News From ACFAS

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Fall has arrived and so has the latest edition of ACFAS’ free patient education newsletter, FootNotes, which is available for download in the ACFAS Marketing Toolbox. The Fall 2014 issue includes the following articles:

• Overdoing Sports Could Lead to Overuse Injuries for Kids
• Shopping Tips for Children’s Shoes
• Do Arches Really Fall?

Once you download, be sure to customize FootNotes with your practice’s contact information in the space provided so your patients and potential patients can contact you. Don’t forget to put copies of the newsletter in your waiting room, post the articles on your social media sites or company website and distribute copies at health fairs or speaking engagements.

You can also take advantage of the many other resources available in the Marketing Toolbox on acfas.org to help grow your practice and attract new patients. The Journal of Foot & Ankle Surgery (JFAS), your top-rated source for the latest research, has just achieved a journal impact factor (JIF) of 0.979—its highest ever!

The JIF measures a journal’s influence based on citation frequency data, and it is considered the industry standard for determining a journal’s impact on its discourse community.

“The increase in JFAS’ impact factor is significant for the publication and the College because it further indicates that the Journal continues to be seen as a leading clinical resource in the field of foot and ankle care, with not only our peers, but with those outside the scope of our profession,” says D. Scot Malay, DPM, MSCE, FACFAS, JFAS editor.

JFAS surveys consistently indicate that you thoroughly read each issue and value the range and scope of material included, so the editor and section editors will continue to ensure the valuable information and high quality that our readers expect from the publication. Has a patient ever been angry with you about a long wait time or been rude to your office staff? Has a patient ever tried to manipulate you into prescribing unnecessary pain medication? If your practice has encountered any of these scenarios, then ACFAS’ latest podcast release, “The Challenging Patient,” is just what the doctor ordered.

Moderator Stephen Schroeder, DPM, FACFAS, and three expert panelists share their strategies for working with difficult patients. You’ll learn how to recognize red flags, set boundaries and document patient behavior, plus you’ll know what language to use to always keep the patient’s needs at the forefront of the conversation.

New podcasts are added to ACFAS’ e-Learning Podcast Library every month, so visit acfasdistancelearning.com/podcasts often to hear the latest releases.

Foot and Ankle Surgery

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A new study that included a long-term follow-up period for patients who underwent total ankle arthroplasty to treat end-stage ankle degeneration has found that the procedure produces mixed results. The study's authors found at follow-up, which was performed a minimum of 10 years after surgery, that the implants had survived in 17 of the 18 patients. That translates to an overall implant survival rate of 94.4 percent. In addition, American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale scores rose from 32.8 to 78.1 at final follow-up. Visual Analog Scale (VAS) pain scale scores improved as well, dropping from 8.1 before surgery to 2.1 at follow-up. All of the study's participants also reported their outcomes as being good or excellent. However, 39 percent of patients required additional surgery and one patient needed a revision of the prosthesis. Because of the high rate of additional procedures, the study's authors concluded that more long-term outcome studies on total ankle arthroplasty need to be performed.


A new study examined the patient-reported outcomes of use of a minimally invasive technique for arthrodesis of the first metatarsophalangeal joint. These results have never been published in the U.K. until now.The study involved 26 patients with symptomatic hallux rigidus, all of whom underwent the procedure. The study found that the use of the technique resulted in a fusion rate of 93 percent. In addition, the study found that the Manchester-Oxford Foot Questionnaire (MOXFQ) score, which was used to assess clinical outcome and patient satisfaction, improved from an average of 42 points before surgery to an average of 18 points at final follow-up. The study’s authors believe the minimally invasive technique was able to achieve results similar to those produced by open techniques. Another advantage of the minimally invasive technique, the authors noted, is that patients require little care following surgery.

Practice Management

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Since at least one survey has shown that consumers are willing to perform certain healthcare-related tasks if they receive incentives for doing so, physicians' practices may want to consider giving their patients rewards for signing up for their patient portals. Incentive programs may be particularly useful for practices that are trying to meet meaningful use goals associated with patient portals, as practices that meet these objectives can receive money from the federal government. Incentive programs can take a variety of forms, including giveaways for patients who sign up to use the patient portal during a certain period of time. Physicians' practices can also give rewards to patients who provide feedback on things such as quality of service and wait times through their portals. These rewards can encourage patients to sign up for patient portals and can provide practices with important information to help improve their operations. In addition, practices may want to consider offering to donate to a particular charity for each patient who signs up to use the portal or sends a secure message during a certain time period. Conversely, charging patients for printed billing statements or lab results may also encourage patients to sign up for patient portals, since they can view these documents for free there.


Rebecca Fox, MD, writes that doctors who own their own practice should make themselves familiar with several responsibilities handled by their office manager, even if the manager is clearly proficient at what he or she does. One aspect of practice management physicians should make themselves familiar with, Fox says, is financial analysis. Fox notes it is important for physicians to be aware of how many patients a provider needs to see each day for the practice to be profitable because it is better for the physician owner to communicate these expectations rather than office managers. Fox also recommends physicians familiarize themselves with how certain human resources issues are handled, particularly employee terminations and other difficult interactions with staffers. Physicians should sit in on these conversations between the office manager and the employee so the employee knows the physician supports the office manager's actions, Fox says. Finally, Fox notes that doctors should be involved in creating a policy for provider vacations so that too many providers are not out of the office at any one time.

Health Policy and Reimbursement

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Centers for Medicare and Medicaid Services (CMS) Administrator Marilyn Tavenner told members of the House Oversight Committee Sept. 18 that 7.3 million people had enrolled in and paid their premiums for insurance plans offered through the Affordable Care Act as of mid-August. The Obama administration had previously said 8 million people had signed up for coverage through the exchanges, a figure that a CMS spokesman now says represented an aggregate number of sign-ups and may have included people who signed up for coverage more than once. Committee Chair Darrell Issa (R-Calif.) said the lower enrollment figure is troublesome because it means 700,000 people received benefits without completing the enrollment process, although the CMS spokesman disputed that claim. Tavenner did not provide the panel with information about how many people have taken advantage of government subsidies to sign up for coverage, noting that her agency will release those figures as soon as it has them.


The Centers for Medicare and Medicaid Services (CMS) is planning to conduct an audit of Healthcare.gov to identify any security vulnerabilities that may still exist following a hack of the site earlier this summer, agency chief Marilyn Tavenner said Sept. 18. Tavenner's announcement came several days after the Government Accountability Office (GAO) released a report that found security for Healthcare.gov, including the enrollment or Marketplace system and the Federal Data Services Hub that connects the Marketplace system to other government systems, is insufficient. The report noted that while the security of Healthcare.gov has improved since it was launched last fall, the security plans and privacy documentation for the site remain incomplete. Security tests have not been completed, and no backup processing site is in place in the event the main site goes down, the report noted. GAO made several recommendations for improving the security of Healthcare.gov, including performing a thorough security assessment of the Marketplace system and ensuring that security plans for both the Marketplace system and data hub meet the National Institute of Standards and Technology's recommendations. The Department of Health and Human Services says it is taking steps to secure Healthcare.gov but does not agree with all of GAO's recommendations.


More than a dozen healthcare industry groups, including the American Medical Association, the American Hospital Association and the Federation of American Hospitals, sent a letter to Health and Human Service Secretary Sylvia Mathews Burwell on Sept. 15 asking her to relax electronic health record (EHR) meaningful use requirements for 2015. The letter states that the compliance period for meaningful use criteria should be shortened to just 90 days. The compliance period for hospitals is currently all of fiscal year 2015, while physicians and other eligible professionals have a compliance period that lasts for the entire 2015 calendar year. The letter's signatories note that the proposed change is necessary for making the electronic health record incentive program successful. The authors also point out that with the deadline for meeting Stage 2 meaningful use requirements rapidly approaching, only 143 hospitals and 3,152 physicians and other eligible professionals are ready. The letter concludes that giving providers more time to transition to Stage 2 will help keep the incentive program "on track."


Dozens of patient advocacy groups are calling for the Centers for Medicare and Medicaid Services (CMS) to make a change to the Sunshine Act, which requires medical device makers and drug companies to report payments made to doctors. The groups want CMS to allow these companies to withhold reporting on payments to patient advocacy organizations that are then funneled to physicians to pay for their research, including research on potential new treatments or education. These payments are known as indirect payments. The organizations want that exemption to apply in cases where the device maker or drug manufacturer gives a patient advocacy organization the freedom to decide to whom it gives the indirect payments. A spokesperson for the National Health Council, one of the organizations calling for the change, says it would be very difficult for patient advocacy groups to create a process for tying payments from a device maker or drug manufacturer to a particular doctor.

Medicine, Drugs and Devices

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A recent Phase III study compared fostamatinib to placebo in treating active rheumatoid arthritis patients who have not been helped by methotrexate. The study found that patients who received fostamatinib 100 mg bid for 52 weeks (Group A) and those who received fostamatinib 100 mg bid for four weeks followed by 150 mg qd (Group B) achieved statistically significant changes in American College of Rheumatology 20 percent response rates (ACR20) from baseline to Week 24 compared to patients who received a placebo for 24 weeks followed by fostamatinib 100 mg bid (Group C). However, the improvements in ACR20 response rates in groups A and B were not clinically significant. No statistically significant change in the modified total Sharp van der Heijde score (mTSS) was seen in Groups A and B. The level of response to fostamatinib observed in this study was lower than what was seen in the Phase II program. The study also found that the most common adverse events seen in patients in all three groups were hypertension and diarrhea.


Older rheumatoid arthritis (RA) patients who have taken one of several different types of biologics with different mechanisms of action have a similar risk of herpes zoster (HZ), a new study has found. The study's authors used Medicare data from 2006-2011 to identify RA patients who had previously used a biologic and had begun a new treatment regimen with abatacept, adalimumab, certolizumab, etanercept, golimumab, infliximab, rituximab and tocilizumab. The study's follow-up period began when patients started taking one of these biologics and ended at first HZ, a 30-day gap in current exposure, death, diagnosis of another auto-immune disease or cancer, loss of coverage or Dec. 31, 2011, whichever came first. The highest incidence rate of HZ was observed among the 5.8 percent of patients who took certolizumab, while the lowest was among the 4.4 percent of patients treated with golimumab. These two biologics had the lowest rates of usage among the patients studied. However, none of the differences in the crude incidence rates nor the adjusted hazard ratios among the patients who took one of the various biologics were significant.