News From ACFAS

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ACFAS President-Elect Michelle L. Butterworth, DPM, FACFAS, represented ACFAS at the Coalition for Patients’ Rights (CPR) meeting with American Medical Association (AMA) Chair of the Board of Trustees Ardis Hoven, MD; Chief Executive Officer Michael Maves, MD; and key legal and state government affairs staff. AMA invited CPR to a dialogue on May 10, and the discussion centered on ways to work together in the area of healthcare teams. Members of the coalition were invited to share current information about the training, education and certification of their membership. ACFAS looks forward to continuing this dialogue to benefit patients.
Educational resources are at your fingertips any time at ACFAS e-Learning. Refresh your knowledge with the latest additions:

• Scientific Session Video: Complex Cases
  This video is designed to help you refine skills in evaluating patients with musculoskeletal deformities and injuries, predicting potential complications and formulating a treatment plan.
• Podcast: Integrating Scholarly Programs into Residency Training
  “Early integration of scholarly activity into residency training,” says podcast moderator Paul J. Kim, DPM, FACFAS, “is vitally important in equipping future practicing foot and ankle surgeons with the skills and knowledge to appropriately treat patients.”

ACFAS members can earn continuing education contact hours at no cost with selected materials on the website. Visit often to browse the online library of videos, podcasts and DVDs at acfas.org/elearning.

ACFAS’ April survey on your educational needs has concluded successfully, with more than 700 responses received. This gives the survey a 95% confidence rating and 3-point margin of error. The results will be the basis of CME planning for the ACFAS Board of Directors and all education-related committees, beginning in 2012.

Three survey respondents were winners of $100 American Express gift cards:

• Ralph S. Dixon, DPM, FACFAS
• Eric M. Hart, DPM, AACFAS
• John T. Sanders, DPM, FACFAS

Look for more information on the survey results in future issues of This Week @ ACFAS.

ACFAS looks to you to learn how to improve our educational programming. Thank you to everyone who participated!

Legal Briefs

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The Kentucky Supreme Court has ruled that a patient claiming the care she received after a colonoscopy procedure was negligent must present expert testimony concerning the applicable standard of care and causation. In Jones v. Gaes, Ky., the state high court said a lower court erred in allowing the plaintiff to use a res ipsa loquitur negligence theory that allows a jury to conclude conduct was obviously negligent or to infer negligence in circumstances where a given outcome could not occur in the absence of negligence.

Foot and Ankle Surgery

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Researchers explored the difference in callus progression between tibial lengthenings with and without intramedullary nail. Seventy tibiae in 38 patients with a mean age of 24 years were lengthened with Ilizarov external fixator and nail, while 56 tibiae in 40 patients with a mean age of 28.6 years were lengthened with the same fixator but without nail; callus progression was compared with reference to pixel value ratio (PVR) and Ru Li's classification. No statistically PVR trend was observed in posterior, lateral, and medial aspects of the callus between the two groups, but an averagely lower trend in the anterior aspect in the group without nail was recorded. The researchers concluded that the callus experienced a more positive progression with nail, and that even longer lengthening could be permitted.



Researchers compared the amount of lengthening and strength of the tendon after Achilles tendon lengthening via either helical cutting method or z-plasty. Forty Achilles tendons were harvested from freshly slaughtered calves, 30 of which were cut along a helical axis located at the tendon centerline, with helical angles of 60°, 45°, and 30°; these tendons either were left unsutured or were sutured with mattress stitches along the cut lines. To provide a performance benchmark, five of the forty tendons were lengthened with use of z-plasty, while the other five tendons were left untreated to serve as a general point of reference. Standard z-plasty yielded a mean length increase (and standard deviation) to 172% ± 10% of the original length, with a mean tensile strength of 70 ± 15 N. Helical cutting resulted in a wide range of lengths and strengths, depending on the helical angle. A maximal length increase (279% ± 80% of the original length) was achieved with a cut angle of 30°, with an associated load to failure of 30 ± 7.6 N. In tendons cut helically with an angle of 60°, a length of 212% ± 29% was achieved, with a corresponding load to failure of 222 ± 62 N.



Researchers evaluated the ability of miniplate fixation in navicular fractures to restore medial column stability and maintain reduction. A retrospective chart review was performed on 24 patients with navicular fractures treated with open reduction and internal fixation with minifragment plate fixation. All fractures united. No patient developed a deep infection, and there was no loss of reduction. Isolated broken screws were evident in three patients (12.5%), with no plate breakage, and no implant failure by pullout. Four patients (17%) underwent plate removal for painful prominent hardware following fracture healing. Four patients (17%) developed radiographic arthrosis of the talonavicular joint. One patient (4%) had radiographic avascular collapse evident at six months and was treated with plate removal and an orthotic device.

Practice Management

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Starting in 2012, more than 4 million Medicare fee-for-service beneficiaries are expected to receive medical care through accountable care organizations (ACOs). Consequently, physicians and hospitals are now aligning themselves to provide the coordinated care that could eventually entitle them to federal financial incentives. However, a paper from the actuarial and consulting firm Milliman suggests that becoming an integrated delivery system, partnering with a health plan, and focusing on the Medicare Advantage market may actually make more sense.



There was a slight increase in physician turnover last year, while higher turnover rates were observed in smaller medical practices, according to the 2010 Physician Retention Survey published April 16 by Cejka Search and the American Medical Group Association. Cejka President Lori Schutte says small practices need to boost their competitiveness, while experts note that factors underlying the higher turnover at small practices include more flexible work schedules at large hospitals and health systems. Between 2005 and 2010, the percentage of female physicians who worked part-time increased from 29 percent to 38 percent, while the percentage of part-time male doctors rose from 7 percent to 13 percent. In addition to younger doctors putting lifestyle first, hospitals and large healthcare systems are hiring more physicians.

Health Policy and Reimbursement

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Physicians could soon be using an e-patient consent system if the Office of the National Coordinator for Health Information Technology (ONC) succeeds in its plans. ONC is currently looking for a vendor to conduct market research to identify patient concerns while they design an e-consent pilot to improve patient trust. The vendor is being asked to partner with medical facilities that are exchanging health information electronically, develop a way to secure patient participation, identify key pieces of information relating to the exchange of health information and patient choice, and analyze consumer understanding of patient consent to share their health information. ONC believes developing an electronic patient consent system will inspire patient trust as medical records are increasingly computerized and electronically shared between healthcare professionals. ONC has made several policy statements on patient privacy, security, and the control of medical records. "The benefits of health IT can only be realized if individuals are fully involved in the development of health IT policy and confident that electronic health information is kept private and secure," states The Federal Health Information Technology Strategic Plan 2011-2015. The vendor awarded the contract will have to devise a way to get patients involved in the development, use, and evaluation of the e-consent system, and find innovative ways to inform people of their individual choices in a clinical setting. ONC will also require the contractor to explore ways of electronically obtaining and recording meaningful and informed choices made by individuals in a clinical setting, and find a way to analyze patient satisfaction.



A final rule to streamline credentialing processes for physicians and other telemedicine services providers has been issued by the Centers for Medicare and Medicaid Services (CMS) to encourage small and critical access hospitals to participate in telemedicine programs that larger hospitals offer. Such facilities have been previously mandated by CMS to accord practice privileges—after individualized consideration of qualifications—to the participating physicians supplying the consultations from distant hospitals. The final rule stipulates that the facility receiving the telemedicine services "may rely upon" information supplied by the consulting hospital when making privileging decisions for physicians offering the consultations.



The Society of Hospital Medicine (SHM) has issued a position statement on hospitalist credentialing and medical staff privileges. "It is reasonable to anticipate that hospitalists will increasingly be required to develop skills and competencies beyond those gained in their original training," writes SHM. "Hospital Medicine groups and hospital medical staffs should jointly determine the point at which it may be appropriate to develop a separate medical staff credentialing category and privileging criteria for hospitalists, because the skill set required of hospitalists in that institution no longer fits within an existing credentialing category." SHM lists eight principles that organizations should address regarding hospitalists.

Medicine, Drugs and Devices

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The U.S. Court of Appeals for the District of Columbia Circuit has ruled that federal government financing of human embryonic stem cell research can continue. The ruling blocks a lower-court decision last August that ruled such research is illegal under a law that bans public spending on research in which human embryos are damaged or destroyed. That decision shocked government scientists, who said it would force the cancellation of dozens of experiments on an array of diseases, from diabetes to Parkinson’s.



Researchers have developed a borate glass nanofiber material that appears to have helped the final healing long-term wounds in eight out of 12 venous stasis wound sufferers in a recent clinical trial. All of the participants had diabetes and several of them had wounds that had been unhealed for more than a year. Details about the trials and the glass fiber material were published in the May issue of the American Ceramic Society's Bulletin magazine.



Comparative-effectiveness data was available for only about 50 percent of new drugs approved by the FDA during the past decade, according to study published in the May 4 issue of the Journal of the American Medical Association. Of 197 drug products approved by the FDA between 2000 and 2010, only 100 had comparative-effectiveness data. The American Recovery and Reinvestment Act of 2009 allocated $1.1 billion to boost comparative-effectiveness research efforts.