News From ACFAS

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The ACFAS Board of Directors has adopted a new position statement urging DPMs and their patients to use guidance related to complementary and alternative medicine (CAM). The statement explains that ACFAS recognizes that there are different types of practitioners and proponents of various forms of alternative and conventional medicine. But, as the statement also makes clear, foot and ankle surgeons must base their treatment pathways on science, evidence, and published data on safe and effective treatment of foot and ankle conditions.

For these reasons, the College recommends that podiatric foot and ankle patients considering using CAM therapy consult with their physicians, and utilize the information resources available through the National Center for Complementary and Alternative Medicine (NCCAM), a center of the National Institutes for Health, at nccam.nih.gov.

The full position statement is available at acfas.org/positions.
In 2002, ACFAS assembled a task force to develop a set of clinical tools: four anatomically based scoring scales to measure subjective and objective parameters connected to foot and ankle surgery. Last year, a second task force was assembled to perform the first review and validation of these ACFAS Scoring Scales.

"Our efforts have resulted in a full validation of the original scales," reports task force chair Thomas A. Roukis, DPM, PhD, FACFAS. "The scales were developed with a systematic and comprehensive approach, and the statistical methods and instrument development process were appropriately conducted."

"I was fortunate," continues Roukis, "to work with task force members Adam S. Landsman, DPM, PhD, FACFAS; Barry I. Rosenblum, DPM, FACFAS; Emily A. Cook, DPM, MPH, AACFAS and Jeremy J. Cook, DPM, MPH, AACFAS. Collectively we spent over 150 hours gathering, reviewing, discussing and analyzing the data. Thanks are also due the ACFAS Board of Directors and in particular the current president, Glenn M. Weinraub, DPM, FACFAS, for creating this task force."

The resulting article will publish in the July/August issue of the Journal of Foot & Ankle Surgery — but you can read it online today! Just visit acfas.org/jfas, click on "Read current and past issues online" and log in with your ACFAS member ID. When you reach the JFAS home page, click on "Articles in Press" to read this article and many more.
View and print your 2011 Annual Scientific Conference attendance certificate and CME hours quickly and conveniently on the ACFAS website! But please do it soon, because after May 15, 2011, no changes can be made online. For questions about the online CME records, contact the ACFAS Education Department at 800-421-2237.

Conference attendees can also download the session handouts online. Just log in at handouts web page with your member or attendee number to get even more from your participation in this educational event.
The Centers for Medicare and Medicaid Services recently held a webinar with the professional coder association and a hot topic was, “What is GEMs?” GEM stands for General Equivalence Mappings, and they act mainly as a crosswalk of ICD-9 and ICD-10 codes. You can look up an ICD-9 code and be provided with the most appropriate ICD-10 matches and vice versa. More information is available on the CMS website.

Presentation materials, including a list of questions and answers, and a recording and transcript of the event, will be posted to the CMS ICD-10 website soon. CMS encourages you to check this website often for the latest news and resources to help you prepare!

Foot and Ankle Surgery

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A comparison was made between the efficacy of ankle foot orthoses and Denis Browne boots and bar in the prevention of idiopathic clubfoot recurrence following successful initial management. Forty-five children with idiopathic clubfeet achieved full correction following Ponseti casting with or without a tenotomy between 2001 and 2003, 17 of whom were braced with an ankle foot orthosis, while 28 were prescribed Denis Browne boots and bars. The mean follow-up was 60 months in the ankle foot orthosis group and 47 months in the group with boots and bars. Recurrence was observed in 25 of 30 of the ankle foot orthosis group and 12 of 39 of the group with boots and bars, and additional treatment included repeat tenotomy, limited posterior release with or without tendon transfers, posteromedial releases, and midfoot osteotomies. Following initial correction via the Ponseti technique, patients managed with boots and bars had far fewer recurrences than those managed with ankle foot orthoses.



Researchers evaluated the mid-term results of a series of patients arthroscopically treated by autologous chondrocyte implantation (ACI) and investigated the nature of the repair tissue by MRI T2 mapping. Twenty patients with an osteochondral lesion of the talus underwent ACI and were evaluated at 5 ± 1 years’ follow-up clinically (AOFAS score) and by the MRI T2-mapping sequence. Healthy volunteers were enrolled, and their T2 map values were used as a control. The AOFAS score increased from 59 ± 16 pre-operatively to 84 ± 18 at follow-up. Patients with more than 4 years’ follow-up were found to have the most satisfactory results. On the basis of the controls, healthy hyaline cartilage tissue showed a T2 map value of 35–45 ms. A mean T2 map value compatible with normal hyaline cartilage was found in all the cases treated, covering a mean percentage of 69% ± 22 of the repaired lesion area.



Researchers determined through a Phase I study of 29 subjects that autologous bone marrow mononuclear cell (ABMNC) therapy is safe and effective in promoting amputation-free survival (AFS) in critical limb ischemia patients. Patients were treated with an average dose of 1.7 ± 0.7 × 109 ABMNC injected intramuscularly in the index limb distal to the anterior tibial tuberosity. The primary safety end point was accumulation of serious adverse events, and the primary efficacy end point was AFS at one year. Secondary end points at 12 weeks posttreatment were changes in first toe pressure (FTP), toe-brachial index (TBI), and ankle-brachial index (ABI). AFS at 12 months was 86.3 percent. There was a significant increase in FTP (10.2 ± 6.2 mm Hg; P = .02) and TBI (0.10 ± 0.05;P = .02) and a trend in improvement in ABI (0.08 ± 0.04; P = .73).

Practice Management

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If physicians' practice management systems are not up to new standards as of January 1, 2012, they will risk not receiving electronic payments from private insurers and Medicare. Despite that risk, many physicians have not started checking to see if they are compliant with HIPAA Version 5010 standards. A survey of 349 practices with 13,290 doctors by the Medical Group Management Association says that 56 percent of practices have not scheduled any internal testing to 5010, and 61 percent have not scheduled any testing with their major health plans. The new data standards require additional specificity in what data must be entered and transmitted. The hope is that the claims process will be more efficient, and there will be less of a need to refile claims due to errors and confusion. For example, physicians will have to submit a nine-digit, instead of a five-digit, ZIP code on all claim submissions, and provide a street address instead of a post office box. Additionally, 5010 allows physicians to differentiate between principal diagnosis, admitting diagnosis, external cause of injury, and patient reason for visit codes.



Five national healthcare organizations have issued an updated how-to guide for healthcare professionals transitioning from paper to e-prescribing systems. The 2011 edition of A Clinician's Guide to Electronic Prescribing is a collaborative effort by the American Medical Association, the American Academy of Family Physicians, the American College of Physicians, the Medical Group Management Association, e-Health Initiative, and The Center for Improving Medication Management. The guide can be found here.



The rise in electronic medical records is creating new job opportunities in the medical field. The new electronic record-keeping systems, intended to improve efficiency and quality, are slowing down some emergency medicine physicians so much that they are hiring young people to input data for them. These new workers are being called "medical scribes." The largest medical scribe company, ScribeAmerica, now has 800 employees in 21 states, up from 350-400 in 10 states in 2009. Other medical scribe companies have experienced similar growth. Medical professionals nearly universally agree that electronic records are an improvement, and result in more detailed and legible records that are easier to share and use for population research. In May, the federal government will start offering $27 billion in incentives over the next few years for hospitals and physicians who implement electronic health record systems, and after 2015 the Medicare program will penalize providers who do not use electronic records.

Health Policy and Reimbursement

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The Massachusetts House has voted to repeal a 2008 law that bans pharmaceutical companies from giving gifts to doctors. Those opposed to the ban feel that the business generated by events hosted by pharmaceutical companies for physicians is essential to the state economy. Those supporting the ban believe that the drug industry passes the cost of these events on to the consumer. “The only thing that’s being hurt is the ability of the drug industry to market their high-priced drugs by wining and dining doctors at our expense,” says research director at the consumer group Health Care for All Brian Rosman. The Senate blocked the House’s attempt to appeal the ban last year and will vote on its own budget proposal next month.



None of the many outpatient surgical facilities in Iowa is licensed, and few are subjected to state inspections. Rising infection rates from surgical centers are a source of concern for federal officials. There are an unknown number of ambulatory surgical centers in Iowa that are not in the Medicare system, and they are not tracked or monitored by the federal government—nor are they tracked by the state because Iowa is one of just seven states that does not mandate that they be licensed. The national Ambulatory Surgical Center Association says that for the past five years, it has been calling on the federal government to set up a uniform quality disclosure system that would allow the centers to publicly demonstrate their performance on specific quality measures. Many of Iowa's outpatient surgical centers are inspected by private accrediting groups that are paid by the centers themselves, but the inspector general at the U.S. Department of Health and Human Services has long called the value of such inspections into question, alleging that the inspections concentrate more on education than on adherence to minimum standards of care.

Medicine, Drugs and Devices

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Researchers have developed a tool for identifying orthopedic prostheses that are becoming loose after total joint replacement surgery. Loosening is often initiated by breakdown of the prosthetic materials that generates wear debris composed of particles of the prostheses that are released into the tissues surrounding the prosthetic implants. The particles are inflammatory, and they accumulate between the bone and the prosthesis. The local inflammation destroys the bone and the prosthesis becomes loose. The study shows that a nanocarrier used to deliver chemotherapeutic agents to cancer cells can also be used to identify patients who are at risk for failure and potentially deliver drugs to stop this process. Nanocarriers tagged with a near infrared fluorescent marker injected into the bloodstream of mice gravitated toward inflammatory cells. Autopsies of the mice verified this finding. Investigators then showed that the nanocarrier system could deliver dexamethasone, an anti-inflammatory drug, directly to the site of inflammation where it effectively inhibited inflammation and prevented osteolysis. The research was published online in the journal Molecular Pharmaceutics.



Several Supreme Court justices strongly suggested during oral arguments in Sorrell v. IMS that Vermont’s attempt to restrict the use of drug prescription records for marketing purposes violates corporate free-speech rights. Vermont’s law is aimed at companies that buy prescription records from pharmacies and sell them. The most lucrative sales are to drug companies, which use the information to target doctors to try to persuade them to order drugs other than the ones they are currently prescribing. Vermont Assistant Attorney General Bridget C. Asay argued that the state’s interest is to “allow doctors to decide whether this information that they’re compelled to provide to pharmacies may be used in marketing that is directed at them.” The federal government and 35 states are siding with Vermont in the fight, which has split lower federal courts.



Savatri Cole had surgery for a broken ankle and ended up losing her foot because of a bone infection. She and her husband believe she got the infection in the medical center where she had the surgery. The surgeon and the hospital contend that the infection occurred because she ripped open surgical wounds by walking on the foot too soon. The Coles tried to sue the hospital, but they said lawyers refused to take the case because of the front-end cost of hiring a doctor as a medical expert. Their chances of finding a lawyer would have been better had they tried to sue before 2008, when Tennessee started requiring a “certificate of good faith” from medical experts that a malpractice suit has merit. Their chances will likely get even worse, however, if a proposed bill to impose caps on damages becomes law.



Researchers have assessed the evolutionary path of quality improvement in U.S. healthcare, and propose a scheme that hospitals and other organizations can follow to migrate toward high reliability. They recommend that healthcare organizations start with a self-evaluation that grades their organizational readiness in terms of leadership, safety culture, and the capacity of perform robust process improvement. Possibly the most common approach individual organizations that want to progress toward high reliability have taken involves training their personnel to employ robust process tools and techniques and then to apply those tools to various organizational processes, including financial and other business processes. Adoption costs can be remunerated by using these methods to enhance revenue-producing activities.