News From ACFAS

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Foot and Ankle Surgery

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Standard-of-care (SOC) therapy alone is not sufficient to heal diabetic foot ulcers, resulting in application of adjuvant wound therapies including biologic skin substitute. The authors conducted a systematic review and meta-analysis, in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), on the efficacy of healing diabetic foot ulcers with biologic skin substitutes. Four electronic databases were searched with keywords and subject headings pertaining to the concepts of biologic skin substitutes, wound healing and diabetic foot ulcers. Data were extracted from 54 included articles, and two independent reviewers conducted risk-of-bias assessments. Authors identified 25 studies that assessed the proportion of complete wound closure by 12 weeks and found that wounds treated with biologic dressings were 1.67 times more likely to heal by 12 weeks than those with SOC dressings.

Five studies assessed the proportion of complete wound closure by six weeks, and wounds treated with biologic dressings were 2.81 times more likely to heal by six weeks than those treated with SOC dressings. Twenty-nine of the 31 studies that assessed time to healing favored biologic dressings over SOC dressings. The review provides evidence that biologic skin substitutes are more effective than SOC dressings at healing diabetic foot ulcers by 12 weeks. Future studies must address the relative benefits of different skin substitutes, the long-term implications of these products and their financial considerations.


Arterial duplex ultrasound (DUS) and ankle-brachial indices (ABIs) can be used to assess lower limb arterial perfusion, but in a significant number of diabetic patients, medial wall calcification precludes an ABI measurement. The study sought to define the utility of Plantar Acceleration Time as a surrogate for ABIs. Patients undergoing DUS including Plantar Acceleration Time for suspicion of peripheral arterial disease (PAD) were retrospectively reviewed in a prospective database over a one-year period. Plantar Acceleration Time was calculated in each limb in the lateral plantar artery, and statistical analyses of that data were performed. Patients were then grouped into four classes based on their clinical symptoms and ABI. Plantar Acceleration Time was similarly grouped into four distinct classes and correlated with the clinical and ABI classes. The analysis indicated a significant correlation of Plantar Acceleration Time with ABI in patients with compressible arteries. Based on their results the authors propose four categories of Plantar Acceleration Time, which appear to correlate with clinical and ABI findings. Ongoing investigations seek to confirm whether Plantar Acceleration Time may stand in for ABIs in patients with noncompressible arteries that preclude meaningful ABIs and give more information regarding targeted angiosome perfusion to the foot.


The study aimed to evaluate the relationship between isokinetic muscle strength and functional tests in chronic ankle instability (CAI). Between April 2014 and August 2016, 103 patients with unilateral CAI were studied. Researchers performed single-leg balance, single-heel raise and single-leg squat tests for static balancing assessment, and single-leg hop, double-leg jump and sidestep tests were performed for dynamic balancing assessment. A dynamometer was used to measure the isokinetic muscle strength of both ankles. The involved ankle showed lower muscle strength in inversion than the uninvolved ankle, while eversion, dorsiflexion and plantarflexion muscle strength had no significant differences between ankles. There were significant correlations between the isokinetic muscle strength of inversion and the single-leg balance, single-heel raise and sidestep tests. The single-heel raise test was the most reliable test to reflect muscle strength deficiency in CAI.

Practice Management

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The article reviews five trends that are shaping the healthcare industry, starting with the growing number of practice sales. Reports indicate that fewer than half of all physicians now have an ownership stake in their practices, and the number of hospital-employed doctors increased by 9 percent from July 2015 to July 2016. Primary care practices that do not sell might choose to adopt a concierge model or invest in technology and staff to increase efficiencies. Specialist practices are increasingly selling stakes to private equity firms to avoid being bought by hospitals. Because of the rapid growth in popularity of retail medical clinics and urgent care centers, physicians must continue to deliver on the value of an ongoing doctor-patient relationship, which patients rarely find in an urgent care. Some practices have responded by extending hours, opening emergency clinics, working with nontraditional care settings by linking electronic health records (EHRs) and using outside clinics to source patient referrals.

As a result of regulatory uncertainty around the future of the Affordable Care Act, many physicians are postponing decisions to sell, expand or participate in the patient-centered innovations encouraged by current law. Intense competition for skilled workers has led to staffing lags, which services can address by directing physicians and nurses to practices whenever they are needed. Developments in artificial intelligence, data analytics, robotics and 3D printing suggest that these technologies have the potential to transform patient care and practice operations. Yet new technologies often come with costs and complications, as seen in the difficulties many have experienced with EHRs. When considering new technologies, physicians should carefully research what options make sense for their specific practice and how they would be implemented.


The article looks at some of the key financial decisions that physicians have to make over the course of their careers. Most physicians carry significant student debt, and it can be difficult to make decisions about refinancing it. Physicians with private loans should consider refinancing them as early as the first year of residency, while those with federal loans may already have low effective interest rates or may be pursuing public service loan forgiveness, so refinancing may not be beneficial. When it comes to life and disability insurance, physicians should have their own individual coverage, specifically a term policy rather than whole life insurance, on top of what they receive from their employers. Residents should purchase an individual, "own occupation" disability insurance policy specific to their specialty with a rider that allows them to buy more coverage when their salaries increase.

Every physician should have documents designating a healthcare surrogate and a power of attorney, and those with children should have a will or trust. Experts recommend that physicians focus on saving for retirement as early as possible through qualified retirement plans like 401(k)s and 403(b)s, which provide tax benefits and are protected from creditors. For physicians who work in a locum tenens role, a simplified employee pension account may provide an additional tax-advantaged vehicle to save some of their independent contracting income. Most physicians should aim to save at least 15 to 20 percent each year for retirement.


According to a new survey of 2,250 adults aged 50 to 80 conducted by the National Poll on Healthy Aging, only 4 percent of respondents had taken part in a video-based telehealth visit in the past year. Fifty-eight percent of those who had used telehealth said that office visits offered better care quality, and 48 percent were concerned about the privacy of telehealth visits. Seventy percent of all respondents voiced concerns that providers could not do a physical exam over a webcam or smartphone camera, and 68 percent said that remote care would be inferior to an office visit. Half of those polled did not know whether their health providers offer telehealth visits. More than 80 percent expressed at least one concern about seeing a provider virtually rather than in person, and 47 percent were worried about getting the technology to work.

Health Policy and Reimbursement

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President Trump has directed the U.S. Department of Health and Human Services (HHS) to consider tying Medicare reimbursement more closely to time spent with patients, to address potential pay inconsistencies between nurse practitioners, physician assistants (PAs) and other healthcare professionals. HHS Secretary Alex Azar noted Medicare policies sometimes "prevent people...from really maximizing the full value and training and licensure that they have through supervision requirements or other artificial limitations." The U.S. Centers for Medicare and Medicaid Services (CMS) included in its draft 2020 Medicare physician fee schedule a proposal that would chiefly favor state law and state scope of practice for PAs, specifically for "services that are unique and appropriate for their respective state."

The American Medical Association recommended Medicare maintain current rules on physician supervision for PA services and requested CMS further amend the rules to ensure physicians have ultimate responsibility for coordinating and managing patient care if the proposed changes are finalized. Meanwhile, the Medicare Payment Advisory Commission has urged the removal of "incident-to" billing for advanced practice registered nurses and PAs, preferring both professions consistently bill Medicare directly under their own national provider identifier for provided services.


A new report from the U.S. Department of Health and Human Services' Office of the Inspector General found that between 2013 and 2017, dozens of states failed to survey their ambulatory surgery centers (ASCs) for safety compliance at required intervals. These states violated Medicare rules applying to 3,372 of the 5,603 "non-deeming" ASCs, which are supposed to be surveyed by state health agencies instead of a Medicare-approved "deeming" agencies. The report finds that 15 states representing a total of 764 ASCs failed to inspect at least 25 percent of non-deemed ASCs annually. In addition, 28 states failed to inspect all non-deemed ASCs at least once every six years, although 19 states surveyed more than 95 percent of their non-deemed ASCs. Though some of the non-deemed ASCs that were not inspected by a state agency may have been inspected by a non-state entity, the report nonetheless highlights the importance of routine inspections as ASCs grow in numbers and authority.


The U.S. Centers for Medicare and Medicaid Services (CMS) said that the Medicare Shared Savings Program generated $1.7 billion in total savings in 2018, and Medicare netted $739 million of this after paying out shared savings bonuses. CMS Administrator Seema Verma said that accountable care organizations (ACOs) that received shared savings payments had decreases in inpatient, emergency room and post-acute care spending and utilization, while ACOs that increased spending relative to their targets tended to show increases in these areas. ACOs that took on downside risk reduced spending by an average of $96 per enrollee, compared to $68 per enrollee in ACOs that did not.


The U.S. Centers for Medicare and Medicaid Services (CMS) cut payments to 2,583 hospitals on Tuesday as part of its Hospital Readmission Reduction Program (HRRP), implemented in 2012 to reduce one-month readmission rates. Eighty-three percent of the 3,129 general hospitals evaluated in the HRRP received a penalty, which will be taken out of each payment for a Medicare patient stay over the fiscal year beginning today. The HRRP has encouraged hospitals to focus on how their patients recuperate, sometimes assisting in medication procurement and follow-up appointments. However, some have raised concerns that hospitals may avoid readmitting patients who need additional inpatient care to avoid financial repercussions. CMS determines its penalties by looking at national averages for each condition it tracks, so hospitals that reduce readmissions from past years can still take a hit.

Medicine, Drugs and Devices

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The U.S. Food and Drug Administration (FDA) has warned consumers that hackers could remotely hijack certain medical devices, by exploiting cybersecurity flaws. The vulnerable devices use third-party software called IPnet, and FDA is uncertain precisely which devices or how many are at risk. The agency said scientists have identified 11 flaws that could allow any hacker to remotely commandeer a device, "and change its function, cause denial of service or cause information leaks or logical flaws, which may prevent device function."

FDA added that it is evaluating the security risk and identifying affected devices in collaboration with stakeholders and subject matter experts. FDA spokesperson Alison Hunt said compiling a list of affected devices will be difficult, given the complexities in how the IPnet code was embedded within devices and the availability of operating system iterations impacted by the flaws.


As part of a five-year agreement with Novartis, Microsoft will develop new tools intended to make artificial intelligence (AI) easier to apply to all areas of the drug company's business. The partnership will also focus on using deep learning to improve the speed and precision with which it develops new products. Novartis CEO Vas Narasimhan suggested Tuesday that AI could hold particular promise in personalized medicine, such as assisting with the identification of patient groups most likely to benefit from new therapies. Novartis has been ahead of the curve as the pharmaceutical industry moves to embrace new technologies, and Narasimhan says he aims to turn Novartis into a data science company. The company already employs hundreds of data scientists, and its internal information is stored in three centralized "lakes" that facilitate the combination of different data sets.