News From ACFAS

---

You've graduated but the learning doesn't stop there. Take advantage of the next step in your career development by joining ACFAS -- for free! The ACFAS Regional Divisions is proud to support first-year podiatric surgical residents with a complimentary first-year membership in the College. This offer provides the benefits of membership with dues waived for one year. That's a direct value of $118, plus additional savings through member pricing on conferences, products and services.

Kick-start your career with ACFAS! The College connects residents to a community of your peers — the best and brightest foot and ankle surgeons in the country. You will have access to the College’s premiere website, acfas.org, and a subscription to the prestigious online Journal of Foot & Ankle Surgery (JFAS) — a must-have to increase your knowledge of the latest surgical techniques and research.

Applications for membership are available through the ACFAS website; joining now will provide an additional three months of membership, through September 2015 — and put JFAS at your fingertips that much sooner!

Once again, congratulations to the Class of 2014. The ACFAS Regional Divisions look forward to welcoming you to the College. Visit the Journal of Foot & Ankle Surgery's online home page at acfas.org/jfas and click “Read Current and Past Issues Online,” then "Articles in Press" to get a leg up on the latest research in your profession. New articles are available as soon as their proofs have been approved — even before they're assigned to an issue.

Enjoy tomorrow’s news today, including original research, case reports, tips, quips and pearls. It's quick and easy with your free member access!

Foot and Ankle Surgery

---

A recent study examined the outcomes of 17 patients who experienced failed total ankle replacement (TAR) and subsequently underwent tibiotalar or tibiotalocalcaneal arthrodesis an average of 49.8 months later. The study found that both types of arthrodesis were effective salvage procedures following failed TAR. Of the 17 ankles that surgeons examined, 13 were considered to be radiographically healed an average of 3.7 months after the first arthrodesis. A subsequent arthrodesis resulted in radiographic healing after an average of three months. The study also noted that the median post-operative American Orthopaedic Foot and Ankle Society (AOFAS) score was 74.5, while the average Meary angle of the hindfoot was 5 degrees of valgus. Finally, the study noted that large cancellous allografts were a good alternative to preserve the length of patients' legs and to compensate for the large bone defects that existed following the removal of the prosthesis.


A recent study by orthopaedic surgeons in China sought to answer the question of whether to perform open reduction and internal fixation (ORIF) of closed type C pilon fractures promptly after injury or to delay surgery until soft tissue swelling subsides. The 46 closed type C pilon fracture patients who were examined were divided into two groups: one group that underwent ORIF within 36 hours of injury and another that was surgically treated 10 days to three weeks following their fractures. Nine of the patients in the second group were first treated with temporary external fixation. Patients in the first group had a significantly shorter mean time to fracture union, operating time, and hospital stay than did patients in the second group. Both groups displayed similar rates of soft tissue complication, rate of fracture union, and final functional scores. The study concluded that performing ORIF on patients with closed type C pilon fractures soon after injury can be both safe and effective if patients' soft tissue conditions permit surgery.

Practice Management

---

Physicians' practices should take steps to ensure that staff morale is good, as having unhappy employees can negatively impact the care and service a practice provides to its patients, writes practice management expert Bob Levoy. According to Levoy, employees who are not happy with their jobs and/or the people they work for do not perform as well as and are not as interested in their work as satisfied staff members. Such sub-par performance and lack of interest can result in problems such as carelessness and rudeness to patients, which can in turn make patients less satisfied with the practice and damage the reputation of physicians, Levoy says. Levoy notes that there are a number of steps doctors' practices can take to keep their employees happy, including giving them the flexibility to take care of personal matters such as caring for children or sick family members. Employees also appreciate it when doctors afford them with opportunities to advance their careers, such as attending coding seminars and achieving certain certifications, Levoy says. Doing so carries the added bonus of bringing in higher reimbursements for the practice. Levoy also offers a number of situations that hurt employee morale and should be avoided if at all possible, such as telling staffers that they will not be getting raises, giving employees a workload that they cannot realistically handle, and yelling at staffers in front of patients.


The recent scandal at the Veterans Affairs (VA) Healthcare System, in which some patients waited as long as a year for an appointment while employees tried to conceal the long wait times by using secret waiting lists, offers a number of important lessons for physicians' practices, writes OmniMD CEO Divan Dave. For instance, the scandal has highlighted the importance of health information exchange, Dave says. He notes that health information exchange technology such as an integrated cloud-based system should allow practice staff members to view patient charts, lab results, and information about medications from anywhere while also allowing them to collaborate closely with physicians without any significant wait time. Dave also notes that the VA scandal underscores importance of regular, automated communications with patients about appointments, medications, and treatment regimens. Doctors should not simply wait until a patient's next appointment to discuss these issues, Dave says. Finally, Dave notes that the problems at the VA show that physicians' practices must monitor electronic health records systems for problems such as irregular usage and incomplete documentation and hold those responsible accountable.

Health Policy and Reimbursement

---

Fort Wayne, Ind.-based Parkview Health System will pay $800,000 to end a federal investigation into whether it violated the Health Insurance Portability and Accountability Act (HIPAA) by putting patient information at risk of theft. The probe by the Department of Health and Human Services' Office of Civil Rights was prompted by an incident on June 9, 2009, in which Parkview employees dropped of 71 boxes containing the medical records of between 5,000 and 8,000 patients in the driveway of a physician's home and left them in full view of the public even though he was not home. The doctor in question had given the medical records to Parkview because the hospital system wanted to purchase a share of his practice and move some of his patients to other providers. OCR says that because the physician was not home at the time the boxes were dropped off, the records were unattended and thus accessible to unauthorized individuals. In addition to the penalties, Parkview will also be required to take steps to address the problems in its HIPAA compliance program.


A new analysis from PricewaterhouseCoopers' (PwC) Health Research Institute has found that the continued efforts by hospitals to purchase physician groups, coupled with the ongoing economic recovery and the increased numbers of consumers with health insurance, will help push up healthcare spending by 6.8 percent next year. The absorption of physician groups by hospitals is spurring an increase in healthcare spending because the trend has allowed a growing number of doctors to charge insurers hospital facility fees even when a procedure is not performed in a hospital. However, PwC's analysis found that health insurers are closely watching an effort by Highmark that would prevent doctors from charging such fees. The company expects to reduce claims by $200 million annually by no longer reimbursing doctors at hospital-based rates for outpatient cancer treatments. The analysis also found that there are a number of factors that are helping to keep a lid on rising healthcare spending, including the growth in the number of employers offering employees high-deductible plans. The number of employees enrolled in high-deductible plans has increased by more than 200 percent over the past six years, and is likely to increase further as a large number of employers that do not currently offer such plans are considering doing so. The growing use of private health insurance exchanges, which tend to offer employees a greater selection of insurance policies, is also helping to hold the line on healthcare spending, PwC found.


The Department of Health and Human Services' Office of the National Coordinator (ONC) for Health Information Technology is considering changing the way it enforces the electronic health records (EHR) incentive payment program's Stage 1 criteria. That criteria currently includes a number of clinical quality measures providers must meet in order to achieve meaningful use and obtain incentive payments from the federal government. Those requirements have been criticized by both healthcare providers and EHR system developers who say they are making it difficult for them to improve quality of care and other IT systems. ONC is now considering a different approach that will include giving healthcare providers credit for developing their own quality-improvement programs, says ONC Deputy National Coordinator and Chief Medical Officer Dr. Jacob Reider. Such a shift could help reduce the disruption to provider workflows caused by data collection and reporting for the clinical quality measures. However, it remains unclear how ONC will bring about this change, Reider says. He notes that ONC is soliciting input from relevant parties about how they measure quality improvement apart from federal programs.


The Department of Health and Human Services (HHS) is still planning to allow hospitals that participate in the 340B federal drug discount program to receive discounted orphan drugs used for non-orphan diseases or conditions. The effort to move forward with the plan comes after a federal court ruled last month that HHS did not have the authority to allow these hospitals to receive such discounts. However, the Obama administration does not believe that the court's ruling meant that HHS could not allow hospitals to receive discounts for orphan drugs even when they are used for non-orphan conditions. The administration has also said that it plans to appeal the ruling or issue guidance that would replace the rule that allows HHS to provide the disputed discounts. Drugmakers would also be required to continue to provide the discounts, the Obama administration says. Meanwhile, hospitals that participate in the 340B program should work with drug manufacturers to resolve any issues they have before the third quarter begins on July 1, a spokesman for the agency that administers the 340B program says. The spokesman also notes that manufacturers that do not comply could be required to provide refunds to covered hospital entities or have agreements terminated.


Congress' Medicare Payment Advisory Committee has released a report that proposed a number of policy changes that would help ensure that healthcare providers are reimbursed fairly. The first of those recommendations calls for standardizing payment rules and incentives across Medicare's fee-for-service (FFS), Medicare Advantage (MA) and accountable care organization (ACO) payment models. The report also outlines three approaches for improving Medicare's risk adjustment. Payment rates for Medicare Advantage plans are currently based on a basic rate plus a demographic rate that takes a patient's health costs into consideration, though the report noted that these payment rates can result in providers being over or under paid. However, each of the three alternatives that were outlined in the report also contain flaws that might make it difficult to reimburse providers in a more appropriate manner. A third recommendation calls for using population-wide outcome measures in place of or along side the process measures that are currently used to provide payment incentives to providers using one of the three payment models. But the report noted that such a step might be better for making payment adjustments within the MA and ACO models than it would be for adjusting FFS payments.

Medicine, Drugs and Devices

---

Sivextro, an antibiotic drug intended to treat acute skin and soft tissue infections caused by various methicillin-resistant strains of bacteria, was approved by the Food and Drug Administration (FDA) on June 20. The drug, which is produced by Cubist Pharmaceuticals, is intended to be administered in the hospital intravenously for roughly two days and is subsequently administered in the form of a once-daily pill that can be taken at home after patients are released from the hospital. The approval of Sivextro comes about a month after the FDA approved Dalvance, another antibiotic that is also used to treat acute skin infections. Both have been designated as qualified infectious disease products (QIDPs), which is used to denote anti-bacterial and anti-fungal drugs that are used to treat serious or potentially fatal infections.


A recent study examined the use of compression stockings in facilitating the recovery from an ankle sprain, in an effort to help resolve the debate over what type of care for this injury is appropriate. The group of 117 ankle sprain patients were roughly equally divided into two groups: one that was treated with class II compression stockings and another that was treated with placebo Jersey stockings. The study found that the class II compression stockings generally did not provide a benefit in speeding the recovery from an ankle sprain. The use of the class II compression stockings did not result in a significant decrease in median time to normal painless walking. No significant differences were seen between the two groups in terms of pain, analgesic consumption, and bimalleloar and midfoot circumferences. However, the class II compression stockings did allow patients who regularly participated in sports to resume their athletic activities sooner than did the placebo stockings.


Two new studies have found that diabetics are at a higher long-term risk of fracture and are more likely to experience adverse events and death after a fracture than non-diabetics. The diabetics who participated in the study had a fracture rate of 24.2 fractures per 1,000 person-years, compared to 17.1 fractures per 1,000 person-years among non-diabetics. The studies also found that diabetics had an adjusted fracture hazard ratio of 1.66 compared to individuals without diabetes. In addition, diabetics were more likely to suffer from deep-wound infection, septicemia, death, and other adverse events after a fracture compared to their non-diabetic counterparts, the studies found. An increase in mortality was also observed in patients whose diabetes was poorly controlled, individuals with Type 1 diabetes, and those suffering from diabetic complications. Researchers believe that the association between diabetes and fracture may be the result of a variety of health problems that diabetics suffer from, including lower levels of bone mineral density, increased cognitive dysfunction, and eye problems such as cataracts and retinopathy. However, no definitive explanation was given for the relationship between diabetes and higher rates of fractures. The studies concluded that more research on strategies for reducing fracture risk and post-fracture adverse outcomes in diabetics is needed.


Two studies presented at the European League Against Rheumatism Annual Congress on June 11 suggest that there is a relationship between diet and disease activity in patients with rheumatoid arthritis (RA) and osteoarthritis (OA). The first of those studies found that consuming monounsaturated fatty acids as part of a Mediterranean diet is an independent predictor of remission in RA patients. The patients in this study were considered to have active disease or be in remission after their Disease Activity Score 28 - Erythrocyte Sedimentation Rate (DAS28-ESR) was assessed. The second study found that the accumulation of low-density lipoprotein cholesterol (LDL-C) increased synovial thickening and ectopic bone formation in an experimental animal model of OA. In addition, cholesterol levels that were too high resulted in increased cartilage damage in the OA model, the study found. The results of the studies suggest that it is important to address the consumption of monunsaturated fatty acids and cholesterol in RA and OA patients, respectively.