Virtual care and emergency department use

Chami and colleagues1 have clearly shown that the shift from predominantly in-person outpatient encounters to mixed models (with most visits being virtual) during the first year of the COVID-19 pandemic did not result in increased use of the emergency department (ED) by rostered patients of Ontario family physicians practising in family health groups or family health organizations. Despite the robustness of their study, some questions remain unanswered.

The generalizability of their findings outside of Ontario or for patients cared for by fee-for-service physicians is unclear. A recent study from Alberta of 33.7 million outpatient encounters between March 2019 and March 2021 can help fill this gap.2 We found that the COVID-19 pandemic did not negatively affect the frequency of outpatient follow-up or prescribing for community-dwelling adults with ambulatory care–sensitive conditions. In the year before the pandemic, 97.2% of the study cohort saw a primary care physician (median 6 visits), 59.0% had at least 1 specialist visit and 98.5% were prescribed medications (median 9 drugs); in the year after March 2020, 96.6% saw a primary care physician (median 3 in-person and 2 virtual visits), 62.6% saw a specialist and 98.6% were prescribed medications (median 8 drugs). Similar to Chami and colleagues,1 we also found that virtual outpatient visits were not associated with increased visits to the ED or hospital admissions in the subsequent 90 days, compared with in-person outpatient visits. Of note, we conducted the Alberta analyses at the level of the patient and, thus, we were able to adjust for patient-specific demographics and comorbidities. This helps confirm the results of the Ontario analyses, which were done at the physician level and modelled average patient complexity for each physician. However, it should be acknowledged that neither study can adjust for a number of unmeasured factors that may influence physician or patient decisions about type of outpatient follow-up or willingness to visit an ED during a pandemic.

As both studies could evaluate only short-term outcomes in the first year of the pandemic, it remains unknown whether virtual outpatient visits will have different long-term effects than in-person visits. Initial studies on this question have reported less medication intensification and far fewer assessments of blood pressure, cholesterol, hemoglobin A_1C or other screening measures after virtual visits than in-person visits.3^–5 Whether this pattern persisted as the pandemic continued, as physicians were learning how best to use virtual care, is an important research priority.

Although the work of Chami and colleagues is a nice start, much remains to be answered before we can establish the right balance between virtual and in-person encounters that optimizes access, patient and provider experiences, quality and cost-effectiveness of outpatient care in Canada.