Trends in pulmonary exercise testing utilization after the COVID-19 pandemic in Ontario: A population-cohort study
Javier Silva-Valencia, Karen Tu, Rahim Moineddin, Debra A. Butt, Braden O’Neill, Anthony Train, Jessica Gronsbell, Andrea S. Gershon
Abstract:
Pulmonary exercise testing, including six-minute walk tests, exercise oximetry, and independent exercise assessments, are critical tools for managing chronic respiratory and cardiac conditions, evaluating treatment response, and determining long-term oxygen therapy needs. During the COVID-19 pandemic, testing was reduced to limit viral spread.
Introduction
The COVID-19 pandemic significantly disrupted healthcare, resulting in widespread changes to the availability and accessibility of essential medical services. Since the peak of the pandemic, healthcare systems have largely recovered, enabling the return of many health services, including cancer screening, imaging, and surgeries [1–3].
Methods
We conducted a population-based cohort study of pulmonary exercise testing utilization from April 2015 to December 2023 in Ontario, Canada, focusing on changes in uptake with the onset of the COVID-19 pandemic and trends over the subsequent three years.
Results:
There were 505,902 pulmonary exercise tests performed in Ontario during the study period (2015–2023). Of these, 91.0% were 6-minute walk tests, 5.3% were exercise oximetry tests, and 3.7% were independent exercise assessments. This distribution remained relatively consistent across study years (S1 Appendix).
Discussion
We conducted a population-based cohort study of pulmonary exercise testing in a large Canadian population and found prolonged disruption in pulmonary exercise testing rates that persisted three years after the onset of the COVID-19 pandemic. This was most pronounced in males, those of lower socioeconomic status, and those living in northern Ontario.
Conclusions
We conducted a population study of pulmonary exercise testing in Ontario, Canada and found that more than three years after the pandemic began, rates had not yet returned to pre-pandemic levels, with certain groups being more affected than others. This undermines efforts to deliver quality and potentially life-saving care for individuals with cardiac and respiratory conditions.
Citation: Silva-Valencia J, Tu K, Moineddin R, Butt DA, O’Neill B, Train A, et al. (2026) Trends in pulmonary exercise testing utilization after the COVID-19 pandemic in Ontario: A population-cohort study. PLoS One 21(5): e0349020. https://doi.org/10.1371/journal.pone.0349020
Editor: Jeremy B. Coquart, Université de Lille: Universite de Lille, FRANCE
Received: November 7, 2025; Accepted: April 23, 2026; Published: May 26, 2026
Copyright: © 2026 Silva-Valencia 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: Our study uses de-identified patient data obtained from the Ontario Ministry of Health (MOH) through the Ontario Health Data Platform (OHDP). Due to legal and ethical restrictions, these data cannot be publicly shared. The use of these data is governed by Ontario’s privacy regulations and institutional agreements, which prohibit direct sharing of individual-level health data. Researchers interested in accessing the data can contact healthprivacy.moh@ontario.ca for data requests.
Funding: This study received funding from the Ontario Ministry of Health (MOH) (Ministry Grant ID Number: FMF732). Parts of this material are based on data and information compiled and provided by Ontario Ministry of Health (Ontario Health Data Platform). However, the analyses, conclusions, opinions and statements expressed herein are those of the author, and not necessarily those of the Ministry. The study also received funding from the Rathlyn Foundation Primary Care Big Data Research and Discovery Fund (no number). KT, AG, DB, BO, JG, AT received the funding Award from the Ontario Ministry of Health. KT received the funding award from the Rathlyn Foundation. KT, DB, BO and JG received salary support for research from the Rathlyn Foundation Primary Care Big Data Research and Discovery Fund. Karen Tu receives a Chair in Family and Community Medicine Research in Primary Care at University Health Network, Toronto, Canada. Karen Tu and Debra Butt receive Research Scholar Awards from the Department of Family and Community Medicine at the University of Toronto. 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.
