Association of physician-delivered virtual care near the end of life with healthcare use outcomes: A national population-based study of Canadians

Abstract

Background: The last 90 days of life are marked by high healthcare utilization in acute care settings, often conflicting with the preference to remain at home. The COVID-19 pandemic accelerated the adoption of virtual care, but its impact on healthcare utilization near the end-of-life remains unclear. This study assessed the association between physician-delivered virtual care use near the end-of-life and acute healthcare utilization, before and during the COVID-19 pandemic across four Canadian provinces.

Methods: A retrospective population-based cohort study using linked health administrative data from January 1, 2018, to December 31, 2021, across British Columbia (BC), Alberta (AB), Ontario (ON), and Newfoundland & Labrador (NFLD). The study included 548,955 adult decedents who died within the study period. Virtual care use in the last 90 days of life, categorized by pre-pandemic and pandemic periods, was the primary exposure. Primary outcomes were rates of ED visits, hospitalizations, and in-hospital deaths during the last 90 days of life. Modified Poisson regression models were used to measure associations, adjusting for demographic and clinical characteristics.

Results: Among the 548,955 decedents, virtual care utilization during the pandemic varied by province, ranging from 53% in NFLD to 78% in BC. During the pandemic, virtual care was associated with higher ED visits (adjusted rate ratios [aRateRs] ranging from 1.12 to 1.72) and hospitalizations (aRateRs: ranging from 1.01 to 1.59) in most provinces. Virtual care was linked to a higher risk of in-hospital death in AB (adjusted risk ratios [aRiskR]: 1.11; 95% CI: 1.08-1.14; P < 0.001) and ON (aRiskR: 1.04; 95% CI: 1.03-1.05; P < 0.001). Pre-pandemic, associations were weaker, with virtual care linked to lower in-hospital death rates in ON, AB and BC.

Conclusion: Virtual care during the pandemic was linked to increased acute healthcare utilization, contrasting with pre-pandemic patterns when it appeared more selective and associated with fewer in-hospital deaths. Findings highlight the evolving role of virtual care and the need for region-specific policies to optimize end-of-life care delivery.

Fig 1. The figure illustrates how the study cohort was created and the distribution of patients across the provinces.

Fig 2. The Love plots illustrate the association between receipt of virtual care near EOL and acute health services utilization rates and location of death among adults, who either received (exposed) or did not receive (unexposed) virtual care.

Panel A shows the association during the COVID-19 pandemic. Panel B displays the association in the pre-pandemic period. Red circles represent Ontario, Yellow triangles are for Newfoundland, Blue boxes for British Columbia, and Green diamonds for Alberta.