Are primary care virtual visits associated with higher emergency department use? A cross-sectional analysis from Ontario, Canada

Importance The COVID-19 pandemic has resulted in increased use of virtual care, however, few studies have looked at the association between virtual primary care visits and other healthcare use. Objective To determine whether there was an association between a high proportion of virtual visits in primary care and more emergency department visits Design A cross-sectional study, using routinely collected data Setting Ontario, Canada Participants Ontario residents alive on March 31st 2021 and family physicians with at least 1 visit claim between February and October 2021. Exposure Family physicians stratified by the percentage of total visits that were virtual (phone or video) between February and October 2021 Main outcome(s) and measure(s) We calculated the emergency department visit rate for each stratum of family physician virtual care use. We used multivariable logistic regression models to understand the relative rate of patient emergency department use after stratifying for rurality and adjusting first for patient characteristics and then the 2019 emergency department visit rate. Results We analyzed data for 15,155 family physicians and 12,951,063 Ontarians attached to these physicians. The mean number of emergency department visits was highest among patients whose physicians provided only in-person care (470.3 ± 1918.8 per 1,000) and was lowest among physicians who provided >80 to <100% care virtually (242.0 ± 800.3 per 1,000). After adjustment for patient characteristics patients seen by physicians with >20% of visits delivered virtually had lower rates of emergency department visits compared to patients of physicians who provided >0%-20% virtually (e.g. >80 to <100% vs >0%-20% virtual visits in Big Cities, Relative Rate (RR) 0.80 [95%CI 0.76-0.83]). This trend held across all rurality strata and after adjustment for 2019 emergency department visit rates. In urban areas, there was a gradient whereby physicians providing the highest level of virtual care had the lowest emergency department visit rates. Conclusions and Relevance Physicians who provided a high proportion of care virtually did not have higher emergency department visits than those who provided the lowest levels of virtual care. Our findings refute hypotheses that emergency department use is being driven by family physicians providing more care virtually. Question Do family physicians who provide more care virtually have higher emergency department visit rates among their patient panel? Findings In this cross-sectional study from Ontario, Canada, we examined data from February to October 2021 for 12,951,063 patients attached to 15,155 family doctors and found that physicians who provided a high proportion of virtual care did not have higher emergency department visits than those who provided the lowest levels of virtual care. This finding remained true after adjusting for patient characteristics. Meaning Our findings refute hypotheses that emergency department use is being driven by family physicians providing more care virtually. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and Ministry of Long-Term Care (MLTC). This study also received funding from Ontario Health, the Canadian Institutes of Health Research funding reference number SOP 162662, and the INSPIRE Primary Health Care Research Program which is funded through the Health Systems Research Program of the Ontario Ministry of Health (MOH). The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES, Ontario Health, or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and information compiled and provided by Ontario Ministry of Health (MOH) and the Canadian Institute for Health Information (CIHI). The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. Drs. Kiran and Glazier are supported as Clinician Scientists by the Department of Family and Community Medicine at the University of Toronto and at St. Michaels Hospital. Dr. Kiran is the Fidani Chair of Improvement and Innovation in Family Medicine at the University of Toronto. Michael Green is supported by the Brian Hennen Chair in Family Medicine at Queens University. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The use of the data in this project is authorized under section 45 of Ontario Personal Health Information Protection Act (PHIPA) and does not require review by a Research Ethics Board. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes The data sets from this study are held securely in coded form at ICES. Data-sharing agreements prohibit ICES from making the data sets publicly available, but access may be granted to those who meet pre-specified criteria for confidential access, available at [www.ices.on.ca/DAS][1]. The complete data set creation plan, and underlying analytic code are available from the authors upon request, understanding that the programs may rely upon coding templates or macros unique to ICES. [1]: http://www.ices.on.ca/DAS