Virtual Care Not Linked With Greater ED Use During Pandemic

Marilynn Larkin

May 05, 2023

Canadian family physicians' increased use of virtual care during the first years of the pandemic was not associated with increased emergency department (ED) use among patients, a new analysis of data from Ontario suggests.

In a cross-sectional study that included almost 14,000 family physicians and almost 13 million patients in Ontario, an adjusted analysis indicated that patients with physicians who provided more than 20% of care virtually had lower rates of ED visits, compared with patients whose physicians provided the least virtual care.

Dr Tara Kiran

"I was surprised to see that ED visit volumes in fall 2021 were below prepandemic levels," study author Tara Kiran, MD, who practices family medicine at St. Michael's Hospital of the University of Toronto, told Medscape Medical News.

"At that time, there was a lot in the news about how our EDs were overcrowded and an assumption that this related to higher visit volumes. But our data [suggest] there were other factors at play, including strains in staffing in the ED, hospital inpatient units, and in long-term care." Kiran also is the Fidani chair in improvement and innovation and vice-chair of quality and innovation at the Department of Family and Community Medicine of the University of Toronto.

The study was published online April 28 in JAMA Network Open.

Embrace of Telehealth

The investigators analyzed administrative data from Ontario for 13,820 family physicians (mean age, 50 years; 51.5% men) and 12,951,063 patients (mean age, 42.6 years; 51.8% women) under their care.

The family physicians had at least one primary care visit claim between February 1 and October 31, 2021. The researchers categorized the physicians by the percentage of total visits they delivered virtually (via telephone or video) during the study period, as follows: 0% (100% in person), >0% to 20%, >20% to 40%, >40% to 60%, >60% to 80%, >80% to <100%, or 100%.

The percentage of virtual primary care visits peaked at 82% in the first 2 weeks of the pandemic and decreased to 49% by October 2021. ED visit rates decreased at the start of the pandemic and remained lower than in 2019 throughout the study period.

Most physicians provided between 40% and 80% of care virtually. A greater percentage of those who provided more than 80% of care virtually were aged 65 years or older, were women, and practiced in large cities.

Patient comorbidity and morbidity were similar across all categories of virtual care use. The mean number of ED visits was highest among patients whose physicians provided only in-person care (470.3 per 1000 patients) and was lowest among those whose physicians provided > 0% to <100% of care virtually (242 per 1000 patients).

After adjustment for patient characteristics, patients of physicians who provided more than 20% of care virtually had lower rates of ED visits, compared with patients of physicians who provided the least virtual care (eg, >80% to <100% vs 0% to 20% virtual visits in big cities; relative rate, 0.77). This pattern was consistent across all rurality of practice categories and after adjustment for 2019 ED visit rates.

The investigators observed a gradient in urban areas. Patients of physicians who provided the highest level of virtual care had the lowest ED visit rates.

Investigating Virtual Modalities

Some policymakers worried that inappropriate use of virtual care was leading to an increase in ED use. "Findings of this study refute this hypothesis," the authors write. Increases in ED use seemed to coincide with decreases in COVID-19 cases, not with increases in virtual primary care visits.

Furthermore, at the population level, patients who were cared for by physicians who provided a high percentage of virtual care did not have a higher rate of ED visits, compared with those cared for by physicians who provided the lowest levels of virtual care.

During the pandemic, the switch to virtual care worked well for some of Kiran's patients. It was more convenient, because they didn't have to take time off work, travel to and from the clinic, find and pay for parking, or wait in the clinic before the appointment, she said.

But for others, "virtual care really didn't work well," she said. "This was particularly true for people who didn't have a regular working phone, who didn't have a private space to take calls, who weren't fluent in English, and who were hard of hearing or had severe mental illness that resulted in paranoid thoughts."

Clinicians also may have had different comfort levels and preferences regarding virtual visits, Kiran hypothesized. Some found it convenient and efficient, whereas others may have found it cumbersome and inefficient. "I personally find it harder to build relationships with patients when I use virtual care," she said. "I experience more joy in work with in-person visits, but other clinicians may feel differently."

Kiran and her colleagues are conducting a public engagement initiative called OurCare to understand public perspectives on the future of primary care. "As part of that work, we want to understand what virtual modalities are most important to the public and how the public thinks these should be integrated into primary care."

Virtual care can support access, patient-centered care, and equity in primary care, Kiran added. "Ideally, it should be integrated into an existing relationship with a family physician and be a complement to in-person visits."

The Right Dose?

In an accompanying editorial, Jesse M. Pines, MD, chief of clinical innovation at US Acute Care Solutions in Canton, Ohio, writes, "There is no convincing mechanism consistent with the data for the observed outcome of lower ED use at higher telehealth use."

Additional research is needed, he notes, to answer the "Goldilocks question" – that is, what amount of telehealth optimizes its benefits while minimizing potential problems?

"The right dose of telehealth needs to balance (1) concerns by payers and policy makers that it will increase cost and cause unintended consequences (eg, misdiagnosis or duplicative care) and (2) the desire of its proponents who want to allow clinicians to use it as they see fit, with few restrictions," writes Pines.

"Future research would ideally use more robust research design," he suggested. "For example, randomized trials could test different doses of telehealth, or mixed-methods studies could help elucidate how telehealth may be changing clinical management or care-seeking behavior."

Equitable Reimbursement Needed

Commenting on the findings for Medscape, Priya Nori, MD, associate professor of infectious diseases at Montefiore Health System and associate professor at the Albert Einstein College of Medicine, both in New York City, said, "I agree with their conclusions and am reassured about telehealth as a durable form of healthcare delivery."

Dr Priya Nori

Large, population-level studies such as this one might persuade legislators to require equitable reimbursement for in-person and virtual visits "so providers have comparable incentives to provide both types of care," she said. "Although only primary care was addressed in the study, I believe that virtual care is here to stay and can be applied to primary care, subspecialty care, and other services, like antimicrobial stewardship, infection prevention, et cetera. We need to embrace it."

A similar study should be conducted in the United States, along with additional research "to ensure that visits done by telephone have similar outcomes as those done by video, as not all communities have adequate internet access or video conferencing technology," said Nori.

The study was supported by ICES and grants from Ontario Health, the Canadian Institutes of Health Research, and the Health Systems Research Program of Ontario MOH. Kiran, Pines, and Nori have disclosed no relevant financial relationships.

JAMA Netw Open. Published online April 28, 2023. Full text, Editorial

Follow Marilynn Larkin on Twitter: @MarilynnL.

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