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

ImportanceThe 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. ObjectiveTo determine whether there was an association between a high proportion of virtual visits in primary care and more emergency department visits DesignA cross-sectional study, using routinely collected data SettingOntario, Canada ParticipantsOntario residents alive on March 31st 2021 and family physicians with at least 1 visit claim between February and October 2021. ExposureFamily 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. ResultsWe 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 RelevancePhysicians 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. Key pointsO_ST_ABSQuestionC_ST_ABSDo family physicians who provide more care virtually have higher emergency department visit rates among their patient panel? FindingsIn 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. MeaningOur findings refute hypotheses that emergency department use is being driven by family physicians providing more care virtually.

Keeping doors open: A cross-sectional survey of family physician practice patterns during COVID-19, needs, and intentions

ObjectiveTo determine the extent to which family physicians closed their doors altogether or for in-person visits during the pandemic, their future practice intentions, and related factors. MethodsBetween March and June 2021, we conducted a cross-sectional survey using email, fax, and phone of 1,186 family doctors practicing comprehensive family medicine in Toronto, Ontario. We asked about practice patterns in January 2021, use of virtual care, and practice intentions. ResultsOf the 1,016 (86%) that responded to the survey, 99.7% (1001/1004) indicated their practice was open in January 2021 with 94.8% (928/979) seeing patients in-person and 30.8% (264/856) providing in-person care to patients reporting COVID-19 symptoms. Respondents estimated spending 58.2% of clinical care time on phone visits and an additional 5.8% on video and 7.5% on email. 17.2% (77/447) were planning to close their current practice in the next five years. There was a higher proportion of physicians who worked alone in a clinic among those who did not see patients in-person (27.6% no vs 12.4% yes, p<0.05), did not see symptomatic patients (15.6% no vs 6.5 % yes, p<0.001), and those who planned to close their practice in the next 5 years (28.9% yes vs 13.9% no, p<0.01). InterpretationThe vast majority of family physicians in Toronto were open to in-person care in January 2021 but almost one-fifth are considering closing their practice in the next five years. Policy-makers need to prepare for a growing family physician shortage and better understand factors that support recruitment and retention.

Did the COVID-19 pandemic result in more family physicians stopping practice? Results from Ontario, Canada

PurposeTo understand changes in family physician practice patterns and whether more family physicians stopped working during the COVID-19 pandemic compared to previous years. MethodsWe analyzed administrative data from Ontario, Canada two ways: cross-sectional and longitudinal. First, we identified the percentage and characteristics of all family physicians who had a minimum of 50 billing days in 2019 but no billings during the first six months of the pandemic. Second, for each year from 2010 to 2020, we calculated the percentage of physicians who billed for services in the first quarter of the calendar year but submitted no bills between April and September of the given year. ResultsWe found 3.1% of physicians working in 2019 (N=385/12,247) reported no billings in the first six months of the pandemic. Compared with other family physicians, a higher portion were age 75 or older (13.0% vs. 3.4%, p<0.001), had fee-for-service reimbursement (38% vs 25%, p<0.001), and had a panel size under 500 patients (40% vs 25%, p<0.001). Between 2010 and 2019, an average of 1.6% of physicians who practiced in the first quarter had no billings in each of the second and third quarters of the calendar year compared to 3.0% in 2020 (p<0.001). ConclusionsApproximately twice as many family physicians stopped work in Ontario, Canada during COVID-19 compared to previous years, but the absolute number was small and those who did had smaller patient panels. More research is needed to understand the impact on primary care attachment and access to care.

Sociodemographic differences in patient experience with virtual care during COVID-19

PurposeWe sought to understand patients care-seeking behaviours during the pandemic, their use and views of different virtual care modalities, and whether these differed by sociodemographic factors. MethodsWe conducted a multi-site cross-sectional patient experience survey at thirteen academic primary care teaching practices between May and June of 2020. An anonymized link to an electronic survey was sent to a subset of patients with a valid email address on file; sampling was based on birth month. For each question, the proportion of respondents who selected each response was calculated, followed by a comparison by sociodemographic characteristics using chi-squared tests. ResultsIn total, 7482 participants responded to the survey. Most received care from their primary care clinic during the pandemic (67.7%, 5068/7482), the majority via phone (82.5%, 4195/5086). Among those who received care, 30.53% (1509/4943) stated that they delayed seeking care because of the pandemic. Most participants reported a high degree of comfort with phone (92.4%, 3824/4139), video (95.2%, 238/250) and email or messaging (91.3%, 794/870). However, those reporting difficulty making ends meet, poor or fair health, and arriving in Canada in the last 10 years reported lower levels of comfort with virtual care and fewer wanted their practice to continue offering virtual options after the pandemic. ConclusionsOur study suggest that newcomers, people living with a lower income, and those reporting poor or fair health have a stronger preference and comfort for in-person primary care. Further research should explore potential barriers to virtual care and how these could be addressed.

Association of homelessness with COVID-19 positivity among individuals visiting a testing center

We conducted a chart audit of all patients attending an inner-city COVID-19 testing centre in Toronto, Canada between March and April 2020. Of the 2050 unique individuals tested, 214 (10.4%) were homeless. People experiencing homelessness were more likely to test positive for COVID-19 compared to those not experiencing homelessness even after adjustment for age, sex, and the presence of any medical co-morbidity (15.4% vs. 6.7%, p<0.001; OR 2.41, 95% CI 1.51 to 3.76, p<0.001).

Mobile outreach testing for COVID-19 in twenty homeless shelters in Toronto, Canada

BackgroundIt is unclear what the best strategy is for detecting COVID-19 among homeless shelter residents and what individual factors are associated with positivity. MethodsWe conducted a retrospective chart audit obtaining repeated cross-sectional data from outreach testing done at homeless shelters between April 1st and July 31st, 2020 in Toronto, Canada. We compared the positivity rate for shelters tested because of an outbreak (at least one known case) versus surveillance (no known cases). A patient-level analysis examined differences in demographic, health, and behavioural characteristics of residents who did and did not test positive for COVID-19. FindingsOne thousand nasopharyngeal swabs were done on 872 unique residents at 20 shelter locations. Among the 504 tests done in outbreak settings, 69 (14%) were positive and 1 (0.2%) was indeterminate. Among the 496 tests done for surveillance, 11 (2%) were positive and none were indeterminate. Shelter residents who tested positive were significantly less likely to have a health insurance card (54% vs 72%, p=0.03) or have visited another shelter in the last 14 days (0% vs 18%, p<0.01) compared to those who tested negative; There was no association between COVID-19 positivity and medical history (p=0.40) or symptoms (p=0.43). InterpretationOur findings support testing of asymptomatic shelter residents for COVID-19 when a positive case is identified at the same shelter but suggest limited utility of testing all shelter residents in the absence of a known case. Visiting another shelter in the last 14 days is associated with a decreased risk of COVID-19 positivity.