Health care utilization and outcomes of patients seen by virtual urgent care versus in-person emergency department care

The birth of the virtual clinic: welcome to the Mediverse

The COVID-19 pandemic triggered a global pivot to virtual care (VC) technologies. While there has been considerable academic work exploring the "how" of VC, few studies have explored the impact of this pivot, its unintended consequences, and its governing rationales. This study addresses this gap in relation to care, professional identity and the evolving requirements for health professions education. Collected over three years, data for this study included evaluation surveys (134), interviews (59), publicly-available documents (240), and academic articles (217). Interviews and surveys were conducted in the Toronto Academic Health Science Network (TAHSN) and in a European academic medical centre (Maastricht UMC). Criteria for academic literature were that they addressed the shift to VC and were published between 2019 and 2023. Foucault's work, The Birth of the Clinic, his methodologies of Critical Discourse Analysis and his concept of spatiality, guided the analysis. Patients, clinicians and institutional leaders were appreciative of VC and the perceived improvements brought to care logistics, patient experience and efficiencies. Two discourses governed these sentiments-VC as a tool for both "service" and "managerialism." Assessing changes in clinical practice, experience and professional identity, our analysis suggested that a new virtual clinical space was being produced, one in which rules and experiences were different from that of a classical clinic. We named this new space the "Mediverse"-a space of undiscovered complexity with material and unintended consequences on user experience. This study identifies a new framework in which to study and assess this new clinical space.

Health service access and quality of care provided by the Western NSW Local Health District Virtual Rural Generalist Service: a retrospective analysis of linked administrative data

OBJECTIVE

To evaluate the quantity and quality of medical care provided by the Western NSW Local Health District Virtual Rural Generalist Service (VRGS).

DESIGN

Retrospective cohort study; analysis of emergency department and administrative hospital data.

SETTING

Twenty-nine rural or remote hospitals in the Western NSW Local Health District at which the VRGS was providing medical care in the emergency department (ED) and/or inpatient setting. The VRGS was providing predominantly virtual medical support when local doctors needed relief or were unavailable, typically for lower acuity ED presentations and scheduled inpatient ward rounds.

PATIENTS

All patients who presented or were admitted to a Western NSW Local Health District hospital serviced by the VRGS between 1 July 2021 and 30 June 2022.

MAIN OUTCOME MEASURES

Treatment completions, transfers, ED departure within 4 hours, length of stay, and hospital mortality.

RESULTS

During 2021-22, 34% of ED presentations (13 660/39 701) and 40% of admissions (2531/6328) involved VRGS care. For ED presentations, after adjusting for socio-demographic and clinical factors, patients attended by VRGS doctors had higher odds of not waiting (adjusted odds ratio [aOR], 3.69; 95% CI, 2.79-4.89), lower odds of transfer to another hospital (aOR, 0.66; 95% CI, 0.60-0.72) and slightly lower odds of ED departure within 4 hours (aOR, 0.92; 95% CI, 0.86-0.98) when compared with patients not attended by VRGS doctors (ie, those provided usual care). For admissions, after adjusting for socio-demographic and clinical factors, inpatients attended exclusively by VRGS doctors had higher odds of discharging at their own risk (3.33; 95% CI, 1.98-5.61) and lower odds of being a long stay outlier (aOR, 0.51; 95% CI, 0.35-0.74) when compared with inpatients not attended by VRGS doctors. The odds of inpatient mortality were equivalent when comparing VRGS and non-VRGS care (aOR, 0.78; 95% CI, 0.48-1.28) and when comparing combined (VRGS and non-VRGS) and non-VRGS care (aOR 1.21; 95% CI, 0.91-1.61).

CONCLUSIONS

In the current environment of rural medical workforce shortages, the VRGS achieved similar outcomes on routinely collected measures of quality of care. It is demonstrably an option for complementing and enhancing the delivery of medical care in rural and remote communities with limited or no local medical services.

From fragmentation to functionality: Enhancing coherence of digital health integration in health systems

Digital health programs continue to be implemented within Canadian health systems at a steady pace. The effectiveness of digital health initiatives has been rigorously analyzed, with both benefits and drawbacks extensively commented on. While the discussion about digital health continues, both positive and negative perspectives of it are approaching saturation in their themes. Accepting that digital health is here to stay post-pandemic, the focus should shift to strategies and supports needed to avoid the fragmentation of care through digital health implementation. This short article poses three questions which policy-makers and decision-makers should explore as part of a level-setting exercise with involved stakeholders at the outset of a digital health program's consideration. An implementation team should design the digital health program to have equity as its foundational focus, conduct value-based evaluations, and position the program in a learning health system framework to guard against the fragmentation of care.

Cost Evaluation of the Ontario Virtual Urgent Care Pilot Program: Population-Based, Matched Cohort Study

BACKGROUND

In 2020, the Ministry of Health (MoH) in Ontario, Canada, introduced a virtual urgent care (VUC) pilot program to provide alternative access to urgent care services and reduce the need for in-person emergency department (ED) visits for patients with low acuity health concerns.

OBJECTIVE

This study aims to compare the 30-day costs associated with VUC and in-person ED encounters from an MoH perspective.

METHODS

Using administrative data from Ontario (the most populous province of Canada), a population-based, matched cohort study of Ontarians who used VUC services from December 2020 to September 2021 was conducted. As it was expected that VUC and in-person ED users would be different, two cohorts of VUC users were defined: (1) those who were promptly referred to an ED by a VUC provider and subsequently presented to an ED within 72 hours (these patients were matched to in-person ED users with any discharge disposition) and (2) those seen by a VUC provider with no referral to an in-person ED (these patients were matched to patients who presented in-person to the ED and were discharged home by the ED physician). Bootstrap techniques were used to compare the 30-day mean costs of VUC (operational costs to set up the VUC program plus health care expenditures) versus in-person ED care (health care expenditures) from an MoH perspective. All costs are expressed in Canadian dollars (a currency exchange rate of CAD $1=US $0.76 is applicable).

RESULTS

We matched 2129 patients who presented to an ED within 72 hours of VUC referral and 14,179 patients seen by a VUC provider without a referral to an ED. Our matched populations represented 99% (2129/2150) of eligible VUC patients referred to the ED by their VUC provider and 98% (14,179/14,498) of eligible VUC patients not referred to the ED by their VUC provider. Compared to matched in-person ED patients, 30-day costs per patient were significantly higher for the cohort of VUC patients who presented to an ED within 72 hours of VUC referral ($2805 vs $2299; difference of $506, 95% CI $139-$885) and significantly lower for the VUC cohort of patients who did not require ED referral ($907 vs $1270; difference of $362, 95% CI 284-$446). Overall, the absolute 30-day costs associated with the 2 VUC cohorts were $18.9 million (ie, $6.0 million + $12.9 million) versus $22.9 million ($4.9 million + $18.0 million) for the 2 in-person ED cohorts.

CONCLUSIONS

This costing evaluation supports the use of VUC as most complaints were addressed without referral to ED. Future research should evaluate targeted applications of VUC (eg, VUC models led by nurse practitioners or physician assistants with support from ED physicians) to inform future resource allocation and policy decisions.

A qualitative study on the Virtual Emergency Department care experiences of equity-deserving populations

Patients from equity-deserving populations, such as those who are from racialized communities, the 2SLGBTQI+ community, who are refugees or immigrants, and/or who have a disability, may experience a unique set of challenges accessing virtual models of care. The objective of this qualitative study was to describe the experiences of patients from equity-deserving communities and their family members who received care from a Virtual Emergency Department (ED) in Toronto, Canada. Forty-three participants (36 patients and 7 family caregivers) with different and intersecting identities who used the Virtual ED participated in the study. Semi-structured interviews were conducted to explore reasons for accessing the Virtual ED, barriers to access, and how the Virtual ED met their care needs and expectations, including ways their experience could have been improved. Thematic analysis was used to identify themes from the data. Patients from equity-deserving populations described negative past experiences with ED in-person care, which included recounts of discrimination or culturally insensitive care while waiting to see the ED physician or nurse. Conversely, participants found the Virtual ED to be a socially and culturally safe space since they could now by-pass the waiting room experience. However, virtual care could not replace in-person care for certain issues (e.g., physical exam), and there was a need for greater promotion of the service to specific communities that might benefit from having access to the Virtual ED. Targeted outreach to help raise awareness of the service to equity-deserving communities is an important future direction.