News From ACFAS

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Our latest poll in This Week @ ACFAS revealed that kicking back is not high on readers’ projected to-do list after retirement. Thirty-five percent plan to pursue a second career after they retire, while 27 percent intend to continue practicing once they reach retirement age. Only 23 percent said they will relax and take it easy, and 15 percent are have not yet decided how they will spend their retirement.

Watch next week’s issue for a new monthly poll and be sure to cast your vote so we can learn more about you and your practice! Last week, ACFAS brought its national public relations campaign to 3,500 family physicians at the American Academy of Family Physicians (AAFP) annual conference in Orlando. Alan MacGill, DPM, FACFAS, Chris Reeves, DPM, FACFAS, and Amber Shane, DPM, FACFAS, welcomed FPs to the College’s booth and explained how FPs and foot and ankle surgeons can collaborate in patient care. Dr. MacGill and ACFAS staff also met with AAFP board members to discuss future partnerships and educational programs.

For more on ACFAS’ referral campaign and how you can help spread the word, visit TakeANewLook.org. You count on This Week @ ACFAS for weekly abstracts of studies from leading medical journals. Count on our monthly Scientific Literature Reviews (SLRs) to bring you concise summaries of scientific studies that may affect your surgical cases.

Written by podiatric surgical residents, SLRs include podiatric relevance, methods, results and conclusions. New SLRs are posted each month at acfas.org/SLR to help you stay ahead of the latest research without having to spend hours mining through journals or multiple websites.

Visit acfas.org/SLR to read this month’s reviews or to browse through our SLR archive for studies dating back to 2009. The ACFAS Fellowship Committee recently determined the following fellowship exceeds the minimal requirements to be upgraded to full Recognized Status with the College after having completed its first successful year with a fellow matriculating through the program:

Newport Advanced Foot & Ankle Surgery Fellowship
Newport Beach, California
Program Director: D. Jeffrey Haupt, DPM, FACFAS
acfas.org/fellowshiphaupt

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

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Intermittent negative pressure (INP) on the lower leg and foot may increase peripheral circulation, but it is not clear how patterns of INP affect macro- and microcirculation. The aim of a recent study was to determine the effect of different patterns of negative pressure on foot perfusion in healthy volunteers. In 23 volunteers, researchers recorded blood flow velocity in a distal foot artery, skin blood flow, heart rate and blood pressure during applications of negative pressure to the lower leg. An airtight chamber connected to an INP generator applied four different 120-second sequences with either constant negative pressure or INP patterns. Blood flow velocity reached an average 44 percent increase above the baseline at four seconds after the onset of negative pressure. Average blood flow velocity, skin blood flow and skin temperature decreased during constant negative pressure. Skin blood flow and skin temperature increased during all INP sequences.


Diabetic foot infections (DFIs) are the leading cause of nontraumatic lower extremity amputations, but limited data exists supporting the use of antimicrobials against methicillin-resistant Staphylococcus aureus (MRSA) in patients with associated risk factors. Researchers identified 318 culture-positive DFI patients at University Hospital in San Antonio. Common comorbidities included hypertension (76 percent), dyslipidemia (52 percent) and obesity (49 percent). Male gender and bone involvement were found to be independent risk factors for MRSA DFI. S. aureus was identified in 46 percent of culture-positive DFIs, and MRSA was present in 15 percent. Eighty-six percent of patients received MRSA antibiotic treatment, resulting in 71 percent unnecessary use.


A study evaluated the local control, survival and complications associated with treating soft-tissue sarcomas (STS) in the wrist, hand, ankle and foot with limb-sparing surgery (LSS) and postoperative radiotherapy (PORT). Researchers reviewed 17 patients with STS in the wrist, hand, ankle and foot who received PORT after LSS. Fourteen patients (82 percent) underwent wide resection with flap grafts, and the same number of patients achieved clear resection margins. The median postoperative radiation dose was 54 Gy. At a median follow-up of 39 months, five-year local recurrence-free survival and distant metastasis-free survival were both 100 percent. One patient experienced grade three radiation dermatitis, and radiation-induced bone fracture occurred in two patients.

Practice Management

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Patients who fail to keep appointments are a persistent problem, but many practices are testing new technologies to better the chances that patients will show up on schedule, or at all. Texting appointment reminders is one approach, and it has helped some practices reduce their no-show rate by 10 percent to 20 percent. Some practices are experimenting with online scheduling, and athenahealth research indicated the further out patients book appointments, the more likely they are to cancel or fail to show up. The cancellation rate for appointments scheduled more than 20 days in advance is about 40 percent, declining to 11 percent for appointments scheduled the same day. Smart scheduling initiated by software that analyzes a patient's appointment history to determine the probability that he or she will appear has been beneficial for some practices. For those with websites, electronic self-scheduling also raises the odds that patients will show up.


Failing to budget for regular employee training and courses on updated rules could put a practice at risk of violating current regulations or laws and working under outdated assumptions. Just as physicians are required to take continuing medical education courses, administrators should also regularly attend professional association meetings in their specialties. Billing staff should undergo updated coding and billing training, and all staff must have annual Health Insurance Portability and Accountability Act (HIPAA) classes. An undertrained staff could unknowingly violate the False Claim Act, HIPAA and other regulations. An investment in employee development will impact a practice’s efficiency, morale and revenue. If funds are earmarked for specific training purposes, a practice is more likely to seek out training opportunities knowing there is a budget to cover them. An annual budget for professional development is often a positive and welcome announcement for employees looking for opportunities to advance. Educated and informed teams bode well for practices’ bottom lines; when billing staff understand rule changes and coding procedures, billable services will be more likely to be billed and paid. Finally, a training budget sets a benchmark against which to measure progress. Managers can monitor the percentage spent each month and adjust each year’s budget accordingly.


Almost 90 percent of healthcare institutions have experienced a data breach in the past two years, and 45 percent had five or more breaches, according to a report from the Ponemon Institute. Many breaches are the results of employee mistakes or lost devices, but half of all healthcare data breaches are due to cybercrime. Breaches can irreparably harm a practice’s reputation and place sensitive patient data at risk. In addition to abiding by regulations regarding the handling of protected health information, practices should take extra steps to safeguard their systems from cyberthreats. Software should be programmed to update automatically, ensuring virus, spam and malware-scanning software are continuously up to date and working properly. Employees are often targets for cybercriminals spreading malware through email attachments, so policies for dealing with unknown attachments should be enforced. Information technology experts also recommend encrypting sensitive data instead of relying solely on strong passwords. Finally, practices should conduct regular risk assessments of their systems and data.

Health Policy and Reimbursement

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More than 1,300 health centers will receive funding from the U.S. Department of Health and Human Services to continue the development of health information technology tools, including electronic health records (EHRs) and big data analytics. A total of $87 million in funding will be distributed to healthcare providers who deliver primary care services to more than 24 million vulnerable patients, including 10 percent of U.S. children and more than a million homeless patients. Centers that plan to put the funding toward EHR system upgrades must purchase certified EHR technology that meets Medicare Access and CHIP Reauthorization Act (MACRA) requirements. California will receive the greatest share of grant money, totaling $12 million to support programs focused on caring for children, underserved communities and other vulnerable patients. The awards will be granted through the Community Health Center Fund under the Affordable Care Act and MACRA.


The U.S. Department of Health and Human Services has released a final rule that details requirements for registering certain clinical trials and submitting summary results information to ClinicalTrials.gov. The new rule does not apply to phase 1 trials of drug and biological products or small feasibility studies of device products. However, the final rule says how and when information collected in a clinical trial must be submitted to ClinicalTrials.gov. It does not say how clinical trials should be designed or conducted, or what data must be collected. Other important features of the rule include:

• requiring additional types of adverse event information;
• providing a list of potential legal consequences for noncompliance; and
• providing a checklist for evaluating which clinical trials are subject to the regulations and who is responsible for submitting required information.

Medicine, Drugs and Devices

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In response to growing criticism over higher-priced medicines, the Generic Pharmaceutical Association (GPA) says a Senate bill would increase the number of cheap generic drugs on the market and lower drug spending. GPA said the Creating and Restoring Equal Access to Equivalent Samples Act would prevent brand-name companies from blocking or delaying generic drug development. Separately, the Fair Drug Pricing Act would force drug manufacturers to justify price increases of 10 percent or greater. Companies would also need to reveal information behind those cost increases. Meanwhile, the Preserve Access to Affordable Generics Act would ban brand-name drug makers from using pay-for-delay agreements with generic companies to keep competing products off the market. All three pieces of legislation are said to be bipartisan, but critics argue they could have negative ramifications on the market.


A new study from the Health Industry Distributors Association (HIDA) determined equipment and products used in healthcare facilities can significantly influence patient satisfaction. For example, HIDA's Gina Smith notes the time a patient spends in an office is influenced by the speed of lab and diagnostic imaging equipment and the efficiency of office management software. The study found 37 percent of patients reported dissatisfaction because they could not receive lab or imaging results during their appointment, which is possible with fast tests and diagnostic equipment. Infection control and cleanliness also were rated as extremely important by patients, with 66 percent saying they value a clear commitment to infection prevention via a clean environment, and by having plenty of hand sanitizer, masks and infection control signage present. Meanwhile, 40 percent of patients said a provider surpassed their expectations by having up-to-date equipment, and 41 percent said amenities, such as comfortable furniture and refreshments, enhanced their satisfaction. Almost 50 percent said a healthcare provider failed to meet their expectations last year, and 12 percent changed providers because their expectations were not met. In response to HIDA's query on how they intend to improve patient satisfaction, healthcare executives said they are looking to invest in different products, including higher-quality bedding, patient entertainment, improved bedside diagnostics and new lab and imaging equipment.


Type 2 diabetes is associated with an increased risk of fracture, further elevated by certain diabetes treatments. Data regarding dipeptidyl peptidase-4 inhibitors is inconclusive, so a study was conducted to examine fracture incidence in the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS). Researchers examined fracture rates from 14,671 TECOS patients; 375 experienced fractures, of which 146 were major osteoporotic fractures. Fracture risk increased independently with older age, female sex, white race, lower diastolic blood pressure and diabetic neuropathy. Sitagliptin was not associated with increased fracture risks, major osteoporotic fractures or hip fractures. Insulin and metformin treatments were associated with increased and decreased fracture risks, respectively.