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Primary Health Care in CanadaA Chartbook of Selected Indicator Results, 2016

Methodology NotesApril 2016

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ISBN 978-1-77109-442-9 (PDF)

© 2016 Canadian Institute for Health Information

How to cite this document:Canadian Institute for Health Information. Primary Health Care in Canada: A Chartbook of Selected Indicator Results, 2016 — Methodology Notes. Ottawa, ON: CIHI; 2016.

Cette publication est aussi disponible en français sous le titre Soins de santé primaires au Canada : recueil de graphiques sur les résultats d’indicateurs sélectionnés 2016 — notes méthodologiques.ISBN 978-1-77109-443-6 (PDF)

Table of contents Introduction ................................................................................................................................ 5

Indicator selection ...................................................................................................................... 5

Data sources .............................................................................................................................. 7

Canadian Community Health Survey ...................................................................................... 8

The Commonwealth Fund International Health Policy Surveys ............................................... 8

Discharge Abstract Database, CIHI, and MED-ÉCHO, ministère de la Santé et des Services sociaux du Québec .................................................................................................. 9

National Physician Survey ...................................................................................................... 9

Scott’s Medical Database, CIHI .............................................................................................. 9

Health Workforce Database, CIHI ..........................................................................................10

Significance testing ...................................................................................................................10

Indicator technical specifications ...............................................................................................11

Smoking Rate ........................................................................................................................11

Overweight and Obesity Rate for Youth and Adults ...............................................................12

Fruit and Vegetable Consumption Rate .................................................................................14

Physical Activity Rate During Leisure Time ...........................................................................15

Family Medicine Physician Supply .........................................................................................17

Registered Nurses/Nurse Practitioners (RNs/NPs) Employed in a PHC Setting ....................19

Uptake of Information and Communication Technology (ICT) in Primary Health Care ...........21

Population With a Regular Medical Doctor ............................................................................23

Difficulties Obtaining After-Hours Primary Health Care ..........................................................24

Smoking Cessation Advice From a Regular Medical Doctor ..................................................25

Eye Examinations in Adults With Diabetes ............................................................................27

Influenza Immunization for Seniors ........................................................................................29

Colorectal Cancer Screening .................................................................................................30

Cervical Cancer Screening ....................................................................................................32

Ambulatory Care Sensitive Conditions (ACSCs) Hospitalization Rate ...................................33

Medication Lists in Primary Health Care Using a Computerized System ...............................36

Primary Health Care in Canada: A Chartbook of Selected Indicator Results, 2016 — Methodology Notes

4

Appendix 1: Pan-Canadian PHC Indicator Update Report (2012) — Indicators excluded from this chartbook ...................................................................................................................38

Appendix 2: Text alternatives for figures 1 and 2 .......................................................................41

References ...............................................................................................................................42


5

Introduction In 2006, CIHI developed 105 pan-Canadian primary health care (PHC) indicators, which were identified through a consensus process as being necessary to measure and compare PHC performance at multiple levels within and across jurisdictions in Canada.1 These indicators were developed to increase standardized PHC measurement across Canada.

In 2008, CIHI released the Primary Health Care (PHC) Indicators Chartbook: An Illustrative Example of Using PHC Data for Indicator Reporting.2 It profiled a subset of the 105 PHC indicators related to access, recommended care and organization and delivery of services. Its purpose was to illustrate the use of these indicators for performance measurement and reporting.

Building on this work, in 2012, CIHI published the Pan-Canadian Primary Health Care Indicator Update Report, which included a priority subset of 51 PHC indicators. These indicators were categorized as for use either by policy-makers or by primary health care providers.3 The 2012 report reflects efforts to update and streamline the 2006 PHC indicators. It presents technical specifications for each indicator, outlining the definition, numerator/denominator, inclusion/exclusion criteria, data source, notes and rationale. This report is available on CIHI’s website at www.cihi.ca/phc.

The current chartbook profiles a selected group of PHC indicators featured in the 2012 report, with the aim of providing an integrated view of PHC information in Canada in 2016.

Indicator selection The 51 PHC indicators in the 2012 report were reviewed for their suitability for inclusion in the 2016 chartbook. Selection criteria included the following:

• Data availability and quality;

• Data with sufficient detail for comparisons over time, and by geography, age and gender; and

• 2012 indicator technical specifications that could be used without major modifications.

See Appendix 1 for the list of 2012 indicators excluded from this chartbook.

As a result of the indicator review and selection process, 16 indicators were identified for inclusion in this chartbook. Related refinements to the indicator methodology were also noted; updated technical specifications are presented later in this document.

http://www.cihi.ca/phc


6

This chartbook is meant to provide stakeholders with an overview of selected pan-Canadian PHC information in Canada. The 16 selected PHC indicators can also be organized according to CIHI’s Health System Performance (HSP) Measurement Framework. This framework is composed of 4 interrelated quadrants: Social Determinants of Health, Health System Inputs and Characteristics, Health System Outputs and Health System Outcomes (Figure 1).4 Figure 2 presents the selected 16 PHC indicators, organized according to CIHI’s HSP Measurement Framework.

Figure 1 CIHI’s Health System Performance Measurement Framework

Additional information on the framework can be found in A Performance Measurement Framework for the Canadian Health System.

https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC2196

https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC2196


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Figure 2 Selected PHC indicators organized according to 3 quadrants of CIHI’s 2013 Health System Performance Measurement Framework

For more information on the PHC indicators, data sources and reporting initiatives, visit CIHI’s website or send us an email.

Data sources The project team used CIHI’s 2012 Pan-Canadian Primary Health Care Indicator Update Report as a basis for confirming the data sources for each indicator.3

Data sources for the indicators included population and patient surveys, provider surveys and clinical and administrative data. For the purposes of this chartbook, 5 years of data are presented when available, and CIHI’s standard data suppression rules were applied where applicable, such that any cell size less than 5 was suppressed.

https://www.cihi.ca/en/types-of-care/primary-health-care

mailto:[email protected]


8

Canadian Community Health Survey The Canadian Community Health Survey (CCHS) is a cross-sectional survey of the Canadian population, with approximately 65,000 respondents per year. The survey covers the population age 12 and older living in the 10 provinces and 3 territories. Excluded from the survey’s coverage are persons living on reserves and other Aboriginal settlements in the provinces; full-time members of the Canadian Forces; the institutionalized population and persons living in the Quebec health regions of Région du Nunavik and Région des Terres-Cries-de-la-Baie-James. Together, these exclusions represent less than 3% of the Canadian population age 12 and older. Visit Statistics Canada’s website for more detailed information and to learn more about the CCHS.

For all of the CCHS-based indicators, population estimates were calculated using survey weights. CANSIM tables from Statistics Canada were used to obtain the data for most CCHS-based indicators. However, CANSIM tables were not readily available for some of the selected indicators. For these indicators, analysis was performed using the CCHS public use microdata files for 2 years combined. Of note, the 2-year combined data is less current than annual estimates, but it has higher precision (i.e., less variability). Further information can be found on Statistics Canada’s public use microdata file website.

For the cervical and colorectal cancer screening indicators using CCHS data, CIHI collaborated with the Canadian Partnership Against Cancer (CPAC). Further information on CPAC can be found on its Cancer System Performance website.

The Commonwealth Fund International Health Policy Surveys

The Commonwealth Fund (CMWF) International Health Policy Surveys are annual surveys that are conducted in 11 countries and run on 3-year cycles: the 2013 version was a general population survey, 2014 was a population survey of older adults (55+) and the 2015 version surveyed primary care physicians. Specific information on the survey cycles can be found on The Commonwealth Fund’s website. The general population and older adult surveys always include some questions on topics related to primary care, such as access and wait times, quality of care, patient experience and continuity of care with other providers.

The 2015 survey examined similar themes, but from the physician’s perspective. It also included questions around practice, information technology (IT) adoption and performance measurement. Canadian data is available at a national and provincial level. Territorial data has been suppressed due to small sample size. Data from Prince Edward Island has been included in the grouping “Total for Canada excluding the territories” but was suppressed at the provincial level due to small sample size. In 2015, there were 2,284 respondents, representing a response rate of 32%.

To learn more about the CMWF International Health Policy Surveys, please visit CIHI’s website.

http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SurvId=144171&InstaId=164081&SDDS=3226

http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getInstanceList&Id=164081

http://www5.statcan.gc.ca/olc-cel/olc.action?lang=en&ObjId=82M0013X&ObjType=2

http://www.systemperformance.ca/

http://www.commonwealthfund.org/interactives-and-data/surveys

https://www.cihi.ca/en/health-system-performance/performance-reporting/international


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Discharge Abstract Database, CIHI, and MED-ÉCHO, ministère de la Santé et des Services sociaux du Québec

The Discharge Abstract Database (DAD) contains data on hospital discharges across Canada. CIHI receives data directly from participating hospitals — currently, hospitals in every province and territory except Quebec. This database contains demographic, administrative and clinical data for hospital discharges (inpatient acute, chronic, rehabilitation) and day surgeries (with some exceptions). Data from Quebec was obtained from the Maintenance et exploitation des données pour l’étude de la clientèle hospitalière (MED-ÉCHO), which is submitted to CIHI directly by the ministère de la Santé et des Services sociaux du Québec (MSSS). Further information can be found on the MED-ÉCHO website.

To learn more about the DAD, please visit CIHI’s website.

National Physician Survey

The National Physician Survey (NPS) is an annual census of physicians licensed to practise in Canada, including family physicians and specialists. This survey is led by the College of Family Physicians of Canada (CFPC), the Canadian Medical Association (CMA) and the Royal College of Physicians and Surgeons of Canada (Royal College). Response rates have varied over the past several years, with considerable non-response (response rates: 2007 — 31.6%; 2010 — 20.3%; 2013 — 17.5%; 2014 — 16.0%). The non-response is assumed to be random and thus not likely to introduce bias. In order to be more representative of the total physician population, response estimates were weighted to account for the non-response. For the purposes of our analysis, only family physicians who indicated that they provided patient care were included. In 2014, there were 4,957 respondents.

To learn more about the NPS, please visit the NPS website.

Scott’s Medical Database, CIHI

CIHI purchases data annually for Scott’s Medical Database from Scott’s Directories. This database includes demographic, education and employment information on physicians in Canada. It is sourced from jurisdictional registrars, medical schools, the Royal College, the CFPC, the Collège des médecins du Québec and Canadian hospitals. The survey from Scott’s Directories is sent to all active physicians and medical school graduates. It excludes physicians who are semi-retired, who are in the military, who request to be excluded from the publication (non-registered physicians only) and who are practising abroad. In terms of geography, Scott’s Directories assigns physicians to the province or territory where they report their primary postal code. This may underestimate the level of access to physicians in the territories or other remote areas where physicians may provide service on a temporary basis. For the purposes of our analysis, we restricted inclusion to family medicine physicians whose medical activity code was “active.” Medical residents were excluded from the analysis.

To learn more about Scott’s Medical Database, please visit CIHI’s website.

http://www.ramq.gouv.qc.ca/fr/donnees-statistiques/sur-demande/donnees-msss/Pages/med-echo.aspx

https://www.cihi.ca/en/types-of-care/hospital-care/acute-care/dad-metadata

http://nationalphysiciansurvey.ca/surveys/

https://www.cihi.ca/en/spending-and-health-workforce/health-workforce/scotts-medical-database-smdb-metadata


10

Health Workforce Database, CIHI

Nursing regulatory authorities submit information to CIHI for inclusion in the Health Workforce Database, which includes information on a variety of health professions. CIHI’s database captures demographic, education and employment information on regulated nurses in Canada and includes 3 distinct categories of regulated nursing professionals: registered nurses including nurse practitioners, licensed practical nurses and registered psychiatric nurses. Of note, only Manitoba, Saskatchewan, Alberta and British Columbia regulate registered psychiatric nurses as a separate nursing profession.

To learn more about the Health Workforce Database, please visit CIHI’s website.

Significance testing Tests of significance were performed when possible to examine whether provincial and territorial results were significantly different from the Canadian average. For indicators based on CCHS data from CANSIM tables, information on significant differences was made available by Statistics Canada.

It must be cautioned, however, that sample sizes in some provinces or age cohorts are much smaller than in others and have wider margins of error. For this reason, 2 groups may have the same numeric results but vary in whether they have been identified as being statistically different from the average. For example, province A’s result might be coloured blue, or “same as average” as described in the legend, while province B’s result might be coloured orange, or “below average,” despite having an identical rate. This arises from a difference in margins of error: the wider the margin of error, the less likely it is for a result to show up as significantly different from the Canadian average.

In certain instances where formal significance testing could not be performed, significant differences are based on whether the 95% confidence intervals (CIs) do not overlap. In situations where the confidence intervals are overlapping, results are displayed within the category “same as average.”

To help interpret results, the following colour codes are used throughout the chartbook to denote results that are statistically different from the Canadian average.

Results compared with the Canadian average

Above average Same as average Below average

Interpretation note: “Above average” results are more desirable relative to the Canadian average; “below average” results often indicate areas in need of improvement.

https://www.cihi.ca/en/spending-and-health-workforce/health-workforce/nurses


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Indicator technical specifications The technical specifications published in the 2012 Pan-Canadian Primary Health Care Indicator Update Report have been adapted where necessary to account for changes in data sources since 2012. Refined indicator technical specifications are presented in the rest of this document.

Smoking Rate

Indicator description Indicator name Smoking Rate

Definition Percentage of the population age 12 and older who reported being current cigarette smokers, on either a daily or occasional basis

HSP dimension Social Determinants of Health: Behavioural factors

Data source Canadian Community Health Survey (CCHS) data from CANSIM table 105-05015

Method of calculation

Number of people who reported current smoking, either daily or occasionally, divided by the number of survey respondents.

Population estimates are calculated using survey weights.

Numerator Description: Respondents age 12 and older who reported being current smokers, either daily or occasionally

Denominator Description: Survey respondents age 12 and older

Exclusions: Non-response categories (“refusal,” “don’t know” and “not stated”)

Years 2010–2014

Age breakdown Total 12+, 12–19, 20–34, 35–44, 45–64, 65+

Sex breakdown Both sexes, males, females

Geographic coverage and breakdown

National, provincial/territorial and regional

Geographic assignment

Place of residence

Adjustment applied None

Confidence intervals Available

Limitations This indicator does not take into account the number of cigarettes smoked.

Original indicator source and intended audience

CIHI’s Pan-Canadian Primary Health Care Indicator Update Report, 2012, pp. 97–99.

Target audience: Policy-makers

https://secure.cihi.ca/free_products/Pan-Canadian_PHC_Indicator_Update_Report_en_web.pdf


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Overweight and Obesity Rate for Youth and Adults

Indicator description Indicator name Overweight and Obesity Rate for Youth and Adults

Definition Percentage of the population age 12 and older who are currently overweight or obese, based on self-reported height and weight

HSP dimension Social Determinants of Health: Biological and Behavioural factors



Number of respondents who reported a height and weight that corresponds to a body mass index (BMI) categorized as overweight or obese, divided by the total number of respondents. The youth rate (age 12–17) is presented separately from the adult rate (age 18+). Population estimates are calculated using survey weights.

Numerator Description (Overweight and Obesity Rate for Youth):

Survey respondents 12–17 years old who reported a height and weight that corresponds to a BMI categorized as overweight or obese. Youth BMI is categorized using the Cole classification system. For youth, the Cole classification system for BMI is based on pooled international data. It classifies children age 12 to 17 as “obese,” “overweight” or “neither obese nor overweight” according to age- and sex-specific BMI cut-off points. For further details, including the age- and sex-specific BMI cut-off points, see Cole TJ, et al.6

Description (Overweight and Obesity Rate for Adults):

Survey respondents age 18+ who reported a height and weight that corresponds to a BMI categorized as overweight or obese. Adult BMI is categorized using the standards endorsed by Health Canada and the World Health Organization (WHO). According to Health Canada and WHO guidelines, the index for BMI classification is as follows:

BMI <18.50: Underweight

BMI 18.50–24.99: Normal weight

BMI 25.00–29.99: Overweight

BMI 30.00+: Obese

Exclusions: Pregnant women; adults 18+ with height <0.914 m or >2.108 m; adults 18+ with weight >260 kg


13

Indicator description Denominator Description: For youth rate, survey respondents age 12–17; for adult

rate, survey respondents age 18 and older.

Exclusions: Pregnant women; adults 18+ with height <0.914 m or >2.108 m; adults 18+ with weight >260 kg; non-response categories (“refusal,” “don’t know” and “not stated”)

Years 2010–2014

Age breakdown Youth: 12–17

Adults: Total 18+, 18–19, 20–34, 35–44, 45–64, 65+





Place of residence



Limitations Measures of BMI can be used to understand how the weight of a population changes over time and how weight is related to health risks. However, while BMI is useful to monitor the health of a population, it does not necessarily reflect health risks for a person. Individuals should be cautious if using BMI to classify themselves since this measure is not as precise for predicting health risks for people who are naturally very lean or muscular, or for people from certain minority ethnic groups.7

These results are based on height and weight as reported by Canadians. Comparisons of self-reported height and weight with actual measurements from the Canadian Health Measures Survey (CHMS) have shown that women are more likely to underestimate their weight, while men tend to overestimate their height. Moreover, under-reporting of weight increases proportionately with actual weight. In other words, the more overweight people are, the more likely they are to under-report their weight.7

Respondents with higher BMIs may be more likely to be in the non-response categories and therefore to be excluded from the indicator calculation.






14

Fruit and Vegetable Consumption Rate

Indicator description Indicator name Fruit and Vegetable Consumption Rate

Definition Percentage of the population age 12 and older who reported consuming fruits and vegetables 5 or more times daily




Number of people age 12 and older who reported consuming fruits and vegetables 5 or more times daily, divided by the number of survey respondents age 12 and older. Population estimates are calculated using survey weights.

Numerator Description: Survey respondents age 12 and older who reported consuming fruits and vegetables 5 or more times daily



Years 2010–2014






Place of residence



Limitations This measure does not take into account the amount consumed, only the number of times (frequency) per day a person reported eating fruits and vegetables.






15

Physical Activity Rate During Leisure Time

Indicator description Indicator name Physical Activity Rate During Leisure Time

Definition Percentage of persons age 12 and older who reported being physically active to moderately active during their leisure time. Physical activity is derived from the Canadian Community Health Survey based on responses to questions about the frequency, nature and duration of participation in leisure-time physical activity in the last 3 months by the population age 12 and older.


Data source Canadian Community Health Survey (CCHS) table 105-05015

data from CANSIM


For each leisure-time physical activity reported, average daily energy expenditure is calculated by multiplying the number of times the activity was performed by the average duration of the activity by the energy cost (kilocalories per kilogram of body weight per hour). The index is calculated as the sum of the average daily energy expenditures of all activities. Respondents are then classified based on the index score, as follows:

• Physically active: 3.0 kcal/kg/day or more

• Moderately active: 1.5 to 2.9 kcal/kg/day

• Inactive: Less than 1.5 kcal/day

This indicator focuses on respondents who reported that they were at least “moderately active” during their leisure time. Energy expended at

work, in transportation or doing housework is excluded. “Moderately active” would be equivalent to walking at least 30 minutes a day or taking an hour-long exercise class at least 3 times a week.

Population estimates are calculated using survey weights.

Numerator Description: Population age 12 and older who reported a level of active or moderately active physical activity, based on their responses to questions about the nature, frequency and duration of their participation in leisure-time physical activity

Denominator Description: Survey respondents age 12 and older who reported a level of physical activity


Years 2010–2014



16

Indicator description Sex breakdown Both sexes, males, females




Place of residence



Limitations None






17

Family Medicine Physician Supply

Indicator description Indicator name Family Medicine Physician Supply

Definition Practising family medicine physicians per 100,000 population

HSP dimension Health System Inputs and Characteristics: Health system resources

Data source CIHI, Scott’s Medical Database.8

Statistics Canada, CANSIM table 109-5335.9


Statistics Canada, Jurisdictional and Canadian population estimates.11


The number of family medicine physicians whose medical activity code is “active” divided by 100,000 population

Numerator Description: The number of active family medicine physicians in a designated geographic area. Family medicine physicians include the following: general practice, family medicine and emergency family medicine.

Exclusions: Military physicians; semi-retired physicians; medical residents

Denominator Description: National, provincial and regional population estimates from Statistics Canada. Population (residents of Canada) divided by 100,000 as of July 1 of the reference year

Years 2010–2014

Age breakdown No age breakdown

Sex breakdown No sex breakdown


National, provincial, regional


Place of residence or service


Confidence intervals n/a; no sampling variability


18

Indicator description Limitations The accuracy of the number of active physicians depends greatly on

the validity of physicians’ mailing addresses. Under-coverage issues may occur when physicians work in locum positions, since they may change locations frequently. Scott’s Directories cannot add locum physicians to its “active” physicians group if there is insufficient information on them. Therefore, these physicians will be absent from the Scott’s Medical Database (SMDB) counts. Where sufficient address information is available, locum physicians are assigned to just 1 province or territory within the SMDB, even if they do locum work in multiple jurisdictions.


CIHI’s Pan-Canadian Primary Health Care Indicator Update Report,

2012, pp. 109–112.

Note that the original indicator, PHC Provider Supply, has been split into 2:

• Family Medicine Physician Supply

• Registered Nurses/Nurse Practitioners (RNs/NPs) Employed in a PHC Setting




19

Registered Nurses/Nurse Practitioners (RNs/NPs) Employed in a PHC Setting

Indicator description Indicator name Registered Nurses/Nurse Practitioners (RNs/NPs) Employed in a

PHC Setting

Definition Practising registered nurses and nurse practitioners in primary health care per 100,000 population

HSP dimension Health System Inputs and Characteristics: Health system resources

Data source CIHI, Health Workforce Database — Nurses.12



Statistics Canada, Jurisdictional and Canadian population estimates.11


The number of registered nurses/nurse practitioners whose work status is “working” and whose place of work is either a nursing station, a community health centre or a physician’s office/family practice unit, divided by 100,000 population

Numerator Description: The number of registered nurses/nurse practitioners whose working status is “working” and place of work is a nursing station, a community health centre, or a physician’s office/family practice unit

Exclusions: Nurses who have a primary responsibility of administration, education or research; registered psychiatric nurses; licensed practical nurses

Denominator Description: National, provincial/territorial and regional population estimates from Statistics Canada. Population (residents of Canada) divided by 100,000 as of July 1 of the reference year

Years 2010–2014


Sex breakdown No sex breakdown


20

Indicator description Geographic coverage and breakdown

National, provincial/territorial, regional




Confidence intervals n/a; no sampling variability

Limitations The nursing workforce of the territories may be under-represented due to the number of nurses providing short-term relief work who may not have been identified with the methodology used to create the geographic breakdown of the data.

The employment status of nurses (full-time, part-time, casual) has not been accounted for in this analysis. This could potentially over-represent the level of access to primary health care nurses in areas where nurses are working on a part-time or casual basis.


CIHI’s Pan-Canadian Primary Health Care Indicator Update Report,

2012, pp. 109–112.

Note that the original indicator, PHC Provider Supply, has been split into 2:

• Family Medicine Physician Supply

• Registered Nurses/Nurse Practitioners (RNs/NPs) Employed in a PHC Setting




21

Uptake of Information and Communication Technology (ICT) in Primary Health Care

Indicator description Indicator name Uptake of Information and Communication Technology (ICT) in Primary

Health Care

Definition Percentage of primary health care providers who use electronic systems to complete their professional tasks

HSP dimension Health System Outputs: Person-centred

Data source National Physician Survey13


Number of family physicians who reported currently using electronic records to enter and retrieve clinical patient notes as well as at least 2 other activities for patient care, divided by the total number of family physicians. The responding sample has been weighted to represent the family physician population.

Numerator Description: Number of family physicians in the denominator who reported currently using electronic records to enter and retrieve clinical patient notes, as well as at least 2 of the following for patient care:

• Electronic reminders for recommended patient care

• Electronic warnings for adverse prescribing and/or drug interactions

• Electronic interface to external pharmacy/pharmacist

• Electronic interface to external laboratory/diagnostic imaging services

• Electronic interface to other external systems (e.g., hospitals, other clinics) for accessing or sharing patient information

Denominator Description: Family physicians who provide patient care

Years 2007, 2010, 2014

Age breakdown For national estimates, age breakdown available (<35, 35–44, 45–54, 55–64, 65+, age non-response)

Sex breakdown For national estimates, sex breakdown available (male, female, sex non-response)


National, provincial/territorial




Confidence intervals Not available


22

Indicator description Limitations Age and sex breakdowns are not overlaid and are only at the

national level






23

Population With a Regular Medical Doctor

Indicator description Indicator name Population With a Regular Medical Doctor

Definition Percentage of the population that reported having a regular medical doctor

HSP dimension Health System Outputs: Access to Comprehensive, high-quality health services



Number of people who reported that they have a regular medical doctor, divided by the number of survey respondents. Population estimates are calculated using survey weights.

Numerator Description: Respondents who reported that they have a regular medical doctor



Years 2010–2014






Place of residence



Limitations A low percentage may be related to the use of options other than a doctor’s office. In the territories, a nurse practitioner is often used as the first point of medical contact, rather than a medical doctor, which is excluded from the present definition.






24

Difficulties Obtaining After-Hours Primary Health Care

Indicator description Indicator name Difficulties Obtaining After-Hours Primary Health Care

Definition Percentage of respondents who found it somewhat difficult or very difficult to access medical care in the evenings, on weekends or on holidays without going to the hospital emergency department

HSP dimension Health System Outputs: Access to comprehensive, high-quality health services

Data source The Commonwealth Fund International Health Policy Survey (version for adults age 18+)14


Number of respondents who found it somewhat difficult or very difficult to access medical care in the evenings, on weekends or on holidays without going to the hospital emergency department, divided by the number of total respondents. Population estimates are calculated using survey weights.

Numerator Description: Number of respondents who found it somewhat difficult or very difficult to access medical care in the evenings, on weekends or on holidays without going to the hospital emergency department

Denominator Description: All respondents who answered the survey question regarding after-hours care. This includes all response categories: “very easy,” “easy,” “somewhat difficult,” “very difficult,” “never needed care at those times,” “not sure” and “decline to answer.”

Years 2007, 2010, 2013

Age breakdown Total 18+, 18–24, 25–34, 35–44, 45–54, 55–64, 65+



National, provincial, territorial data is suppressed.


Place of residence



Limitations Age breakdown available in 2013 and only at the national level for the “both sexes” category






25

Smoking Cessation Advice From a Regular Medical Doctor

Indicator description Indicator name Smoking Cessation Advice From a Regular Medical Doctor

Definition Percentage of current smokers who reported being offered specific help or information to quit smoking by their regular medical doctor in the past 12 months

HSP dimension Health System Outputs: Appropriate and effective

Data source Canadian Community Health Survey (CCHS) from the Public Use Microdata Files15


The number of current smokers who reported being offered specific help or information to quit smoking by their regular medical doctor in the past 12 months, divided by the number of smokers who visited their regular medical doctor in the past 12 months. Daily and occasional smokers are included as smokers. Population estimates are calculated using survey weights.

Numerator Description: Respondents who reported current daily or occasional smoking, age 12 and older, whose regular medical doctor offered them specific help or information to quit smoking within the past 12 months.

Denominator Description: Respondents who reported current daily or occasional smoking, age 12 and older, who visited their regular medical doctor within the past 12 months


Years 2007 and 2008 combined calendar years: Alberta

2009 and 2010 combined calendar years: Manitoba

2011 and 2012 combined calendar years: Prince Edward Island, British Columbia


Sex breakdown Male, female, both sexes


No national coverage; provinces/territories are limited.


Place of residence




26

Indicator description Limitations This was an optional CCHS module and was chosen by a limited

number of jurisdictions. The reduced coverage prevented a pan-Canadian comparison and the development of a national average.



Target audience: Providers



27

Eye Examinations in Adults With Diabetes

Indicator description Indicator name Eye Examinations in Adults With Diabetes

Definition Percentage of the population age 20 and older with diabetes mellitus who had an eye exam within the past 24 months


Data source Canadian Community Health Survey (CCHS) data from the Public Use Microdata Files15


Number of respondents age 20+ who reported having diabetes and having an eye exam within the past 24 months, divided by the number of respondents age 20+ who reported having diabetes. Population estimates are calculated using survey weights.

Numerator Description: Respondents who reported having diabetes and having an eye exam in the last 24 months

Exclusions: Women who reported having gestational diabetes

Denominator Description: Respondents age 20 and older who reported having diabetes

Exclusions: Women who reported having gestational diabetes; non-response categories (“refusal,” “don’t know” and “not stated”)

Years 2007 and 2008 combined calendar years: Newfoundland and Labrador, Prince Edward Island, Nova Scotia, New Brunswick, Ontario, British Columbia

2009 and 2010 combined calendar years: Newfoundland and Labrador, Prince Edward Island

2011 and 2012 combined calendar years: Newfoundland and Labrador, Nova Scotia, New Brunswick, Ontario


Sex breakdown Male, female, both sexes


No national coverage; provinces/territories are limited.


Place of residence




28

Indicator description Limitations This was an optional CCHS module and was chosen by a limited

number of jurisdictions. The reduced coverage prevented a pan-Canadian comparison and the development of a national average.






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Influenza Immunization for Seniors

Indicator description Indicator name Influenza Immunization for Seniors

Definition Percentage of persons age 65 and older who reported that they had their last influenza immunization (flu shot) less than 1 year ago




Number of respondents age 65 and older who received an influenza immunization (flu shot) less than 1 year ago, divided by the total number of survey respondents age 65 and older. Population estimates are calculated using survey weights.

Numerator Description: Respondents age 65 and older who reported that they had been immunized for influenza within the past year

Denominator Description: Survey respondents age 65 and older who responded to the question on influenza immunization


Years 2010–2014






Place of residence



Limitations In 2010, H1N1 immunization was offered separately from seasonal influenza vaccine and may not be comparable with other data years.






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Colorectal Cancer Screening

Indicator description Indicator name Colorectal Cancer Screening

Definition Percentage of the population age 50 to 74 who reported having received a screening test for colorectal cancer within the specified time frame


Data source Canadian Community Health Survey, Statistics Canada, as provided by the Canadian Partnership Against Cancer in November 201516, 17


Number of respondents age 50 to 74 who self-reported having at least 1 fecal occult blood test (FOBT, gFOBT or FIT) within the past 24 months and/or a screening colonoscopy or sigmoidoscopy within the past 5 years, divided by the number of respondents age 50–74. Population estimates are calculated using survey weights.

Numerator Description: Individual is age 50 to 74 and reported having received at least 1 of the following screening tests:

• A fecal occult blood test (FOBT, gFOBT or FIT) within the past 24 months;

• A screening colonoscopy or sigmoidoscopy within the past 5 years; excludes tests done to investigate symptoms.

Procedures were considered to be for screening purposes and not diagnostic purposes if the reason for the procedure was 1 of the following: family history of colorectal cancer, regular check-up/routine screening, age or race.

Denominator Description: Respondents age 50 to 74

Years 2012 and 2013

Age breakdown Total 50–74, 50–59, 60–74



National, provincial and territorial data in 2012. Nunavut data is suppressed. In 2013, questions on colorectal cancer screening were optional content and for this reason there is limited coverage in 2013, which includes Newfoundland and Labrador, Prince Edward Island, New Brunswick, Quebec, Manitoba, Alberta, Yukon and the Northwest Territories.


Place of residence

Other breakdown By screening test modality: All, FOBT, colonoscopy/sigmoidoscopy



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Indicator description Confidence intervals Available

Limitations Due to the nature of the survey setup, screening colonoscopy and sigmoidoscopy screening rates cannot be assessed individually.






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Cervical Cancer Screening

Indicator description Indicator name Cervical Cancer Screening

Definition Percentage of the female population age 20 to 69 who reported having had a Papanicolaou (Pap) test in the past 36 months.


Data source Canadian Community Health Survey, Statistics Canada, as provided by the Canadian Partnership Against Cancer in November 201516, 17


Number of women age 20 to 69 who self-reported having a Pap test in the past 36 months, divided by the number of female respondents age 20 to 69. Population estimates are calculated using survey weights.

Numerator Description: Female respondents age 20 to 69 who reported having a Pap test in the past 36 months

Denominator Description: Female respondents age 20 to 69

Exclusions: Non-response categories (“refusal,” “don’t know” and “not stated”); individuals who reported not having a Pap test because of a hysterectomy

Years 2012 and 2013

Age breakdown Total 20–69, 20–34, 35–49, 50–69

Sex breakdown Females only


National, provincial and territorial data in 2012. In 2013, questions on cervical cancer screening were optional content and for this reason there is limited coverage in 2013, which includes Newfoundland and Labrador, Prince Edward Island, New Brunswick, Yukon, the Northwest Territories and Nunavut.


Place of residence

Adjustment applied Age-adjusted for the group “total 20–69.” Direct standardization, standard population: Canada 2011


Limitations None






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Ambulatory Care Sensitive Conditions (ACSCs) Hospitalization Rate

Indicator description Indicator name Ambulatory Care Sensitive Conditions (ACSCs) Hospitalization Rate

Definition Age-standardized acute care hospitalization rate for conditions where appropriate ambulatory care prevents or reduces the need for admission to hospital, per 100,000 population younger than age 75


Data source Data from the DAD, CIHI;18 Fichier des hospitalisations MED-ÉCHO, ministère de la Santé et des Services sociaux du Québec;19 and Population projections, Demography division of Statistics Canada20


(Total number of acute care hospitalizations for ambulatory care sensitive conditions in patients younger than age 75 ÷ total mid-year population younger than age 75) × 100,000 (age-adjusted)

Numerator Description: Total number of acute care hospitalizations for ACSCs in patients younger than age 75.

1. Hospitalization for an ACSC is identified as any most responsible diagnosis code of

• Grand mal status and other epileptic convulsions ICD-9/9-CM: 345 ICD-10-CA: G40, G41

• Chronic obstructive pulmonary disease (COPD)

a. Any most responsible diagnosis (MRDx) code of ICD-9/9-CM: 491, 492, 494, 496 ICD-10-CA: J41, J42, J43, J44, J47

b. MRDx of acute lower respiratory infection, only when a secondary diagnosis* of J44 in ICD-10-CA or 496 in ICD-9/9-CM is also present ICD-9/9-CM: 466, 480–486, 487.0 ICD-10-CA: J10.0, J11.0, J12–J16, J18, J20, J21, J22

*Secondary diagnosis refers to a diagnosis other than the most responsible one.

• Asthma ICD-9/9-CM: 493 ICD-10-CA: J45

• Diabetes ICD-9: 250.0, 250.1, 250.2, 250.7 ICD-9-CM: 250.0, 250.1, 250.2, 250.8 ICD-10-CA: E10.0, E10.1, E10.63, E10.64, E10.9


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Indicator description E11.0, E11.1, E11.63, E11.64, E11.9 E13.0, E13.1, E13.63, E13.64, E13.9 E14.0, E14.1, E14.63, E14.64, E14.9

• Heart failure and pulmonary edema† ICD-9/9-CM: 428, 518.4 ICD-10-CA: I50, J81

• Hypertension† ICD-9/9-CM: 401.0, 401.9, 402.0, 402.1, 402.9 ICD-10-CA: I10.0, I10.1, I11

• Angina† ICD-9: 411, 413 ICD-9-CM: 411.1, 411.8, 413 ICD-10-CA: I20, I23.82, I24.0, I24.8, I24.9

† Excluding cases with cardiac procedures.

List of cardiac procedure codes for exclusion: CCP: 47^^, 480^–483^, 489.1, 489.9, 492^–495^, 497^, 498^ ICD-9-CM: 336, 35^^, 36^^, 373^, 375^, 377^, 378^, 379.4–379.8 CCI: 1.HA.58, 1.HA.80, 1.HA.87, 1.HB.53, 1.HB.54, 1.HB.55, 1.HB.87, 1.HD.53, 1.HD.54, 1.HD.55, 1.HH.59, 1.HH.71, 1.HJ.76, 1.HJ.82, 1.HM.57, 1.HM.78, 1.HM.80, 1.HN.71, 1.HN.80, 1.HN.87, 1.HP.76, 1.HP.78, 1.HP.80, 1.HP.82, 1.HP.83, 1.HP.87, 1.HR.71, 1.HR.80, 1.HR.84, 1.HR.87, 1.HS.80, 1.HS.90, 1.HT.80, 1.HT.89, 1.HT.90, 1.HU.80, 1.HU.90, 1.HV.80, 1.HV.90, 1.HW.78, 1.HW.79, 1.HX.71, 1.HX.78, 1.HX.79, 1.HX.80, 1.HX.83, 1.HX.86, 1.HX.87, 1.HY.85, 1.HZ.53 rubric (except 1.HZ.53.LA-KP), 1.HZ.55 rubric (except 1.HZ.55.LA-KP), 1.HZ.56, 1.HZ.57, 1.HZ.59, 1.HZ.80, 1.HZ.85, 1.HZ.87, 1.IF.83, 1.IJ.50, 1.IJ.55, 1.IJ.57, 1.IJ.76, 1.IJ.80, 1.IJ.86, 1.IK.57, 1.IK.80, 1.IK.87, 1.IN.84, 1.LA.84, 1.LC.84, 1.LD.84, 1.YY.54.LA-NJ‡

‡ 1.YY.54.LA-NJ was retired as of CCI version 2012 and was included when calculating indicator results prior to 2012–2013.

Note: Code may be coded in any position. Procedures coded as cancelled or abandoned after onset are excluded.

2. Age at admission younger than 75

3. Sex recorded as male or female

4. Canadian resident (Canadian postal code)

Exclusions: Records with discharge as death (Discharge Disposition Code = 07); newborn, stillbirth or cadaveric donor records (Admission Category = N, R or S)


35

Indicator description Denominator Total mid-year population younger than age 75

Years 2010–2011 to 2014–2015






Place of residence

Adjustment applied Age-adjusted. Direct standardization, standard population: Canada 2011


Limitations None






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Medication Lists in Primary Health Care Using a Computerized System

Indicator description Indicator name Medication Lists in Primary Health Care Using a Computerized System

Definition Percentage of primary care physicians who are able to generate a medication list for their patients using a computerized system.

Note that the 2012 indicator definition of medication lists was slightly adapted to include an ICT component.

HSP dimension Health System Outputs: Safe health services

Data source The Commonwealth Fund International Health Policy Survey of Primary Care Physicians14, 21


Number of primary care physicians who report that it is easy for them to generate a list of their patients’ medications with their current records system, divided by the number of primary care physicians who responded to the question on medication lists. Estimates were weighted by age, gender and province.

Numerator Description: Total number of primary care physicians who responded that it would be easy (“easy” in 2009 and 2012 surveys and “yes” in 2015 survey) to generate a list of all medications taken by an individual patient (including those that may be prescribed by other doctors).

Denominator Description: Total number of Canadian primary care physicians who responded to the question on medication lists.

For the 2009 and 2012 surveys: “With the patient medical records system you currently have, how easy would it be for you (or staff in your practice) to generate a list of all medications taken by an individual patient (including those that may be prescribed by other doctors)?”

For the 2015 survey: “Can your practice generate the following information about your patients using a computerized process: List of all medications taken by an individual patient (including those that may be prescribed by other doctors)?”

Years 2009, 2012, 2015

Age breakdown <35, 35–49, 50–64, 65+, all ages

Sex breakdown Both sexes, males, females,


National, provincial. Data from P.E.I. and the territories was suppressed.


Place of work


37

Indicator description Adjustment applied None


Limitations The question format changed slightly for 2015. The answer categories changed from “easy/somewhat difficult/difficult/cannot generate medication lists” to “yes/no” for whether or not medication lists could be generated. The “easy” category was aligned to the “yes” category to conduct this analysis over the different time periods, yet the change in categories could create inconsistencies over time.


CIHI’s Pan-Canadian Primary Health Care Indicator Update Report, 2012, pp. 173–174. Note that the original indicator, Maintaining Medication and Problem Lists in PHC, has been adapted to focus on medication lists using a computerized system due to data availability.




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Appendix 1: Pan-Canadian PHC Indicator Update Report (2012) — Indicators excluded from this chartbook In 2012, CIHI released the Pan-Canadian Primary Health Care Indicator Update Report, which included 51 PHC indicators categorized as for use either by policy-makers or by primary health care providers.

36 indicators were excluded from the current chartbook. The list of excluded indicators, as well as the rationale for exclusion, appears below.

2012 Primary Health Care indicators excluded

Intended audience, 2012

Proposed data source in 2012

Rationale for exclusion from this chartbook

Scope of PHC Services Policy-makers

Canadian Practice-Based Primary Health Care Survey Tools: Organization Component

Pan-Canadian practice-based survey data not available Uptake of Information and

Communication Technology (ICT) in PHC Organizations*

Providers

Collaborative Care With Other Health Care Organizations

Policy-makers

PHC Needs-Based Planning Policy-makers

PHC Provider Full-Time Equivalents

Providers

Point-of-Care Access to PHC Client/Patient Health Information

Policy-makers

Canadian Practice-Based Primary Health Care Survey Tools: Provider Component

PHC Team Effectiveness Score Providers

Unnecessary Duplication of Medical Tests Reported by PHC Providers

Providers

PHC Services Meeting Client’s/Patient’s Needs

Providers Canadian Practice-Based Primary Health Care Survey Tools: Patient Component

PHC Support for Self-Management of Chronic Conditions

Providers

Wait Time for Immediate Care for a Minor Health Problem

Providers


39





Screening in Adults With Diabetes Policy-makers

Survey on Living With Chronic Diseases in Canada

Data not available over time; there is only 1 survey cycle devoted to each condition in the Survey on Living With Chronic Diseases in Canada

Blood Pressure Control for Hypertension

Policy-makers

Difficulties Accessing Routine or Ongoing PHC

Policy-makers

CCHS Substantial deviations from the 2012 indicator methodology would be required

Complications of Diabetes Policy-makers

Discharge Abstract Database, MED-ÉCHO, CCHS

Time With PHC Provider for Patients With Chronic Conditions

Policy-makers

The Commonwealth Fund International Health Policy Survey of Adults

Wait Time for Immediate Care for a Minor Health Problem

Policy-makers

Emergency Department (ED) Visits for Asthma

Policy-makers

National Ambulatory Care Reporting System (NACRS) and CCHS

Limited coverage of NACRS (only 2 provinces have full coverage for ED data)

Breast Cancer Screening Policy-makers

CCHS CIHI/Choosing Wisely Canada measurement collaborative initiative, and CPAC, are examining mammography in greater detail

PHC Physician Remuneration Method

Policy-makers

National Physician Survey (NPS)

Data quality concerns around survey low response rate and inability to validate findings with a secondary data source


40





Screening in Adults With Diabetes Providers Electronic medical record (EMRs)

Comprehensive pan-Canadian availability of EMR data is lacking

Blood Pressure Control for Hypertension

Providers

Child Immunization Providers

Child Immunization Policy-makers

Antidepressant Medication Monitoring

Policy-makers

Well-Baby Screening Providers

Blood Pressure Testing Providers

Screening for Modifiable Risk Factors in Adults With Coronary Artery Disease

Providers

Screening for Modifiable Risk Factors in Adults With Hypertension

Providers

Treatment of Dyslipidemia Providers

Treatment of Acute Myocardial Infarction

Providers

Treatment of Anxiety Providers

Breast Cancer Screening Providers

Cervical Cancer Screening† Providers

Colon Cancer Screening† Providers

Overweight and Obesity Rate† Providers

Notes * This ICT indicator is intended for providers, and the methodology differs from the ICT indicator included in this chartbook, which is

intended for policy-makers. Please refer to the 2012 report for additional information. † These indicators are intended for providers, and the methodology differs from similar indicators included in this chartbook, which

is intended for policy-makers. Please refer to the 2012 report for additional information.


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Appendix 2: Text alternatives for figures 1 and 2 Figure 1 CIHI’s Health System Performance Measurement Framework

The framework is composed of 4 interrelated quadrants: Health System Outcomes, Social Determinants of Health, Health System Outputs, and Health System Inputs and Characteristics. Each quadrant is composed of different performance dimensions linked through expected causal relationships. These 4 quadrants sit within a demographic, political, economic and cultural context.

Figure 2 Selected PHC indicators organized according to CIHI’s Health System Performance Measurement Framework

This figure shows the 16 PHC indicators arranged by quadrant of CIHI’s Health System Performance Measurement Framework. The indicators fall within 3 of the quadrants: Social Determinants of Health, Health System Inputs and Characteristics, and Health System Outputs. None of the indicators were categorized in the Health System Outcomes quadrant. 3 indicators relate to the behavioural factors of the Social Determinants of Health quadrant: Smoking Rate, Fruit and Vegetable Consumption Rate and Physical Activity Rate During Leisure Time. Overweight and Obesity Rate is aligned to both biological and behavioural factors within the Social Determinants of Health quadrant. 3 indicators relate to health system resources within the Health System Inputs and Characteristics quadrant: Family Medicine Physician Supply, Registered Nurses/Nurse Practitioners (RNs/NPs) Employed in a PHC Setting, and Uptake of Information and Communication Technology (ICT) in Primary Health Care. Within the Health System Outputs quadrant, there are 2 groupings. Under Access to Comprehensive, High-Quality Health Services, there are 2 indicators: Population With a Regular Medical Doctor and Difficulties Obtaining After-Hours Primary Health Care. Under Appropriate, Effective and Safe, there are 7 indicators: Smoking Cessation Advice From a Regular Medical Doctor, Eye Examinations in Adults With Diabetes, Influenza Immunization for Seniors, Colorectal Cancer Screening, Cervical Cancer Screening, Ambulatory Care Sensitive Conditions (ACSCs) Hospitalization Rate and Medication Lists in Primary Health Care Using a Computerized System.


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References 1. Canadian Institute for Health Information. Pan-Canadian Primary Health Care Indicators,

Report 1, Volume 2. 2006.

2. Canadian Institute for Health Information. Primary Health Care Indicators Chartbook: An Illustrative Example of Using PHC Data for Indicator Reporting. 2008.

3. Canadian Institute for Health Information. Pan-Canadian Primary Health Care Indicator Update Report. 2012.

4. Canadian Institute for Health Information. A Performance Measurement Framework for the Canadian Health System. 2013.

5. Statistics Canada. CANSIM Table 105-0501, health indicator profile, annual estimates, by age group and sex, Canada, provinces, territories, health regions (2013 boundaries) and peer groups. Accessed September 2015.

6. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ. 2000.

7. Statistics Canada. Overweight and obese adults (self-reported), 2014. Accessed December 2015.

8. Canadian Institute for Health Information. Scott’s Medical Database (SMDB) Metadata. Accessed September 2015.

9. Statistics Canada. CANSIM Table 109-5335, estimates of population (2011 Census and administrative data), by age group and sex for July 1st, Canada, provinces, territories, health regions (2013 boundaries) and peer groups, Terminated. Accessed September 2015.

10. Statistics Canada. CANSIM Table 109-5345, estimates of population (2011 Census and administrative data), by age group and sex for July 1st, Canada, provinces, territories, health regions (2014 boundaries) and peer groups. Accessed September 2015.

11. Statistics Canada. Quarterly demographic estimates 2015. Accessed September 2015.

12. Canadian Institute for Health Information. Health Workforce Database — Nurses. Accessed September 2015.

13. National Physician Survey, College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada. National Physician Surveys. Multiple data years. Accessed September 2015.

https://secure.cihi.ca/free_products/PHC_Indicator_Report_1-Volume_2_Final_E.pdf

https://secure.cihi.ca/free_products/PHC_Indicator_Report_1-Volume_2_Final_E.pdf

https://secure.cihi.ca/free_products/phc_chartbook_en.pdf

https://secure.cihi.ca/free_products/phc_chartbook_en.pdf



https://secure.cihi.ca/free_products/HSP_Framework_Technical_Report_EN.pdf

https://secure.cihi.ca/free_products/HSP_Framework_Technical_Report_EN.pdf

http://www5.statcan.gc.ca/cansim/a26?lang=eng&id=1050501



http://www.bmj.com/content/320/7244/1240

http://www.bmj.com/content/320/7244/1240

http://www.statcan.gc.ca/pub/82-625-x/2015001/article/14185-eng.htm

https://www.cihi.ca/en/spending-and-health-workforce/health-workforce/scotts-medical-database-smdb-metadata







http://www5.statcan.gc.ca/olc-cel/olc.action?objId=91-002-X&objType=2&lang=en&limit=0

https://www.cihi.ca/en/spending-and-health-workforce/health-workforce/nurses




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14. The Commonwealth Fund. Surveys. Accessed September 2015.

15. Statistics Canada. Canadian Community Health Survey: Public Use Microdata File. Accessed September 2015.

16. Statistics Canada. Canadian Community Health Survey (all reference periods). Accessed September 2015.

17. Canadian Partnership Against Cancer. Cancer System Performance. Accessed September 2015.

18. Canadian Institute for Health Information. Discharge Abstract Database (DAD) Metadata. Accessed September 2015.

19. Régie de l’assurance maladie Québec. Banque de données ministérielles MED-ÉCHO. Accessed September 2015.

20. Statistics Canada. Estimates of population by age and sex for Canada, provinces and territories. Accessed September 2015.

21. Canadian Institute for Health Information. How Canada Compares: Results From The Commonwealth Fund 2015 International Health Policy Survey of Primary Care Physicians. 2016.

http://www.commonwealthfund.org/interactives-and-data/surveys

http://www5.statcan.gc.ca/olc-cel/olc.action?lang=en&ObjId=82M0013X&ObjType=2

http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getInstanceList&Id=164081

http://www.systemperformance.ca/

https://www.cihi.ca/en/types-of-care/hospital-care/acute-care/dad-metadata

http://www.ramq.gouv.qc.ca/fr/donnees-statistiques/sur-demande/donnees-msss/Pages/med-echo.aspx

http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&Id=238498

http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&Id=238498

https://www.cihi.ca/en/commonwealth-survey-2015

https://www.cihi.ca/en/commonwealth-survey-2015

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