RESUMEN
BACKGROUND: Uptake of virtual care increased substantially during the first year of the COVID-19 pandemic. The aim of this study was to evaluate whether a shift from in-person to virtual visits by primary care physicians was associated with increased use of emergency departments among their enrolled patients. METHODS: We conducted an observational study of monthly virtual visits and emergency department visits from Apr. 1, 2020, to Mar. 31, 2021, using administrative data from Ontario, Canada. We used multivariable regression analysis to estimate the association between the proportion of a physician's visits that were delivered virtually and the number of emergency department visits among their enrolled patients. RESULTS: The proportion of virtual visits was higher among female, younger and urban physicians, and the number of emergency department visits was lower among patients of female and urban physicians. In an unadjusted analysis, a 1% increase in a physician's proportion of virtual visits was found to be associated with 11.0 (95% confidence interval [CI] 10.1-11.8) fewer emergency department visits per 1000 rostered patients. After controlling for covariates, we observed no statistically significant change in emergency department visits per 1% increase in the proportion of virtual visits (0.2, 95% CI -0.5 to 0.9). INTERPRETATION: We did not find evidence that patients substituted emergency department visits in the context of decreased availability of in-person care with their family physician during the first year of the COVID-19 pandemic. Future research should focus on the long-term impact of virtual care on access and quality of patient care.
Asunto(s)
COVID-19 , Servicio de Urgencia en Hospital , Pandemias , Telemedicina , Femenino , Humanos , Ontario , Atención Primaria de SaludAsunto(s)
Anestesiólogos/provisión & distribución , Anestesiología , Canadá , Humanos , Recursos HumanosAsunto(s)
Hemorragia/complicaciones , Aturdimiento Miocárdico/etiología , Traumatismos de la Médula Espinal/complicaciones , Cardiomiopatía de Takotsubo/etiología , Ecocardiografía/métodos , Femenino , Hemorragia/etiología , Humanos , Persona de Mediana Edad , Aturdimiento Miocárdico/fisiopatología , Cardiomiopatía de Takotsubo/diagnóstico , Cardiomiopatía de Takotsubo/fisiopatologíaRESUMEN
PURPOSE: Pulmonary dysfunction commonly occurs following coronary artery bypass graft (CABG) surgery, increasing morbidity and mortality. We hypothesized that thoracic epidural anesthesia (TEA) would improve pulmonary function and would decrease complications in patients undergoing CABG surgery. METHODS: This prospective, randomized, controlled trial was conducted with Ethics Board approval. Fifty patients, undergoing CABG surgery, were randomized to the epidural group or to the patient-controlled analgesia morphine group. Patients in the epidural group received a high, thoracic epidural, preoperatively. Intraoperatively, 0.75% ropivacaine was infused, followed postoperatively, by 0.2% ropivacaine for 48 hr. Outcome measurements included: visual analogue pain scores; spirometry; atelectasis scores on chest radiographs; and the incidence of atrial fibrillation. RESULTS: Twenty-five patients were enrolled in each group. Patients in the epidural group had significantly less pain on the operative day, and for the subsequent two days. Compared to baseline, the forced expiratory volume in one second was significantly higher in the epidural group, on the first and second postoperative days (43.7 +/- 12.2% vs 36.4 +/- 12.0%, p < 0.002, and 43.3 +/- 12.5% vs 38.4 +/- 11.0%, p <0.05). There was significantly more atelectasis in the control group, four hours postoperatively (p < 0.04); however, on the third, postoperative day, the groups were similar with regards to this outcome. The incidence of atrial fibrillation was similar in both groups, and there were no complications related to the epidural. CONCLUSIONS: High TEA decreases postoperative pain and atelectasis and improves pulmonary function in patients undergoing CABG surgery. Our results support the use of TEA in this group of patients.