News From ACFAS

---

Last month’s poll in This Week @ ACFAS asked if readers plan to change their prescribing habits given the opioid abuse epidemic. Fifty-eight percent of respondents said they would, while 33 percent said they would not and 8 percent said they have not thought about it. With more than half planning to change how and when they prescribe opioids to patients, it will be worth watching how this shift could help improve patient health.

Thank you to everyone who voted in this latest poll! Be sure to take today’s poll at right to let us know about your plans for retirement and visit acfas.org for up-to-the-minute results. Would you walk away from $40,000 in possible funding for your latest research project? Submit your application for the 2016 ACFAS Clinical and Scientific Research Grant by September 15, and you could earn a portion of that money for your research.

Each year, the College provides funding to help set members' research in motion and to close knowledge gaps in the field of foot and ankle surgery.

Visit acfas.org/grant to apply before time runs out. Send any questions regarding criteria, research topics or the application process to research@acfas.org. Download the latest edition of FootNotes from acfas.org/marketing and give your patients proven and practical tips to keep their feet in top shape this fall.

Customize this free patient education newsletter with your office’s contact information then post it on your practice website and social media channels. You can also print FootNotes and distribute copies to your patients.

Articles in the fall issue include:

• Make the Switch from Sandals to Shoes Safely
• Regular Foot Exams Help Keep Diabetic Feet Healthy
• Wear the Right Shoe to Avoid Achilles Tendon Injuries

For maximum impact, supplement this issue with the free PowerPoint presentation Dos and Don’ts for Diabetic Foot Care, to raise awareness of National Diabetes Month in November. Visit the ACFAS Marketing Toolbox often for new products designed to both educate your patients and promote your practice. Register now for the year's last Coding and Practice Management Workshop, October 21–22 in Chicago, and learn how to get reimbursed for the care you provide. You'll code real-time patient scenarios and gain new strategies for streamlining your coding and reimbursement process.

Expert faculty will explain how to code for:

• multiple-procedure cases when performing forefoot, rearfoot or ankle reconstructive surgery
• open reduction and internal fixation of multiple fractures
• complex arthroscopy cases
• diabetic foot surgery

You'll also receive helpful handouts and customized checklists and forms, specially created for this workshop. Only a few spots remain, so
sign up now at acfas.org/practicemanagement.

Foot and Ankle Surgery

---

Evidence-based strategies are needed to prevent the progression of dysglycemia in patients with newly diagnosed type 2 diabetes. A secondary analysis of the Early Diabetes Intervention Program (EDIP) was conducted to evaluate the physiology of progression and the features that were protected from progression during EDIP. Researchers administered either acarbose or a placebo to 219 overweight individuals with fasting glucose of <7.8 mmol/L and two-hour OGTT glucose >11.1 mmol/L. Patients were assessed during quarterly visits for glycemia, lifestyle management and intervention adherence for up to five years. Delays in progression were associated with reductions in weight, fasting glucose, two-hour OGTT glucose and increases in HDL/TG ratio. Acarbose treatment did not explain these changes.


A study was conducted to clarify the roles of the peroneal and anterior tibial arteries in regards to the vascular anatomy of the lateral supramalleolar flap (LSMF). The anatomic relationships between the cutaneous branches of LSMF and the peroneal and anterior tibial arteries were analyzed in 28 perfused fresh cadaver legs. In 20 limbs, the main cutaneous branch of the flap arose from the anastomosis of the collateral inferolateral branch of the anterior tibial artery and the perforating branch of the peroneal artery around the inferior tibiofibular angle. In eight limbs, the collateral inferolateral branch was absent or very small. The anastomosis of the descending branch of the peroneal artery and anterior lateral malleolar artery was always found around the tibiotalar joint. In addition to the peroneal artery, the LSMF may receive blood from the anterior tibial artery through the collateral inferolateral branch.


Evidence for the usefulness of silicone gel sheeting in scar healing is limited, so a new study examines the efficacy of silicone sheeting on scars from a bilateral hallux valgus surgery. The silicone gel sheeting was applied to a hallux valgus incision scar on one foot for 12 weeks upon removal of the stitches. A symmetrical scar from the other foot was left untreated. At weeks four and 12, the experimental group scored significantly better on the Vancouver Scar Scale compared with the control group in all items, except scar length. Adverse effects were significantly lower in the experimental group than in the control group at week 12.

Practice Management

---

Reducing patient wait times can increase care quality, improve the patient experience and maximize reimbursement under value-based payment models. Practice managers can decrease wait times at every step of the healthcare process by analyzing scheduling data and working with physicians and staff to make small, gradual changes. First, managers should partner with a physician leader to drive change in the practice and set an example for their clinical colleagues. Practices should then analyze the average wait time for the third available appointment, as the wait time for the first available appointment is not a reliable metric due to frequent cancellations and no-shows. Practice managers can look for blocks of unused overbooking time to address scheduling inefficiencies. If providers are not working at full capacity, hours of direct patient care can be added gradually. To shorten lines at the front desk, benefits verifications and any other authorizations should be completed before each appointment. Cutting back on overbooked slots for new patients can also reduce wait time, allowing practices to focus on serving existing patients. Lastly, practices should consider moving telephones and one or two employees to a separate office area so front desk staff can greet and check in patients quickly and without interruptions.


The Electronic Health Records Incentive Program is due to begin its third iteration in 2018, but preparation for the Stage Three Meaningful Use requirements could prove challenging for many providers. Stage Three aims to facilitate the secure and efficient movement of health information, and the U.S. Centers for Medicare and Medicaid Services have outlined three health information exchange (HIE) requirements, including provider-to-provider exchange, provider-to-patient exchange and provider-to-public health agency exchange. Achieving the HIE measures will require providers to possess certified health IT systems that can transfer and receive data from other systems. Providers will also be responsible for communicating the capabilities of application programming interfaces to patients. Under the new patient engagement requirements, providers must use certified electronic health record technology (CEHRT) to engage 5 percent of patients or caregivers in 2017 and 10 percent in 2018. Meaningful users will be required to respond to 5 percent of secure patient messages by 2017 and 25 percent of messages by 2018. Providers might also struggle with meeting clinical quality measure (CQM) requirements. According to a study conducted by the American Hospital Association and the Federation of American Hospitals, 37 percent of hospitals have a considerable amount of work to do before they will be ready to report CQMs. Inadequate or newly implemented EHRs are a primary concern for CQM reporting.


Patients who are engaged participants in their care tend to live healthier lives and experience better outcomes, but only 10 percent of healthcare organizations are successfully fostering patient engagement, according to a study by KLAS. Patient education must be a priority, and physicians should guide patients and their families to credible resources for information and support. An open and honest dialogue gives physicians a way to gauge patient comprehension and encourage patients to take greater initiative in their health. Physicians should provide patients with the tools and resources that will help them to manage their conditions, practice preventative care and communicate with others living with the same conditions. Lastly, every patient interaction should be seen as an opportunity to adjust treatment and communication plans and learn how to better engage with that patient.

Health Policy and Reimbursement

---

The Agency for Healthcare Research and Quality has released online resources intended to expand the agency’s guidelines for communicating adverse events to patients and their families. Hospitals are often reluctant to share the specifics of medical errors for fear of malpractice lawsuits, but there has been a culture shift toward openness and honesty in conversations with patients. Maryland and Washington, DC health provider MedStar Health has been implementing a standardized approach for communication between physicians and patients and their families since 2012. Physicians complete an initial training program and booster courses every six to eight months to help prepare them for difficult conversations. During these training sessions, doctors and professional actors participate in role-playing exercises to simulate patient scenarios and learn about the importance of honesty and empathy. “Instead of shutting down conversations with patients, we want to respond to them immediately, we want to share everything we can with them,” says David Mayer, vice president of quality and safety for MedStar. “Many times when they get their questions answered in an open and honest way, they realize a lawsuit wasn’t really necessary.”


The U.S. Centers for Medicare and Medicaid Services (CMS) has proposed a series of changes that could correct some of the Affordable Care Act’s problems, as the public exchanges have been hurt in recent weeks by exits from major insurers. Two of the biggest issues for the exchanges have been a lack of young, healthy people to offset costs and a bigger pool of sicker, high-cost patients. CMS has offered 14 suggestions that would make it less risky for insurers to handle sick patients, including a proposal to use fees from the marketplace for outreach to encourage more young people to sign up. Enrollment rules could be strengthened to ensure that people do not wait until they are sick to get coverage, and insurers could be granted more flexibility in their bronze plan offerings to reduce cost burdens. CMS also recommends insurers take prescription drug use into account when evaluating patient risk profiles. Overall, the proposed changes attempt to make the marketplace more economically sound and encourage higher enrollment. The proposal is open for comments until October 6.


The U.S. Centers for Medicare and Medicaid Services (CMS) plans to replace health insurance identifiers for 150 Medicare recipients by the end of 2019. As part of the 2015 Medicare Access and CHIP Reauthorization Act, CMS has four years to issue IDs that do not bear the Social Security numbers of beneficiaries and will instead consist of randomly generated alphabetical and numeric characters. The provision is intended to make seniors less vulnerable to identity theft. The conversion will require updating hundreds of thousands of private sector computers handling healthcare claims, including systems in hospitals, private practices, claims clearinghouses and billing companies. All organizations that process Medicare claims must have their IT systems modified by April 2018 as CMS rolls out the new identifiers to nearly 60 million active Medicare beneficiaries and updates 90 million records of deceased beneficiaries. Both old and new ID numbers will be used during a transition period ending in December 2019.

Medicine, Drugs and Devices

---

A study published in JAMA Internal Medicine of 2013 insurance claims from about 1.5 million adults with commercial insurance determined slightly fewer than 8 percent received "low-value services," defined as providing little value to patients, given all the costs and other options. The researchers found those services can include hormone tests for thyroid problems, x-rays or magnetic resonance imaging scans for lower-back pain and brain scans for simple headaches. The costs for 28 low-value medical services comprised 0.5 percent of total spending, but amounted to $32.8 million of spending in 2013 alone. Scans for headaches totaled $3.6 million and imaging for low-back pain $3.1 million. An earlier study estimated that more than $750 billion of the total $2.5 trillion spent yearly on U.S. healthcare represents waste. The researchers also discovered low-value spending was less among patients who were older, male, black or Asian, lower-income or enrolled in high-deductible health plans.


The U.S. Food and Drug Administration (FDA) and the medical device industry have reached an agreement on the guidelines for user fees medtech companies pay to have the agency review their products. According to the 4^th version of the Medical Device User Fee & Modernization Act, FDA would be able to collect nearly $1 billion in user fees for five years, beginning in October 2017. Lobbying organizations say the agreement is the first to include metrics intended to shorten review times, increased interaction with FDA during the review period and analyze how FDA manages the approval process.


In an effort to reduce the risk of future fractures among individuals with a fragility fracture, researchers examined prescription drug patterns before and after a fracture. The retrospective cohort study used a 40 percent random sample of Medicare beneficiaries from 2007–2011, including more than 168,000 community-dwelling Medicare beneficiaries who survived a fracture of the hip, shoulder or wrist. For the four-month period before and after a fragility fracture, the researchers looked at prescription fills for drug classes associated with increased fracture risk using Part D community pharmacy claims. These were divided into three groups: drugs that increase fall risk, drugs that decrease bone density and drugs with unclear fracture risk mechanism. The data show that approximately three-quarters of the patients were exposed to at least one non-opiate drug associated with increased fracture risk in the four months before fracture. While about 7 percent of these patients discontinued this drug exposure after the injury, this was offset by new patients initiating high-risk drugs after a fracture. As a result, the proportion of the cohort that was exposed following fracture remained about the same. The researchers also noted that use of drugs that increase bone density was 25 percent or lower both before and after fracture. Based on the findings, the authors suggest that "some secondary fragility fractures may be preventable through a more concerted effort to manage high-risk drugs around a primary fracture event."