News From ACFAS

---

Manuscript submissions for the ACFAS 2014 Annual Scientific Conference are due August 15. If you are involved in a study that would be beneficial to the profession, be sure to submit your paper by this deadline so it can be considered for oral presentation at the Annual Conference. The Manuscript Judging Committee thoroughly reviews manuscript submissions to choose the best ones for presentation at the conference.

Take a peek into how the manuscript judging process works:

• All manuscripts submitted are “blinded,” meaning they are made anonymous.
• Manuscripts are then sent to a committee of judges and scored based on the official grading criteria published in the Call for Manuscripts (Information and Policies).
• Up to 30 papers will be selected for oral presentation at the Annual Scientific Conference in Orlando, February 27 - March 2, 2014.
• Seven of the 30 papers selected to be presented will be announced at the Honors and Awards Ceremony as winners of the ACFAS Manuscript Awards of Excellence, and will divide $10,000 in prize money from a generous grant given to ACFAS by the Podiatry Foundation of Pittsburgh.

For more information on manuscript submission or the ACFAS 2014 Annual Scientific Conference, please visit acfas.org/asc. Two weeks ago, we announced the final transition of our ACFAS Facebook Group to a Facebook Page by giving away two $50 gift cards and one $100 American Express "grand prize" gift card to three random members who make the social switch. Our first winner who “Liked” the ACFAS Facebook Page is Zach Thomas, DPM, of Beaver, PA. Congratulations and thank you for staying social with ACFAS!

Please continue to spread the word about the new ACFAS Facebook Page so your peers will have the same access to all the latest news from the College and in the Foot and Ankle Surgery profession. Also, encourage colleagues to “Like” the Page so they too have an opportunity to win the next $50 prize, which will be announced in the July 31 edition of This Week @ ACFAS. Stay tuned! If you are searching for a foot and ankle surgeon, practice manager, or staff member to add to your growing or changing practice, ACFAS’ one-of-a-kind Benefits Partner PodiatryCareers.org is the place to start your search. With many of the nation’s graduates utilizing their summer to search for a job and many fully accomplished professionals using the site as well, you have a vast pool of competent candidates from which to select. Nevertheless, now is the ideal time to post all your open positions on ACFAS’ official online career center, PodiatryCareers.org.

Visit PodiatryCareers.org today, or call (888) 884-8242 to begin your search.

Foot and Ankle Surgery

---

A recent study recommends that the oblique Weil metatarsal osteotomy should be used for treating rheumatic forefoot. Researchers analyzed the results of 216 osteotomies in 63 consecutive patients with a mean age of 59.3 years at the time of the surgery. All of these patients, who displayed long-standing rheumatoid arthritis for an average of 57.4 months, received a Weil osteotomy of the lesser metatarsals as well as at least one additional procedure of the forefoot.

Significant increases were seen in American Orthopaedic Foot and Ankle Society scores in all subgroups in terms of pain, function and alignment. All joints were dorsally dislocated before the operation, and a subluxation was seen in 13.6 percent of patients at follow-up. Researchers observed a significant decrease in callositas as well as a decrease in the need for orthopaedic shoes and MTP joint stiffness in the overwhelming majority of patients. Nearly all of the patients, 97 percent, reported relief from severe pain. In addition, 55 of the 63 patients involved in the study reported good or excellent results.


A recent study examined the effectiveness of using a modified procedure for osteochondral autologous transplantations, in which bony periosteum-covered plugs are taken from the iliac crest and transplanted into a talar osteochondral lesion. This procedure was performed on 14 patients, 13 of whom were followed clinically and radiographically for a median of 25 months.

The AOFAS hindfoot score increased in these 13 patients from 47 points before the operation to 81 points afterward, while average pain scores simultaneously decreased from 6.6 points to 1.4 points. Nine out of 11 ankles displayed radiographically good plug osteointegration. Fibrous cartilage was observed in four ankles, periosteum hypertrophy was seen in five and partial or total missing coverage of the bone was observed in three. Three revision surgeries needed to be performed.

The study concluded that this procedure could be recommended for severe and recurrent osteochondral lesions of the talus. The study also concluded that the operation could lead to the restoration of the subchondral bone stock, the formation of fibro-cartilage and stable joint function.


Researchers from the Shanghai Jiao Tong University School of Medicine in China have performed a study that examined the effectiveness of using the distally based sural flap to reconstruct soft tissue defects of the distal third of the lower leg and foot. Researchers began by dissecting 20 freshly amputated lower limbs within two hours after amputation so that they could design an island flap that was supplied by the vascular axis of the lesser saphenous vein and the lateral sural nerve. The flap was then used in clinical reparative applications in 24 cases.

Complete survival was seen in 21 out of 24 flaps, while marginal flap necrosis was observed in two patients. Distal wound dehiscence was seen in one patient. Appearance and functioning were satisfactory, with filling maintained in the heel and the lateral side of the foot. No sensory loss or venous congestion was observed in any of the patients. Researchers concluded that the distally based lesser saphenous veno-lateral sural neurocutaneous flap effectively covers soft tissue defects of various sizes on the lower third of the lower leg and foot.

Practice Management

---

Physicians practices such as Colorado Springs Internal Medicine are rushing to implement electronic health records (EHR) systems before federal funds that have been allocated to help them make the switch from paper records are gone. Dr. Jay Kinsman of Colorado Springs Internal Medicine says that he has been overwhelmed with all of the choices that need to be made in the process of implementing EHR. Among the considerations that Kinsman says he has had to make are how many different EHRs the practice needs, what kinds of computers will be used in the exam room, and whether the system will be hosted on the practice's server or in the cloud. Kinsman also says that he also has to consider the cost of purchasing and installing an EHR--which he said could be as much as $40,000 per doctor--as well as the revenue that will be lost in the first several weeks that the system is being used. However, the practice's business manager, Vicky Bonato, says that the biggest challenge associated with implementing an EHR is ensuring that staff members have positive attitudes during the installation process. "If we could all keep positive and just get through it and learn it," she said, "if we could do that I think we'll be OK."


Medical liability experts say that doctors could potentially face the threat of lawsuits if they fail to follow-up with patients or when patients fail to show up for appointments. No-shows are particularly problematic if doctors fail to inform their patients about the importance of a procedure being done during an appointment. If patients subsequently develop a serious medical condition, they can argue in court that they would have showed up for their treatment had their doctor informed them about the medical risks of not doing so.

But experts say that there are a number of steps that doctors can take to protect themselves from legal liability in such cases. For example, doctors should be sure to document efforts to follow-up with no-shows. Beth Cushing, the vice president of claims for the professional medical liability insurer CRICO, says that this will allow doctors to demonstrate in court that they made an effort to have a particular patient evaluated. Doctors should also develop a written policy for their staff members that instructs them on how to handle patients that do not show up for appointments, said Dr. Anthony Volpe, the medical director of professional liability and risk management at Medical Group of Ohio. Volpe added that designated staff members should contact no-shows and should inform doctors when patients fail to come in for their appointments.

Health Policy and Reimbursement

---

Federal health officials said July 17 that hospitals will still be required to meet stage 2 meaningful use requirements for the electronic health record (EHR) adoption program, despite concerns among lawmakers representing rural states that healthcare providers in remote areas have been slow to adopt EHRs.

Among the federal officials who spoke out against a delay was Dr. Farzad Mostashari, the national coordinator for health information technology at the Department of Health and Human Services. Mostashari said that his office has been successful in helping rural hospitals meet the stage 2 requirements, as evidenced by the fact that 1,000 critical-access hospitals are expected to achieve meaningful use this year--a milestone that Mostashari said will occur faster than expected.

But Democratic and Republican lawmakers from rural states say that healthcare providers in their jurisdictions face a number of obstacles in implementing EHR systems, including a dearth of information technology professionals who can install and maintain the technology. Some congressional Republicans have also called for a delay in the overall EHR program in order to address concerns among advanced providers that the program is moving too slowly toward interoperability and to prevent any negative effects on providers when Medicare penalties for not fully complying with the program's requirements take effect in 2015. The Centers for Medicare and Medicaid Services has pushed back against any suggestion that the implementation of the overall EHR program should be delayed.


The House Energy and Commerce Health Subcommittee approved a bill on July 23 to repeal the sustainable growth rate (SGR) formula that is used by the Medicare physician payment system. In its place would be a new fee-for-service system based on quality of care measures and new care models. Doctors would be given a 0.5 percent annual increase per year for the first five years of fee-for-service and would be eligible for an additional 1 percent increase beginning in 2019 if their performance meets certain quality standards. Providers would be required to report quality measures under the new system, though those who do not want to participate in fee-for-service can leave the system and use other ways of delivering care.


The House of Representatives voted July 17 to delay until 2015 a provision in the Affordable Care Act that requires individuals to carry health insurance. The House also voted to codify President Obama's decision to delay the implementation of the Affordable Care Act's employer mandate, which requires companies with 50 or more employees to provide full-time workers with health insurance, until 2015. The measure passed on a mostly party-line vote, with Republicans arguing that the employer mandate in particular will have a number of unintended consequences for the business sector. The legislation is essentially dead on arrival in the Senate, and it has also drawn a veto threat from President Obama.


The findings of a study by researchers at the University of Michigan suggest that the use of electronic health records (EHRs) can help slow the increase in healthcare costs. Researchers came to that conclusion after comparing the healthcare costs of 179,000 patients in Brocktown, Newburyport, and North Adams, Mass.--all of which widely adopted EHRs--with six control communities that did not. EHRs did not bring about any savings when researchers looked at measures of total cost or inpatient cost, though the technology did help reduce the cost of outpatient care by about 3 percent compared to paper record systems.


The Affordable Care Act is spurring hospitals across the country to monitor the progress their doctors make towards achieving various goals in order to improve the way they practice medicine. One hospital system that is taking part in this trend is California's MemorialCare Health System, whose flagship hospital uses a system called Crimson to monitor metrics such as complications, hospital readmissions, and measures of cost. The system also uses color-coding so that users can quickly see how a doctor is performing in comparison to his peers. Data kept by MemorialCare on its doctors is ultimately used to help determine how much money doctors will earn. In addition, hospital officials in charge of performance improvement sit down with doctors and use the data to help them find ways that they can improve.

Hospital systems are increasingly using such technology because hospital payments and penalties from Medicare are linked to their performance on rehospitalizations and other metrics under the provisions of the Affordable Care Act. Hospitals also say that the technology also helps improve the care provided to patients. But some doctors have raised concerns about the use of data collection technology, saying that it could result in non-physicians deciding what constitutes good performance. Other critics say that the data collection efforts could prompt doctors to avoid treating older and sicker patients who might make their numbers look bad.


The House Ways and Means Committee's Subcommittee on Health held a hearing on July 11 to discuss the impact of the Affordable Care Act's employer mandate, which requires companies to provide health insurance to their employees if they have more than 50 full-time staff members. Rep. Ron Kind (D-Wis.) said during the hearing that the mandate, the implementation of which has been pushed back a year, would not be burdensome for employers because providing healthcare to employees would be good for employee recruitment and retention. But Rep. Paul Ryan (R-Wis.) said that the mandate could have unintended consequences, including employers who choose to pay fines rather than provide coverage for employees because they believe that doing so makes more financial sense. Several experts also testified at the hearing and said that the mandate would encourage employers to avoid hiring low-income workers who might need subsidies and instead hire illegal immigrants would be ineligible for subsidies.


According to data released Tuesday by the Centers for Medicare and Medicaid Services (CMS), just 18 of the 32 participating health systems were able to achieve one of the major goals of the Pioneer Accountable Care Organization program: reducing costs for the Medicare patients they treat. Of the participating health systems that did save money, 13 saved so much that they split their savings--a combined total of $87.6 million last year--with Medicare. Healthcare analysts said that they were not surprised that more health systems failed to achieve savings partly because many patients being treated by these health systems are still under traditional payment contracts. Other analysts said that the program cannot be expected to meet its goals after only one year, when it was given three years to reach its objectives. CMS also reported that the Pioneer health systems were able to slow the increases in the cost of treating Medicare beneficiaries. Costs for the more than 669,000 Medicare beneficiaries treated at the participating health systems grew by just 0.3 percent last year, compared with the 0.8 percent increase in costs for typical Medicare beneficiaries.

Medicine, Drugs and Devices

---

A recent meta-analysis by researchers in the Philippines has found that moderate- to high-intensity extracorporeal shock wave therapy (ESWT) is an effective treatment for chronic plantar fasciitis. After examining the results of 11 randomized control trials that examined the use of ESWT in managing chronic plantar fasciitis, researchers concluded that ESWT was more effective in reducing pain that occurs during the morning hours. The analysis also showed that moderate-intensity ESWT was more effective in decreasing overall and activity pain. Both moderate- and high-intensity ESWT were found to be effective in improving functional outcome. However, a number of adverse effects were seen more commonly in patients who underwent ESWT, including pain on the calcaneal area as well as calcaneal erythema.


A number of healthcare industry groups are asking federal regulators to issue the final version of the unique-device identification (UDI) rule, which would require medical device manufacturers to mark their products with unique identifiers. Among the groups calling for the release of the final rule is the Advancing Patient Safety Coalition, which says that the rule will play an important part in executing patient safety improvement initiatives and in reducing medical errors.

The Food and Drug Administration, which is currently carrying out an administrative review after failing to release the final version on June 30 as promised, has called for a risk-based approach to implementing the UDI system. This approach would last seven years and would begin by requiring the identifiers to be placed on high-risk medical devices before eventually requiring the identifiers to be placed on low-risk devices. Device manufacturers, meanwhile, have said they need more time to comply with the rule and have expressed concerns that the identifiers may not benefit patients.