Virtual Care Use Among Older Immigrant Adults in Ontario, Canada During the Covid-19 Pandemic: a Repeated Cross-sectional Analysis

Janette Brual, Cherry Chu, Jiming Fang, Cathleen Fleury, Vess Stamenova, Onil Bhattacharyya, Mina Tadrous


The critical role of virtual care during the COVID-19 pandemic has raised concerns about the widening disparities to access by vulnerable populations including older immigrants. This paper aims to describe virtual care use in older immigrant populations residing in Ontario, Canada. In this population-based, repeated cross-sectional study, we used linked administrative data to describe virtual care and healthcare utilization among immigrants aged 65 years and older before and during the COVID-19 pandemic. Visits were identified weekly from January 2018 to March 2021 among various older adult immigrant populations. Among older immigrants, over 75% were high users of virtual care (had two or more virtual visits) during the pandemic. Rates of virtual care use was low (weekly average <2 visits per 1000) prior to the pandemic, but increased for both older adult immigrant and non-immigrant populations.


In March 2020, the World Health Organization declared the outbreak of the novel coronavirus disease (COVID-19) a pandemic [1], and as a result, health systems around the world had to adapt quickly in order to continue providing access to healthcare services. To accommodate safety protocols of physical distancing and to reduce virus transmission, health care shifted from predominantly in-person care to remote care using virtual modalities such as telephone and video-based visits, asynchronous messaging, and digital applications. In response, the Ontario government issued temporary billing codes which expanded on the types of visits that physicians are eligible to bill for, specifically telephone and video visits [2]. Prior to the pandemic, physician reimbursement for virtual care was restrictive in that it only covered videoconferencing on specific government-run platforms [3] and was mainly targeted towards rural patients.

Materials and method

We received approval from the Women’s College Hospital Research Ethics Board for use of the IRCC–Permanent Residents Database. Ethics review through a research ethics board was not required for use of the other administrative databases for the purposes of this study as authorized under section 45 of Ontario’s Personal Health Information Protection Act.


Baseline patient characteristics are summarized in Table 1 comparing older adult immigrants and non-immigrants. Overall, a greater proportion of older adults were women compared to men (54.2% versus 45.8%). Immigrants were younger with 73.7% compared to 66.6% of non-immigrants in the youngest-old category (65–74 years). A higher proportion of older immigrants lived in urban areas compared to non-immigrants (99.0% versus 89.1%), and they had lower incomes, with 26.3% of older immigrants compared to 18.0% of non-immigrant older adults in the lowest income quintile.


Overall, this study showed that virtual care use was lower among older immigrant populations when the pandemic began compared to non-immigrant populations—however, as the pandemic progressed the rates between these groups converged and became similar. Among older immigrant populations, immigration admission category and language ability were found to be consistent differentiators in the rates of virtual care use throughout the pandemic in Ontario. Despite the consistent finding of increased virtual care uptake across all demographic groups assessed, there remains potential equity issues with adoption within the older adult immigrant population.


To our knowledge, this is the first study that examines virtual care use among older immigrant populations, particularly during the COVID-19 pandemic. Our results suggest that there is a clear link between immigration status and virtual care use. In response to the pandemic, public health measures facilitated the rapid uptake of virtual care among the total older adult population, and while there was a lagged difference in use between immigrant and non-immigrant populations in the early months of the pandemic, these rates converged as time progressed.


This study was supported by ICES. This document used data adapted from the Statistics Canada Postal CodeOM 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 Ministry of Health (MOH) and the Canadian Institute for Health Information (CIHI).

Citation: Brual J, Chu C, Fang J, Fleury C, Stamenova V, Bhattacharyya O, et al. (2023) Virtual care use among older immigrant adults in Ontario, Canada during the COVID-19 pandemic: A repeated cross-sectional analysis. PLOS Digit Health 2(8): e0000092.

Editor: Giuseppe Boriani, University of Modena and Reggio Emilia, Policlinico di Modena, ITALY

Received: July 19, 2022; Accepted: February 22, 2023; Published: August 2, 2023

Copyright: © 2023 Brual 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.

Data Availability: The dataset from this study is held securely in coded form at the Institute for Clinical Evaluative Sciences (ICES). While legal data sharing agreements between ICES and data providers (e.g., healthcare organizations and government) prohibit ICES from making the dataset publicly available, access to data and analytic code may be granted to those who meet pre-specified criteria for confidential access, available at (email: A summary of basic codes, definitions, and data sources is included as Supporting Information.

Funding: This study received funding from Canada Health Infoway. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.


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