Congestive Heart Failure (G14051)

Heart failure is a complex syndrome associated with a high rate of hospitalization and short-term mortality, especially in elderly patients with co-morbidities. Early diagnosis and treatment can prevent complications. 

In 2003, the General Practice Services Committee (GPSC) identified a gap in the care of patients with congestive heart failure (CHF) and developed the CHF Chronic Disease Management (CDM) incentive (now billed using G14051) to encourage family physicians to provide guideline-informed care for these patients. 

The CHF CDM may be billed for eligible patients:

• By the GP who is providing the ongoing longitudinal coordinated care for the patient in the community. 
• After a GP has provided guideline-informed care for at least 1 year following the diagnosis of CHF (see “Diagnosing heart failure” below).  NB: The GP must have provided at least two visits in the previous 12 months and completed at least two columns of a CHF flow sheet (paper or electronic).

Billing the CHF incentive

While the proportion of patients with CHF who have had the CDM incentive billed for them has slowly increased, it has significantly lagged behind the other CDM incentives [i.e., diabetes (14050), hypertension (14052), and chronic obstructive pulmonary disease (COPD) (14053)]. Feedback from family physicians has identified challenges in diagnosis confirmation as a barrier to providing guideline-informed care to these patients; the inability to access a timely echocardiogram (if accessible at all) is a common obstacle.

NB: the Guidelines and Protocols Advisory Committee (GPAC) (www.bcguidelines.ca/gpac/pdf/heart_failure.pdf) CHF guideline indicates that if echocardiogram/radio nucleotide ventriculography (RNV)/brain natriuretic peptide (BNP) confirmation is not available, a detailed history and physical examination supporting a clinical diagnosis of CHF, along with a therapeutic trial, is acceptable to confirm the diagnosis.

Patients with CHF confirmed by the process detailed below are eligible.

Diagnosing heart failure

Evaluation of heart failure should include:

• A thorough history and physical examination focusing on:
  • Current and past symptoms of heart failure (i.e., fatigue, dyspnea, decreased exercise capacity, and fluid retention/weight gain).
  • Functional limitation by New York Heart Association (NYHA) Class.
  • Cardiovascular risk factors, cardiovascular disease, and other co-morbid conditions.
  • Assessment of a patient’s endurance, cognition, and ability to perform activities of self-management and daily living.
  • Clinical assessment of volume status (e.g., peripheral edema, rales, hepatomegaly, ascites, weight, jugular venous pressure, and postural hypotension).

• Initial investigations in all patients (where available):
  • Complete blood count, serum electrolytes, creatinine, eGFR, urinalysis, microalbuminuria, fasting blood sugar, fasting lipid profile, AST, albumin, and thyroid-stimulating hormone (TSH).
  • Twelve-lead ECG and CXR.
  • If available, all patients should have an objective determination of left ventricular ejection fraction (LVEF) by transthoracic echocardiogram or RNV.
  • BNP has high diagnostic value for heart failure and is recommended where available when the diagnosis is unclear.
  • In cases of doubt or when an objective determination of LVEF is not immediately available, response to a therapeutic trial may increase the diagnostic accuracy and is acceptable for making the diagnosis.

Benefits

Evaluation of those patients for whom the CHF CDM has been billed shows lower rates of hospitalization and morbidity, resulting in significant cost savings to the system. 

By supporting the delivery of complex patient care by full-service family practitioners, the CHF incentive—along with the suite of CDM incentives developed by the GPSC—can help BC family physicians meet the growing demands of caring for an aging population with more complicated conditions.

—Dr Cathy Clelland,
Family physician and Executive Director,
Society of General Practitioners

Click here for more information on the complete suite of Chronic Disease Management incentives.