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• These are pan-Canadian health system indicators on access to primary care as reflected by the proportion of visits to the emergency department that could potentially be managed in the community. 
• One indicator examines visits that could potentially be managed in primary care. The other indicator measures the subset of conditions that could potentially be managed virtually in primary care.
• These indicators were developed to address a health system information priority around access to primary care and the role of virtual care.
• They are designed to monitor the current state of primary care and its relationship to emergency department use, drive improvement in and access to primary care and virtual primary care, shape the future of primary care, and also shape the role virtual primary care should play within it.
• Results are available in to the regional level.

• These indicators provide system-level insights to help health system decision-makers and planners improve these systems to better meet patient needs.
• The indicators may help to
  • Shed light on access to primary care by comparing  across geographies and populations, as well as monitoring over time
  • Gain insight into the volume of emergency department visits that potentially could have been managed through primary care, including virtual care
  • Provide information to decision-makers to inform services and care for underserved regions and populations
  • Drive health system improvements to serve patient needs, including integrating virtual options
• These indicators are not intended to
  • Speak to individual scenarios or appropriateness of a patient’s ED visit, which will vary
  • Influence patient choice, assign blame, penalize individuals for or deter them from visiting the emergency department
  • Imply that virtual primary care is a replacement for in-person primary care or a stand-alone solution
  • Imply that diverting visits for minor conditions will solve the health system challenges that manifest in EDs

Primary care includes routine care occurring in the community provided by clinicians such as family doctors or nurse practitioners, alongside other health care providers such as dietitians, dentists or physiotherapists, to address care needs such as screening and preventative medicine, care for urgent but minor conditions or other common health problems, and management of chronic diseases.Reference1

Virtual primary care is primary care that occurs remotely using any form of communication or information technology.Reference2 This may occur through an appointment (e.g., through phone or video) or asynchronously (e.g., through secure messaging).Reference2

• Primary health care data systems are poorly integrated across Canada and minimal granular data on primary care access exists.
• Using emergency department data as a proxy helps us understand what is happening in the community regarding access to primary care.
• Emergency department data offers insight about the right care in the right place at the right time, including through virtual services.
• Emergency department data are available at a geographically granular level, allowing local and regional calculation of the indicators.
• Refer to to explore indicator results for your region.

• Briefly, the indicators measure the following: 
  • The percentage of emergency department visits that could potentially be managed in primary care
  • The percentage of emergency department visits that could potentially be managed virtually in primary care
• The denominator of both indicators is all unscheduled emergency department visits in patients age 2 and older.
• To count toward the numerator for the in-person visits indicator, a patient must meet the conditions for the denominator and additionally meet all of the following criteria:
  • The main diagnosis must be on the list of 173 primary care sensitive conditions or 97 virtual primary care sensitive conditions
  • The patient must have been discharged home
  • The patient must not have had a triage level of emergent (II) or resuscitation (I) based on the Canadian Triage and Acuity Scale (CTAS)  
• Unless otherwise indicated, provincial and regional results are adjusted by age and sex.

For more information on methodology, refer to Visits to the Emergency Department for Conditions That Could Be Managed in Primary Care (In Person and Virtual).

• An initial list of family practice sensitive conditions, later referred to as primary care sensitive conditions (PCSCs), was developed by the ºìÁì½í¹Ï±¨ Quality Council of Alberta (HCQA) and later adapted for a 2014 ºìÁì½í¹Ï±¨report in partnership with the HCQA.
• ºìÁì½í¹Ï±¨recently validated the PCSC list and developed a new list for virtual primary care sensitive conditions (V-PCSCs) through a multi-stage consultation process with clinical experts in 2023. This is a subset of the primary care sensitive conditions list.
• When developing the list of V-PCSCs, ºìÁì½í¹Ï±¨considered the minimum level of expertise and technology that should be available to most primary care providers and patients.
• For more information on the lists, refer to Visits to the Emergency Department for Conditions That Could Be Managed in Primary Care (In Person and Virtual).
   

The top 10 conditions seen in ED visits that could potentially be managed in primary care are

• Other medical care such as chemotherapy (e.g., antibiotic therapy)
• Acute upper respiratory infections of multiple and unspecified sites (e.g., colds)
• Acute pharyngitis (i.e., inflammation of the throat)
• Suppurative and unspecified otitis media (i.e., bacterial infection of the middle ear)
• Persons encountering health services in other circumstances (mainly for issue of repeat prescription)
• Other surgical follow-up care (e.g., change of dressings, removal of sutures)
• Cough
• Unspecified anxiety disorder
• Rash and other nonspecific skin eruption
• Diseases of pulp (centre of tooth) and periapical (apex of the root of the tooth) tissues

However, 41% of visits to the emergency department for conditions that could be managed in primary care are for other conditions.

The top 10 conditions seen in ED visits that could potentially be managed virtually in primary care are

• Acute upper respiratory infections of multiple and unspecified sites (e.g., colds)
• Acute pharyngitis (inflammation of the throat)
• Persons encountering health services in other circumstances (mainly for issue of repeat prescription)
• Cough
• Unspecified anxiety disorder
• Rash and other nonspecific skin eruption
• Conjunctivitis (inflammation of the outermost layer of the eye and the inner surface of the eyelids)
• Migraine
• Otitis externa (e.g., abscess of external ear)
• Urticaria (hives)

Collectively, these make up 72% of the visits to the emergency department for conditions that could be managed virtually in primary care. The other 28% of those visits are for other conditions.

• The primary care sensitive conditions (PCSC) list is a set of minor conditions that could be managed in primary care and are unlikely to result in admission to the hospital.
• Ambulatory care sensitive conditions (ACSCs) are generally chronic conditions that could be prevented by managing the health issue that leads to the condition. These are often severe and lead to admission to the hospital, but appropriate primary care could reduce the need for hospital admission. Examples include chronic lung disease, heart failure and diabetes.Reference3
• Both condition lists can be used for indicators of access to primary care: the PCSC list is used to identify visits to the emergency department for conditions that could potentially be managed in primary care for non-admitted patients; the ACSC list is used for admissions to the hospital for conditions that could potentially have been prevented with appropriate primary care.

• Emergency department data is used as a proxy for access to primary care in the community.
• Not all provinces/territories, regions and emergency departments submit data to CIHI, and not all that submit data have full coverage. Interpret results with caution where there is a note to indicate partial coverage.
• Risk adjustment for age and sex facilitates comparability across the country but does not account for all differences between jurisdictions. 
• The indicators cannot speak to individual patient scenarios or to the appropriateness of ED visits. The indicators are based on diagnoses which patients do not know when they go to the ED; patients may have signs, symptoms or histories that make them concerned about an emergency for which an ED visit may be appropriate. Conditions considered for the indicator are in most cases manageable in primary care, but for some situations, patients may still be best served in the ED.
• The newly developed list of virtual primary care sensitive conditions represents the minimum of what could be addressed virtually with the technology and skill sets that most health care providers should have available today to serve most patients most of the time.
• We expect that the condition lists may evolve over time as virtual care technology and expertise also evolves. The indicators’ methodologies will be reviewed and updated as needed.

• Quebec and British Columbia’s discharge diagnosis data in EDs are coded with the CED-DxS rather than with the ICD-10-CA system.
• These 2 diagnosis systems were mapped to allow calculation of the indicators.
• Patients who left the ED without being seen or who left against medical advice are given a specific code in the CED-DxS system that cannot map to another diagnosis. 
• Therefore, people who left the ED without being seen could not be included in the indicators for Quebec and British Columbia. 
• This represents 12% of emergency department visits in Quebec and 6% of such visits in British Columbia.
• Results for these provinces are therefore underestimated and are not comparable with results for other provinces or territories.