severity of skin disease with significance.

^* P < 0.05.

^** P < 0.01.

Discussion

These findings replicate and extend previous work to show that caregiver burden is related to skin disease severity and treatment complexity (both subjective and objective) in owners of dogs with atopic or other chronic allergic dermatitis. The significance of the relationship between burden and treatment complexity was present independent of skin disease severity.

This work confirms the previously demonstrated link between severity of a dog’s skin disease and caregiver burden in the owner, ⁶ and extends past research by showing a correlation between treatment plan complexity and burden specifically in a dermatological sample. This relationship, which had been shown in a general veterinary clinic sample, appears robust given its presence in this specialty population. ²

Also noteworthy is the link between caregiver burden and an objective measure of treatment complexity. Previous work ² examining only self‐reported experience, the owner’s perception of difficulty following/understanding a treatment plan, could have been influenced by reactivity – that is, high levels of distress in a burdened owner could prompt a more negative view of the treatment plan. A tally of weekly treatments is more objective, yet exhibits a similar relationship; the more involved a treatment plan is, the greater the owner’s caregiver burden.

The significance of these correlations after controlling for severity of disease demonstrates the relative independence of this connection. Past work ⁶ and the current sample show a clear link between owner distress and presence of poorly controlled clinical signs in a dog with dermatological problems. By controlling for the contribution of skin disease severity, these new findings suggest that the complexity of the treatment plan itself contributes to owner experience of burden.

The primary implication of this work is the importance of simplicity in treatment planning. Aetiologies of, and existing treatments for, skin disease are highly varied. ¹⁴ Each case is different and successful management will at times require complex treatment planning. However, this study highlights the importance of starting with the simplest effective treatment, as it may reduce owner strain. Reduced burden might, in turn, enhance the owner’s treatment compliance, leading to better long‐term management and disease control for the dog, and decreased burden transfer for the veterinarian.

Limitations of this work include the low number of dogs with well‐controlled skin disease; the current sample does not represent the full spectrum of this population. This range restriction suggests that the strength of the relationships detected here might actually be of greater magnitude in samples including more owners of dogs with well‐controlled skin disease. Replication in broader samples, such as combined general veterinary and veterinary dermatology clinic recruitment, is recommended. Such data would likely yield greater variance in burden (i.e. more participants with low levels of burden), allow for a more objective assessment of disease severity by a veterinarian, provide specific information regarding onset and duration of disease, and could better facilitate understanding of any regionally‐specific differences. A further limitation lies in the cross‐sectional study design, which precludes determination of directionality. It cannot be ruled out that owners in the current sample are following treatment regimens reflecting the absolute minimum treatment necessary to control their dog’s skin disease. However, suboptimal treatment was likely present in at least part of the sample, as <30% were followed by a specialist veterinary dermatologist, and some were managing skin disease with no professional monitoring. Additionally, participant responses in this study precluded direct comparison of how specific treatment types (e.g. oral versus injection or topical treatment) contribute to caregiver burden, an important future direction of study.

In summary, owners of dogs with atopic or other chronic allergic dermatitis demonstrated caregiver burden that was related to skin disease severity and measures of subjective and objective treatment complexity. Because the relationship between burden and treatment plan was not driven solely by skin disease severity, the complexity of treatment itself appears to be an important contributor to owner burden. Findings emphasize the importance of utilizing the simplest effective treatment possible.

Supporting information

Table S1. Percentage of sample reporting use of various treatments.

Appendix S1. Online Qualtric protocol utilized in data collection for current study.