Virtual Visits With Own Family Physician vs Outside Family Physician and Emergency Department Use

This cross-sectional study investigates differences in rates of emergency department use among patients who had virtual visits with their own vs outside family physicians.


Discharge Abstract Database (DAD)
Information on all admissions (excluding designated mental health beds) to acute care hospitals in Ontario.This includes dates of admission as well as diagnostic and procedural codes.Overall, diagnostic codes were found to be 82% sensitive for primary diagnosis when verified against chart abstraction. 4National Ambulatory Care Reporting System (NACRS) Includes information for all emergency department visits since 2000.A reabstraction study of diagnostic codes found 85% agreement for the main presenting problem. 5

Ontario Health Insurance Plan (OHIP)
Contains information on all billing claims submitted by Ontario physicians (consultations, assessments and procedures).Physicians practicing in non feefor-service models (capitation-based patient enrolment models) submit shadow billings to OHIP, which appear as billing claims with a payment value of $0.A visit within 7 days of the index virtual visit with location = O (office) or H (home) for at least one code in that encounter, and: 1.Any family physician (SPEC = 00, family physician).2. The same family physician as the index virtual visit (OHIP PHYSNUM = PHYSNUM at index visit).

The patient's own enrolling physician (OHIP PHYSNUM = PHYSNUM in PCPOP). Virtual visit with any/same/own enrolling family physician or own group physician-7 days OHIP PCPOP
A visit within 7 days of the index virtual visit with location = P (virtual) for at least one code in that encounter, and: 1.Any family physician (SPEC = 00, family physician).2. The same family physician as the index virtual visit (OHIP PHYSNUM = PHYSNUM at index visit).Using a keyword search in Excel, we examined all group names present in the Canadian Physician Database (CPDB) that included the term 'virtual' or 'tele' (n = 43).We then used Google to search each clinic name, and included clinics that had a working website, offered services to patients in Ontario, and provided virtual appointments only (i.e., no brick-and-mortar clinic for in-person visits nor the option of home visits).We excluded clinics that did not provide primary care (e.g., specialty clinics such as pain or cannabis clinics).

Google Search to Group Name
Strategy-Search was performed in duplicate, and each clinic website was double-checked by CS and JS to confirm eligibility Next, we conducted a Google search using the following Boolean search term: (Canada OR Ontario) AND ("virtual clinic" OR "telemedicine").We examined the preview of all available pages and found 5 virtual additional walk-in clinics present in the CPDB that met the inclusion criteria above.Three more virtual clinics were included based on our team members' knowledge of virtual walk-in services available in Ontario.To find any additional clinics, we used the Boolean search term created by Matthewman et al. ( 2021

): (Canada) AND (virtual healthcare OR virtual health) AND (family medicine OR clinic OR general practitioner OR personalized care).
No other virtual clinics from this search met the inclusion criteria (same as step 1 above).

Active Billings During the Study Period
Of the 14 virtual walk-in clinics obtained from steps 1 and 2 above, 6 clinics had no billings during the study time period, and we removed 1 clinic because it had only a total of 4 virtual claims in the study period.Note.Vr = 0 (blue line), virtual encounter with enrolling physician.Vr = 1 (red line), virtual encounter with a physician outside the enrolling group.Visit with their Own Enrolling Family Physician and with a Physician Outside the Enrolling Group.
Note: Patients with an index virtual visit with their own enrolling family physician (coded as '0', in blue), and with a physician outside the enrolling group (coded as '1', in red).Visit with their Own Enrolling Physician and a Virtual-Only Walk-In Clinic.
Note: Patients with an index virtual visit with their own enrolling family physician (coded as '0', in blue), and with a virtual-only walk-in clinic (coded as '1', in red).
PCPOPWhether the index virtual visit occurred on a weekday (Monday to Friday) and contained any of the following after-hours codes: ). Search Strategy for Direct-to-Consumer Telemedicine (Virtual-Only Walk-in Clinic) Group Numbers.

In-person visit with own enrolling physician-7 days
Characteristics of Patients in the Unmatched Cohort.Top 20 Diagnoses of All Patients in the Matched Cohort.Sensitivity Analysis: Characteristics of Patients in the Matched Cohort*.Variables in PS model were: age (in years), sex, neighborhood income quintile, recent immigrant status, count of visits with own physician in previous 2 years, resource utilization band, type of enrolment model, diagnosis (top 20, and other), index visit on a weekend, after-hours on a weekday, and modality (phone, video or missing).Age was fitted with a spline using 5 knots at the 5, 27.5, 50, 72.5 and 95 th percentile values, and visits were fitted using 3 knots at values of 2, 4 and 8 visits.Match was 99% (30216/30392 observations in the virtual walk-in group were matched).Patient Outcomes in the Matched Sensitivity Cohort.

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Study Population Flowchart.Density of Propensity Scores Before and After Matching.