News From ACFAS

---

You’ve just experienced a total solar eclipse. Now get ready to hear American astronaut Captain Mark Kelly’s out-of-this-world advice for tapping into your potential at any stage of your career when he delivers the ACFAS 2018 keynote address on March 22, 2018 in Nashville.

A NASA space mission commander and member of the Commercial Crew Safety Board at Space X, Captain Kelly will explain how focus, dedication and persistence can help you overcome the obstacles standing in the way of your success in both work and life. His experiences in the Navy, in outer space and on the ground will inspire you to accomplish any mission you decide to pursue.

ACFAS 2018 will take place March 22–25 at the Gaylord Opryland Hotel in Nashville. Visit acfas.org/nashville for details and updates. As part of the College’s Take a New Look campaign, Sean T. Grambart, DPM, FACFAS, past ACFAS president, authored the article “Treating Patients with a Fracture: Engage an Expert” for The Clinical Advisor, a monthly journal sent to 94,000 nurse practitioners (NPs) and 41,000 physician assistants (PAs) in primary care.

Dr. Grambart’s article outlines which conditions NPs and PAs should look for if a patient presents with a fracture specific to the foot or ankle and when NPs and PAs should consult a foot and ankle surgeon. He also speaks to the importance of cultivating collaborative-care relationships in practice and shares examples of how he partners with NPs in cases where surgery is not required.

This article is just one of many ways Take a New Look is working to promote foot and ankle surgeons’ expertise to medical providers. Log into the ACFAS Marketing Toolbox to download referral guides, fact sheets and other resources you can use to increase referrals to your practice. Last month’s poll in This Week @ ACFAS asked readers if they actively pursue patient referrals from Diabetes Educators (DEs). The majority of respondents (60 percent) said they do not, which indicates an even greater opportunity for ACFAS to educate DEs on foot and ankle surgeons’ qualifications and expertise. Twenty percent of respondents said they actively pursue referrals from DEs, while another 20 percent said they would like more information on how to do so.

Take a New Look at Foot & Ankle Surgeons, the College’s national public relations campaign, has developed tools that ACFAS members can use to increase referrals from DEs to their practices. Visit the Increasing Referrals to Your Practice section of the ACFAS Marketing Toolbox at acfas.org/marketing to download the Take A New Look Referral PowerPoint, Partners in Diabetes Care Referral Guide, Take A New Look Fact Sheet (Diabetes Care) and other resources to illustrate to DEs how they can collaborate with you in treating patients living with diabetes.

Thank you to everyone who voted in the August poll, and watch for next month’s poll in the September 6 issue of This Week @ ACFAS. The ACFAS Fellowship Committee recently determined the following fellowships exceed the minimal requirements to be upgraded to Recognized Status with the College after their first successful year:

Penn Lower Extremity Plastic & Reconstructive Surgery Fellowship, Philadelphia
Program Director: Albert D'Angelantonio, III, DPM, FACFAS
acfas.org/fellowshipdangelantonio

CHI Franciscan Health Advanced Foot & Ankle Fellowship, Federal Way, Washington
Program Director: Byron Hutchinson, DPM, FACFAS
acfas.org/fellowshiphutchinson

The CORE Foot and Ankle Advanced Reconstruction Fellowship, Phoenix
Program Director: Ryan Scott, DPM, FACFAS
acfas.org/fellowshipscott

NOFA Foot and Ankle Reconstruction Fellowship, Concord, Ohio
Program Director: Jonathan Sharpe, DPM, FACFAS
acfas.org/fellowshipsharpe

Henry Ford Allegiance Foot and Ankle Surgery Fellowship, Jackson, Michigan
Program Director: Tudor Tien, MD, AOFAS
acfas.org/fellowshiptien

The following fellowships have been granted Conditional Status with ACFAS since the programs are new to the College and have not yet had a fellow matriculate through:

Salt Lake Orthopaedic Foot & Ankle Reconstruction Fellowship, Salt Lake City
Program Director: Gregory Anderson, DPM, FACFAS
acfas.org/fellowshipandersong

Orthopedic Center of Florida (OCF) Foot and Ankle Reconstruction and Trauma Surgery Fellowship, Fort Myers, Florida
Program Director: Andrew Belis, DPM, FACFAS
acfas.org/fellowshipbelis

FFLC Reconstructive and Limb Salvage Surgical Fellowship, Naples, Florida
Program Director: Kevin Lam, DPM, FACFAS
acfas.org/fellowshiplam

Foot & Ankle Specialists of Central Ohio Foot & Ankle Surgery Fellowship, Newark, Ohio
Program Director: Daniel Logan, DPM, FACFAS
acfas.org/fellowshiplogan

Penn Presbyterian Podiatric Research Fellowship, Philadelphia
Program Director: D. Scot Malay, DPM, FACFAS
acfas.org/fellowshipmalay

Active Orthopedics and Sports Medicine Podiatric Fellowship, Hackensack, New Jersey
Program Director: Ralph Napoli, DPM, FACFAS
acfas.org/fellowshipnapoli

Foot & Ankle Specialists of Central Ohio Foot & Ankle Surgery Fellowship, Smyrna, Georgia
Program Director: Allen Raphael, DPM, FACFAS
acfas.org/fellowshipraphael

Emory Midtown Foot & Ankle Surgical Fellowship, Atlanta
Program Director: Mohammad Sharif, DPM, FACFAS
acfas.org/fellowshipsharif

All Conditional Status programs are considered for Recognized Status with ACFAS after they have received status and the first fellow completes the program.

ACFAS highly recommends taking on a specialized fellowship for the continuation of foot and ankle surgical education after residency. If you are considering a fellowship, visit acfas.org/fellowshipinitiative to review a complete listing of programs and minimal requirements.

Foot and Ankle Surgery

---

Research was conducted to determine the intraoperative and perioperative complications observed in patients who underwent conversion of an ankle arthrodesis to a total ankle replacement (TAR). Also investigated was the durable fixation achieved in the short term and component alignment. In addition, the subsequent surgical procedures performed were studied, along with improvements in pain, tibiotalar range of motion (ROM) and quality of life. Eighteen patients with a painful ankle arthrodesis underwent conversion to TAR at a tertiary referral center between January 2007 and December 2014. Two patients sustained an intraoperative medial malleolar fracture, and delayed wound healing was observed in three patients. At latest follow-up, four patients exhibited incomplete osseointegration, and none in the cohort had prosthesis loosening. In all patients, both components were neutrally aligned. Two patients had painful arthrofibrosis with reduced ROM, which was treated with an open arthrolysis and exchange of mobile-bearing inlay. One other patient is weighing a revision for substantial tibial component medial tilt with collapse of the medial arch. At the most recent follow-up, the mean dorsiflexion and plantar flexion were about eight degrees and 15 degrees, respectively. The average visual analog scale score fell from about nine to about 1.7, and the Short Form Health Survey questionnaire physical and mental outcome scores improved from about 34 to about 74 and from about 49 to about 75.5.


A study was conducted to examine outcomes following primary total ankle replacement (TAR) in patients from the Swedish Ankle Registry using Patient Reported Outcome Measures (PROMs) and the Self-Reported Foot and Ankle Score (SEFAS). Included in the study were 241 patients registered with primary TAR between 2008 and 2016 who completed PROMs preoperatively and postoperatively up to two years. The researchers assessed changes in PROMs after surgery and estimated effects of age, diagnosis, prosthetic design and preoperative functional score on the outcomes. All absolute scores improved from preoperative to two years post surgery, 71 percent of the patients were satisfied or very satisfied at the latest follow-up and 12 percent were dissatisfied or very dissatisfied. Postoperative SEFAS correlated with age and preoperative SEFAS, along with patient satisfaction. Postoperative SEFAS and EQ-5D bore a similarity between different diagnoses or prosthetic designs. Preoperative SF-36 was associated with diagnosis, while postoperative SF-36 was associated with age and diagnosis.


A study was conducted to probe the difference of the vein course between normal and hallux valgus foot using the VeinViewer Flex and to confirm that the dorsomedial cutaneous nerve was accompanied with its vein. Included were 27 feet with hallux valgus and 27 feet in healthy subjects. The vein was projected onto the skin at the metatarsal head by the VeinViewer Flex. The distance between the vein and the midline of the metatarsal head was quantified, followed by analysis of the correlation of the distance and hallux valgus angle or 1-2 intermetatarsal angle (IMA). The vein depicted by the VeinViewer Flex and operative findings were compared in four patients during surgery. The researchers determined the vein in the hallux valgus patients shifted toward the dorsolateral side on the metatarsal bone head versus that in healthy subjects. The distance from the midline of the first metatarsal bone to the vein in the hallux valgus was substantially higher than that in healthy subjects. A significant correlation was observed between the shift of the vein course toward dorsolateral and IMA. Surgical exploration showed the vein depicted by VeinViewer Flex could be easily identified and the nerve was along with this vein in all four surgical cases.

Practice Management

---

Medical office morale can be greatly improved by celebrating successful situations or accomplishments as a group. Examples of events worth celebrating include completed chart notes, cleared billing errors and that inflow goals were met. These accomplishments can be celebrated through verbal encouragement. Experts say it is important to remain consistent when congratulating employees. This will make the idea of celebrating events a relevant office topic. An added bonus is that staff will become more productive and will communicate better as well.


A new study by the University College Cork School of Medicine in Ireland suggests many seniors may not hear everything their physicians tell them. That, in turn, could raise the risk of medical errors. Lead researcher Simon Smith comments, "In our study of 100 patients 60 and older, 43 reported mishearing a doctor or nurse in an inpatient or community healthcare setting, lending vulnerability to unintended error." Earlier research had determined that improved communication between doctors, nurses, and caregivers could prevent 36 percent of medical errors, Smith added. It is not just a matter of healthcare professionals speaking to older adults louder. In loud settings, the ability to separate speech from background noise is more intricate than volume alone. Part of the solution could be quiet rooms in hospitals and clinics where the flow of medical information between doctors and those in their care can occur in private. The report was published online August 24 in the journal JAMA Otolaryngology—Head & Neck Surgery.


Machines and devices used by medical professionals are not immune to ransomware attacks. Even the U.S. Department of Homeland Security issued a report warning the healthcare industry that it was one of the richest targets for ransomware attacks and hackers. The risk to medical machinery and devices comes from backdoor access, which is used for maintenance purposes. Hackers can exploit this access point to gain access to a larger computer network. This would allow hackers to spread harmful software across an entire system of machines, computers and devices. Experts say medical facilities can protect themselves by conducting security risk assessments regularly and mitigating any potential risks.

Health Policy and Reimbursement

---

The U.S. Centers for Medicare and Medicaid Services (CMS) is rolling out a new approach to claims review that targets fewer providers and requires the review of fewer claims than the current approach does. The new policy reduces the likelihood that physicians who follow sound billing practices will be audited. In an August 14 update on its website, CMS explained that its medical review process will target only specific providers or suppliers who have billed Medicare for particular services, rather than all of them. The agency calls this new approach Targeted Probe and Educate, which replaces the current Probe and Educate program that began in 2014 and targets all providers who bill for particular services or items. In the nationwide program, the Medicare administrative contractors who perform audits focus on providers and suppliers who, on the basis of data analyses, have the highest claim error rates or whose billing practices differ significantly from those of their peers. "Providers/suppliers with continued high error rates after three rounds of [reviews and individualized education] may be referred to CMS for additional action, which may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor or other action," according to CMS.


Colorado Gov. John Hickenlooper (D) and Ohio Gov. John Kasich (R) are working on a plan to stabilize the country's health insurance markets. Kasich and Hickenlooper said they did not want to discuss specifics of the plan until they have everything in stone. However, they have said they both agree on changing the Affordable Care Act mandate that employers with 50 or more employees provide insurance. They say that number is too low, which discourages hiring at small companies. The governors also said a national single-payer coverage is not a part of their plan. They expect to release the plan ahead of September hearings in the U.S. Senate.


Republican lawmakers returning from recess on September 5 will have only 12 legislative days to decide whether to pass a bipartisan bill intended to prop up the Affordable Care Act (ACA) markets before insurers must commit to participating in ACA exchanges in 2018. Meanwhile, a plan from U.S. Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) that would largely overturn most of the law is gaining traction among Republicans. The bipartisan plan from U.S. Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) would likely preserve billions of dollars in cost-sharing reduction subsidies for next year. Insurers have said without the payments, they likely would boost premiums or exit the ACA's individual markets. In return for guaranteeing the payments next year, any bill would likely give states more flexibility on ACA implementation. Meanwhile, Graham's plan would give states the billions of dollars spent on the ACA to create their own healthcare approaches and end the requirement that most people purchase insurance or pay a penalty.

Medicine, Drugs and Devices

---

Recent data from the International Safety Center (ISC) found an increase in sharps injuries and blood and bodily fluid exposure has not spurred many healthcare workers to wear personal protective equipment (PPE). Analysis of 2015 surveillance data from hospitals participating voluntarily in ISC's Exposure Prevention Information Network determined fewer than seven percent of workers exposed to blood and bodily fluid splashes used eye protection, although about 66 percent of the workers' eyes were splashed. Furthermore, 48.7 percent of workers who reported sharps injuries and 68.6 percent of those exposed to fluids said they think those exposures were preventable, versus about 30 percent for both groups in 2014. ISC released a consensus statement and call to action to boost awareness and urgency in addressing the lack of PPE use. ISC estimated that about 70 percent of fluid splashes were tainted with blood, yet only 17 percent of healthcare workers wore protective gowns, while more than 40 percent wore regular clothes or nonprotective scrubs. More than 80 percent of exposures involved unprotected skin.


More than seven in 10 Americans still consider drug prices unreasonable, and generic competition may not change their minds. Government forecasts show that the amount Americans pay for drugs is set to rise at some of the highest rates ever seen. The rollout of costly hepatitis C and oncology treatments in 2014 and 2015 are widely viewed as spurring public backlash against drug pricing, along with price hikes for daraprim and the EpiPen injection. Prescription drugs have a reputation for being costly because they're “one of the touchpoints of the healthcare system,” notes the Kaiser Family Foundation's Bianca DiJulio. “At some point you will need to take a prescription drug. It's one of the places where people see the prices.” U.S. government health analysts project that in 2016-2018, out-of-pocket spending will increase just three percent annually versus the seven percent elevation in all prescription drug spending and six percent climb for private health insurance. They also forecast a reversion of that rate to five percent from 2019 to 2025.


California lawmakers, wielding greater support than ever before, have proposed five new measures to rein in pharmaceutical costs as they enter their final month of the legislative year, forcing the drug industry to combat multiple threats. A price disclosure bill, SB 17, would require health plans to report to the state the 25 drugs that are most frequently prescribed, most expensive and with the highest year-to-year increase in spending. The measure would also require drugmakers to notify health plans and other purchasers 60 days in advance of a planned price increase, if the hike exceeds certain thresholds. A second bill, AB 265, would limit when manufacturers could offer rebates or discounts for brand-name drugs when generic alternatives are available. A third measure, AB 315, would require pharmacy benefit managers to register with the state and disclose upon the purchaser's request information about their dealings with drug manufacturers. Other measures would place new restrictions on gifts from manufacturers to doctors and require state agencies to meet regularly to identify ways to address rising drug costs.