Trends in companion animal access to veterinary care in Canada, 2007 to 2020

Abstract

Objective

Assess trends in access to veterinary care for companion animals in Canada.

Procedure

Analysis and integration of available data, 2007 to 2020.

Results

Cumulative growth in the Canadian veterinary workforce was 38%, and 49% for companion animal veterinarians. Clients per companion animal veterinarian decreased 30% from 2008 to 2020. Absolute client numbers increased 1.3%, compared to pet population growth of 17%. Medicalized pets (those that had received veterinary care in the past year) increased 25%, from 9.02 million in 2007 to 11.24 million in 2020. Non-medicalized pets increased 1.8%, from 4.48 million to 4.56 million. In 2007, 33% of pets were non-medicalized, compared to 29% (15% of dogs and 42% of cats) in 2020. There was a cumulative increase of 31% for total non-medicalized dogs, and a change of −5.6% for cats. Gross and net revenues per client increased by 99 and 112%, respectively, compared to cumulative inflation of 21%.

Conclusion and clinical relevance

The analysis identified a large cohort of pets that had not received veterinary care each year. The trends were fewer clients per veterinarian, each paying higher veterinary costs, and suggested a relative, rather than absolute, veterinary capacity shortage overall. Accessible care-provision models must be encouraged, regulated for, and allowed to flourish alongside traditional models.

Introduction

The lack of available and affordable veterinary care for companion animals is an important animal welfare and societal concern (1,2). Targeted measures and appropriate funding to address access-to-care challenges rely on credible data. However, although problems have been eloquently articulated (3,4), there is a lack of peer-reviewed, data-driven Canadian studies that address this issue. The lack of previous analyses addressing this area of animal welfare and the difficulty accessing accurate data in Canada are concerning. As a result, assumptions and extrapolations about Canadian veterinary care are frequently made using information from the United States. Considering differences in income distributions and inequality between the 2 countries (5,6), as well as myriad other differences, this is not a valid approach.

Available data are primarily profession- and business-centered rather than patient- and family-centered, and frequently are proprietary or situated behind paywalls. Provincial and territorial data for licenced veterinarians are collected inconsistently between jurisdictions. Further, available data and analyses do not integrate key factors that affect access to veterinary care. There is growing literature on accessible veterinary care, but it remains primarily United States-centric (7). An accessible care-focused understanding of the interplay between even some of the pertinent factors in Canada would be an important step forward.

This study gathered data relating to the Canadian veterinary workforce, client and pet numbers, pets receiving veterinary care (“medicalized”) and those not receiving veterinary care (“nonmedicalized”), and veterinary clinic revenues. We integrated these data into an analysis that focused on factors relevant to access to veterinary care in Canada, and assessed trends from 2007 to 2020.

Materials and methods

The study analyzed trends in Canada from 2007 to 2020 using available data for numbers of licenced veterinarians, pet population, pets receiving medical care, clients per veterinarian, and revenue per veterinarian. Data sources are listed in Table 1.

Table 1.

Data sources used to assess trends in companion animal veterinary care in Canada, 2007 to 2020.

Veterinary workforce
Alberta	CVMA study (8), Alberta VMA annual reports
British Columbia	CVMA study (8); Dr. Megan Bergman, personal communication (2015 to 2016); VMA annual reports (2009 to 2010, 2017 to 2020)
Manitoba	CVMA study (8), Manitoba VMA annual reports (2009 to 2018)
New Brunswick	CVMA study (8); Dr. Nicole Jewett, personal communication
Nova Scotia	Nova Scotia VMA, Fair Registration Practices Act review 2019
Northwest Territories	Ravan Bedingfield, personal communication
Ontario	CVMA study (8), CVO annual reports (2011 to 2020)
Prince Edward Island	CVMA study (8)
Quebec	CVMA study (8), OMVQ annual reports
Canada (2007 baseline)	CVMA study (8)
% companion animal veterinarians	CVMA study (8)
Population data
Pet population, medicalized petsa, % households with pets	2020 Canadian pet ownership study (9)
Economic data
Clients per companion animal veterinarian, revenues	CVMA practice owners’ economic survey (2013, 2017, 2018, 2019, 2021) (10–14)
CPI inflation	Statistics Canada (15)

CVMA — Canadian Veterinary Medical Association; VMA — Veterinary Medical Association; CVO — College of Veterinarians of Ontario; OMVQ — Ordre des médecins vétérinaires du Québec; CPI — Consumer price index.

^aDefined as a pet that had visited a veterinary clinic in the past 12 mo.

Total licensed and companion animal veterinarian numbers were obtained from the 2020 Canadian Veterinary Medical Association (CVMA) Workforce Study (8). In addition, veterinarian numbers were sourced directly from provincial and territorial licensing bodies or annual membership reports. All licensing bodies for which the data were not openly available in annual reports were contacted to request the annual number of licensed veterinarians in their jurisdiction from 2008 onwards. These numbers were used for years or provinces for which data were not provided in the CVMA Workforce Study.

Estimates of companion animal veterinarians were available for some provinces and some years (8). To generate counts for years for which estimates were not provided, the estimated percentage of companion animal veterinarians was extrapolated forward or backward from the most recent year for which an estimate was provided.

Annual pet (cat and dog) populations were estimated from graphs published in the Canadian Animal Health Institute (CAHI) 2020 Pet Ownership Survey (9). The percentage of pets receiving veterinary care was obtained from the same survey. Economic data regarding the number of companion animal clients and revenue per full-time equivalent companion animal veterinarian were obtained from CVMA practice owners’ economic surveys (10–14). Canadian population figures and consumer price index (CPI) were sourced from Statistics Canada (15,16).

Due to the absence of complete national or provincial/territorial veterinary workforce data, the annual Canadian veterinary workforce was calculated using the 2007 CVMA estimate (8) as a baseline and applying year-on-year growth calculations. Year-on-year percentage growth was calculated using pooled data for all provinces, with data for the year in question and the previous year:

$$\frac{(\mathrm{\Sigma }\hspace{0.17em}\text{Current\hspace{0.17em}year\hspace{0.17em}licenses})-(\mathrm{\Sigma }\hspace{0.17em}\text{Previous\hspace{0.17em}year\hspace{0.17em}licenses})}{(\mathrm{\Sigma }\hspace{0.17em}\text{Previous\hspace{0.17em}year\hspace{0.17em}licenses})}\times 100\%$$

Sensitivity analysis was done to assess effects of altering assumptions used in the extrapolation, as well as effects of including only provinces with complete data.

Total number of companion animal clients was calculated as a product of clients per companion animal veterinarian and estimated companion animal veterinarians. Average annual revenues per companion animal client were calculated from economic survey data (10–14).

Measures of uncertainty (standard error, 95% confidence interval, margin of error) were compiled for survey datasets using data provided by Kynetec and CVMA. Key data were converted to cumulative percentage changes over the study interval to better assess and visualize patterns of change.

Results

Numbers of total licensed veterinarians were obtained for all years from 2008 to 2020 for Ontario, Quebec, and the Northwest Territories, and were available for at least 2 consecutive years from all other jurisdictions except Newfoundland, Nova Scotia, Nunavut, and the Yukon (Table 2). The average year-on-year change in the Canadian veterinary workforce was 2.5%, with a range of 1.1 to 4.1% (Table 2). By applying year-on-year changes to the 2007 baseline of 10 139 total veterinarians in Canada (8), we calculated that there were 14 010 total veterinarians in 2020, an increase of 38% over the study interval (and of 33% to 2019, the last year of the CVMA study). When comparing the 20 province/year pairs for which both Toronto Humane Society and CVMA data were available, the difference between veterinarian numbers ranged from 0.1 to 18%, with all differences being < 1% for Ontario, the largest province (by population) for which this comparison could be made (see Appendix 1, available online from: www.canadianveterinarians.net). Furthermore, based on sensitivity analysis, using more conservative estimates or including only provinces with complete data had limited effects on results (data not shown).

Table 2.

Total licensed veterinarians in Canada, 2007 to 2020. Data are number of veterinarians and % change from previous year.

	2007	2008	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019	2020
AB						1455	1511		1604	1639	1672	1709	1782	1832
AB %							3.8			2.2	2.0	2.2	4.3	2.8
BC		1225	1301	1329			1343	1354	1432	1427	1528	1594	1507	1757
BC %			6.2	2.2				0.8	5.8	−0.3	7.1	4.3	−5.5	17
MB			345	347	345	387	383		358	359	371	381	388
MB %				0.6	−0.6	12	−1.0			0.3	3.3	2.7	1.8
NB	175	150		185	193	194	209	214	219	214	229	232	246
NB %		−14			4.3	0.5	7.7	2.4	2.3	−2.3	7.0	1.3	6.0
NWT		17	19	18	22	21	22	30	29	30	28	28	28	27
NWT %			12	−5.3	22	−4.5	4.8	36	−3.3	3.4	−6.7	0.0	0.0	−3.6
ON	3850	3983	4087	4206	4304	4401	4542	4588	4564	4674	4758	4867	5023	5124
ON %		3.5	2.6	2.9	2.3	2.3	3.2	1.0	−0.5	2.4	1.8	2.3	3.2	2.0
PEI								182	182	182	185	179	191
PEI %									0.0	0.0	1.6	−3.2	6.7
QC		2030	2090	2158	2291	2342	2375	2449	2494	2520	2578	2640	2646	2697
QC %			3.0	3.3	6.2	2.2	1.4	3.1	1.8	1.0	2.3	2.4	0.2	1.9
SK				457	467	489	493	511	514	529	533	530	540
SK %					2.2	4.7	0.8	3.7	0.6	2.9	0.8	−0.6	1.9
Total % change		2.7	3.3	2.8	3.4	2.8	2.6	1.8	1.1	1.6	2.7	2.3	1.6	4.1
Canadian veterinariansa	10 139	10 411	10 758	11 055	11 431	11 749	12 060	12 278	12 417	12 611	12 947	13 249	13 458	14 010

Numbers in regular font are values sourced from the CVMA study (8); numbers in bold font are primary data.

AB — Alberta; BC — British Columbia; MB — Manitoba; NB — New Brunswick; NWT — Northwest Territories; ON — Ontario; PEI — Prince Edward Island; QC — Quebec; SK — Saskatchewan; Total % change — year-on-year % change, all veterinarians.

^aCalculated from 2007 baseline, using year-on-year percentage changes derived from the raw data and shown in the row above.

Estimated percentages of companion animal veterinarians, defined as those who spent at least 10% of total time on companion animals (8), were available or could be extrapolated for British Columbia, Manitoba, New Brunswick, Ontario, Prince Edward Island, Saskatchewan, and Quebec (Table 3). Average annual growth for companion animal veterinarians was 3.1%, with a range of −0.8 to 7.9%. The number of companion animal veterinarians grew steadily from 2007, except for a slight decrease in 2015. Applying calculated growth rates to the 2007 estimate of 8000 companion animal veterinarians (8) resulted in 11 885 companion animal veterinarians in 2020, an overall growth of 49% (42% to 2019, the last year of the CVMA survey) (Figure 1).

Table 3.

Companion animal veterinarians in Canada, 2007 to 2020, calculated from total veterinarian numbers for provinces for which estimates were available.

	2007	2008	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019	2020
BC — total		1225	1301	1329			1343	1354	1432	1427	1528	1594	1507	1757
BC — CAV %		73	73	73			73	73	73	73	73	73	73	73
BC — CAV		894	950	970			980	988	1045	1042	1115	1164	1100	1283
MB — total			345	347	345	387	383		358	359	371	381	388
MB — CAV %			42	42	42	42	42		42	44	44	45	41
MB — CAV			145	146	145	163	161		150	157	163	171	161
NB — total	175	150		185	193	194	209	214	219	214	229	232	246
NB — CAV %	71	71		71	71	73	74	73	75	77	77	76	77
NB — CAV	124	107		132	137	141	154	157	165	165	176	176	190
ON — total	3850	3983	4087	4206	4304	4401	4542	4588	4564	4674	4758	4867	5023	5124
ON — CAV %	75	75	75	75	75	81	83	84	81	81	84	84	84	84
ON — CAV	2888	2987	3065	3155	3228	3565	3770	3854	3697	3786	3997	4088	4219	4304
PEI — total								182	182	182	185	179	191
PEI — CAV %								27	27	27	27	28	27
PEI — CAV								49	49	49	50	50	52
QC — total		2030	2090	2158	2291	2342	2375	2449	2494	2520	2578	2640	2646	2697
QC — CAV %		67	67	67	67	67	67	67	67	67	67	67	67	67
QC — CAV		1360	1400	1446	1535	1569	1591	1641	1671	1688	1727	1769	1761	1807
SK — total				457	467	489	493	511	514	529	533	530	540
SK — CAV %				20	20	22	21	23	24	24	24	25	25
SK — CAV				92	95	107	105	115	124	128	126	131	136
CAV % change		2.7	3.3	2.8	3.4	7.9	4.3	2.3	−0.8	1.6	4.9	2.6	0.9	4.4
Total CAV	8000	8218	8490	8728	9027	9738	10 153	10 391	10 310	10 479	10 987	11 277	11 382	11 885

Values in regular font were sourced from the CVMA study (8); numbers in bold font are primary data; shaded cells show percentages extrapolated backward or forward from the most recent year where an estimate was provided.

BC — British Columbia; MB — Manitoba; NB — New Brunswick; ON — Ontario; PEI — Prince Edward Island; QC — Quebec; SK — Saskatchewan; CAV — Companion animal veterinarian; CAV % change — year-on-year % change, all CAV.

Figure 1.

Cumulative changes in veterinarian numbers in Canada in relation to client numbers, 2007 to 2020. Data are shown as percentage change from the first year for which data were available.

Average number of clients per companion animal veterinarian was highest (1266) in 2008, decreased 35% to 826 by 2015, and then partly rebounded to 887 in 2020 (Table 4), 30% below the 2008 peak. Total number of companion animal clients decreased from 10.40 million in 2008 to a low of 8.30 million in 2011, and then increased to 10.54 million in 2020, an increase of 27% from the lowest point and 1.3% over the entire study interval (Figure 1). Measures of uncertainty for the practice economic survey are shown in Appendix 2 (available online from: www.canadianveterinarians.net).

Table 4.

Veterinarians, clients, pets, and medicalized pets in Canada, 2007 to 2020.

	2007	2008	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019	2020	Changea
Clients
Clients per CAV		1266	1101	1116	919	903	888	845	826	865	855	828	816	887	−30%
Total CAV clients (106)		10.40	9.35	9.74	8.30	8.79	9.02	8.78	8.52	9.06	9.39	9.34	9.29	10.54	1.3%
Pets
Pets (millions)
Households with pets						7.67		7.71		9.17		9.08		10.31	34%
Total pets	13.5			14.5		14.9		15.2		15.5		15.7		15.8	17%
Medicalizedb	9.02			9.19		10.10		10.42		10.67		11.15		11.24	25%
Medicalized %	67			63		68		69		69		71		71
Non-medicalized	4.48			5.31		4.80		4.78		4.83		4.55		4.56	1.8%
Non-medicalized %	33			37		32		31		31		29		29
Dogs (millions)
Total dogs	5.5			6.4		6.8		7.1		7.4		7.6		7.7	40%
Medicalized	4.62			5.06		5.64		5.96		6.22		6.54		6.55	42%
Medicalized %	84			79		83		84		84		86		85
Non-medicalized	0.88			1.34		1.16		1.14		1.18		1.06		1.16	31%
Non-medicalized %	16			21		17		16		16		14		15
Cats (millions)
Total cats	8.0			8.1		8.1		8.1		8.1		8.1		8.1	1.3%
Medicalized	4.40			4.13		4.46		4.46		4.46		4.62		4.70	6.8%
Medicalized %	55			51		55		55		55		57		58
Non-medicalized	3.60			3.97		3.65		3.65		3.65		3.48		3.40	−5.6%
Non-medicalized %	45			49		45		45		45		43		42

CAV — Companion animal veterinarian.

^aPercentage change from first to last available data point.

^b“Medicalized” and “non-medicalized” were defined as pets that had or had not visited a veterinary clinic in the past 12 mo, respectively.

Estimates for households with pets were only available from 2012, and increased from 7.67 million in that year to 10.31 million in 2020 (34%) (Table 4). Total pet numbers increased from 13.5 million in 2007 to 15.8 million in 2020 (17%). The number of medicalized pets [defined as those that had received veterinary care in the past year (9)] rose 25%, from 9.02 million in 2007 to 11.24 million in 2020, representing 67% of pets in 2007 and 71% of pets in 2020. Total non-medicalized pets [defined as those that had not received veterinary care in the past year (9)] rose 1.8% over the same interval (4.48 million to 4.56 million), representing 33% of pets in 2007 and 29% of pets in 2020. Measures of uncertainty for the pet population survey are shown in Appendix 3 (available online from: www.canadianveterinarians.net).

Different trends were observed for dogs versus cats (Figures 2, 3). There was an increase of 40% in the total dog population over the study interval, which markedly exceeded the 1.3% increase in the pet cat population. The percentage of medicalized dogs remained close to 85%, except for a decrease to 79% in 2010. Absolute medicalized dog numbers increased from 4.62 million (84%) in 2007 to 6.54 million (86%) in 2018; this was similar in 2020 (6.55 million, 85%) (Figure 3). There was a 42% cumulative increase in the number of medicalized dogs over the study interval, compared to 6.8% for cats. Cumulative changes for medicalized dogs were similar to those for companion animal veterinarians (Figure 3). There was a sharp cumulative increase in non-medicalized dogs in 2010, with a partial reversal of this trend in 2012 and limited change to 2020, except for a cumulative decrease in 2018 (Figure 3). There was a cumulative increase of 31% for non-medicalized dogs over the entire study interval, with absolute numbers remaining at ~1.1 to 1.2 million from 2014 to 2020 (Table 4). Over the study interval, averages of 16% of dogs and 45% of cats had not been seen by a veterinarian in the previous year (i.e., were “non-medicalized”).

Figure 2.

Cumulative changes in medicalized and non-medicalized cat populations in Canada, in relation to changes in client and veterinarian numbers, 2007 to 2020. Data are shown as percentage change from the first year for which data were available.

Figure 3.

Cumulative changes in medicalized and non-medicalized dog populations in Canada, in relation to changes in client and veterinarian numbers, 2007 to 2020. Data are shown as percentage change from the first year for which data were available.

Average gross revenue per companion animal client in 2008 was $366, with average net revenue of $110. In 2020, average gross revenue per client was $729, 99% higher than in 2008; and average net revenue was $233, 112% higher than in 2008 (Figure 4). Gross revenue per client grew by an average of 5.9% annually in the 12 y after 2008. By comparison, the average annual inflation rate, or growth in the CPI, was 1.6% during this interval (15). If revenue growth had approximated the CPI, this would have resulted in average gross revenue per client of $444, and net revenue of $133, in 2020. The cumulative 99% increase in costs to clients from 2008 to 2020 exceeded the cumulative 21% increase in CPI by 78%. Cumulative trends for revenues and client numbers/ratios are shown in Figure 4.

Figure 4.

Cumulative changes in gross and net revenues reported by Canadian companion animal hospitals, in relation to changes in clients and inflation, 2007 to 2020. Data are shown as percentage change from the first year for which data were available.

Discussion

This study represents the first analysis of veterinary care in Canada through an accessible care lens. Throughout the study interval, several million Canadian pets had consistently not visited a veterinarian in the previous year, and compared to dogs, a markedly higher percentage of cats had not seen by a veterinarian. This was consistent with the fact that cat owners are less likely to take their cats to the veterinarian due to the stress of transport and veterinary visits (17). In the 2018 United States Access to Veterinary Care study, within the past 2 y, 23% of pet owners had not been able to access preventative care when they wanted to receive it, 14% were unable to access sick care, and 7.7% could not access emergency care when needed (18). The survey data used for our study (9) did not include reasons for not visiting a veterinarian. It was therefore impossible to estimate how many were healthy animals whose caregivers did not see the need for preventive care or were unable to access it, and how many were sick animals that were unable to access care. The scale of the welfare implications for this large cohort of non-medicalized pets is therefore unclear. However, it is reasonable to assume that it includes many animals that required, but did not receive, care.

Immediately after the recession of 2007 to 2009, numbers of clients and medicalized cats decreased, whereas numbers of non-medicalized dogs and cats both increased. The change for non-medicalized dogs was substantial. Decreases in the number of patient visits were also noted in the United States following the recession (17). As in our study, this occurred despite an increase in the pet population. The Canadian pet population increase was driven primarily by increases in the dog population, whereas in the United States, both cat and dog populations increased (17). The American study identified multiple factors that contributed to decreases in client visits, including factors that predated the recession and were unrelated to it. However, pet owners with lower household incomes and those who were affected by unemployment, which doubled during the recession, were less likely to take their pets to the veterinarian (17). The impact of the recession on access to veterinary care has not been directly analyzed for Canada, but based on our data, it was likely substantial. This has self-evident implications for the post-pandemic interval.

Client numbers recovered very slowly after the nadir in 2011, and the small cumulative increase from 2008 to 2020 lagged far behind the increase in pet numbers, particularly for dogs. For dogs, cumulative changes in medicalization quite closely tracked changes in companion animal veterinarian numbers, whereas changes were negligible for cats from 2012 to 2016, followed by a modest improvement. Stagnation in total client numbers was at odds with trends for medicalized pets. This could be explained by a greater number of pets per client, although this was not supported by available data, which were limited (9).

Despite primarily using CVMA study data, our estimate of 13 458 total veterinarians in 2019 differed by 572 (4.3%) from the reported 12 886 (8). Growth in the veterinary workforce from 2007 to 2019 was reported as 21% (8), compared to 33% using our estimates. One reason for apparent differences between datasets might be that the CVMA study included veterinarians employed in practice, whereas our count included all licensed veterinarians. Another might be that our study included more complete data, as more provinces and years were represented. Calculation methods may also have had a role.

Establishing companion animal veterinarian numbers was problematic. Not only were years and provinces missing, but “companion animal veterinarians” were loosely defined (8). The study unavoidably provided an unverifiable estimate of the number of full-time equivalent companion animal veterinarians in Canada. A repeat analysis using a lower, “best-guess” estimate of 75% companion animals for all years and provinces (data not shown) did not affect trends in our study. Veterinary regulators must collect information from all licensees annually. Consistent information about practice types and hours worked would be of great value for future analyses.

The CVMA has identified a lack of capacity for the current veterinary workforce to meet the demand, and strategies to address this problem (8,19). The capacity shortage is counterintuitive given that, based on our study, growth in the number of veterinarians outpaced growth in client and pet numbers. A partial explanation for the capacity shortage could be the cumulative increase in dog numbers to 2020, which was slightly greater than the increase in the veterinary workforce and quite closely tracked growth in the companion animal veterinarian workforce. The dog population drives more demand for companion animal veterinary services, as dogs are more likely than cats to be taken to a veterinarian (9). However, this is unlikely to entirely account for the shortage, as number of clients per veterinarian did not increase.

The time available for each animal is likely an important contributor to the capacity shortage. The outgoing president of the CVMA stated that veterinarians “spend twice as much time with each pet as we used to” (20). There can be no general argument against offering more sophisticated and labor-intensive care if it improves welfare and outcomes. However, it is not always clear that better outcomes are necessarily achieved through more intervention, and there are relatively few outcomes-based veterinary studies to guide clinical practice and cost-effective interventions (1). Client expectations, as well as concerns about lawsuits, disciplinary action, and negative comments on social media are all likely to contribute to a culture of practising defensive medicine (1). Eighty-four percent of United States veterinarians surveyed were comfortable offering alternatives to the perceived standard of care if clients could not afford that level of care, but 80% felt obligated to offer the same standard of care to all clients, and 41% were concerned about professional liability if they provided care that did not meet the standard (18). Another explanation for insufficient capacity is the possibility that veterinarians may work fewer hours, on average, than in 2008. It is difficult to assess this for the study interval, as CVMA estimates of veterinarians working part time, full time, and overtime (8) provide only a partial picture. Finally, the total number of veterinarians does not reflect the geographic realities of Canada, with few veterinarians in remote areas and some areas lacking veterinary services entirely — an acknowledged problem for which no ready solution has been identified (8).

Senior members of the North American veterinary community have voiced concerns that veterinary care may be becoming a luxury (21,22). Veterinary care is paid for with disposable income (8), placing a disproportionate burden on low-income families. In 2008, 22% of Canadian households that did not have pets cited cost as the main reason (23). Veterinary costs were reported to be 1/5 to 1/3 of the annual cost of pet care (23).

Higher cost of care was suggested as a reason for the decline in new client acquisitions in the United States to 2011 (17), and could explain why the decrease in client numbers per veterinarian in our study was associated with per-client revenues that substantially outpaced inflation over the study interval. This trend of increased revenues alongside lower client numbers has continued since 2020 (24).

Increased willingness of more affluent clients to spend more on advanced care creates additional demand for the currently inadequate capacity and resources within the industry. Substantial growth in referral and specialty qualifications and services is an important factor (8,25). Primary care veterinarians may no longer feel equipped to manage conditions or procedures that, until recently, were dealt with in-house. When surgeries, in particular, are referred without in-house alternatives, costs escalate drastically and clients may be faced with surrender or euthanasia as their only options (26,27).

Gross revenue reflects direct costs to clients and is the more important measure from an accessible care perspective. It must be noted that the overall increase in veterinary revenues represents an average, does not account for practices that are struggling, and could reflect survey self-selection bias toward practices that are thriving. Many practitioners provide discounted services to clients in need, as well as to rescue and shelter organizations, and this is not reflected in economic surveys.

Net income in the CVMA economic surveys reflects gross income less non-veterinarian expenses, and does not include veterinarians’ salaries, bonuses, and practice owner income (28). Wages for veterinarians have historically been low (29), with median compensation of $79 000 in 2015 (30), compared to average payments of $271 000 to family practice physicians (31). Production-based pay has been suggested as a way to increase associate compensation (30) but could be expected to contribute to escalating client costs. However, failure to improve compensation could result in fewer entrants to the profession as well as greater attrition, further exacerbating the capacity shortage.

All these factors make it increasingly difficult for conventional veterinary practices to offer more equitable, lower-cost care. Unless addressed, this will result in veterinary care being priced further out of the reach of lower income clients.

Although not the focus of the study, the large cumulative increase in the dog population over the study interval warrants comment. This increase did not parallel statistics from the United States (32,33) and cannot be accounted for by very different increases in population growth or number of households (34–36) The percentage of households with dogs in Canada decreased from 2011 to 2020, the only years for which this information was available (16). Growth in dog numbers would therefore have been driven by a greater number of dogs per household, population growth, or both. Alternatively, the increase might be due to survey error. Pet population numbers can differ substantially between surveys, with the American Veterinary Medical Association reporting estimates 20 to 25% lower than the American Pet Products Association, and both having higher estimates than a Census Bureau study (33).

The main limitations of this study were the lack of studies directly addressing access to care, the need to rely on multiple data sources that were not intended to be integrated, and some missing data. The study ended at the year 2020, in part because most data were only available to that point at the time of writing, but also because the pandemic and post-pandemic intervals are likely to differ substantially from the pre-pandemic interval and warrant separate analysis. This analysis should be viewed as a starting point, and further investigations are strongly encouraged.

Survey focus and methodology, as well as inherent limitations in survey results, may have affected study findings. Probability surveys are intended to be extrapolated to a target population with reasonable confidence. Various sources of error exist, including sampling, coverage, non-response, measurement, and processing errors (37). These challenges have been compounded in recent years by changes in technology and social norms, which have required adaptations of traditional surveying methods (37). Practice records are not always accurate or complete (17), and accurate population estimates are difficult to access and are influenced by many factors (33,38). Surveys used for our study were conducted to investigate veterinary business performance, supply and demand for professional services, and market opportunities. Practice geography and type were not reported for economic surveys, and owner demographics and socioeconomic status were not reported for pet population surveys. Finally, the pet population survey included only respondents who spoke English or French, thereby potentially excluding respondents who are not proficient in these languages and may face greater socioeconomic challenges. Surveys conducted with an equity lens (18,39) are specifically designed to include low-income and underserved families and communities, and results of such surveys may differ from those presented.

Survey trends are generally more reliable than absolute estimates (33), supporting the decision to primarily present study data as cumulative changes over time rather than as absolute values. Trends from a single source also tend to be reliable (33). Although there was uncertainty in the data [margin of error > 5% for the practice economic survey and > 1% for the pet population survey (see Appendices 2, 3, available online from: www.canadianveterinarians.net)], they were considered accurate enough to identify general trends in access to veterinary care.

We identified a relatively stable percentage of non-medicalized animals over time. Therefore, absolute numbers will continue to increase even if these trends hold, which seems unlikely (40,41). Current practice and regulatory models will not be able to address these needs. Even if numbers of veterinarians increase at the desired rate (8,19), this is unlikely to address lack of access resulting from socioeconomic and geographic factors. Other care-provision models should be encouraged, regulated for, and allowed to flourish alongside traditional models of care. Unless actively addressed, all identified trends will accelerate the phenomenon demonstrated by our analysis: fewer clients, each paying higher veterinary costs, with the inevitable future exclusion of many who are currently able to access veterinary care, and the continued exclusion of those who are not.