News From ACFAS

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What makes ACFAS such a successful organization? The volunteer members who donate their time and expertise to making a difference for the profession and the College by serving on the numerous committees, programs, initiatives and the Board of ACFAS. In honor of National Volunteers Week, the staff at ACFAS would like to personally thank each of our volunteers for their passion and dedication--it's your determination that brings strength to the whole.

Thank you! If you’ve changed any information about your practice, don’t forget to update your profile so the College and potential new patients can reach you. Remember to include updates to your practice’s website, any email addresses you use (work or personal), your fax number and your work, home or cell number. Do you want to change your “preferred address” for receiving The Journal of Foot & Ankle Surgery and other valuable ACFAS mailings? Make sure you log in to acfas.org/profile and update your member profile so we can stay in touch with you and ensure proper delivery.

Your contact information can also be listed in the College’s online membership directory so your colleagues can find you by clicking “Yes” to the Members-Only Directory in your profile. And, don’t forget to include yourself in the “Find an ACFAS Physician” search tool on FootHealthFacts.org so consumers can find you by clicking “Yes” for “Consumer Physician Search.”

Change can be a wonderful thing, but remember to let us know about any updates so you can keep yourself available to peers, potential patients and the College! Update your profile today.
In an effort to support and encourage research efforts by local residents, ACFAS Divisions created a standard of support offered to poster presenters at this year's Annual Scientific Conference in Orlando, FL. The following Divisions provided support to residents within their geography. The residents’ poster titles can be found on the Division’s website, where most of their posters are viewable as well.

• Division 2: Northwest/Canada supported four local residents acfas.org/division2: Marc D. Jones, DPM, and Rebecca Omana-Daniels, DPM, residents at Madigan Army Medical Center, in Tacoma, WA; and Ian Burtenshaw, DPM, and Gavin Ripp, DPM, residents at Swedish Medical Center, in Everett, WA.
• Division 4: Desert States supported one local resident acfas.org/division4: Ian Yarger, DPM, a resident at the North Colorado Medical Center, in Greeley, CO.
• Division 5: Florida supported three local residents acfas.org/division5: Nathan Graves, DPM, a resident at Shands Jacksonville Medical Center, in Jacksonville, FL; Desiree Barzon, DPM, and Sidharth Reddy, residents at Bethesda Memorial Hospital, in Boynton Beach, FL.
• Division 6: Midwest supported three local residents acfas.org/division6: Jon Goldsmith, DPM, from Grant Medical Center in Omaha, NE; Nathan Sanders, DPM, from Hennepin County Medical Center, in Minneapolis, MN; and Kyle Abben, DPM, from HealthPartners Institute/Regions Hospital in Minneapolis, MN.
• Division 7: Michigan supported two local residents acfas.org/division7: Karl W. Dunn, DPM, and Austin Matthews, DPM, residents at Henry Ford Macomb Hospital, in Clinton Township, MI.
• Division 13: Ohio Valley supported 11 local residents acfas.org/division13: Thomas Paulick, DPM, resident at Jewish Hospital Cincinnati; Frank Luckino III, DPM*, James Connors, DPM, Nicole Nicolosi, DPM, Eric Lew, DPM, Lauren Kishman, DPM, Jennifer Gerres, DPM, residents at Cleveland Clinic Health Span; Morgan Kizzar, DPM, Levi Berry, DPM, residents at Northside Medical Center in Youngstown, OH; Jordan Meyers, DPM, resident at Jewish Hospital of Lewisville; Kati Rush, DPM*, and Jesse Riley, DPM, residents at Saint Mary's Medical Center in Hobart, IN.

Congratulations to all of the residents who provided research and participated in the Annual Scientific Conference poster and manuscript competition.

Foot and Ankle Surgery

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A survey performed by the Centers for Disease Control and Prevention (CDC) and published in the New England Journal of Medicine estimated that 648,000 hospital patients, or 4 percent of those who were hospitalized, had at least one hospital-acquired infection in 2011. Of those individuals, 74,000 had more than one infection. The survey also found that there were an estimated 721,800 hospital-acquired infections in 2011, 22 percent of which occurred at the surgical site following surgery. Roughly 28 percent of the infections were linked to a device that the patient was hooked up to, such as a catheter or ventilator. In addition, the survey found that 22 percent of the infections were cases of pneumonia, while 17 percent were stomach or intestinal illnesses. Infections of the urinary tract were the fourth most common type of infection, while bloodstream infections came in fifth. The deputy director of the CDC's Division of Healthcare Quality Promotion, Dr. Mike Bell, said the survey's findings were good news, as they showed that the number of hospital-acquired infections has fallen from the 1.7 million infections that were recorded each year between 1990 and 2002.


A new study has concluded that triple-threaded, cannulated headless screws may be a good alternative to partially threaded lag screws when used in first metatarsophalangeal arthrodesis, due to their greater biomechanical strength. During the study, first metatarsophalangeal joint arthrodesis using a crossed screw technique was performed on 11 paired, preserved cadaver first rays. The technique was performed using either two 4 mm triple-threaded, cannulated headless screws or two 4 mm partially-threaded, cannulated lag screws. Dorsally directed cantilever bending was then performed on the constructs. Significantly greater bending stiffness and failure load was observed in the constructs that used the triple-threaded, cannulated headless screws than those that utilized the partially-threaded, cannulated lag screws.

Practice Management

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Hiring the wrong person to fill a vacant position can have significant consequences, including the cost and time involved in having to re-start the hiring process and hire another candidate. As a result, doctors' practices should resist the urge to hastily hire someone to alleviate the problems caused by being short staffed and instead take their time to develop a process that will help them hire the right candidate. This process should begin with identifying traits that an ideal candidate would have, such as type of personality, work ethic, and appearance and manner. In addition, physicians' practices should come up with a broader description of their ideal candidate that goes beyond these attributes and determine how such a person would handle situations they would see in the course of their job. It is also helpful to determine what type of person would be interested in the vacant position. Knowing this can help physicians' practices tailor the job and its compensation and benefits to the ideal candidate. Once resumes start to come in, physicians' practices should be sure to verify important information provided by selected candidates to ensure it is accurate. Finally, medical practices should give a new employee a short trial period that will allow them to easily quit if they decide that the job is not right for them.


Physicians need to ensure that so-called "soft skills," such as the ability to listen to patients, getting patients involved in their appointments, and understanding patients' health experiences, are strong in order to protect themselves from medical malpractice suits, writes MGIS Companies President Jeffrey D. Brunken, whose firm provides insurance products for doctors. Brunken notes that miscommunication between doctors and patients, rather than clinical error, is the biggest contributor to medical malpractice suits in over 70 percent of cases. In addition, attorneys representing the plaintiffs in malpractice cases often look at information about doctors' soft skills contained in patient surveys and other quality assessment tools in order to build their cases against the physicians they sue. Interpersonal skills will play a bigger and bigger role in doctors' quality assessment rankings as time goes on--a reality doctors should try to accept, Brunken says. He adds that there a number of things that doctors can do to protect themselves from medical malpractice suits filed by patients who believe their interpersonal skills are sub-par, including taking CME-accredited courses aimed at teaching physicians how to improve their soft skills. Finally, Brunken urges doctors to be aware of the types of questions being asked by quality assessment tools so that they can be sure they are not rated poorly by patients.

Health Policy and Reimbursement

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The Centers for Medicare and Medicaid Services (CMS) said April 7 that Medicare Advantage rates will rise by 0.4 percent on Jan. 1, instead of declining by 1.9 percent as previously announced. CMS Principal Deputy Administrator Jonathan Blum said the reversal is the result of four policy changes, including a decision not to finalize a proposal that would have excluded from payment calculations diagnoses identified during home risk assessments but not confirmed during subsequent clinical visits. That proposal was expected to have a negative impact on payments. In addition, changes made to the risk adjustment methodology to account for healthier baby boomers who are becoming Medicare beneficiaries also resulted in rates rising next year instead of declining, Blum said. CMS' announcement comes after lawmakers from both parties, insurance companies, and others tried to convince the agency to maintain this year's funding levels in 2015. Lawmakers said their constituents had expressed concern about the drop in Medicare Advantage rates that was announced by CMS in February. However, the reversal has been criticized by the National Committee to Preserve Social Security and Medicare, which said that CMS' latest announcement shows that maintaining government overpayments to the private insurers who participate in Medicare Advantage is "bad policy and bad economics" for Medicare.


President Obama has signed the Protecting Access to Medicare Act, which delays the deadline for complying with ICD-10 by one year until October 1, 2015. This is the third such delay for ICD-10 compliance. In addition to delaying ICD-10, the bill also calls for the mandatory use of clinical decision support tools when ordering diagnostic imaging studies. In other legislative news, President Obama has also signed the temporary sustainable growth rate (SGR) "doc fix" bill. The president's decision to sign the bill, which expires March 31, 2015, averted a 24 percent cut to Medicare physician payment rates that would have taken place on April 1.


A recent study commissioned by Pew Charitable Trusts has found that there is no correlation between the amount of evidence needed for a medical device to be approved under one of the Food and Drug Administration's approval pathways and a payer's decision to cover that device. Researchers came to that conclusion after analyzing the FDA's premarket approvals (PMAs) pathway, which requires clinical trials of medical devices and a reasonable assurance that such devices are effective before they can be approved, and the humanitarian device exemptions (HDEs) pathway, which does not require such evidence. The study found that a device that is approved under the PMA pathway will not necessarily be covered by payers, while devices approved under HDE are not necessarily not covered. Indeed, devices approved under HDE are actually more likely to be covered by payers, the study found. The study also looked at how different payers take the FDA's approval notice into consideration, as well as how they decide to cover medical devices. Both public and private payers take the FDA's approval notice into account when deciding on medical device coverage, though private payers also take clinical trials and other sources of data into consideration. In addition, medical devices are automatically not covered by private payers if no specific coverage policy exists, while the reverse holds true for public payers.


The Centers for Medicare and Medicaid Services (CMS) could begin releasing Medicare billing and payment data belonging to 880,000 doctors and other healthcare providers as early as April 9, despite opposition from the American Medical Association (AMA) and individual physicians. The data that will be released will be taken from $77 billion worth of Medicare Part B payments from 2012, and will include information about how healthcare providers billed Medicare for services as well as what they were paid. Doctors' provider IDs and their patient volumes will also be released. Patient advocates have said the information about patient volumes will help consumers determine which doctors are proficient at performing complex procedures. CMS Principal Deputy Administrator Jonathan Blum said making the data available to the public will make Medicare payments to doctors more transparent and will help identify fraud, waste, and abuse in Medicare. But AMA has said it is concerned that members of the public who view the data will use the information to make potentially harmful decisions about treatments while at the same time encouraging an "unwarranted bias" against physicians that could make it difficult or even impossible for them to practice medicine. AMA has called on CMS to take a number of steps to correct what it believes are the pitfalls of releasing the data, including allowing doctors to review and correct their information before it is made public.


Two bills that would permanently replace Medicare's sustainable growth rate (SGR) formula failed in the Senate on March 31 amid disagreements among Democrats and Republicans over how to pay for the measures. One of those bills was a measure supported by Senate Finance Committee Chairman Ron Wyden (D-Ore.) that would pay for the repeal of SGR by using funds that will no longer be needed for the war in Afghanistan. Wyden's motion to move the bill forward was opposed by Senate Budget Committee ranking member Jeff Sessions (R-Ala.), who said using the unneeded war funding to pay for the repeal of SGR was a "gimmick." Sessions then made a motion to pass a Republican-backed bill that would pay for the repeal of SGR by eliminating the Affordable Care Act's individual mandate. However, Wyden said he opposes that bill because it allows Congress to avoid having to deal with the problems caused by SGR. Senate Majority Leader Harry Reid said the failure of the two bills means that the effort to permanently repeal SGR is dead for now.


Five Democratic senators and one independent have proposed legislation that would modify several provisions of the Affordable Care Act (ACA). For example, the bill would require business that have 100 employees to offer their workers insurance, instead of 50 employees as the ACA currently calls for. In addition, the legislation would allow consumers to use the health insurance exchanges to purchase plans that have lower premiums and higher deductibles than what is currently being offered. Insurance products offered in one state could also be sold in another if the bill passes.


The Government Accountability Office (GAO) has issued a report criticizing the Department of Health and Human Services (HHS) for how it is implementing its strategy of promoting health information exchange (HIE). The authors of the report noted that while the strategy includes principles that will guide future actions for promoting exchanges, it does not specify what future actions will be needed to advance exchanges nor does it state how these actions should be prioritized, what goals these actions should achieve, or when these goals should be accomplished. GAO concluded that specifying actions, priorities, and milestones for the promotion of HIE is an important part of determining the progress that is being made in advancing exchange, achieving results within a certain amount of time, and ensuring the effectiveness of oversight and accountability efforts. The report called on HHS to devise and prioritize certain actions that are part of its strategy for promoting HIE and to come up with milestones for these actions that need to be achieved within a certain period of time. HHS says it agrees with these recommendations and has begun to put them into practice.


Several political scientists say that Republican lawmakers are not likely to offer any substantive proposals for replacing the Affordable Care Act any time soon. University of Minnesota political science professor Larry Jacobs says Republicans are likely to continue focusing on simply repealing the Affordable Care Act in order to turn out their base for this year's mid-term elections. DePaul University political science professor Michael Mezey agrees, saying that Republicans are not likely to make any specific healthcare reform proposals before the mid-term elections because they fear that shifting attention away from the Affordable Care Act could potentially split the party. Meanwhile, congressional Republicans have yet to make any specific proposals for how they would improve the Affordable Care Act or replace it altogether. The House Obamacare Accountability Project (HOAP) has not yet released any formal proposals for healthcare reform, while other House lawmakers are still trying to come up with ideas to make good on Majority Leader Eric Cantor's vow to take up an alternative to the Affordable Care Act sometime this year. With congressional Republicans focused primarily on repealing the Affordable Care Act, something President Obama and a number of congressional Democrats are opposed to, there is unlikely to be much in the way of substantive healthcare policymaking for some time to come, Jacobs said.

Medicine, Drugs and Devices

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A new study has found that buprenorphine transdermal patches are equally safe and effective in treating osteoarthritis pain in patients who are 75 and older and in those who are between 50 and 60 years old. The 122 osteoarthritis patients who participated in the study, all of whom had moderate to severe levels of pain, were treated with paracetamol for two weeks and then given a 12-week supply of buprenorphine transdermal patches along with paracetamol rescue. Researchers found that there was no significant difference between patients aged 75 and older and those between 50 and 60 years old in terms of the changes in Box-Scale-11 (BS-11) pain scores from baseline to final visit. Patients in both groups also displayed significant improvements in Western Ontario and McMaster Universities Arthritis Index total scores, overall levels of health, and sleep quality. In addition, both groups displayed similar reductions in the usage of paracetamol rescue and the number of times they were woken during the night because of pain. Patients over the age of 75 also tolerated buprenorphine transdermal patches at least as well as those in the younger age group. The study concluded that the amount of buprenorphine administered via transdermal patches does not need to be adjusted on the basis of a patient's age.


A new study has concluded that hyperbaric oxygen chambers can help heal certain diabetic foot ulcers with impaired cicatrization. Hyperbaric oxygen therapy was used to treat 26 foot lesions, including 13 foot ulcers with Wagner grade 2 or higher and 13 amputation stump ulcers. However, the complete treatment was performed on 23 foot lesions. The study found that complete epithelialization was achieved in 15 primary lesions, and that lesions were healed an average of 16 weeks after first undergoing hyperbaric oxygen therapy. Three limbs required amputations above the ankle, while transmetatarsal amputations were performed on another two limbs.