Virtual care provision and emergency department use among children and youth

Importance — Use of virtual care has rapidly expanded, but its impacts in pediatric emergency department use remain unclear.

Objective — To assess whether modality of primary care visits (in-person visit or virtual visit) is associated with subsequent emergency department (ED) use in acutely ill children.

Design, setting, and participants — Population-based cohort study using routinely collected administrative data of children and youth (age 0-17 years) in Ontario, Canada. Participants were children who had a primary care sick visit between September 2020 and March 2024. One visit per child was randomly selected during the study period and children were categorized by age group (aged <3 months, 3 months to <2 years, and 2-17 years).

Exposures Primary care sick visit modality identified from physician billing codes.

Main outcomes and measures — The primary outcome was an ED visit within 3 days of the primary care visit. Secondary outcomes included (1) ED visits leading to hospitalization or death, (2) high-acuity ED visits, and (3) low-acuity ED visits. Age-stratified multivariable logistic generalized estimating equation models were used to estimate the association between modality of the primary care visit and each outcome, clustering patients within physicians and adjusting for sociodemographic, clinical, and health system factors.

Results — Participants included 2 608 503 unique children with a sick visit (132 352 [5.1%] aged <3 months; 282 720 [10.8%] aged 3 months to <2 years; 2 608 503 [84.1%] aged 2-17 years). Virtual visits comprised 719 119 (27.6%) of sick visits. Children aged 3 months to less than 2 years had an increased adjusted risk of a subsequent ED visit when seen virtually compared with in person (4.4% vs 3.5%; adjusted risk ratio [ARR], 1.49; 95% CI, 1.41-1.57) as did children aged 2 to 17 years (2.2% vs 2.4%; ARR, 1.19; 95% CI, 1.15-1.24). Children aged 3 months to less than 2 years and aged 2 to 17 years seen virtually had a lower risk of ED visits leading to hospitalization or death, similar risk of high-acuity ED visit, and higher risk of low-acuity ED visits. Children aged less than 3 months seen virtually had a similar risk of subsequent ED visits to those seen in person.

Conclusions and relevance — In this population-based cohort study of Ontario children and youth, while emergency department visits following a primary sick visit were infrequent, virtual sick visits to primary care were associated with a small increase in emergency department use in children aged 3 months or older, especially low-acuity emergency department visits. Judicious use of virtual primary care to manage acute illness in children is warranted.