Patients who use virtual walk-in clinics more likely to go to ER later: study

People who used a virtual-only medical service — a kind of virtual walk-in clinic — during the pandemic were more likely to later go to an emergency room than patients who did appointments with their own family doctor online, a study by Toronto researchers has shown.

The study published Thursday in the Journal of Medical Internet Research explores the different outcomes between two kinds of virtual medical care during the pandemic — that given by walk-in-style clinics and that given by family doctors.

Conducted by the University Health Network, ICES, Women’s College Hospital and Unity Health Toronto, the study found that the patients who saw a physician who was not their family doctor through a virtual-only medical service were twice as likely to visit an emergency department within 30 days.

The visits “can add to an already overwhelming strain” on emergency departments caused by staff shortages and the prevalence of viruses, says lead author Dr. Lauren Lapointe-Shaw, a general internist at Toronto General Hospital and an assistant professor at U of T.

“To add any potential demand related to these virtual appointments is suboptimal.”

Emergency departments in Ontario have been experiencing record-high wait times and some rural emergency departments have closed temporarily because of a lack of staff.

The study showed that patients who had a virtual-only walk-in appointment often had a virtual followup and then ended up in emergency, in contrast to patients who had a virtual appointment with their family doctor and then could have an in-person followup, possibly avoiding a hospital visit because they were able to have a physical exam.

The “concern with virtual walk-in clinics is the lack of a physical exam,” says Lapointe-Shaw.

“We know that acute problems, which is what people tend to go to both virtual and physical walk-in clinics for, in most cases require a physical exam.”

The other problem is the lack of continuity, because a patient’s medical information from a walk-in visit, whether in person or virtual, isn’t available to their family doctor due to limits in electronic record keeping.

The study looked at more than 132,000 patient visits at 13 virtual walk-in clinics in the province from April 1 to Dec. 31, 2020, and compared the data to all virtual appointments by Ontario residents during the same time period, most of which were with the patients’ regular family physician.

By late 2020, infection-control measures to reduce the spread of COVID were leading to a marked increase in the practice of virtual-only medicine in Ontario.

The number of physicians providing virtual-only care, with no in-person component, by November of that year was 2.5 times higher than in February, according to the study.

Because so many family doctors were seeing patients virtually, mostly by phone, the government let doctors bill on par for what they would if they saw a patient in person, which gave rise to a host of virtual-only websites.

The government recently lowered fees for virtual-only care, even where no in-person component is available, claiming they want to encourage doctors to see patients in person as well as virtually, which many medical experts agree is the best way to provide ongoing, comprehensive care.

However, some specialists think that virtual-only appointments are a good alternative, eliminating the need for patients to drive hundreds of kilometres to see them for certain types of appointments. What’s more, doctors at hospital clinics who provide one-off virtual outreach appointments to homeless populations, or who rotate and therefore aren’t considered to be providing ongoing care to a patient, object to the lower fees.

Others claim the virtual-only appointments are a necessity because of a shortage of family doctors in the province.

The study found that 60 per cent of patients using the virtual-only sites had a family doctor.

“We don’t know why they’re not seeing their own physician,” says Lapointe-Shaw. “To what extent is it patient choice versus difficulties accessing their own physician, which certainly have been described as well.”

For the 40 per cent without a family doctor, Lapointe-Shaw says the study highlights how important it is to connect more Ontarians with a family physician, so that their choice for medical care isn’t limited to a virtual-only site or an emergency department.

The study adjusted for patient characteristics such as age, sex, urban/rural status, previous health-care use and neighbourhood income levels.

The research was conducted when most virtual appointments were being conducted by phone. Ongoing studies, after OHIP fee codes were created to differentiate between video and phone appointments, may determine whether the outcomes differ according to the type of technology used.

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