Children under 2 more likely to visit ED after virtual care visit than in-person visits

A new Ontario-based study finds that children aged three months to two years are more likely to visit the emergency department (ED) within three days after a virtual primary care appointment compared to an in-person visit. While virtual care remains an appropriate option for many children, the findings suggest that in-person appointments may be preferable for young children with acute concerns.

The study, conducted by teams at The Hospital for Sick Children (SickKids) and ICES and published in JAMA Network Open, analyzed administrative data from children and youth aged zero to 17 who had a primary care sick visit between September 2020 and March 2024.  

“For the vast majority of kids, virtual appointments are appropriate. Our study showed that children under two, whose communication of their needs and symptoms is more subtle, should probably be seen in person,” says Dr. Natasha Saunders, senior author, paediatrician and Senior Associate Scientist in the Child Health Evaluative Sciences program at SickKids, and Senior Adjunct Scientist at ICES. 

Researchers believe this is the first study to report on the association of virtual care and subsequent ED use for sick visits in children. Existing research that has informed virtual care policies has focused on adults, highlighting the need to consider virtual care policies that are specific to children. 

Knowing when an ED visit is necessary  

The research found children under two who were seen in the ED following a virtual care appointment were more likely to have a non-urgent visit, suggesting the concern could be better managed through primary care.  

For infants under three months old, there were no major differences. Researchers note this may be because, given their increased risk of serious illness particularly when they have a fever, infants are often referred to the ED for assessment or testing regardless of where the initial primary care visit takes place. 

“Virtual care definitely has a place in increasing access to primary care providers, with the caveat that in-person exams seem to be more important in young children than in adults in terms of resolution of acute concerns,” says Dr. Gabrielle Freire, Paediatric Emergency Physician and Associate Scientist Track Investigator at SickKids. 

While the study did not specify which clinical concerns should be treated in-person, she points to ear pain, sore throat and abdominal pain as examples that would need an in-person clinical exam. For non-urgent issues, parents may not feel fully reassured after a virtual visit and may be seeking reassurance or a second opinion by coming to the ED, she notes.

“If you are seen virtually and you’re still concerned, consider requesting an in-person visit to your primary care doctor,” Saunders says. “This can help avoid crowded EDs during viral illness season while ensuring patients can get a physical exam in person if needed.” 

However, the team notes their findings should be balanced with the current context of difficult access to primary care, which can lead to higher use of virtual care for children.  

Dr. Daniel Rosenfield, Paediatric Emergency Physician and director of SickKids’ Virtual Urgent Care program, says expectations are important.  

“This study is really important in showing that parents shouldn’t necessarily go into a virtual care appointment with the expectation that they’re going to be able to manage their child at home,” he says. “Virtual has a role, but in the context of an acute illness in young children, it may not always be the ideal modality.” 

SickKids’ Virtual Urgent Care program offers a symptom checker that directs families to the most appropriate care setting, which may include a virtual urgent care visit with a member of SickKids’ ED team or a recommendation to visit a primary care provider or local ED. 

This research was supported by the Canadian Institutes of Health Research (CIHR) and ICES.