Trends and inequities in primary and emergency care use among older adults in British Columbia: an analysis across age, sex, income, and rurality (2018–2023)

BACKGROUND: Access to care in Canada has become increasingly unstable, exacerbated by workforce shortages and the COVID-19 pandemic, which disrupted in-person care and accelerated the shift to virtual modalities. This hugely affects older adults (65+) as a high-need population. Our study addresses gaps in the literature and the trends of health care service utilization by providing a population-level analysis of trends and inequities in primary and emergency care use among older adults in British Columbia (BC) from the pre-pandemic period through to recovery (2018-2023). METHODS: We conducted a population-based repeated cross-sectional study using linked administrative health data for all BC residents aged 65 years or older, averaging 1.08 million individuals annually. We examined annual trends and calculated population-based rates for Family Physician (FP) visits, virtual visits, Emergency Department (ED) visits, and acute hospital admissions. To assess inequities, we utilized estimated Incidence Rate Ratios (IRRs), stratifying by age, sex, income, and rurality, and evaluating intersectional interactions among these predictors. RESULTS: COVID-19 caused a system-wide shock in 2020; by 2023, in-person outpatient, ED, and hospital utilization remained 7-9% below 2018 levels despite an aging population, suggesting a lower-throughput equilibrium. Conversely, virtual care surged and stabilized at four to five times pre-pandemic levels, indicating a durable shift toward hybrid care. Rural residents exhibited a significantly lower ED use (IRR 0.35) and lower FP visits (IRR 0.97), but higher rates of hospital admissions compared to urban residents; low-income older adults and males relied more on acute care (ED and hospital admission), whereas females had higher rates of FP visits. The oldest-old males (80+) and low-income groups were identified as high-risk clusters for acute care use, facing distinct barriers to longitudinal engagement. CONCLUSION: The COVID-19 pandemic induced a lasting alteration to the healthcare landscape for older adults in BC. While virtual care has become a permanent fixture, it has not uniformly offset persistent deficits in in-person care. The recovery period has exacerbated structural inequities, revealing an "inverse care" pattern where populations with substantial needs - specifically rural residents, low-income older adults, and older males - face the greatest barriers to preventative care.