News From ACFAS

A new revision of the Diagnosis and Treatment of Heel Pain Clinical Practice Guideline has been published as a supplement to the May/June issue of the Journal of Foot & Ankle Surgery.

“Since the publication of the first heel pain guideline in 2001, the body of knowledge regarding the etiology and treatment options has grown substantially,” says lead author James L. Thomas, DPM, FACFAS. “It is now recognized that multiple factors, including nerve entrapment, may be implicated in what may previously have been considered solely a mechanical condition.”

The journal and CPG supplement are on their way to you in the mail, but you can read them now online when you log in at the ACFAS website.

Visit ACFAS e-Learning whenever you’re looking for reliable information on the diagnosis and treatment of foot and ankle conditions. New this month are:

• Podcast: Early vs. Late Metaductus Treatment — Surgeons discuss approaches for evaluation and treatment of metatarsus adductus, as well as the relative value of earlier treatment.
• Scientific Session: Ankle Arthritis — A videotaped exploration of the challenges and potential interventions for this condition, including diastasis, osteotomy, visco supplementation, arthrodesis, and total ankle replacement.

Check back often for new additions to ACFAS e-Learning!

Come to Chicago May 14–15, 2010, and position your practice for success with the knowledge you’ll gain at the ACFAS Coding and Practice Management Seminar.

You’ll get return on your investment with understanding of CPT changes for 2010, refreshed E & M coding and correct coding for prompt reimbursement.

Walk away with what you need to know so your practice will thrive! To find out more and to register, visit the ACFAS web site or call 800-421-2237.

Foot and Ankle Surgery

High Resolution Cutaneous Ultrasonography Differentiates Lipoedema From Lymphoedema

Researchers sought to demonstrate that high-resolution ultrasound imaging of the skin is able to differentiate lipoedema from lymphoedema. Sixteen patients with lymphoedema (22 legs), 8 patients with lipoedema (16 legs), and 8 controls (16 legs) were included. Patients with lipolymphoedema were excluded. Ultrasound examinations were carried out with a real-time high resolution ultrasound device on three different sites for each lower limb. A significant difference in dermal thickness was observed between lymphoedema and lipoedema patients and lymphoedema patients and controls. No significant difference in dermal thickness was shown between lipoedema and controls at the thigh or ankle. Dermal hypoechogenicity was evidenced on at least one of the three sites in all of lymphoedema patients, 12.5 percent of lipoedema patients, and 6.25 percent of controls. Hypoechogenicity affected the entire dermis in all cases of lymphoedema except one. In cases of lipoedema and controls, hypoechogenicity was only localized at the ankle and prevailed in the upper dermis. The researchers concluded that high-resolution cutaneous ultrasonography makes it possible to differentiate lymphoedema from lipoedema.



Radiographic Predictability of Cartilage Damage in Medial Ankle Osteoarthritis

Radiographic grading has been used to assess and select between treatment options for ankle osteoarthritis. To use radiographic grading systems in clinical practice and scientific studies one must have reliable systems that predict the fate of the cartilage. For this study, researchers analyzed whether radiographic grading of ankle osteoarthritis is reliable and whether grading reflects cartilage damage observed during arthroscopy. The researchers examined 74 ankles with medial osteoarthritis and 24 with normal articular cartilage based on arthroscopy. Arthroscopic findings were graded according to the modified Outerbridge grades and all radiographs were graded using the modified Kellgren-Lawrence, Takakura et al., and van Dijk et al. grading systems. The interobserver weighted kappa ranged from 0.58 to 0.89 and the intraobserver weighted kappa from 0.51 to 0.85. The correlation coefficients for the Kellgren-Lawrence, Takakura et al., and van Dijk et al. grades were 0.53, 0.42, and 0.42, respectively. Ankles with medial joint space narrowing (Stage 2 of Takakura et al. and van Dijk et al. grades) showed varying severity of cartilage damage. The positive predictive value of cartilage damage increased from 77 percent for medial joint space narrowing regardless of the presence of talar tilting to 98 percent for medial joint space narrowing with talar tilting. The researchers concluded that the inclusion of talar tilting in grading schemes enhances the assessment of cartilage damage.



Roadmap for HAI Prevention Research: Bench to Bedside and Back

The CDC, in collaboration with the Society for Healthcare Epidemiology of America, the Association for Professionals in Infection Control and Epidemiology, the Infectious Diseases Society of America, and Medscape, is offering the "Roadmap for HAI Prevention Research: Bench to Bedside and Back," which includes a roundtable discussion with four infection prevention experts aimed at improving clinical decision making among clinicians caring for patients in acute care and extended care settings by highlighting hospital-acquired infection prevention measures with a solid evidence base. The activity was taped at the SHEA Fifth Decennial International Conference on Healthcare-Associated Infections 2010, held in Atlanta, Georgia, March 18-22. The transcript of the roundtable discussion— moderated by Robert A. Weinstein, MD, professor of medicine at Rush University Medical Center and Interim Chairman of the Department of Medicine at the Stroger Hospital of Cook County in Illinois—can be accessed here. The video can be accessed here.

Practice Management

Form and Function: Designing an Office Space That Works

Medical practitioners should try to experience their office they same way patients do. Enter into the waiting room, sit down for a bit, walk the halls, and view the exam rooms, front desk, and business office. Try to determine how easy it is to find the tools, equipment, and information that patients and staff may need to find on a daily basis. It is possible that you will discover several things that should be changed, which is the first step toward redesigning your office. Cosmetic elements of a medical office can make a positive impression on patients and quickly put them at ease during a stressful time. Fortunately, an office can be designed to be aesthetically pleasing while enabling optimal patient and clinical workflow. "Our nurses' station is core central," says family physician Susan S. Wilder, MD. "It's right in the middle. It's wide open. There's a lot of space and a lot of ability for doctors and medical assistants to communicate between patients. Doctors will be out there with their computers, so you can accomplish a lot in a short period of time." Divide the station up to handle different types of patients, like urgent patients and routine patients, so paperwork can be located and handed off quickly. Identify bottlenecks around the office, both physical choke-points and places where work slows down, and find ways of improving the flow through these areas. Exam rooms are far more efficient if each one has the same layout. Locating equipment in the same place means physicians can move automatically instead of having to search and struggle with equipment in different places.



Patient Experience Should Be Part of Meaningful-Use Criteria

Researchers suggest that "meaningful use" measures for electronic health records (EHRs) do not go far enough in measuring healthcare quality and should integrate patient experiences. These patient experiences should be measured in how timely care was, whether needs were met, and whether communications with the provider were satisfactory. Moreover, the researchers note that payment policies should be revised to include patient-physician communications outside of office visits, which many believe will be the wave of the future with the help of EHRs. About 90 percent of patients surveyed indicated a desire to communicate electronically with doctors, and nearly 50 percent wanted Internet-accessible medical records. A recent study involving the adoption of EHRs at Group Health Cooperative in Washington State and Idaho revealed that if EHRs are not executed appropriately, patient-provider relations will suffer and have an impact on care quality.



Preventing Missed Appointments With Specialists

Researchers at the Indiana University School of Medicine and the Regenstrief Institute tracked nearly 7,000 primary-care patients age 65 or older at an Indianapolis geriatric clinic who were referred to a specialist, discovering that only 71 percent were ever scheduled for a needed follow-up appointment. Of those, 70 percent were actually seen at the specialist's office, meaning that just 50 percent received the treatment that their primary care doctor intended them to have. Because of the high percentage, researchers called missed specialist referrals the most frequent error in medicine. As a result of this and similar research, some practices are rethinking the way they handle referrals, using low-tech methods such as reminder calls as well as the latest technologies, including computer-based scheduling systems that generate automated reminders if specialist scheduling does not happen in a timely manner.

Health Policy and Reimbursement

Study Shows 'Invisible' Burden of Family Doctors

A study published in the New England Journal of Medicine details the uncompensated work burden on family doctors and points to the need to change how they are paid. The study tracked all the tasks done in a five-physician practice over a year. In the practice in Philadelphia covered by the study, each full-time doctor had an average of 18 patient visits a day. But each doctor also made an average of 24 telephone calls a day to patients, specialists, and others. And every day, each doctor wrote 12 drug prescriptions, read 20 laboratory reports, examined 14 consultation reports from specialists, reviewed 11 X-ray and other imaging reports, and wrote and sent 17 e-mail messages interpreting test results, consulting with other doctors, or advising patients.

The study, medical experts say, suggests that doctors should be compensated for work other than patient visits, including preventive care and helping patients manage chronic illnesses. The new health care legislation includes Medicare payments for preventive health and programs intended to encourage family doctors to assist patients in improving their overall health. Meanwhile, last year’s economic stimulus package included $19 billion in financial incentives for doctors and hospitals to accelerate the adoption of electronic health records, which expert say can help coordinate and improve care.

The Philadelphia practice made the transition to electronic health records in 2004, according to the study. The practice is part of a pilot project that compensates doctors for preventive and disease-management work, not just office visits. That program, begun in 2008, is sponsored by large insurers in the area and some local providers of Medicaid services. The program has increased the practice's revenue by approximately 15 percent annually.



Healthcare Providers Experiment With Lump-Sum Pricing

In a pilot program beginning in August, several of California's best-known healthcare providers—including Cedars-Sinai Medical Center, the UCLA Health System, and Hoag Memorial Hospital Presbyterian in Newport Beach—will begin charging lump-sum fees for hip and knee replacements. The federal government already is testing similar "bundled" payments for its Medicare program in Colorado, Texas, New Mexico and Oklahoma, and the new healthcare law calls for exploring additional arrangements for surgical services for the elderly and the poor. Advocates believe that greater cooperation among healthcare providers, which the programs are designed to encourage, will ultimately slow the rise of spending and drive down insurance premiums.



CMS Aims to Make it Easier for Docs to Collect Incentives

The Centers for Medicare and Medicaid Services (CMS) is expanding its current Medicare provider enrollment system to make it easier for physicians to register to receive meaningful use incentives. The agency has awarded a contract to CGI Federal Inc. to develop the necessary additional functions for the Provider Enrollment Chain Ownership System (PECOS), which manages the enrollment of providers and suppliers in the Medicare program. Physicians and hospitals must confirm that they have met the requirements for meaningful use of electronic health records for 90 days to qualify for the incentives that will be available in 2011. A CMS spokesman says "(CGI's) work is in the context of CMS' proposed rule and interfaces with a variety of provisions." The modification of the PECOS system will take about 10 months.



CMS Seeks to End Remittance Advice Confusion

CMS' Transmittal 659 addresses the issue of reporting of recoupment for overpayment on the remittance advice. The issue and confusion surrounding remittance advice involved the inability to track RAC recoupments back to prior claims electronically. "When RACs had made a denial and were entitled to recoup money, they would recoup it off of a future payment, but this amount was not tied back into a particular claim," explains Kimberly Anderwood Hoy, director of Medicare and compliance for HCPro. "So it was difficult for providers to take that amount and offset it against a prior claim to keep their records correct." Now, when a recoupment demand is made, the system will initially assign a control number at the claim level for the claim being recouped. This control number is later used on the RA when the money is actually offset from the provider's payment. This should allow electronic posting of recoupments to individual claims through the use of the control number.

Technology and Device Trends

FDA Planning More Regulation of Drug-Infusion Pump

The FDA has announced plans to tighten its rules on drug-infusion pumps. The FDA said it has received 56,000 reports of problems in the last five years, and more than 500 deaths have been associated with the devices. The years 2004 to 2009 saw 87 infusion-pump recalls, 14 of which were for potentially life-threatening problems. One frequent problem is "key bounce," which occurs when a number entered into a keypad is record as being hit more than once, which could cause the device to release too much medication. Draft guidelines would require additional testing of the pumps before they are marketed. The FDA has asked for more information on software used with the pumps and also plans to conduct plant inspections before new pumps are approved. The FDA will hold a public meeting next month before it moves to make its proposals final.



ESWT May Provide More Relief of Chronic Plantar Heel Pain Than Placebo Treatment

Extracorporeal shock wave therapy (ESWT) safely and effectively reduced recalcitrant chronic plantar heel pain, according to the findings of a multicenter, randomized, placebo-controlled trial, the results of which were presented at 2010 Annual Meeting of American Academy of Orthopaedic Surgeons in New Orleans. For the study, researchers randomized 250 patients with chronic plantar heel pain that failed conservative treatment and had a Visual Analog Scale (VAS) score of greater than 5 to either an active or control group. The active group received 0.25 mJ/mm2 of ESWT at 4 Hz frequency, which investigators focused on the site of the heel pain. The control group underwent a sham treatment where the ESWT device was used identically, but was de-activated. At 3 months, baseline composite VAS scores of 8.3 decreased to 2.7 points after ESWT in the active group and decreased to 5.3 points in the control group. In the ESWT group, VAS scores further decreased at 12 months to 0.8 points. Differences between baseline and follow-up secondary outcomes also favored the active group. No major adverse events occurred related to ESWT treatment.



Targeting Stents With Local Delivery of Paclitaxel-loaded Magnetic Nanoparticles Using Uniform Fields

A group of researchers employed uniform magnetic fields to propel iron-bearing nanoparticles to metal stents in injured blood vessels to deliver drugs that successfully prevent blockages in an animal study. There is a great unfulfilled need for metal stents among patients with chronic peripheral artery disease, according to study leader Robert J. Levy, MD, at the Children's Hospital of Philadelphia. For instance, he notes that drug-eluting stents have had "disappointing results" in diabetes patients characterized by poor circulation because leg arteries are bigger than coronary arteries and insufficient drug doses are included in the stent coating. "Our technique offers opportunities for a novel approach in which we can vary doses and repeat the treatments," says Levy.



Abstract News © Copyright 2010 INFORMATION, INC.

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