A virtual urgent care (VUC) pilot program in Ontario, Canada, had limited impact on in-person emergency department visits in 2021, according to a new study. The researchers suggest a need to better understand the limitations of virtual care.
In a prospective study involving more than 4000 patients, the rates of index-visit hospital admissions, 30-day emergency department visits, and overall hospital admissions were similar among patients who initially used virtual care and those who visited the emergency department.
“VUC may be an appropriate alternative healthcare option for patients who have non-life-threatening medical concerns or for patients who have difficulty accessing in-person healthcare,” study author Shelley McLeod, PhD, research director of the Schwartz/Reisman Emergency Medicine Institute at Mount Sinai Hospital in Toronto, told Medscape Medical News. The latter group includes patients in rural or remote areas, those with mobility issues, those without a primary care provider, and those who cannot access their primary care provider in a timely fashion, she explained.
“However, the current volume of patients seeking VUC makes the sustainability of multiple programs difficult, both from an economic and human resources perspective,” she said.
The study was published online November 6 in CMAJ.
Exploring Virtual Care
In response to the COVID-19 pandemic, the Ontario Ministry of Health dedicated $4 million to a pilot program involving 14 VUC initiatives across the province. The program was intended to divert patients with non-life-threatening medical concerns from emergency departments. The 14 programs had various start dates, operating hours, screening requirements, and staffing models.
The investigators compared healthcare utilization and patient outcomes among patients who used VUC services with those of similar patients who received traditional in-person emergency department care between December 2020 and September 2021. The researchers matched patients who attended a virtual appointment and were promptly referred to an emergency department with patients who presented first to the emergency department. They also matched patients seen by a VUC clinician but who had not been referred to an emergency department with patients who presented to the emergency department and were discharged home.
Among the 19,595 virtual patient encounters, 85% of patients had a primary care provider. Most visits were for low-acuity complaints, and 70% were managed by the virtual care provider without referral elsewhere. About 12.5% had an in-person emergency department visit within 72 hours, and 21.5% had an in-person emergency visit within 30 days. In addition, 2.1% had a hospital admission within 72 hours, and 3.8% were admitted within 30 days. The mortality rate within 30 days was less than 0.03%.
Virtual patients who were promptly referred to the emergency department and who presented there within 72 hours had outcomes that were similar to those who initially presented to the emergency department. The rates of index visit hospital admissions (9.4% vs 8.7%), 30-day emergency department visits (17% vs 17.5%), and hospital admission (12.9% vs 11%) were similar between these groups. Among patients who were referred to emergency care by a virtual provider, the length of stay in the hospital was 2.4 days longer, and these patients were more likely to have another virtual visit within 72 hours, 7 days, and 30 days, compared with patients who presented first to the emergency department. They also were more likely to have a subsequent specialist visit within 7 days and 30 days.
Virtual patients who weren’t referred to the emergency department were more likely than emergency department patients who were discharged home to have a subsequent in-person emergency department visit in 72 hours (13.7% vs 7%), 7 days (16.5% vs 10.3%), and 30 days (21.9% vs 17.9%). Hospital admissions were similar between groups within 72 hours (1.1% vs 1.3%) and within 7 days (1.6% vs 1.9%). They were higher within 30 days for patients who were discharged home from the emergency department (3.4% vs 2.6%). Among virtual patients, hospital stays were 1 day longer, and fewer than five deaths occurred, which was not significantly different between the groups.
“The overall impact of the provincial VUC pilot program on subsequent emergency department volumes and hospitalizations was limited, but an important percentage of VUC patients subsequently attended an emergency department in person, which may reflect the limitations of VUC services as currently designed,” said McLeod.
“These findings highlight the need to better understand the inherent limitations of virtual care and ensure that future virtual providers have timely access to in-person outpatient resources for follow-up to reduce subsequent emergency department visits and ensure appropriate use of emergency department services.”
Additional research is needed to inform provincial policy decisions on how best to structure virtual services in a sustainable way, the authors wrote, including the role of emergency departments. For instance, nurse practitioners, physician assistants, or primary care providers may be better suited to provide virtual care as part of a “primary care first” strategy, they wrote.
“Our results suggest that patients using VUC often have a primary care provider and seemed to be accessing the VUC more for expedited advice as opposed to emergency care, suggesting that the current system of VUC in Ontario may simply be a stopgap for when primary care is not available in a timely fashion,” said McLeod.
In addition, virtual urgent care providers cannot conduct a physical exam and may not have access to real-time laboratory tests, imaging, and previous medical records, which can limit their ability to diagnose certain conditions, the authors wrote.
Investigating Future Plans
Commenting on the findings for Medscape, Lauren Lapointe-Shaw, MD, staff physician at University Health Network and assistant professor of medicine at the University of Toronto, said, “Previous studies suggest that virtual care is most effective when it is provided by a clinician who knows the patient and is able to examine the patient, if needed.”
Lapointe-Shaw, who wasn’t involved with this study, has researched virtual walk-in clinics in Ontario and found that patients were less likely to have a follow-up in-person visit with the same physician, were more likely to have another virtual visit, and were twice as likely to visit the emergency department within 30 days of the initial virtual appointment.
“VUC met a defined need for care at a time when minimizing COVID-19 exposure risk and preserving personal protective equipment were prioritized. Despite the present study findings, its use may still make sense in that context,” she said. “Future research should assess whether, under typical conditions, introducing a VUC service to a hospital site can reduce overall emergency department volumes.”
The study was conducted without outside funding. One author is an employee of Ontario Health, and another is a paid advisor to the Ministry of Health and has provided executive sponsorship for the virtual urgent care evaluation.
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