Changes in outpatient care patterns and subsequent outcomes during the COVID-19 pandemic: A retrospective cohort analysis from a single payer healthcare system
This article has been Reviewed by the following groups
Listed in
- Evaluated articles (ScreenIT)
Abstract
Background
There have been rapid shifts in outpatient care models during the COVID-19 pandemic but the impact of these changes on patient outcomes are uncertain. We designed this study to examine ambulatory outpatient visit patterns and outcomes between March 1, 2019 to February 29, 2020 (pre-pandemic) and from March 1, 2020 to February 28, 2021 (pandemic).
Methods
We conducted a population-based retrospective cohort study of all 3.8 million adults in the Canadian province of Alberta, which has a single payer healthcare system, using linked administrative data. We examined all outpatient physician encounters (virtual or in-person) and outcomes (emergency department visits, hospitalizations, or deaths) in the next 30- and 90-days.
Results
Although in-person outpatient visits declined by 38.9% in the year after March 1, 2020 (10,142,184 vs. 16,592,599), the increase in virtual visits (7,152,147; 41.4% of total) meant that total outpatient encounters increased by 4.1% in the first year of the pandemic. Outpatient care and prescribing patterns remained stable for adults with ambulatory-care sensitive conditions (ACSC): 97.2% saw a primary care physician (median 6 visits), 59.0% had at least one specialist visit, and 98.5% were prescribed medications (median 9) in the year prior to the pandemic compared to 96.6% (median 3 in-person and 2 virtual visits), 62.6%, and 98.6% (median 8 medications) during the first year of the pandemic. In the first year of the pandemic, virtual outpatient visits were associated with less subsequent healthcare encounters than in-person ambulatory visits, particularly for patients with ACSC (9.2% vs. 10.4%, aOR 0.89 [95% confidence interval 0.87-0.92] at 30 days and 26.9% vs. 29.3%, aOR 0.93 [0.92-0.95] at 90 days).
Conclusions
The shifts in outpatient care patterns caused by the COVID-19 pandemic did not disrupt prescribing or follow-up for patients with ACSC and did not worsen post-visit outcomes.
Funding
None
Registration
None
KEY MESSAGES
What is already known on this topic
There have been rapid shifts in outpatient care models during the COVID-19 pandemic but outcomes are uncertain.
What this study adds
Total outpatient encounters increased by 4% in the first year of the pandemic due to a rapid increase in virtual visits (which made up 41% of all outpatient encounters). Prescribing patterns and frequency of follow-up were similar in the first year after onset of the pandemic in adults with ambulatory-care sensitive conditions. Compared to in-person visits, virtual outpatient visits were associated with less subsequent healthcare encounters, particularly for patients with ambulatory-care sensitive conditions (11% less at 30 days and 7% less at 90 days).
How this study might affect research, practice or policy
Our data provides reassurance that the shifts in outpatient care patterns caused by the COVID-19 pandemic did not negatively impact follow-up, prescribing, or outcomes for patients with ACSC. Further research is needed to define which patients and which conditions are most suitable for virtual outpatient visits and, as with all outpatient care, the optimal frequency of such visits.
Article activity feed
-
SciScore for 10.1101/2022.03.07.22272032: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics IRB: Ethics: The University of Alberta Health Research Ethics Board approved this study (Pro00086861) and granted a waiver for individual patient consent as the investigators were only provided with de-identified data after linkage to conform with provincial privacy regulations.
Consent: Ethics: The University of Alberta Health Research Ethics Board approved this study (Pro00086861) and granted a waiver for individual patient consent as the investigators were only provided with de-identified data after linkage to conform with provincial privacy regulations.Sex as a biological variable not detected. Randomization not detected. Blinding not detected. Power Analysis not detected. Table 2: Resources
No …
SciScore for 10.1101/2022.03.07.22272032: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics IRB: Ethics: The University of Alberta Health Research Ethics Board approved this study (Pro00086861) and granted a waiver for individual patient consent as the investigators were only provided with de-identified data after linkage to conform with provincial privacy regulations.
Consent: Ethics: The University of Alberta Health Research Ethics Board approved this study (Pro00086861) and granted a waiver for individual patient consent as the investigators were only provided with de-identified data after linkage to conform with provincial privacy regulations.Sex as a biological variable not detected. Randomization not detected. Blinding not detected. Power Analysis not detected. Table 2: Resources
No key resources detected.
Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:However, we did not have access to medication dosages prescribed - this is a potentially important limitation since one recent study[9] reported that heart failure patients were 61% less likely to have their antifailure therapy intensified after a virtual visit than an in-person visit and two other studies[7,8] reported that virtual visits were associated with 38% fewer new prescriptions than in-person visits. Thus, further research is needed to investigate whether the shift towards virtual outpatient care has negatively impacted medication intensification for chronic conditions such as heart failure, hypertension, diabetes, or dyslipidemia. Further research is also needed to investigate whether the shift towards virtual outpatient care has negatively impacted diagnostic test ordering practices, particularly screening for and detection of new conditions (such as diabetes, atrial fibrillation, or cancers). For example, a recent US study[6] revealed that while the total number of outpatient visits (virtual and in-person) only decreased by 21% in the second quarter of 2020, assessments of blood pressure decreased by 50% and cholesterol by 37%. Another US academic health system reported that 6 primary care screening quality measures were done less than one-third of usual frequency in the early months of the pandemic and 4 were still being performed at less than two-thirds of pre-pandemic levels even in the lull between the first and second waves.[28] It is not surprising that rep...
Results from TrialIdentifier: No clinical trial numbers were referenced.
Results from Barzooka: We did not find any issues relating to the usage of bar graphs.
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- No protocol registration statement was detected.
Results from scite Reference Check: We found no unreliable references.
-
