Has the Move to Online Primary Care Visits Raised ED Visits?

The shift from in-person primary care to virtual visits during the first year of the COVID-19 pandemic was not associated with an increase in emergency department (ED) visits in Ontario, Canada, data suggest.

Despite the sharp increase in virtual visits and the major decline in the availability of in-person appointments with a family physician, the evidence does not indicate that patients substituted the ED for primary care.

Dr Jasmin Kantarevic

“The association between ED visits and virtual care is important to better understand the drivers of surges in ED visits and policies to address any gaps, as well as to inform policy on the delivery of patient care by different modalities,” study author Jasmin Kantarevic, PhD, chief economist for the Ontario Medical Association, told Medscape Medical News.

Current gaps in the provision of care in the ED are unlikely to be related to primary care physicians’ availability for in-person visits, he added. “This suggests that current record ED volumes are driven by other factors, such as re-engaging patients who did not seek care during the pandemic, increased acuity and need of treatment for patients in the post-COVID era, and staff shortages, including record levels of burnout.”

The study was published January 23 in the Canadian Medical Association Journal.

No Association Observed

The investigators analyzed physician-level administrative claims data from Ontario to estimate the monthly ED visits and proportion of virtual visits among patients enrolled with a primary care physician between April 2020 and March 2021.

The researchers looked at 7936 physicians, including 2458 physicians (31%) in an enhanced fee-for-service model in a family health group and 5478 physicians (69%) in a blended capitation model in a family health organization. Under the Ontario Health Insurance Plan, these are the two most common models chosen by family physicians. They account for more than half of all primary care physicians in the province.

The research team controlled their analysis for factors including monthly and regional variation, patient complexity, and physician characteristics such as total workload and pre-pandemic emergency visits per rostered patient.

Overall, at the beginning of the COVID-19 pandemic in spring 2020 and between October 2020 and February 2021, the average number of ED visits was low, and the proportion of virtual care was high. The trends were similar for both payment models.

Throughout the study period, there was variability between practitioners, with fewer ED visits per patient and more virtual visits among patients with female physicians and those in urban areas. Younger physicians had a higher proportion of virtual visits but about the same number of ED visits per patient as older physicians. In contrast, doctors with higher average patient medical complexity, those in rural areas, and male doctors had higher rates of ED visits.

In an unadjusted analysis, a 1% increase in the proportion of virtual visits was associated with 11 fewer ED visits per 1000 rostered patients. Extending the data period to September 2021, a 1% increase in the ratio of virtual visits was associated with 1.2 fewer ED visits per 1000 rostered patients. The association was no longer observed in the adjusted analysis, however.

In additional analyses, the research team also observed no association between ED visits and the proportion of virtual care for either high or low acuity levels, or for patients with COVID-19 or with suspected COVID-19. They also observed no differences in estimates between COVID-related ED visits and non–COVID-related visits.

“Our analysis documented the lack of any systematic association between the virtual and ED visits. This result was counter to the anecdotal evidence, and we studied carefully whether any other confounders could explain our results,” said Kantarevic. “Of particular interest was the interaction of time with the location of residence, given that the incidence and prevalence of COVID-19 cases varied over time and by geographic areas, which may have affected both virtual care and ED visits. None of these confounders affected our main finding.”

A Reassuring Message

Virtual visits are described as the “new normal” in Canadian healthcare, the investigators wrote, and future studies should evaluate the long-term effects of virtual care and whether it improves the appropriate use of the ED.

“The contextual part here is the perception that people go to the ED when they can’t access primary care. It’s a common belief but not necessarily the case,” Eddy Lang, MDCM, professor and head of emergency medicine at the University of Calgary in Alberta, told Medscape.

Dr Eddy Lang

Lang, who wasn’t involved with the study, has researched ED utilization during the pandemic as scientific director of Alberta Health Services’ Emergency Strategic Clinical Network. He and colleagues have found that patients tend to seek emergency care for immediate issues such as accidents and heart concerns, rather than for the routine management of chronic diseases or medication refills.

“Despite the crisis that we’re hearing about, the reality is that — except for pediatrics over the last few months — there has not been a substantial increase in ED visits,” he said. “Instead, hospitals are operating at higher occupancy levels, and the backlog of patients in the ED awaiting a hospital bed appears to be the main driver of the wait times we’re seeing now.”

At the same time, Lang noted, the study provides a reassuring message that the shift to virtual care didn’t result in higher ED numbers for health issues such as uncontrolled high blood pressure or blood sugar, which are often managed in primary care.

“That shows the function that primary care has in maintaining the health of the population,” he said. “There’s no doubt that virtual care is here to stay, and we need to successfully integrate it with face-to-face care for the future.”

The study authors received no external funding for this study. Kantarevic is an employee of the Ontario Medical Association. Lang reported no relevant financial relationships.

CMAJ. Published January 23, 2023. Full text

Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape, MDedge, and WebMD.

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