News From ACFAS

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The ACFAS Research Committee is pleased to announce the three winners of 2015 ACFAS Clinical and Scientific Research Grants.

Congratulations to the following investigators, whose proposals stood out among a strong field of applicants:

• Cost-Effectiveness Analysis of Pharmacologic DVT Prophylaxis Following Select Foot and Ankle Surgeries
  Richmond Robinson, DPM, AACFAS; Craig Wirt, PhD; Adam Fleischer, DPM, MPH, FACFAS; Arezou Amidi, DPM; Robert Joseph, DPM, PhD, FACFAS
• Functional and Mechanical Changes Following Arthroscopic Lateral Ankle Stabilization and Assessment of the ACFAS Module 4 Scoring Scale
  Naohiro Shibuya, DPM, MS, FACFAS; Jakob Thorud, DPM, MS, AACFAS; Daniel C. Jupiter, PhD
• Quantification of Altered Gait Mechanics and Energetics Following Partial Foot Amputation
  Jarrett D. Cain, DPM, MS, FACFAS; Stephen J. Piazza, PhD; Rebecca K. Rogers, CPO, MS

The ACFAS Clinical and Scientific Research Grant program is in its ninth year of providing financial support for research in foot and ankle surgery conducted by members of the College. The program seeks to educate ACFAS members in the implementation of evidence-based medicine that advances clinical practice of foot and ankle surgery and improves the patient experience. The research must be clinical or laboratory-based, with clearly defined research goals meeting all criteria for grant submissions.

For a full listing of past award recipients, visit acfas.org/grant. ACFAS' Fellowship Committee determined the following fellowships meet the minimal requirements to receive Recognized Status with the College:

Pediatric and Adult Foot & Ankle Surgical Fellowship, Atlanta, Georgia
Program Director: Craig A. Camasta, DPM, FACFAS

SouthWestern Podiatric Surgical Sports Medicine Fellowship, San Clemente, California
Program Director: Philip Radovic, DPM, FACFAS

The following fellowship has been granted Conditional Status with ACFAS since the program is new and has not yet had a fellow matriculate through:

Foot and Ankle Fellowship of South Florida, Plantation, Florida
Program Director: Warren Windram, MS, DPM, FACFAS

All Conditional Status programs are considered for "Recognized Status" with ACFAS after the first fellow completes the program. 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 our Fellowship Initiative page to review a complete listing of programs and minimal requirements. Want to get a head start on your learning a full day before ACFAS 2015 in Phoenix begins? Make plans to attend our pre-conference workshops scheduled for Wednesday, February 18. Choose from three hands-on sessions designed to help you sharpen your surgical technique and more skillfully manage your practice.

Perfecting Your Practice: Coding/Practice Management Workshop (8am–5:30pm) will teach you everything you need to know to keep the business side of your practice running smoothly. Get a leg up on surgical coding, evaluation and management codes, durable medical equipment and meaningful use attestation plus participate in an interactive coding session for wound care, modifiers and surgery.

The cadaveric workshop, Diabetic Deformity: Master Techniques in Reconstruction (7:30am–Noon), will cover complex deformities in diabetic patients. Learn new techniques for treating Charcot deformities, discover the latest in locking plate technology and determine the risks in limb salvage vs. limb amputation. ACFAS faculty will also share their personal experiences with midfoot, rearfoot and ankle amputation cases.

In Master Surgical Techniques: Fine-Tuning with the Experts (12:30–5pm), a six-member ACFAS faculty of expert foot and ankle surgeons will review, demonstrate and teach a specific procedure each has mastered. Hear the newest surgical trends and strategies for complications and revision. This workshop includes brief classroom instruction, but most of the work will take place in the cadaver lab where faculty will perform each procedure.

Space for these workshops is limited, reserve your spot today at acfas.org/phoenix. Because of the huge success of the HUB at the 2014 Annual Scientific Conference, get set for a repeat performance at ACFAS 2015 in Phoenix this February!

Housed in the Exhibit Hall, this intimate, interactive theater encourages open discussion in an informal setting. Get answers to your questions on the great job hunt, cyberliability, patient selection, risk management, fellowships and contracts. Sponsored by PICA, this year’s HUB promises to be better than ever, so make plans to attend as many sessions as you can!

For more on everything the HUB has to offer, visit acfas.org/phoenix.

Foot and Ankle Surgery

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A new study examined the relationship between the hindfoot moment arm, which is used to measure hindfoot valgus deformity in patients with stage 2 adult-acquired flatfoot deformity (AAFD), and a new hindfoot alignment angle that can quantify hindfoot valgus in AAFD patients. The study's authors noted that their research is important because little understanding exists about the relationship between the hindfoot moment arm and angular measurements of hindfoot alignment. The study involved 10 patients scheduled to undergo reconstruction for stage II AAFD, as well as a control group of 10 patients without flatfoot. After reviewing the pre-operative hindfoot alignment radiographs for the AAFD patients, the study's authors observed a strong linear relationship between the new hindfoot alignment angle and the hindfoot moment arm. This means that the angle could be used in the intraoperative correction of hindfoot valgus, the authors noted. The study also found that the angle can reliably measure hindfoot valgus and help physicians diagnose AAFD.

Practice Management

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Billings Clinic, a healthcare organization based in Billings, Mont., that includes multi-specialty physician group practices as well as a hospital, is using a data analytics tool to move physician incentives away from fee-for-service and toward population health. The tool includes a dashboard containing data on patient readmissions, which physicians can use to ensure they are taking the necessary steps to prevent patients from being readmitted to the hospital, says Karen Cabell, DO, the associate chief of quality and patient safety at Billings Clinic. The dashboard also allows physicians to access patient satisfaction data. The system uses the Centers for Medicare and Medicaid Services' 33 accountable care organization metrics to filter information about patient populations based on payer status, location, age and other measures to allow physicians to determine how well they are meeting clinical quality metrics. Billings Clinic is planning to add new features that will give physicians a score on how well they are meeting these metrics each month as well as a yearly score that will partially serve as the basis for their compensation. The system will also eventually include features that will allow physicians to closely examine patient-level data, which will help them better accept the system's reports, Cabell says. She notes that incentivizing physicians to perform well on clinical quality metrics has resulted in half of physician compensation being based on clinical quality performance or performance on access or other operational metrics, while the other half is still based on traditional fee-for-service production.


Physicians' practices are more likely to be successful and sustainable over the long term if practice administrators and executives understand and anticipate the cost of caring for patients, writes Medical Group Management Association Senior Industry Analyst Laura Palmer. Administrators and executives should understand that the cost of caring for patients depends on a variety of factors, including the types of services that have been or will be rendered as well as whether a patient is new or has received care at the practice before, Palmer says. She adds that physicians' practices should be sure to factor overhead expenses into the cost of caring for patients, including bank charges, credit card transaction fees and medical malpractice liability coverage. Palmer notes that physicians' practices can predict the total cost of caring for a patient by taking into consideration what type of care is being provided. Surgical care, for example, would include the cost of patient visits before and after surgery as well as the surgeon or provider's charges for the services they provide in the operating or procedure room. Palmer notes that all of this information can be used to communicate with patients about their cost of care and how much of that cost is their responsibility. Doing so will help patients prepare to pay for care and allow them to determine whether they can put off surgery if they are unable to bear the expense, Palmer says.


Researchers at the Mayo Clinic have released a study that examined the reasons why physicians are dissatisfied with the Maintenance of Certification (MOC) program, as well as the steps that can be taken to address these complaints. The study, published in the Journal of the American Medical Association Internal Medicine, found that the phases of the program that require physicians to complete self-study and self-assessment modules and undergo a study of practice performance were regarded by physicians as being irrelevant to their practice and an inefficient means for updating their clinical knowledge and skills. Physicians also believed that MOC's mandated study of practice performance was the most "difficult and frustrating" part of the program and that it had no connection to patient care activities. The study found that physicians believed the multiple-choice exam they had to take as part of the MOC program was somewhat useful, but they did not like having to travel to a secure testing facility to complete the exam or the lack of feedback about their answers. The authors also included several recommendations for reforming MOC that were based on physicians' responses, including changing the program so physicians can more easily see its benefits and making the requirements more relevant within daily clinical practice.

Health Policy and Reimbursement

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House Republicans have brought a lawsuit against the Obama Administration concerning the Affordable Care Act (ACA). The lawsuit focuses on the ACA's rule that large employees must offer health insurance or pay hefty fines. The suit also questions funding for a provision that helps low income earners afford out-of-pocket medical costs. The suit was filed in the U.S. District Court for the District of Columbia on Nov. 21. Speaker John Boehner (R-Ohio) says the lawsuit is necessary after he says the President rewrote federal law without input from Congress. He added that the lawsuit will prevent future presidents from circumventing the Constitution. Legal scholars say Republicans will have difficulties establishing standing in court. The legal system also has limits on ruling on matters that a judge could consider political.


The Medicare Payment Advisory Commission (MedPAC) is considering eliminating the observation status for hospitalized Medicare beneficiaries in response to criticism over the "two-midnight rule." Under the proposal, which is not expected to be formally suggested to Congress until at least June, Medicare would pay the same amount of money for observation status as it would for a one-day hospital stay. "The notion of eliminating observation status altogether in many respects is the most elegant solution of all," says MedPAC panelist Dr. Craig Samitt. "In essence, if we say we're going to pay observation status and one-day stay equally, then for each of these other downstream problems, the issue goes away." Some MedPAC members gave mixed responses to the proposal, with one saying it has "some appeal" but that the panel needs to look into issues such as whether eliminating observation status would result in Recovery Audit Contractors paying more attention to two-day hospital stays. But Medicare Rights Center President Joe Baker praised the proposal, saying it would "solve a lot of problems for consumers and resolve the issue of whether they're inpatient or outpatient."


The Department of Health and Human Services (HHS) is not planning to issue a so-called "mega-reg" to limit the scope of the 340B drug discount program as hospitals, drug manufacturers and pharmacies had been expecting. HHS' Health Resources and Services Administration (HRSA), which oversees the program, says it has withdrawn a draft regulation that would have limited 340B and will instead propose guidance next year to address "key policy issues raised by various stakeholders committed to the integrity" of the program. HRSA also plans to issue three separate rules that govern civil monetary penalties for drug manufacturers, how the ceiling prices of 340B drugs are determined and dispute resolution. HHS' decision not to issue a mega-reg comes in response to a legal dispute the department had with the Pharmaceutical Research and Manufacturers of America (PhRMA) over a regulation that requires drugmakers to provide discounts for expensive orphan drugs if they are used for non-orphan conditions or diseases. A judge ruled in PhRMA's favor and struck down that rule, forcing HRSA to reissue the regulation as an interpretative policy. HRSA wanted to prevent the draft regulation from experiencing the same fate.


An article published in the Journal of AHIMA (American Health Information Management Association) has found that small physicians' practices may not need to spend as much money on the conversion to ICD-10 as previously thought. An update made earlier this year to a report initially provided to the American Medical Association (AMA) in 2008 found that small practices could expect to spend $22,560-$105,506 on the conversion, although the article published in the Journal of AHIMA noted that such practices would only need to spend $1,900-$5,900. The article in the Journal of AHIMA defined a small practice as three physicians and two staffers, such as coders and/or office personnel, who would be affected by the conversion to ICD-10. The article added that physicians and their office staff, vendors and health plans have already made significant progress in their efforts to adopt the new coding system while devoting fewer resources than were previously thought to be necessary. The article added that some previous estimates of the costs to convert to ICD-10 were at least partially inflated because they included expenses associated with other unrelated healthcare initiatives, including the adoption of electronic health records and meaningful use. AHIMA CEO Lynne Thomas Gordon says the article shows that small practices can easily transition to ICD-10.


The Centers for Medicare and Medicaid Services (CMS) says certain eligible professionals and group practices that submit a full year's worth of data on the 2014 Physician Quality Reporting System (PQRS) program's clinical quality measures (CQM) can satisfy some of the requirements of several other programs as well, including the Medicare EHR Incentive Program, Medicare Shared Savings Program Accountable Care Organization (ACO), the Value-Based Payment Modifier and the Pioneer ACO Program. The reporting requirements for these programs were aligned this year to reduce the amount of data providers are required to submit, CMS says. The agency adds that reporting data from all of 2014 regarding clinical quality measures will allow these providers to obtain this year's PQRS incentive, avoid the 2016 PQRS payment adjustment, meet the Medicare EHR Incentive Program's CQM requirements and satisfy the requirements for the other programs. However, providers participating in the Medicare EHR Incentive Program can only take advantage of aligned reporting if they have participated in the program for at least a year.

Medicine, Drugs and Devices

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Pelubiprofen is just as effective as celecoxib in treating patients with rheumatoid arthritis, a new study has found. Pelubiprofen was found to be non-inferior to celecoxib in terms of its ability to reduce visual analog scale (VAS) pain severity from baseline to week six. Both treatments also demonstrated similar capacity for decreasing the duration of morning stiffness and decreasing the frequency and total amount of rescue medication patients had to take during the six-week trial. However, 31.2 percent of patients in the pelubiprofen group experienced an adverse drug reaction, compared to 20.6 percent of patients given celecoxib.


A recent study has found that low-intensity pulsed ultrasound (LUPUS) is not an effective treatment for lower-limb bone stress. The study involved 30 patients, mostly women, who had a grade II-IV bone stress injury in the postero-medial tibia, fibula or second, third or fourth metatarsal. Participants underwent treatment with LUPUS or a placebo device for 20 minutes each day for four weeks. When the study's authors analyzed the outcomes of 23 patients, they observed no significant differences between the LUPUS group or the placebo group in terms of changes to magnetic resonance imaging (MRI) grade following treatment. Both groups also displayed similar changes in bone marrow edema size. Finally, the study found that both groups of patients displayed similar changes in six clinical parameters: night pain, pain at rest, pain while walking, pain while running, tenderness and pain while performing a single leg hop. However, the study's authors cautioned that the changes were measured after a relatively short treatment period in a small, mostly female group of patients.