{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,6,4]],"date-time":"2025-06-04T04:16:47Z","timestamp":1749010607651,"version":"3.41.0"},"reference-count":23,"publisher":"Public Library of Science (PLoS)","issue":"6","license":[{"start":{"date-parts":[[2025,6,3]],"date-time":"2025-06-03T00:00:00Z","timestamp":1748908800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000024","name":"CIHR","doi-asserted-by":"crossref","award":["CIHR PNN-177924"],"award-info":[{"award-number":["CIHR PNN-177924"]}],"id":[{"id":"10.13039\/501100000024","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>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.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>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 &amp; 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.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>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\u00a0[aRiskR]: 1.11; 95% CI: 1.08\u20131.14; P\u2009&lt;\u20090.001) and ON (aRiskR: 1.04; 95% CI: 1.03\u20131.05; P\u2009&lt;\u20090.001). Pre-pandemic, associations were weaker, with virtual care linked to lower in-hospital death rates in ON, AB and BC.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusion<\/jats:title>\n<jats:p>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.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0324898","type":"journal-article","created":{"date-parts":[[2025,6,3]],"date-time":"2025-06-03T20:01:43Z","timestamp":1748980903000},"page":"e0324898","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Association of physician-delivered virtual care near the end of life with healthcare use outcomes: A national population-based study of Canadians"],"prefix":"10.1371","volume":"20","author":[{"given":"Mohammed Rashidul","family":"Anwar","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rabia","family":"Akhter","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Th\u00e9r\u00e8se A.","family":"Stukel","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hannah","family":"Chung","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Chaim M.","family":"Bell","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"James","family":"Downar","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nathan","family":"Stall","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Peter","family":"Tanuseputro","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7967-159X","authenticated-orcid":true,"given":"Aynharan","family":"Sinnarajah","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sandra","family":"Peterson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Asmita","family":"Bhattarai","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"John C.","family":"Knight","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1681-5170","authenticated-orcid":true,"given":"Kieran L.","family":"Quinn","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2025,6,3]]},"reference":[{"issue":"3","key":"pone.0324898.ref001","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0121759","article-title":"The health care cost of dying: a population-based retrospective cohort study of the last year of life in Ontario, Canada","volume":"10","author":"P Tanuseputro","year":"2015","journal-title":"PLoS One"},{"key":"pone.0324898.ref002","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1186\/1472-684X-12-7","article-title":"Heterogeneity and changes in preferences for dying at home: a systematic review","volume":"12","author":"B Gomes","year":"2013","journal-title":"BMC Palliat Care"},{"issue":"5","key":"pone.0324898.ref003","doi-asserted-by":"crossref","first-page":"627","DOI":"10.1503\/cmaj.050626","article-title":"What matters most in end-of-life care: perceptions of seriously ill patients and their family members","volume":"174","author":"DK Heyland","year":"2006","journal-title":"CMAJ"},{"issue":"2","key":"pone.0324898.ref004","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1177\/08258597211001184","article-title":"Leveraging telehealth for delivery of palliative care to remote communities: a rapid review","volume":"37","author":"B Gordon","year":"2022","journal-title":"J Palliat Care"},{"issue":"16","key":"pone.0324898.ref005","doi-asserted-by":"crossref","first-page":"1593","DOI":"10.1001\/jama.2020.17201","article-title":"Telephone visits surge during the pandemic, but will they last?","volume":"324","author":"MC Jaklevic","year":"2020","journal-title":"JAMA"},{"issue":"5","key":"pone.0324898.ref006","doi-asserted-by":"crossref","DOI":"10.2196\/16218","article-title":"Patients\u2019 experiences of telehealth in palliative home care: scoping review","volume":"22","author":"SA Steindal","year":"2020","journal-title":"J Med Internet Res"},{"issue":"4","key":"pone.0324898.ref007","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1089\/tmj.2015.0090","article-title":"A systematic review of telehealth in palliative care: caregiver outcomes","volume":"22","author":"Y Zheng","year":"2016","journal-title":"Telemed J E Health"},{"key":"pone.0324898.ref008","volume-title":"Expansion of virtual care in Canada: new data and information","author":"Information CIfH","year":"2023"},{"key":"pone.0324898.ref009","doi-asserted-by":"crossref","DOI":"10.2196\/40267","article-title":"Characteristics and health care use of patients attending virtual walk-in clinics in Ontario, Canada: cross-sectional analysis","volume":"25","author":"L Lapointe-Shaw","year":"2023","journal-title":"J Med Internet Res"},{"issue":"3","key":"pone.0324898.ref010","article-title":"Association of virtual end-of-life care with healthcare outcomes before and during the COVID-19 pandemic: a population-based study","volume":"3","author":"JM Lapp","year":"2024","journal-title":"PLOS Digit Health"},{"issue":"4","key":"pone.0324898.ref011","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2023.9602","article-title":"Virtual care and emergency department use during the COVID-19 pandemic among patients of family physicians in Ontario, Canada","volume":"6","author":"T Kiran","year":"2023","journal-title":"JAMA Netw Open"},{"issue":"10","key":"pone.0324898.ref012","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1001885","article-title":"The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement","volume":"12","author":"EI Benchimol","year":"2015","journal-title":"PLoS Med"},{"key":"pone.0324898.ref013","author":"Canada S","year":"2024"},{"key":"pone.0324898.ref014","year":"2024"},{"key":"pone.0324898.ref015","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1186\/1471-2288-10-42","article-title":"Surname lists to identify South Asian and Chinese ethnicity from secondary data in Ontario, Canada: a validation study","volume":"10","author":"BR Shah","year":"2010","journal-title":"BMC Med Res Methodol"},{"issue":"25","key":"pone.0324898.ref016","doi-asserted-by":"crossref","first-page":"3083","DOI":"10.1002\/sim.3697","article-title":"Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples","volume":"28","author":"PC Austin","year":"2009","journal-title":"Stat Med"},{"issue":"3","key":"pone.0324898.ref017","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1089\/jpm.2000.3.287","article-title":"Place of care in advanced cancer: a qualitative systematic literature review of patient preferences","volume":"3","author":"IJ Higginson","year":"2000","journal-title":"J Palliat Med"},{"key":"pone.0324898.ref018","article-title":"Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study","volume":"370","author":"KL Quinn","year":"2020","journal-title":"BMJ"},{"issue":"13","key":"pone.0324898.ref019","first-page":"1591","article-title":"Resurrecting treatment histories of dead patients","volume":"293","author":"AE Barnato","year":"2005","journal-title":"JAMA"},{"key":"pone.0324898.ref020","unstructured":"Association C. Virtual care in Canada: progress and potential. Report of the Virtual care task force. 2022."},{"issue":"2","key":"pone.0324898.ref021","doi-asserted-by":"crossref","first-page":"12","DOI":"10.12927\/hcq.2021.26552","article-title":"Impact of the COVID-19 pandemic on health system use in Canada","volume":"24","author":"A Dudevich","year":"2021","journal-title":"Healthc Q"},{"issue":"6","key":"pone.0324898.ref022","doi-asserted-by":"crossref","DOI":"10.1503\/cmaj.202303","article-title":"Shifts in office and virtual primary care during the early COVID-19 pandemic in Ontario, Canada","volume":"193","author":"RH Glazier","year":"2021","journal-title":"CMAJ"},{"issue":"6","key":"pone.0324898.ref023","doi-asserted-by":"crossref","first-page":"702","DOI":"10.1097\/PHH.0000000000001596","article-title":"Early impacts of the COVID-19 pandemic on public health systems and practice in 3 Canadian Provinces from the perspective of public health leaders: a qualitative study","volume":"28","author":"HS Sandhu","year":"2022","journal-title":"J Public Health Manag Pract"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0324898","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,6,3]],"date-time":"2025-06-03T20:02:04Z","timestamp":1748980924000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0324898"}},"subtitle":[],"editor":[{"given":"Kiyan","family":"Heybati","sequence":"first","affiliation":[],"role":[{"role":"editor","vocabulary":"crossref"}]}],"short-title":[],"issued":{"date-parts":[[2025,6,3]]},"references-count":23,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2025,6,3]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0324898","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,3]]}}}