The economic impact that registered veterinary technicians have on Ontario veterinary practices

Abstract

In Canada, registered veterinary technicians (RVTs) are highly trained, regulated professionals working as an integral part of the veterinary team, but there has been little work to quantify their impact on veterinary practices. The objectives of the study were to explore the utilization rates of RVTs and quantify the economic value that RVTs bring to veterinary practices in Ontario, Canada. An online survey was deployed to explore the function of RVTs and their non-credentialed counterparts in practices. There were 169 responses, with 112 respondents providing economic indicators. For each additional RVT/veterinarian, gross annual revenue per veterinarian (RPV) increased by $79 118 (SE = $21 146, P < 0.0001). For 1- and 2-veterinarian practices, if the veterinarian frequently performed RVT duties, the practices were less profitable than clinics that relied on RVTs to perform such duties (P = 0.0001). Finally, clinics which paid their RVTs over $21 per hour earned $122 342 (SE = $58 874, P = 0.04) more RPV relative to clinics which paid their RVTs $15 or less per hour.

Introduction

In Canada, registered veterinary technicians (RVTs) are highly trained, regulated professionals working as an integral part of the veterinary medical team (1,2). In other countries or regions, RVTs may be referred to as veterinary nurses or certified/credentialed/licensed veterinary technicians. Typically employed in private veterinary practice, an RVT works under the supervision of a licensed veterinarian, employing their knowledge and practical skills in animal health, welfare, and husbandry to deliver high-quality veterinary care. In Ontario, the profession is regulated by the Ontario Association of Veterinary Technicians (OAVT) through the Ontario Association of Veterinary Technicians Act (2). A major mandate of the OAVT is to “promote, maintain, and regulate the professional standards of veterinary technicians and veterinary technologists” in Ontario (2). Use of the title “RVT” requires that an individual has completed a veterinary technician program at an accredited college, passed the Veterinary Technician National Exam, completed a criminal record check, and registered with the OAVT. As a regulated profession, to attain licensure, RVTs are expected to be proficient at a host of core competencies that range from technical duties (e.g., animal restraint, catheter placement) to advanced functions (e.g., anesthesia, dental assessments and treatments, nutritional consulting) (3).

Despite a high level of training and competence, many veterinarians and RVTs feel as though they are underutilized (4,5). In human healthcare, registered nurses (RNs) fill an analogous role to that of RVTs. Numerous studies have found that, when employed to the full extent of their abilities, RNs improve the quality of patient care while concurrently enabling physicians to practice more efficiently (6–9).

A team-based approach to veterinary care has been advocated for, in which “a highly functional, highly coordinated veterinary healthcare team provides the formula for achieving team satisfaction, quality patient care, and profitability” (10). Indeed, a team-based approach in which practices cultivate interpersonal relationships and reciprocity could improve patient outcomes and, potentially practice profitability (11). Despite this, there is little published literature regarding the utilization rates and value that RVTs bring to veterinary practice. One study completed in the United States found that, for every additional RVT per veterinarian added to a practice, gross revenues increased by $93 311 (12). This study is over 10 y old and did not explore other important practice demographics or RVT utilization rates. Therefore, the objectives of the current study are to explore the utilization rates of RVTs and quantify the economic value that RVTs bring to veterinary practices in Ontario, Canada.

Materials and methods

In accordance with the Tri-Council Policy Guidelines on Research Involving Humans, as the focus of the current study was on how RVTs impact the veterinary businesses of survey respondents and not the respondents themselves; ethical approval was not considered necessary (13). Respondents were not required to identify their businesses. Any information provided that may have identified participating businesses was anonymized for analysis and reporting. For the purposes of this study, the title RVT refers to veterinary technicians who have graduated from an accredited college, have passed their licensing exam, and are currently registered with the OAVT. Non-credentialled veterinary assistants (NC) are those auxiliaries who perform tasks outlined in the core competencies of RVTs (3), but are not licensed with the OAVT.

Survey design

Based on the list of essential competencies set out in the “Objects, By-Laws, Code of Ethics of the Ontario Association of Veterinary Technicians” (3), an online survey was constructed using Survey Monkey (SurveyMonkey, San Mateo, California, USA; www.surveymonkey.com). The survey was used to assess the current utilization levels of RVTs and NCs, as well as the value that they bring to Ontario veterinary practices. Specifically, the survey explored practice demographics (e.g., species served, number of clients, number of employees), services provided (e.g., dental, nutritional consulting, physical therapy), economic indicators in practice (e.g., gross practice revenue, RVT and NC hourly wages), and the current functions of both RVTs and NCs in practice. A short survey pretest was conducted with animal health professionals to ensure that the questions were clear. The final survey is included in supplemental materials available from the authors on request.

Survey deployment

The target audience for the survey was veterinary practices serving companion animals in Ontario (small animal, mixed large and small animal, equine, and specialty animal clinics). The targeted person(s) for survey completion were office/business managers and/or managing veterinarians of the practice. Persons filling these roles were expected to have intimate knowledge of the functions that RVTs and NCs had in the practice, as well as the financial status of the business.

The online survey was disseminated by e-mail and trade publications to the memberships of the OAVT (Guelph, Ontario, Canada) and the Ontario Veterinary Medical Association (Milton, Ontario, Canada), the advocacy organization for Ontario veterinarians. In addition, social media platforms (Facebook, LinkedIn, and Twitter) were employed to further increase the reach of the survey within Ontario.

Statistical analysis

Survey response data were downloaded from the survey delivery system. All survey attempts that were made by non-target audiences (e.g., those identifying as RVTs, non-managerial employees) were excluded from the final dataset. The dataset was imported as comma-separated files into the STATA 14 statistical software program (StataCorp LP, College Station, Texas, USA) for statistical analysis.

Descriptive statistics and univariable analysis

Descriptive statistics were generated for all variables. Data were assessed for outliers. There were 4 instances in which values provided for gross practice revenue were single or double digits. These were treated as data entry errors and excluded from the analysis. Values for practice gross revenue were converted into numeric form (e.g., some values entered as 1 million and not $1 000 000). Composite variables assessing the degree to which RVTs and NCs performed tasks within the core competencies of the RVT profession were constructed. Briefly, each clinic received a composite score by summing the ordinal numeric response variables assessing the frequency (0 = never, 1 = sometimes, 2 = often, 3 = always) of all technician activities within the clinic [Supplemental material, questions 12 (RVTs) and 13 (NCs)]. The variable “annual gross revenue per veterinarian (RPV)” was generated by dividing gross revenue by full-time equivalent veterinarians at the practice. Revenue per veterinarian was used as the primary outcome, as it indicates efficiency in practice (i.e., veterinarians able to generate more revenue per unit time are more efficient). It was hypothesized that higher levels and utilization rates of RVTs in the clinic would be associated with increased efficiency as measured by RPV. Normality of all continuous variables was assessed through visual distribution plots, as well as Q-Q plots (14).

Variables assessed at the univariable stage of analysis include: clinic practice class, geographic area, number of veterinary owners, number of employees (veterinarians, RVTs, and NCs), practice employee turnover rates, perception of the importance of RVTs to practice, hourly rates of RVTs and NCs, the frequency that veterinarians, RVTs, and NCs perform tasks within the RVT scope of practice, specialized services offered by the clinics, and the number of RVTs and NCs per full-time veterinarian equivalent employee. All relevant survey variables were screened for their association with RPV via univariable linear regression. Any variable with a liberal statistical association (P < 0.2) was explored further in multivariable linear regression. A LOESS curve was used to assess the linear relationship between RPV and any continuous variable. All continuous variables that did not have a linear relationship with the outcome of interest were categorized into quartiles for further analysis.

Multivariable regression analysis

A multivariable mixed model was constructed using geographic practice location as a random variable to account for clustering of responses within region (e.g., the association of geographic region with service and pharmaceutical sales prices). Geographic clustering was based on Ontario’s Economic Regions (15). A stepwise backwards elimination model building strategy was employed, with all variables identified in univariable analysis initially included in the multivariable model. All plausible 2-way interactions between variables identified as significant (using a liberal P-value) in univariable analysis were explored. Variables were eliminated from the final model if the P-values of their association with RPV were > 0.05, they were not a part of a significant interaction, and they did not play a confounding role in the association of other variables with RPV [e.g., change in coefficient values of > 20% (14)]. Any variable identified as a confounder remained in the model. Residuals were assessed for homogeneity of variance and normality. All outliers were identified and examined for biological plausibility. Marginal linear predictions were made for all significant outcomes identified in the multivariable model. When multiple comparisons were made, Bonferroni corrections were applied.

Results

Respondent clinic demographics and descriptive statistics

In total, there were 509 attempts to complete the survey. Of these, 163 were included for analysis (e.g., were answered by managing employees or owners of the practice). This number represents roughly 7% of licensed veterinary clinics in Ontario. All respondents for whom the survey software prevented survey completion (n = 346) had non-managerial responsibilities in the clinic (primarily RVTs attempting to fill out the survey). When assessing veterinary practice revenue, 112 respondents entered useable values for gross practice revenue. Most (52.2%) of survey respondents identified as clinic managers, followed by veterinarian-owners (33.7%), managing veterinarians (8.6%), and other (5.5%).

Most respondents (90%) represented generalist small animal (predominantly dogs and cats) clinics, followed by small animal specialty clinics (5%), mixed animal (2.5%), and equine (2.5%) clinics. All geographic regions of Ontario were represented, roughly in proportion to their population centers (Figure 1).

Figure 1.

Respondent practice geographic distribution across Ontario.

Table 1 outlines some general practice demographics reported for participating respondents. Most responding practices (58%) had 2 or fewer full-time equivalent veterinarians on staff. This proportion aligns with previous research describing roughly 41% of Ontario practices being staffed by 1 full-time veterinarian (16).

Table 1.

Descriptive statistics of respondent practice age, employee makeup, and size of client-base.

Variable	Mean	SD	Minimum value	Q1	Median	Q3	Maximum value
Practice age (years)	37.1	157.6	1	9	21	36	80
Number of owners	1.9	3.2	0	1	1	2	20
Full-time equivalent veterinarians	2.8	3.2	1	1	2	3	30
Full-time equivalent RVTs	3.2	3.7	0	2	3	4	40
Full-time NCs	3.5	8.9	0	1	2	4	100
RVTs per veterinarian	1.4	0.94	0	1	1	1.7	5
Number of clients	3304	4898	200	1344	2000	3500	25 000
RVTs per veterinarian	1.39	0.94	0	1	1	1.71	5
NCs per veterinarian	1.23	1.01	0	0.5	1	2	5
% Technicians as RVTs	56.58	25.51	0	33.33	58.57	75	100

SD — Standard deviation; Q1 — 25th percentile; Q3 — 75th percentile; RVT — Registered veterinary technician; NC — Non-credentialled veterinary assistant.

Financial descriptive statistics are provided in Table 2. Median gross yearly revenue (professional service charges plus sales) was $1.2 million across practices [interquartile range (IQR) = $850 000 to $1.8 million]. Median hourly rates were reported as $20 (IQR = $18 to $21) and $16 (IQR = $15 to $17) for RVTs and NC, respectively.

Table 2.

Descriptive statistics of practice financial demographics (in Canadian dollars) for respondents.

Variable	Mean	SD	Minimum	Q1	Median	Q3	Maximum
Gross yearly revenue ($)	1 509 295	1 309 282	250 000	850 000	1 200 000	1 800 000	5 500 000
Yearly revenue per vet ($)	601 538	262 771	125 000	435 667	559 536	725 000	1 300 000
RVT hourly rate ($)	19.84	2.29	15	18	20	21	26
NC hourly rate ($)	16.44	2.24	12	15	16	17	23

SD — standard deviation; Q1 — 25th percentile; Q3 — 75th percentile.

Most respondents agreed; 80% saw more value in RVTs over their untrained and uncredentialed counterparts, with 87% preferring RVTs over on-the-job trained technicians (Table 3). Yet, most respondents (80%) found it difficult to hire RVTs, and about 1/4 of respondents reported that veterinarians in their practice performed RVT duties often or always.

Table 3.

The value of RVTs in the practices of respondents.

Question	Frequency	Percentage
RVTs have more value than NCs?
No	27	19.71
Yes	110	80.29
Prefer RVT over on-the-job trained technicians
No	18	13.04
Yes	120	86.96
RVTs are difficult to find
No	28	20.44
Yes	109	79.56
There are more opportunities for RVTs in my practice
No	58	42.65
Yes	78	57.35
DVMs perform RVT duties
Never	16	11.68
Sometimes	89	64.96
Often	28	20.44
Always	4	2.92

RVT — Registered veterinary technician; NC — Non-credentialled veterinary assistant.

When asked about the frequency at which RVTs perform tasks related to their core competencies, most respondents (> 80%) reported that RVTs often or always did each of the following tasks: radiography, medication administration, animal restraint, anesthesia, diagnostic tests, dental scaling/cleaning, and assisting in surgery (Figure in supplemental material available from the author). Conversely, when asked whether NCs performed tasks related to RVT core competencies, responses were far more variable, with most (> 50%) practices reporting that NCs rarely or never performed most of the RVT core competency functions (Figure in supplemental material available from the author).

Clinics varied in the types of services that they offered to their clients. Over 70% of survey respondents offered nutritional, dental, and client education services (Table 4).

Table 4.

Services offered at respondent clinics.

Service	Frequency	Percent
Nutrition	118	72.4
Dental	123	75.5
Rehabilitation	32	19.6
Therapeutic laser	43	26.4
Extension/client education	131	80.4
Wellness plans	55	33.7
Behavior counselling	70	42.9

Of the clinics that did offer services outlined in Table 4, RVTs were often or always involved in their delivery in over 75% of respondent clinics. This was true for all services except the delivery of wellness plans and behavior counselling.

Univariable and multivariable associations of interest

Table 5 outlines the variables that were associated with RPV (P < 0.2) in univariable analysis. Of these variables, only veterinarians performing RVT duties, RVT hourly wages, RVT per veterinarian, and number full-time of veterinarians had a significant effect on RPV.

Table 5.

Univariable associations of interest with annual revenue per veterinarian.

Variable	RPV ($)	SE ($)	P-value	95% CI
Veterinarian performing RVT duties
Never/sometimes	632 178	28 005	Ref	576 678 to 687 679
Often/always	505 078	49 690	0.02	406 603 to 603 554
RVTs utilization
< 23.5	485 368	49 436	Ref	387 355 to 583 381
23.5 to 27	571 428	50 378	0.225	471 548 to 671 308
28 to 30	656 566	46 899	0.014	563 583 to 749 549
> 30	683 209	49 436	0.006	585 197 to 781 222
NCs utilizationa
< 9	670 340	62 275	Ref	546 674 to 794 007
9 to 14	654 224	50 407	0.84	554 125 to 754 323
15 to 21	582 675	41 395	0.22	500 470 to 664 879
> 21	409 166	110 819	0.04	189 100 to 629 323
RVT per veterinarian	154 433	21 921	< 0.0001	110 976 to 197 889
NC per veterinarian	−50 276	24 434	0.04	−98 821 to −1732
Percent of technicians as RVT	2013	999	0.05	30 to 3995
RVT hourly wage	11 849	7924	0.14	−3682 to 27 382
Full-time equivalent veterinarians	−25 888	9138	0.005	−43 997 to −7778

^aUtilization rates are composite numbers — calculated by summing values for each sub-question within questions 12 for RVT and 13 for NCs.

RPV — Annual revenue per veterinarian; SE — Standard error; CI — Confidence interval; RVT — Registered veterinary technician; NC — non-credentialed veterinary technician.

Values were assigned as follows: 0 = never, 1 = sometimes, 2 = often, 3 = always. Scores could range from 0–36 [12 sub-questions × 3 (question max value)].

There was a significant interaction term between the number of full-time veterinarians practicing at the clinic and the frequency with which they performed RVT duties. After controlling for other significant variables, the RPV for single veterinarian clinics was most affected by the frequency with which their veterinarians performed RVT duties. Single veterinarian clinics whose veterinarians rarely/never performed RVT duties had significantly higher RPV when compared to single veterinarian clinics whose veterinarian often/always performed RVT duties ($966 918, SE = $49 863 versus $611 570, SE = $51 949; P = 0.0001). This was also significant in veterinary clinics employing 2 full-time equivalent veterinarians, where those reporting that veterinarians who rarely performed RVT duties had an RPV of $605 585 (SE = $39 015) versus $393 880 (SE = $51 949) for clinics where the veterinarians often performed RVT duties (P = 0.02). In larger clinics, the relationship was not significant (P = 0.27), although there was a numeric trend in the same direction as for clinics with fewer veterinarians (Figure 2).

Figure 2.

Multivariable mixed model predictions for annual gross revenue per veterinarian (SE) stratified by number of full-time veterinarians (DVM) and the frequency at which they perform registered veterinary technician (RVT) duties.

Solid bar = veterinarians never/sometimes perform RVT duties; White bar = veterinarians often/always perform RVT duties; ^a,b,c Superscripts with different letters are significantly different (P < 0.05).

The number of RVTs employed per full-time veterinarian was also significantly associated with an increase in RPV. For each additional RVT at the clinic, gross annual RPV increased by $79 118 (SE = $21 146, P < 0.0001, Figure 3).

Figure 3.

Multivariable mixed model prediction of annual gross revenue per veterinarian (SE) stratified by number of registered veterinary technicians (RVTs) per full-time veterinarian. Each 1 unit increase in RVT/veterinarian is significantly associated with higher revenue per veterinarian (P < 0.001).

In addition, as RVT wages increased, so too did annual gross RPV. Specifically, clinics which paid their RVTs over $21 per hour earned $122 342 (SE = $58 874) more gross RPV per year relative to clinics which paid their RVTs $15 or less (P = 0.04).

The type of practice participating in the survey also had a significant effect on annual gross RPV. Relative to small animal only clinics, specialty clinics participating in the study grossed $199 081 (SE = $102 660) less per veterinarian per year (P = 0.05). Mixed animal clinics tended to gross less ($139 325 per veterinarian per year, SE = $85 317, P = 0.10) than small animal clinics, although this was not a statistically significant difference.

Discussion

The results from this study agree with those from previous research: employing more RVTs per veterinarian results in higher practice revenue for veterinary clinics. Specifically, Fanning (12) found a $93 000 increase in RPV, a similar trend to the $78 118 increase for every additional technician/veterinarian found in the current study. There are a few potential explanations for the discrepancy. The current study controlled for geographic region (random effect), RVT hourly wage (fixed effect), and type of practice (fixed effect) in the linear regression model; whereas it is not clear from the Fanning (12) article if there were any other important, potentially confounding covariates. Additionally, the Fanning (12) study was conducted in the United States at a different time; both of which could greatly influence practice gross revenue and its association with RVT staffing levels. The magnitude of this difference is relatively small; therefore, any discrepancy noted between studies may have been solely due to chance.

One additional interesting parallel between the current study and the study by Fanning (12) is that both found no significant association between NCs employed in the practice and RPV.

To the authors’ knowledge, this is the first Canadian study that has looked at RVT utilization rates and practice efficiency. One interesting finding was that, when looking at the aggregate measure assessing the degree of utilization relative to RVT core competencies, the highest rate of RVT utilization was associated with higher RPV. The opposite trend was true for NCs. When NCs were used more frequently to perform tasks within the purview of RVT competencies, practice revenue decreased. Both trends were only evident in univariable analysis. Further research is necessary to explore these potential associations.

Another finding that addresses RVTs as enablers of efficiency is the negative association between veterinarians performing RVT duties and RPV. This association was only significant for 1- and 2-veterinarian practices. Fully utilizing highly trained and regulated RVTs in veterinary practice could have allowed the veterinarian to concentrate on delivering other advanced services to their clients, thereby increasing practice revenue (17,18). Although not addressed in this study, RVTs who were more fully utilized could have experienced greater levels of satisfaction in their work resulting in higher employee retention rates for the practice and greater team cohesion (19,20). The construct of “value co-creation” in the veterinary team realizes and appreciates the unique expertise of each team member, ultimately improving client loyalty, treatment compliance, and ultimately business success (21). More research is necessary to fully characterize the relationship between RPV and the degree of RVT tasks performed by the veterinarian.

It was interesting that more than 80% of responding clinics saw more value in hiring RVTs than NCs (Table 3). Furthermore, most clinics found it difficult to hire RVTs. Ultimately, these variables did not have a significant effect on RPV. These responses do give insights into responding practices though. First, most respondents value and prefer RVTs to NCs in practice. As this was not a representative sample, it is difficult to extrapolate results to the general population of veterinary clinics. Another interesting finding was that practices in which veterinarians performed more RVT duties were less likely to prefer RVTs to NCs when compared with practices whose veterinarians infrequently performed RVT duties (9/32 versus 7/103, respectively). This could indicate that practices in which veterinarians perform more technical tasks are either unknowledgeable about the skills and abilities of RVTs or are unwilling to delegate such tasks to a qualified employee. It may also have been a spurious finding, given the relatively low number of respondents valuing NCs over RVTs. Results of this study are hypothesis-generating and could inform larger and more specific studies that would more fully qualify the contribution of RVTs to practice efficiency.

One counterintuitive finding of the current study was that, as hourly wages increased, so too did RPV. Increased hourly wages have the potential to reduce business profits (22); however, practices that were in the highest quartile for RVT wages made significantly more RPV relative to practices that paid their technicians $15 (for reference, minimum wage in Ontario, Canada is $14/hour). As employee effort is positively associated with wages (23), RVTs who are better compensated may have been more motivated (relative to lower-paid counterparts), which could in turn have had positive effects on clinic revenues. Better compensated employees could improve overall job satisfaction, further boosting service quality, client satisfaction, and clinic profitability (24). One factor that is not clear is the relationship between RVT hourly wage and the years of experience that they had in the clinic. Some clinics that had a team of experienced RVTs would be more likely to have higher wages and a greater level of productivity per RVT. The answer to this question was beyond the scope of this study and deserves further research.

As with any online survey, this study relied on respondent self-reporting. As such, there was no mechanism to validate the responses provided by those completing the survey. To ensure the appropriate target demographic completed the survey, there was a built-in exclusion mechanism so that only those reporting as having practice management roles could complete the survey. A total of 346 respondents were prevented from completing the survey past the first question, so the mechanism was successful in excluding non-target respondents. Another caution is that this survey was a convenience, rather than a random sample of the veterinary clinic population in Ontario. While the average practice demographics (90% small animal exclusive clinics, the majority of responding clinics being < 2 full-time equivalent veterinarians, geographic representation proportional to population density) roughly approximate practices in Ontario (16), it is difficult to measure the representativeness of the sample. Furthermore, the respondents of this survey represent only around 7% of all clinics in Ontario. To make any concrete inferences regarding the population of clinics in Ontario would require a far larger response rate. Clinics which had strong opinions on the usefulness of RVTs may have been more likely to respond. Ultimately, conclusions beyond that of the sample population are difficult to justify.

Registered veterinary technicians are a core member of the veterinary care team. Their advanced training and expertise reduce the need for veterinarians to perform technical tasks. The associations found in the current study are supportive of previous research findings that credentialed RVTs positively impact the economic viability of veterinary practices. Further research is necessary to fully characterize the specific drivers of this impact.