Virtual Care and Emergency Department Use During the COVID-19 Pandemic Among Patients of Family Physicians in Ontario, Canada

Abstract

ImportanceThe COVID-19 pandemic has played a role in increased use of virtual care in primary care. However, few studies have examined the association between virtual primary care visits and other health care use.ObjectiveTo evaluate the association between the percentage of virtual visits in primary care and the rate of emergency department (ED) visits.Design, Setting, and ParticipantsThis cross-sectional study used routinely collected administrative data and was conducted in Ontario, Canada. The sample comprised family physicians with at least 1 primary care visit claim between February 1 and October 31, 2021, and permanent Ontario residents who were alive as of March 31, 2021. All residents were assigned to physicians according to enrollment and billing data.ExposureFamily physicians’ virtual visit rate was the exposure. Physicians were stratified by the percentage of total visits that they delivered virtually (via telephone or video) during the study period (0% [100% in person], >0%-20%, >20%-40%, >40%-60%, >60%-80%, >80% to <100%, or 100%).Main Outcomes and MeasuresPopulation-level ED visit rate was calculated for each stratum of virtual care use. Multivariable regression models were used to understand the relative rate of patient ED use after adjusting for rurality of practice, patient characteristics, and 2019 ED visit rates.ResultsData were analyzed for a total of 13 820 family physicians (7114 males [51.5%]; mean [SD] age, 50 [13.1] years) with 12 951 063 patients (6 714 150 females [51.8%]; mean [SD] age, 42.6 [22.9] years) who were attached to these physicians. Most physicians provided between 40% and 80% of care virtually. A higher percentage of the physicians who provided more than 80% of care virtually were 65 years or older, female individuals, and practiced in big cities. Patient comorbidity and morbidity were similar across strata of virtual care use. The mean (SD) number of ED visits was highest among patients whose physicians provided only in-person care (470.3 [1918.8] per 1000 patients) and was lowest among patients of physicians who provided more than 80% to less than 100% of care virtually (242.0 [800.3] per 1000 patients). After adjustment for patient characteristics, patients of physicians with more than 20% of visits delivered virtually had lower rates of ED visits compared with patients of physicians who provided more than 0% to 20% of care virtually (eg, >80% to <100% vs >0%-20% virtual visits in big cities: relative rate, 0.77%; 95% CI, 0.74%-0.81%). This pattern was unchanged across all rurality of practice strata and after adjustment for 2019 ED visit rates. In urban areas, there was a gradient whereby patients of physicians providing the highest level of virtual care had the lowest ED visit rates.Conclusions and RelevanceFindings of this study show that patients of physicians who provided a higher percentage of virtual care did not have higher ED visit rates compared with patients of physicians who provided the lowest levels of virtual care. The findings refute the hypothesis that family physicians providing more care virtually during the pandemic resulted in higher ED use.

Virtual Visits With Own Family Physician vs Outside Family Physician and Emergency Department Use

“…We also build on a previous Ontario-based study in which we found that patients who had visits with virtual walk-in clinics in 2020 were twice as likely as those with other types of virtual family physician visits to visit the emergency department within 30 days. In addition to better addressing potential sources of confounding, this study extends our findings to 2021, when emergency department visit volumes began to rise to their pre-COVID-19 levels …”

“…Within-system virtual care (integrated with in-person, office-based care) from US-based Intermountain Healthcare and Kaiser Permanente has compared more favorably with in-person care than has direct-to-consumer telemedicine, which has been associated with increased downstream health care use and costs . In 2 Ontario studies, patients whose regular family physicians provided more virtual care did not have higher rates of emergency department use. Furthermore, within-system virtual care has demonstrated the potential for associated increases in equity of care via improved access for individuals who struggle to afford higher visit-related costs …”

Association of virtual end-of-life care with healthcare outcomes before and during the COVID-19 pandemic: A population-based study

“…During the pandemic, virtual care and virtual end-of-life care use in Ontario rapidly increased [ 4 , 5 ]. Emerging evidence suggests that the use of virtual care for people attending a walk-in clinic during the pandemic was associated with higher use of the emergency department, which may depend upon the type of care received and the provider delivering it [ 6 , 7 ].…”

Family physicians’ experiences with an innovative, community-based, hybrid model of in- person and virtual care: a mixed-methods study

“…Virtual care use increased during the COVID-19 pandemic, especially during pandemic lockdowns [ 16 , 17 ], and evidence is emerging that virtual care may be effective in strengthening access to primary care in rural and remote communities [ 18 ]. Findings show that more virtual care from family physicians during the COVID-19 pandemic did not result in more ED use [ 19 ]. However, especially in the context of the COVID-19 pandemic, there are many services that can only be delivered in person, such as COVID-19 nasal swab testing.…”