Use of virtual care near the end of life before and during the COVID-19 pandemic: A population-based cohort study

Kieran L Quinn; Thérèse A Stukel; Allan Detsky; Hannah Chung; Mohammed Rashidul Anwar; Sacha Bhatia; James Downar; Vivian Hung; Sarina Isenberg; Allison Kurahashi; Douglas S Lee; Nathan Stall; Peter Tanuseputro; Chaim M Bell

doi:10.1371/journal.pone.0313766

Use of virtual care near the end of life before and during the COVID-19 pandemic: A population-based cohort study

PLoS One. 2025 Jan 8;20(1):e0313766. doi: 10.1371/journal.pone.0313766. eCollection 2025.

Authors

Kieran L Quinn^{1

2

3

4

5}, Thérèse A Stukel^{2

5}, Allan Detsky^{1

3

5}, Hannah Chung², Mohammed Rashidul Anwar⁵, Sacha Bhatia^{1

2

6}, James Downar^{7

8

9}, Vivian Hung⁴, Sarina Isenberg^{7

8

10}, Allison Kurahashi⁴, Douglas S Lee^{1

2

5

11}, Nathan Stall^{1

2

3}, Peter Tanuseputro^{2

5

7

8

12}, Chaim M Bell^{1

3

5}

Affiliations

¹ Department of Medicine, University of Toronto, Toronto, ON, Canada.
² ICES, Toronto and Ottawa, ON, Canada.
³ Department of Medicine, Sinai Health System, Toronto, ON, Canada.
⁴ Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada.
⁵ Insitute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
⁶ Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, ON, Canada.
⁷ Division of Palliative Care, Dept of Medicine, University of Ottawa, Ottawa, ON, Canada.
⁸ Bruyere Research Institute, Ottawa, ON, Canada.
⁹ Queensland University of Technology School of Law, Brisbane City, Queensland, Australia.
¹⁰ Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
¹¹ Peter Munk Cardiac Centre and the Ted Rogers Centre for Heart Research, University Health Network, Toronto, ON, Canada.
¹² Ottawa Hospital Research Institute, Ottawa, ON, Canada.

Abstract

Background and aims: The expanded use of virtual care may worsen pre-existing disparities in use and delivery of end-of-life care among certain groups of people. We measured the use of virtual care in the last three months of life before and after the introduction of virtual care fee codes that funded care delivery at the start of COVID-19 on March 14, 2020, and identified changes in the characteristics of people using it.

Methods: We used linked clinical and administrative datasets to study use of virtual care in the last three months of life among 411,564 adults who died between January 25, 2018, and November 30, 2022. Modified Poisson regression was used to measure the association of the use of virtual care in the last three months of life with the pandemic study period and its association with each person- and physician-level factor.

Results: 14,261 people (8%) used virtual care in the last three months of life before the pandemic, and 161,000 people (69%) used it during the pandemic (relative risk [RR] 8.76; 95% CI 8.48-9.05). Several individual patient characteristics were associated with statistically significant increases in the use of virtual care after March 14, 2020 (following the introduction of virtual care fee codes), compared to before such as among older adults, ethnic minorities, multiple chronic comorbid health conditions and higher frailty groups.

Conclusions: The introduction of new fee codes broadening technology and funding for end-of-life care at the start of pandemic combined with pandemic-related effects was associated with a substantial increase in the use of virtual care near the end of life among certain groups and a general leveling of pre-existing disparities in its use. Virtual end-of-life care delivery may strengthen person-centredness for individuals with limited ability to attend in-person appointments and by providers who may not have previously engaged in such care.

Copyright: © 2025 Quinn et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

MeSH terms

Adolescent
Adult
Aged
Aged, 80 and over
COVID-19* / epidemiology
Cohort Studies
Female
Humans
Male
Middle Aged
Pandemics
SARS-CoV-2
Telemedicine*
Terminal Care*
Young Adult

Grants and funding

This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. This study also received funding from the Canadian Institutes of Health Research (CIHR PNN-177923), Health Canada, Health Care Policy and Strategies Program, and the Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario. This document used data adapted from the Statistics Canada Postal Code OM Conversion File, which is based on data licensed from Canada Post Corporation, and/or data adapted from the Ontario Ministry of Health Postal Code Conversion File, which contains data copied under license from ©Canada Post Corporation and Statistics Canada. Parts of this material are based on data and/or information compiled and provided by the Ontario Ministry of Health and the Canadian Institute for Health Information. The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.