The COVID-19 pandemic led to rapid adoption of telemedicine for health-care service delivery. There are concerns that older adults, the highest users of the health-care system, would be left behind because of this shift. It remains unclear how the pandemic impacted telemedicine and other health-care service use in this group. We conducted a population-based, weekly cross-sectional study using administrative data from Ontario, Canada. Telemedicine use was measured for the overall older-adult population aged 65+ and across sociodemographic groups from January 2018 to March 2021. We also assessed the use of key health-care services between high and low patient users of telemedicine who were diagnosed with dementia. We found that telemedicine visits outnumbered in-person visits in older adults during the pandemic (average of 74 vs. 62 visits per 1000 per week). Of all specialties, psychiatrists delivered the most telemedicine visits, reaching 90% of visits in a week. Higher rates of telemedicine use during COVID-19 were found for patients who resided in urban regions (84 visits per 1000 per week), but no differences were found across income quintiles. Among dementia patients, high telemedicine users had higher health-care utilization than low telemedicine users (i.e., 21,108 vs. 3,276 outpatient visits per week) during the pandemic. Findings suggest that telemedicine was crucial in helping older adults, a group most vulnerable to COVID-19, maintain access to care during the pandemic. Telemedicine presents an important opportunity for older adults; however, future research should focus on barriers to equitable access and quality of care provided through telemedicine.

BackgroundThe increased use of telemedicine during the pandemic has led to concerns about potential increased emergency department (ED) admissions and outpatient service use prior to such admissions. We examined the frequency of telemedicine use prior to ED admissions and characterized the patients with prior telemedicine use and the physicians who provided these outpatient visits.MethodsWe conducted a retrospective, population-based, cross-sectional analysis using linked health administrative data in Ontario, Canada to identify patients who had an ED admission between July 1 and September 30, 2021 and patients with an ED admissions during the same period in 2019. We grouped patients based on their use of outpatient services in the 7 days prior to admission and reported their sociodemographic characteristics and healthcare utilization.ResultsThere were 1,080,334 ED admissions in 2021 vs. 1,113,230 in 2019. In 2021, 74% of these admissions had no prior outpatient visits (virtual or in-person) within 7 days of admission, compared to 75% in 2019. Only 3% of ED admissions had both virtual and in-person visits in the 7 days prior to ED admission. Patients with prior virtual care use were more likely to be hospitalized than those without any outpatient care (13% vs 7.7.%).InterpretationThe net amount of ED admissions and outpatient care prior to admission remained the same over a period of the COVID-19 pandemic when cases were relatively stable. Virtual care seems to be able to appropriately triage patients to the ED and may even prove beneficial for diverting patients away from the ED when an ED admission is not appropriate.The COVID-19 pandemic has led to the emergence of standard use of telemedicine in health care across the globe(1,2). In Ontario, Canada the proportion of ambulatory visits completed virtually has been maintained at slightly above 50% from 2020 to 2021 (3). Despite its widespread adoption, it is still unclear when virtual visits are clinically appropriate and how such wide use of telemedicine impacts patient outcomes and healthcare utilization metrics.Before the pandemic, there had been concerns that telemedicine may lead to an increased use of outpatient services with patients having both a virtual and an in-person visit for the same clinical issue(4,5). For example, pre-pandemic data (2007-2016) from Manitoba showed that telemedicine users had on average 1.3 times more ambulatory visits than non-users.(6) In addition, studies have produced mixed evidence with regard to the effect of telemedicine on urgent services such as emergency department (ED) admissions and hospitalizations (7). Many of the studies reported in the literature are based on data from site-specific programs and therefore have limited generalizability. Finally, policymakers and some physicians have become concerned that the high rates of telemedicine during COVID-19 have led to an increase in emergency department admissions because of poor access to in-person outpatient care (8). This concern is exacerbated when one considers rural and lower socioeconomic status patients who already had poor access to care before the pandemic(9). Combined with reports of lower uptake of telemedicine among these patients(10,11), it is not clear how the transition of care from in-person to virtual impacts ED use.The high adoption of telemedicine during the pandemic, in the context of a publicly funded healthcare system allowing us access to most visits across the entire population, offers a unique opportunity to examine the frequency of telemedicine use prior to ED admissions. Therefore, the goal of this study was to characterize the frequency and modality (in-person vs virtual) of outpatient care prior to ED admissions. We examined whether there was an overall increase in outpatient visits prior to ED admissions during a period of the pandemic when access to telemedicine was available compared to a seasonality matched period before the pandemic where access to telemedicine was quite limited.We also aimed to characterize the patients who had a telemedicine visit prior to an ED admission vs. those who had an in-person visit and the physicians who saw patients with virtual only visits prior to their ED admission compared to those who saw patients virtually or in-person prior to their ED admission.

Background The increased use of telemedicine to provide virtual outpatient visits during the pandemic has led to concerns about potential increased emergency department (ED) admissions and outpatient service use prior to such admissions. We examined the frequency of virtual visits use prior to ED admissions and characterized the patients with prior virtual visit use and the physicians who provided these outpatient visits. Methods We conducted a retrospective, population-based, cross-sectional analysis using linked health administrative data in Ontario, Canada to identify patients who had an ED admission between July 1 and September 30, 2021 and patients with an ED admissions during the same period in 2019. We grouped patients based on their use of outpatient services in the 7 days prior to admission and reported their sociodemographic characteristics and healthcare utilization. Results There were 1,080,334 ED admissions in 2021 vs. 1,113,230 in 2019. In 2021, 74% of these admissions had no prior outpatient visits (virtual or in-person) within 7 days of admission, compared to 75% in 2019. Only 3% of ED admissions had both virtual and in-person visits in the 7 days prior to ED admission. Patients with prior virtual care use were more likely to be hospitalized than those without any outpatient care (13% vs 7.7.%). Interpretation The net amount of ED admissions and outpatient care prior to admission remained the same over a period of the COVID-19 pandemic when cases were relatively stable. Virtual care seemed to be able to appropriately triage patients to the ED and virtual visits replaced in-person visits ahead of ED admissions, as opposed to being additive.

The critical role of virtual care during the COVID-19 pandemic has raised concerns about the widening disparities to access by vulnerable populations including older immigrants. This paper aims to describe virtual care use in older immigrant populations residing in Ontario, Canada.In this population-based, repeated cross-sectional study, we used linked administrative data to describe virtual care and healthcare utilization among immigrants aged 65 years and older before and during the COVID-19 pandemic. Visits were identified weekly from January 2018 to March 2021 among various older adult immigrant populations.Among older immigrants, over 75% were high users of virtual care (had two or more virtual visits) during the pandemic. Rates of virtual care use increased for both older adult immigrant and non-immigrant populations. At the start of the pandemic, virtual care use was lower among immigrants compared to non-immigrants (weekly average of 77 vs 86 visits). As the pandemic progressed, the rates between these groups became similar (80 vs 79 visits). Virtual care use was consistently lower among immigrants in the family class (75 visits) compared to the economic (82 visits) or refugee (89 visits) classes, and was lower among those who only spoke French (69 visits) or neither French nor English (73 visits) compared to those who were fluent in English (81 visits).This study found that use of virtual care was comparable between older immigrants and non-immigrants overall, though there may have been barriers to access for older immigrants early on in the pandemic. However, within older immigrant populations, immigration category and language ability were consistent differentiators in the rates of virtual care use throughout the pandemic.Author SummaryWhen the COVID-19 pandemic began, healthcare systems pivoted from in-person to virtual care to maintain physical distancing. Studies have shown that virtual care use became much more frequent during the pandemic as a result. What we do not know is whether virtual care is being used equitably, that is, whether everybody has fair access to the resource. This can be a big issue particularly amongst older adults, who are often battling several diseases and use healthcare frequently. Many older adults are immigrants who may face challenges in accessing healthcare due to reasons such as limited language fluency and resource support. Our study found that older adult immigrants aged 65 and above living in Ontario, Canada had lower use of virtual care initially, but their use eventually caught up with non-immigrants as the pandemic progressed. We also found that older adult immigrants from the family class had lower virtual care use compared to those from the economic, refugee, or other immigration classes. Additionally, immigrants who were not fluent in English had lower use compared to those who were fluent. These results show that virtual care access remains an issue for vulnerable minorities and steps should be taken to ensure these groups are receiving adequate care.

The critical role of virtual care during the COVID-19 pandemic has raised concerns about the widening disparities to access by vulnerable populations including older immigrants. This paper aims to describe virtual care use in older immigrant populations residing in Ontario, Canada. In this population-based, repeated cross-sectional study, we used linked administrative data to describe virtual care and healthcare utilization among immigrants aged 65 years and older before and during the COVID-19 pandemic. Visits were identified weekly from January 2018 to March 2021 among various older adult immigrant populations. Among older immigrants, over 75% were high users of virtual care (had two or more virtual visits) during the pandemic. Rates of virtual care use was low (weekly average <2 visits per 1000) prior to the pandemic, but increased for both older adult immigrant and non-immigrant populations. At the start of the pandemic, virtual care use was lower among immigrants compared to non-immigrants (weekly average of 77 vs 86 visits per 1000). As the pandemic progressed, the rates between these groups became similar (80 vs 79 visits per 1000). Virtual care use was consistently lower among immigrants in the family class (75 visits per 1000) compared to the economic (82 visits per 1000) or refugee (89 visits per 1000) classes, and was lower among those who only spoke French (69 visits per 1000) or neither French nor English (73 visits per 1000) compared to those who were fluent in English (81 visits per 1000). This study found that use of virtual care was comparable between older immigrants and non-immigrants overall, though there may have been barriers to access for older immigrants early on in the pandemic. However, within older immigrant populations, immigration category and language ability were consistent differentiators in the rates of virtual care use throughout the pandemic.