Virtual primary care visits did not increase ED use during pandemic

A recent study in CMAJ found no association between a shift to virtual care during the first year of the COVID-19 pandemic and an increase in ED visits.

Researchers said the findings suggest that patients did not use the ED as a substitution for primary care visits due to a lack of availability of in-person care.

Virtual care offered a safer alternative to in-person care and several other benefits during the pandemic, Nadine Chami, PhD, a health economist at Avalon Health Economics LLC in Los Angeles, and colleagues wrote. Despite that, physicians in Canada had rarely utilized telehealth prior to the pandemic, they noted.

“Some prepandemic studies found reduced quality and inconsistent results regarding patient experiences with virtual care, even with improved access,” the researchers wrote. “In later stages of the pandemic, questions arose about the quality of virtual care and the broader system effects of reduced access to in-person care, such as patients substituting emergency department visits when in-person care options were unavailable.”

Chami and colleagues used claims data to examine monthly ED and virtual visits of patients enrolled in family medicine practices in Ontario, Canada, from April 1, 2020, to Mar. 31, 2021, to find possible correlations between usage of the two services. The analysis included 7,936 physicians. Among them, 31% practiced in family health groups (enhanced fee-for-service) and 69% in family health organizations (blended capitation).

In the spring of 2020 and from October 2020 to February 2021, Chami and colleagues reported that the average proportion of ED visits was low while the proportion of virtual visits was high, with no significant differences between family health groups and family health organizations.

“Trends in emergency department visits, and in overall primary care visits showed a sharp decline around the beginning of the pandemic, while virtual visits increased,” they wrote.

Female physicians had a higher proportion of virtual visits and a lower proportion of ED visits compared with male physicians, according to the researchers. Physicians in urban areas also saw more virtual visits and fewer ED visits compared with rural physicians. In addition, higher patient complexity was associated with more ED visits while older physician age was associated with fewer ED visits.

In an unadjusted analysis, a 1% increase in the proportion of virtual visits was associated with 11 fewer ED visits per 1,000 enrolled patients (95% CI, 10.1-11.8). When the study period was extended to Sept. 30, 2021, the 1% increase in virtual visits was associated with only 1.2 fewer ED visits per 1,000 enrolled patients.

There was no significant association between the ratio of virtual and ED visits and factors such as COVID-19-related vs. non-COVID-19-related ED visits or inpatient vs. long-term care visits.

Chami and colleagues noted that the findings are important “given concerns about virtual care adversely affecting quality of care, leading to calls to substantially reduce care delivered virtually.”

“Future research should consider evaluating the long-term impact of virtual care, and whether it improves appropriate use of emergency departments,” they wrote. “Research from the United States suggests that the benefits of telehealth during the pandemic may include expansion of access to care, reduction in disease exposure for health care workers and patients, preservation of supplies of personal protective equipment and reduction in patient demand on facilities.”