Virtual Visits Substitutive in Ambulatory Care Delivery During COVID-19


In all visits, data show 23.8% were virtual, 8.2% were in-person at home, and 68.0% were in-person and onsite.

Kori S. Zachrison, MD

Kori S. Zachrison, MD

Due to the COVID-19 pandemic leading to more use of virtual care, a recent study evaluated the association between the increased use of virtual care and health care utilization in an integrated delivery network.

Led by Kori S. Zachrison, MD, Department of Emergency Medicine, Massachusetts General Hospital, the team of investigators determined that the transition to virtual care in ambulatory care offerings was not associated with an increase in overall visit volumes, suggesting that virtual care was substitutive, not additive, in care delivery.


Zachrison and colleagues performed a cross-sectional study using data from their large New England health care system to identify all ambulatory visits between October 2019 - April 2021.

The encounters in the study consisted of virtual, in-person at home, and in-person onsite visits. Investigators also examined the subgroups of behavioral health care professional visits to identify any unique behavioral health visit trends.

Other components of the analysis characterized the demographics using race and ethnicity data from the electronic health records. From that, a composite, mutually exclusive race and ethnicity variable based on individual race and ethnicity fields was created. The categories included Hispanic, missing, non-Hispanic Asian, non-Hispanic Black, non-Hispanic White, and other.

Additionally, investigators used a 2-sided Welch t test to compare overall mean monthly visit volume pre pandemic (October 2019 - February 2020) versus current (June 2020 - April 2021). The data was then stratified by encounter type.


The study identified 10,559,857 ambulatory visits within the study period, with a total of 1,530,772 patients. Patients had a median age of 58 years, consisting of 918,463 females (60%) and 612,309 males (40%).

By demographics, data show 61,231 (4%) Asian patients, 122,462 (8%) Hispanic patients, 91,846 (6%) non-Hispanic Black patients, 1,178,693 (77%) non-Hispanic White patients, and 76,540 (5%) patients of an unknown or other race and ethnicity.

Then, investigators found 811,309 (53%) had only in-person visits, 627,617 (41%) had in-person and virtual, and 91,846 (6%) had only virtual visits.

Further, in patients who had both in-person and virtual visits, data show most patients attended fewer than half of visits virtually (median, 33%). In all encounters, 23.8% were virtual, 8.2% were in-person at home, and 68.0% were in-person and onsite.

At the start of the pandemic, data show a dramatic drop in the number of in-person visits, concurrent to an increase in overall virtual visits and among behavioral health visits. However, no significant change in overall ambulatory visit volume and visit patterns had similarity at the patient level.

Among behavioral health visits from October 2019 - April 2021, a small increase in total visit volume was observed. This was due to increased virtual visits (mean increase, 29,609 - 36,901, P <.002). Data show 94% of monthly visits were virtual after May 2020.


“Given the impact of the pandemic on mental health and known pre-existing challenges in access to behavioral health access in general, the increased volume of behavioral health visits in our system over the study period may be merited and high value overall,” investigators wrote.

The study, “Changes in Virtual and In-Person Health Care Utilization in a Large Health System During the COVID-19 Pandemic,” was published in JAMA Network Open.

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