News From ACFAS

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Arthritis of the big toe can cause big problems for your patients. Download the new PowerPoint presentation, Hallux Rigidus and Arthritis of the Big Toe, from the ACFAS Marketing Toolbox to educate your patients on:

• how osteoarthritis of the big toe develops
• the differences between hallux rigidus and hallux limitus and how they are diagnosed
• early and late-stage symptoms
• surgical and nonsurgical treatment options
• why it is best to seek care for this common condition as soon as possible

This free presentation includes a customizable slide for your practice’s contact information as well as an accompanying script to help engage patients in the conversation. Use the PowerPoint and script when giving talks at your hospital or when speaking at local health events.

Finish the year strong by promoting your practice with the many other free resources available at acfas.org/marketing, including the FootNotes patient newsletter, referral tools, press release templates and more. New products are added to the Marketing Toolbox regularly—watch This Week @ ACFAS for updates! Thank you and congratulations to ACFAS’ loyal and dedicated members who have been a part of the College since 1978! In appreciation, these 40-year members receive Life Membership status with ACFAS. The ACFAS Board of Directors honors:

• B. Richard Burke, DPM, FACFAS, Anaheim, CA
• Richard D. DiBacco, DPM, FACFAS, Erie, PA
• Josef J. Geldwert, DPM, FACFAS, New York, NY
• Gary S. Kaplan, DPM, FACFAS, Detroit, MI
• Michael J. Marcus, DPM, FACFAS, Montebello, CA
• Travis C. Westermeyer, DPM, FACFAS, Escondido, CA

Last month’s poll in This Week @ ACFAS asked readers which electronic medical record (EMR) system they use.

Fifty-four percent of respondents said they use an EMR system different from the ones selected for the poll. Thirteen percent use eClinicalWorks, and 10 percent use Practice Fusion followed by Epic (9 percent), Cerner (4 percent), Allscripts (4 percent), ChartLogic (2 percent) and GE Healthcare (2 percent).

These results will serve as a baseline for additional research and will guide ACFAS in developing resources to help you get the most from your EMR system. Thank you to all who voted, and watch for the November poll in next week’s issue of This Week @ ACFAS.

Foot and Ankle Surgery

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A study was conducted to assess the medium-term clinical outcomes of endoscopic plantar fascia release (EPFR) via a suprafascial approach for recalcitrant plantar fasciitis. Twenty-four feet of 23 patients who received EPFR using a suprafascial approach were followed up for more than two years using the American Orthopedic Foot and Ankle Society (AOFAS) score. The score at final follow-up was compared between patients participating in athletic activity (group A) and sedentary subjects (group S) and between those with calcaneal spur (group with CS ) and those without (group without CS). The average follow-up period was 48 months. The average AOFAS score in all patients rose significantly between presurgery and final follow-up. The average score in group A at final follow-up was significantly higher than that in group S, but no significant difference in the average score at final follow-up was observed between the groups with and without CS. All patients in group A could resume athletic activity after an average of eight weeks. Three feet experienced injury to the first branch of the lateral plantar nerve. The outlook of sedentary patients was inferior to that of athletic patients.


A retrospective adult cohort study was conducted to define the clinical and patient-reported outcome of proximal fifth metatarsal fractures and its determinants in order to optimize treatment strategy and lower treatment costs. The study involved 152 proximal fifth metatarsal fractures, including 121 nonoperatively and 31 operatively treated. In the operative group, 21 were zone 1 and 10 were zone 2 fractures. Average follow-up was 37.5 months with a minimal follow-up of six months. Twenty-three demographic, fracture and treatment traits were assessed along with healthcare costs. Outcome was evaluated via patient files, anterior-posterior and oblique x-rays, foot function index (FFI), visual analog score (VAS) and SF-36 questionnaires. The average FFI, physical SF-36 and VAS scores did not significantly differ between nonoperatively and operatively treated patients. The FFI and physical SF-36 were mostly affected by a history of mobility impairment and preexistent cardiovascular diseases, while mental SF-36 correlated significantly with higher ASA score. The general complication rate was 5.9 percent, and nonunion was observed in only one nonoperatively treated patient. The total healthcare costs for operative treatment were 4.2 times higher versus nonoperative treatment. The clinical and patient-reported outcome was positive overall.


A study was conducted to evaluate how diabetes mellitus and body mass index (BMI) contribute to wound healing in patients younger than 65 who underwent surgery for malleoli fractures. The study involved the retrospective enrollment of 90 patients, aged 18 to 65, with surgically treated ankle fractures. The patients were classified as either diabetic or nondiabetic, and all were assessed for wound complications. VAS and Foot and Ankle Disability Index were evaluated for all patients. Logistic regression was applied to identify the risk of wound complications after surgery using age, gender, duration of surgery, BMI, hypercholesterolemia, smoking habit, diabetes mellitus and high blood pressure as explanatory factors. Overall, 38.9 percent of patients had wound complications. Of them, 17.1 percent did not have diabetes, and 82.9 percent had diabetes. A significant association between diabetes mellitus and wound complications following surgery was observed. According to logistic regression analysis, diabetes and BMI were associated with wound complications, and the odds of having a postoperative wound complication climbed 0.16 times in the presence of diabetes and 1.14 times for increasing BMI.

Practice Management

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One major reason to adopt electronic records is to reduce medical errors, according to experts in health information technology (HIT). However, these systems can also result in new types of errors and more errors. Mark L. Graber and colleagues studied the role that HIT played in malpractice claims, using an insurance database containing more than 300,000 cases, and reported their findings in the Journal of Patient Safety. Although less than one percent of the total (248 cases) involved a HIT-component, more than 80 percent of those suits alleged harms of medium to intense severity. The researchers stressed that the 248 claims represented the "tip of an iceberg" because the vast majority of EHR-related cases, even those involving serious harm, never generate lawsuits. Graber's group identified three major reasons for EHR-related suits. The first involved medication errors (31 percent), the second category pertained to diagnostic errors (28 percent) and the third category involved complications of treatment (31 percent).


Daniel Tucker, CEO of Arthritis & Rheumatism Associates, says a simulated phishing scam helped improve cyber security within the company. The fake scam involved an email sent to employees encouraging them to open an attachment that would allow hackers to gain access to computer systems. Tucker says 15 percent of the company's employees failed the fake phishing test. However, employees were urged to use the mistake as a learning experience in the future. Employees were also trained on what to look for in suspicious emails, and the firm's cyber security defenses were strengthened. Experts say the importance of training staff on cyber threats cannot be overstated. Recent research found that it can cost $380 per record when cyber criminals steal the personal information of patients.


A Mayo Clinic study on physician satisfaction with electronic health records (EHRs) found that only 36 percent of 6,375 surveyed physicians were satisfied with their EHRs. A majority of respondents also noted that their EHR systems were causing a clinical burden, which is leading to exhaustion and depersonalization. Bridget Duffy, chief medical officer for Vocera, says the frustration over EHR systems and bureaucracy is preventing doctors from treating patients. Duffy says a possible solution to the problem is more efficient use of tools that can make a doctor's job easier. She said healthcare facilities must use technologies “that enable and restore the sacred relationship between physician and patient.”

Health Policy and Reimbursement

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According to the U.S. Centers for Medicare and Medicaid Services (CMS), a majority of Accountable Care Organizations (ACOs) participating in the Next Generation risk program collected financial rewards in 2016. In contrast, only seven ACOs lost money, and three dropped out of the program. Experts say these results are important because it shows that shared risk among ACOs is effective. The outcome of the risk programs comes as CMS has requested feedback from health systems on current payment models.


White House officials say President Trump is leaning toward the nomination of Alex Azar, a former pharmaceutical industry executive, as U.S. Department of Health and Human Services (HHS) Secretary. If appointed, Azar would replace Tom Price. Azar was HHS general counsel and deputy secretary during the George W. Bush administration. While at the department, he worked closely with Eric Hargan, who was confirmed earlier in October as Trump's deputy HHS secretary and has been acting secretary since Price's exit. Azar joined Eli Lilly in 2007 as a senior vice president of corporate affairs and communications right after departing the Bush administration. He became head of Lilly's U.S. operations in 2012, a position he held until January 2017. At Lilly, Azar focused on both international and federal government affairs and public policy, as well as counterfeit medicines and health information technology. "He brings terrific experience from both the private and public sector leading large and complicated organizations," says former HHS Secretary Tommy Thompson. "He knows HHS and the career staff know and respect him." Azar has lobbied that insurance and drug industries cooperate to reduce drug prices and has criticized the Affordable Care Act, telling Fox Business in May that it is "fundamentally broken" and "circling the drain."


Eighteen states have filed lawsuits against the Trump Administration over the president's efforts to rescind key parts of the Affordable Care Act. Namely, the states have issue with President Trump's attempt to end subsidies that help low-income Americans pay medical bills. The fallout of ending those subsidies could cost $7 billion in 2017, and that amount could rise to $10 billion next year. The states plan to ask the courts to force Trump to make the next subsidy payments. Legal experts predict the states have a hard battle ahead.

Medicine, Drugs and Devices

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A Harvard T.H. Chan School of Public Health study has found that diets high in magnesium can help lower the risk of type 2 diabetes. Researchers studied 42,096 people who completed food frequency surveys every four years to determine their dietary intake. The study found that 17,130 type 2 diabetes diagnoses were made during 28 years of follow-up. Researchers say increased magnesium intake could prevent health complications related to type 2 diabetes. This is so because magnesium deficiency is linked with insulin resistance, which causes type 2 diabetes. Researchers say the risk of developing type 2 diabetes is four percent lower with each additional 50 milligrams of magnesium consumed per day. The findings were published in the online journal Diabetes Care.


University of Virginia School of Medicine researchers say improved communication methods have the potential to improve patient satisfaction. The researchers wrote in their study that a psychosocial intervention called Background, Affect, Trouble, Handling and Empathy (BATHE) allows patients and doctors to develop a meaningful connection. A bonus of BATHE is that it can be done in a short amount of time or in a longer time period. The study found that patients receiving BATHE gave their doctors high scores based on the care they received. Doctors also noted that patients receiving BATHE did not seek more attention from staff out of anxiety.


The U.S. Food and Drug Administration has approved a skin patch that features a small wire that can send glucose readings wirelessly to a reader. The patch must be replaced every 10 days, but it could put an end to skin pricks for people with diabetes. That is just one of a number of medical innovations that could change how people living with diabetes check their blood sugar levels. MIT researchers are studying a tattoo that changes appearance to signal changing glucose levels. Meanwhile, University of Chicago scientists used stem cells and the gene-editing technique CRISPR to create skin cells that emit fluorescent light as blood glucose levels rise. While the light is invisible to the naked eye, it can be detected by electronic sensors. These skin cells could also reveal additional information like cholesterol, sodium and even a tumor.