News From ACFAS

The Patient Protection and Affordable Care Act, along with other economic forces, will significantly change the way hospitals and physicians work with one another. To help measure that change, Modern Healthcare, in partnership with Press Ganey of South Bend, Ind., is conducting an industry-wide survey. The 2010 Hospital-Physician Relations Survey will examine the state of relations between hospitals and their employed physicians and how those relations may change.

The survey is now available to all readers at the Modern Healthcare website. The participation deadline is Sept. 20.

Modern Healthcare and Press Ganey will report findings in the Nov. 8 issues of Modern Healthcare and Modern Physician. For more information, please visit ModernHealthcare.com.

Any surgical procedure carries with it the possibility of complications. “Complication — Rearfoot,” the latest free podcast at ACFAS eLearning, lets you hear how experienced surgeons deal with common problems in rearfoot reconstructive surgery.

Panelists share pearls on complications they’ve actually encountered, and how they’ve modified procedures, techniques, materials and post-operative care to avoid them.

Visit ACFAS eLearning whenever you are ready to download the new podcast or browse the entire educational archive.

Share essential foot and ankle health information with your patients and market your practice with FOOTNOTES, the free patient education newsletter exclusively for ACFAS members.

The Fall 2010 issue helps patients learn how to:

• Avoid running-related stress fractures of the foot
• Make a successful seasonal switch from sandals to shoes
• Care for feet in the holiday season, especially for diabetes

You can personalize FOOTNOTES by adding your practice information on the back. Place it in your waiting room, send it out with your billing, distribute it at community health fairs or post it on your practice’s website. Log in at the ACFAS website to download it today.

Foot and Ankle Surgery

Does the Pirani Score Predict Relapse in Clubfoot?

Researchers performed a retrospective clinical audit of clubfoot patients to assess the value of the Pirani clubfoot scoring system at initial presentation in the estimation of subsequent relapse, and all clubfoot patients treated by the same surgeon from 2002 to 2006 were included. Sixty-one clubfoot patients were treated and 80 clubfeet were included, with 17 relapses occurring. The average period between the initiation of foot abduction splint and relapse was 23 months; the average total Pirani score (TPS) was 3.5 in the zero relapse group and 5.0 in the relapse group, while the average midfoot contracture score (MFCS) was 1.5 in the zero relapse group and 2.0 in the relapse group. The average hindfoot contracture score (HFCS) was 2.0 in the zero relapse group and 3.0 in the relapse group, and higher TPS and HFCS were statistically significant when analysis was conducted between the relapse group and the zero relapse group. An association was drawn between the higher Pirani scores and late relapse group, with TPS and HFCS determined to be statistically significant predictors of potential relapse.



Extensor Hallucis Longus Transfer as an Alternative to Split Transfer of the Tibialis Anterior Tendon to Correct Equinovarus Foot in Hemiplegic Patien

Researchers evaluated whether transfer of the extensor hallucis longus is a credible alternative treatment to split transfer of the tibialis anterior tendon in adult hemiplegic patients without overactivity of the tibialis anterior. One group of 15 patients exhibited overactivity of tibialis anterior in the swing phase and underwent the split transfer, while a second group of 14 patients had no overactivity of tibialis anterior and underwent transfer of extensor hallucis longus. Lengthening of the tendo Achillis and tenotomies of the toe flexors was observed in all patients, and all were assessed clinically and by three-dimensional gait analysis pre- and at 12 months following surgery. At this point both groups exhibited substantially improved walking in terms of gait speed, stride length, and paretic propulsion; dorsiflexion in the swing phase, the step length of the healthy limb, and the step width improved in both groups, but only achieved statistical significance in the patients with transfer of the extensor hallucis longus. The researchers determined that when coupled with lengthening of the tendo Achillis, transfer of the extensor hallucis longus can be a valid alternative to split transfer of the tibialis anterior tendon to correct equinovarus foot deformity in patients without overactivity of tibialis anterior.



Joint Fusion for Hallux Rigidus and Hallux Valgus Improved Function

Dutch researchers have determined that fusion of the first metatarsophalangeal joint for hallux rigidus and hallux valgus improves foot function in a study of 62 consecutive patients who underwent crossed screw fusion of the first metatarsophalangeal joint without concomitant surgery of the same or contralateral foot from 2002 to 2005. Twenty-seven patients exhibited hallux rigidus while 35 patients exhibited hallux valgus. Hallux valgus and dorsiflexion angles were measured on standing radiographs preoperatively and at follow-up; the postoperative median hallux valgus angle was 14 degrees while the median dorsiflexion angle was 23 degrees. The median Dutch Foot Function Index score improved from 38 preoperatively to 8 postoperatively, while scores were identical for the hallux valgus and hallux rigidus groups. The researchers observed that "there was no significant correlation between foot function and hallux position. This could be due to the fact that the desired position of the hallux was most often achieved."

Practice Management

Physician Visits Down 7% in July

Total patient visits to physician offices were down 7.3 percent in July 2010 compared to July 2009—the fourth consecutive month of negative growth in physician visits, according to researchers with the North American offices of Deutsche Bank Securities. The downward trend could cause major outpatient service provider chains to continue to be "constrained" into the third quarter, with a possible continued downward slide if the trend continues. Physician office visits tend to be an important leading indicator for elective outpatient surgery volumes as well, noted the researchers. Ambulatory surgical centers may be impacted with not only soft demand but over-capacity to create a "very difficult fundamental environment" over the near-term, they said.



Physicians Use Photos From Patients' Cellphones to Deliver 'Mobile Health'

In May, Neal Sikka, an emergency physician at George Washington University (GWU), began a six-month study examining how accurately emergency doctors and physician assistants at GWU Hospital could diagnose wounds from patient-generated cellphone images. According to Sikka, it is the largest "mobile health" study looking at acute wound care.

Mobile health goes further than traditional forms of telemedicine, eliminating the need for scheduling conference rooms and reserving equipment, says Sikka. It could especially benefit patients living in isolated areas and those who do not want to spend the time, money and energy waiting for evaluation of a superficial injury.



Why Physicians Should Get to Know Google

Google claims that 86 percent of doctors say they now regularly use the Internet on the job. A 2006 study published in the British Medical Journal had physicians read the histories of 26 tough cases published in the New England Journal of Medicine and attempt to make a diagnosis by entering search terms into Google. The physicians in the study arrived at the right diagnosis 58 percent of the time.

Search engine algorithms, which are not made public, may be part of the reason for the difficulty. Google's "advanced search" feature can shrink the size of a search, as can using quotation marks for exact phrases and excluding words by putting a minus sign in front of them. Gaining expertise in Internet searching, especially in a world in which medical knowledge exponentially outpaces anyone's ability to know it all, is a valuable skill set for doctors to gain.

Health Policy and Reimbursement

Growth Slows in Health Spending

Healthcare spending in 2010 has grown at its slowest rate in a half-century, a sign that people are forgoing medical care, USA TODAY analysis of government data finds. Spending on doctors, hospitals, drugs and other medical care climbed at a 2.7 percent annual rate per person in the first half of 2010, the smallest increase since the Bureau of Economic Analysis began tracking medical care in 1959.

The recession has shifted some people from private insurance to government programs, says healthcare economist Robert Brook of the Heritage Foundation. This may have cut overall spending because the government generally pays lower rates than private insurers.



Medicaid EMR Guidelines Spell Out State Help for Doctors

CMS has published details for state Medicaid directors on what they should expect from the federal government as they administer the Medicaid portion of the electronic medical records (EMR) incentive program starting in 2011. The incentive program stipulates that the federal government will pay the full cost of Medicaid bonuses to eligible physicians who adopt certified EMR technology in a way that meets the government's "meaningful use" criteria. It also will pay 90 percent of states' eligible administrative expenses.

According to the new CMS guidance, states must satisfy at least three basic requirements to receive the federal funding: administer Medicaid bonuses to eligible physicians and hospitals, routinely track meaningful use reports and conduct other oversight activities, and pursue initiatives that encourage EMR adoption to promote healthcare quality.



New Tax Rule Targets Salaries of Health Insurance Executives

A provision of the federal healthcare reform law imposes limits on how much insurance companies can deduct executive compensation from their taxes -- limits similar to what the government put on financial institutions that accepted Troubled Asset Relief Program (TARP) funds. The new threshold of $500,000 for deductions related to executive compensation at health insurers will raise $651 million in the next decade for Medicare, according to lawmakers. Experts say the measure will push insurance companies to re-examine and possibly restructure their executive compensation programs.

Technology and Device Trends

Bone-Fusion Protein Raises Questions About Doctors' Financial Stakes

In 2002, Food and Drug Administration advisers met to discuss a biological agent that could essentially turn whatever it touched to bone, which could be fantastic if it could be confined to tiny spaces between vertebrae, but calamitous if it leaked out. An FDA advisor at the meeting raised a concern about nine of the doctors whose research on the product had been submitted to the FDA. The doctors in question had a financial stake in the product, and their test results were nearly twice as good as results from doctors with no financial interest. The concern of the FDA advisor was dismissed, and the panel deferred the issue to Medtronic, a company that could gain billions in sales as the maker of the product, known as Infuse.

Since recombinant bone morphogenetic protein-2, the biological agent used in Infuse, was approved for fusion surgery, there has been widespread concern about unapproved use and adverse reaction in patients. Studies warn that it can cause life-threatening swelling in the neck, form bone in unwanted locations, and possibly even drive cancer cell growth or cause adverse immune system reactions.

The usage trend of Infuse is familiar. Buzz in the medical community is generated by a potential new therapy. Then research, often by doctors with a financial interest in the product, is presented to the FDA for a specific use on a small group of people. Once approved, doctors start receiving promotional material on other uses, presented by the manufacturing company and financially invested doctors. "The information that comes from the manufacturers and people who are very vested in the product succeeding often dominates the literature," says Dartmouth Medical School professor of orthopedics Sohail Mirza. "That does taint the information. There is a conflict there."



FDA Approves Surgical Instrument Tracking Tool

The FDA has approved a radio-frequency identification (RFID) tool that tracks instruments and sponges during surgical procedures. Developed by Maumelle, AR-based Haldor Advanced Technologies, the system uses RFID to help surgical teams reduce the number of items left in patients during operations and is designed to ease counting procedures that are prone to human error. More than a third of all retained surgical items are instruments (52 percent radiopaque sponges and 43 percent instruments), according to a 2007 study in the Journal of Surgical Research. The need to correct such errors adds about $2 billion each year to U.S. healthcare costs.



Protective Effect of P188 in the Model of Acute Trauma to Human Ankle Cartilage: The Mechanism of Action

Researchers conducted a study into the mechanism of P188 poloxamer's action in promoting cell survival in acute trauma models, with a focus on glycogen synthase kinase-3 (GSK3) activation, interleukin-6, and p38 signaling. The study involved impacting 16 normal human tali using a 4-mm diameter indenter with an impulse of 1 Ns; removing and culturing 8-mm cartilage plugs containing the 4-mm impacted core and 4-mm adjacent nonimpacted ring with or without P188; analyzing cell lysates using Western blots with antibodies against total and phosphorylated extracellular signal-regulated protein kinase, c-Jun NH(2)-terminal kinase, p38, ATF-2, GSK3, Stat1, and Stat3; and executing additional tests with the p38 inhibitor SB203580. The results of the study indicate a unique mechanism via which P188 protects cartilage in the model of acute trauma. P188 additionally impacts stress-related p38 signaling, apoptosis-related GSK3, and inflammation-related IL-6 signaling. Collectively, these conclusions suggest that P188 by itself or in conjunction with proanabolic agents may have a therapeutic potential in preventing progressive cartilage degeneration and the development of post-traumatic osteoarthritis.



iPhone App May Replace Stethoscope

IPhones can function as stethoscopes using a new application developed by a University College of London (UCL) computer scientist and cardiologist researchers. The app, known as iStethoscope pro, allows users to listen to heartbeats, and displays the heat waveform on the screen. Users can email the audio file and spectrogram to colleagues. They also can shake the iPhone to hear the last eight seconds, and see a phonocardiograph display and a spectrogram. UCL's Peter Bentley says cardiologists believe the app works better than expensive custom medical devices. "Because it is designed to play MP3 files and is mass produced, the audio hardware in a smartphone is of higher quality than is normally used in stethoscopes," he says. Future medical uses of smartphones could include ultrasounds and monitoring blood pressure.



Abstract News © Copyright 2010 INFORMATION, INC.

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