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Attending physicians’ annual service volume and use of virtual end-of-life care: a population-based cohort study in Ontario, Canada


Importance — Physicians and their practice behaviors influence access to healthcare and may represent potentially modifiable targets for practice-changing interventions. Use of virtual care at the end-of-life significantly increased during the COVID-19 pandemic, but its association with physician practice behaviors, (e.g., annual service volume) is unknown.

Objective — Measure the association of physicians’ annual service volume with their use of virtual end-of-life care (EOLC) and the magnitude of physician-attributable variation in its use, before and during the pandemic.

Design, Setting and Participants — Population-based cohort study using administrative data of all physicians in Ontario, Canada who cared for adults in the last 90 days of life between 01/25/2018-12/31/2021. Multivariable modified Poisson regression models measured the association between attending physicians’ use of virtual EOLC and their annual service volume. We calculated the variance partition coefficients for each regression and stratified by time period before and during the pandemic.

Exposure — Annual service volume of a person’s attending physician in the preceding year.

Main Outcomes and Measures — Delivery of ≥1 virtual EOLC visit by a person’s attending physician and the proportion of variation in its use attributable to physicians.

Results — Among the 35,825 unique attending physicians caring for 315,494 adults, use of virtual EOLC was associated with receiving care from a high compared to low service volume attending physician; the magnitude of this association diminished during the pandemic (adjusted RR 1.25 [95% CI 1.14, 1.37] pre-pandemic;1.10 (95% CI 1.08, 1.12) during the pandemic). Physicians accounted for 36% of the variation in virtual EOLC use pre-pandemic and 12% of this variation during the pandemic.

Conclusions and Relevance — Physicians’ annual service volume was associated with use of virtual EOLC and physicians accounted for a substantial proportion of the variation in its use. Physicians may be appropriate and potentially modifiable targets for interventions to modulate use of EOLC delivery.



Rodin R, Stukel TA, Chung H, Bell CM, Detsky AS, Isenberg S, Quinn KL. PLoS One. 2024; 19(3):e0299826. Epub 2024 Mar 8.

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