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The pandemic-related expansion of virtual medical care in Ontario did not widen the geographic reach of specialists in the province, according to a population-based cohort study.
While COVID changed patient and physician attitudes about virtual care and heralded new billing codes and reimbursement rates for video and telephone medical consultations, these changes did not expand physicians’ practices to include patients who lived further away.
“Given our results, if virtual care is to increase access to specialty care for rural patients, efforts are required to identify and target other barriers for virtual care,” wrote senior author Natasha Saunders, MD, associate professor of pediatrics at the University of Toronto, Toronto, and health services researcher at ICES (formerly the Institute for Clinical Evaluative Sciences), and coauthors.
The study was published on September 22 in CMAJ.
No Meaningful Changes
The investigators used linked health and administrative databases to compare the proximity of all Ontario specialists and their patients in the previrtual care period (January 1, 2019, to November 30, 2019) and the virtual care period (January 1, 2022, to November 30, 2022).
A total of 11,096 specialists (4232 surgical and 6864 medical) were included, of whom 61% were men and 0.8% practiced in rural locations.
Community and family medicine practitioners were excluded, as were specialties generally not amenable to virtual care, such as laboratory and pathology medicine, emergency medicine, and nuclear medicine. Physicians were also excluded if there was incomplete information on them, if they entered or moved practices during the study period, if they did not see at least one patient in either era, or if they had visit numbers below the 5th percentile or greater than the 95th percentile.
The researchers obtained specialist physician characteristics using the Corporate Provider Database, data on patient visits from the Ontario Health Insurance Plan database, patient demographics from the Registered Persons Database, rurality from the Postal Code Conversion File, and geographic areas to identify the distance between specialist practice location and patient residential location using the Ontario Road Network File.
Proximity was measured for each specialist’s patient panel, which included all patients who had one or more visits with that specialist. Proximity was measured in several ways, including 90th-percentile driving distance, mean driving time, and the proportion of patients with driving times longer than 60 minutes.
After adjustment for physician age, sex, practice size, and location, the study authors concluded that there was no meaningful change in the distance between specialists and their patients from the previrtual to virtual period. Specifically, the 90th-percentile driving distance did not change meaningfully between time periods for either surgical or medical specialties (difference 6.7 km and 1.3 km, respectively).
Similarly, the mean driving time increased by 5 minutes, and the proportion of patients living more than 60 minutes away increased by 2.1% for surgical specialists, but there was no significant change for medical specialists in these measures.
The Role of Referrals
“We were somewhat surprised,” Saunders told Medscape Medical News. “Our hypothesis was that virtual care, especially among nonsurgical medical specialists, would allow physicians to reach patients living farther away, since a physical exam might not always be necessary. But the data didn’t support that.”
She added that the study wasn’t designed solely to assess whether rural patients saw more specialists during the virtual care period but rather whether virtual care allowed physicians to consult with patients living farther away than they typically did when care was delivered only in person.
“Not all patients who live far from a specialist are technically rural,” Saunders explained. “Some live in urban or suburban areas where a particular type of specialist isn’t available, requiring them to travel to another region. So we aimed to go beyond a simple rural-urban comparison and look more broadly at geographic access to specialist care: specifically, how virtual care might have changed that dynamic.”
Saunders suggested several possible explanations for the study’s findings. “One is that existing referral patterns remained largely unchanged during the study period,” she said. “Referring physicians may have continued to send patients to specialists they already knew and worked with. Another possibility is that although virtual care offered clear advantages like convenience and reduced travel time, physicians or patients still preferred to keep care local when possible and so continued seeing nearby providers, even when virtual options were available.”
One limitation of the study was that satisfaction with care and outcomes were not available in the databases used. Residual confounding likely arose from unmeasured factors such as training for using virtual care, access to technology, or patient-provider language concordance.
No New Patients
Commenting on the findings for Medscape Medical News, Arthur Sweetman, PhD, professor of economics at McMaster University in Hamilton, Ontario, and specialist in healthcare systems and health economics research, said that the results were not “overly surprising,” given that most specialist visits result from referrals, “and that the technology and social norms for referrals had no obvious source of change” during the study period.
“It may motivate us to think more carefully about developing a systematic, province-wide approach to referrals,” he said. “This might have the benefit of not only improving service to those in underserved areas but also improving the efficiency of healthcare delivery.”
Sweetman, who is also co-director of the Centre for Health Economics and Policy Analysis in the Faculty of Health Sciences and holds the Ontario Research Chair in Health Human Resources, said that one important consideration when interpreting the results is that the study did not include new patients. “For some specialties, a very high share of patients is new, whereas for others, repeat visits are common. Including repeat visits or longstanding patients would attenuate any impact of the introduction or expansion of virtual care on the geographic distance of new patients.”
Sweetman also suggested that it would have been important to differentiate between patient-physician interactions that are fully virtual and those where a combination of virtual and in-person visits reflects one episode of care. “You might expect the fully virtual episodes to be less bound by geography,” he said.
This study was supported by the Canadian Institutes of Health Research (CIHR).Saunders reported receiving research funding from CIHR, travel funding from CIHR and the Department of Paediatrics at The Hospital for Sick Children, and personal fees from the BMJ Group and the Archives of Disease in Childhood. She also reported sitting on the Canadian Post-COVID Condition Guideline Team and the Canadian Paediatric Society Mental Health and Developmental Disabilities Committee. Sweetman reported having no relevant financial relationships.
Kate Johnson is a Montreal-based freelance medical journalist who has been writing for more than 30 years about all areas of medicine.
