News From ACFAS

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Fellow and Associate members, don't let your ACFAS membership lapse! Renew your membership today at acfas.org/paymydues or via mail or fax by the December 31 deadline to avoid a late fee. The 2015 dues reminders were mailed to all Fellow and Associate members in November.

Your ACFAS membership is your connection to the best and brightest in the foot and ankle surgery profession. Start 2015 off right by continuing your membership and making the most of everything the College has to offer! Congratulations to Lauren L. Kishman, DPM, AACFAS, of Akron, Ohio! Of the new ACFAS Associate Members, she is the lucky winner of a complimentary registration to the 2015 Annual Scientific Conference in Phoenix this February. The ACFAS Membership Committee sponsored the contest to celebrate residents who have recently passed the ABFAS Board Qualifying exam and upgraded their membership to “Associate Member” with ACFAS.

Again, congratulations to Dr. Kishman and welcome to all of our new Associate Members. We hope to see you in Phoenix! Wish you had time to read studies published in other scientific specialty journals? ACFAS is here to help. Our monthly Scientific Literature Reviews (SLRs), written by podiatric surgical residents, summarize the latest studies that may affect your surgical cases.

Visit acfas.org/SLR to read new SLRs on the treatment of diabetic neuropathy and foot ulcers, arthroscopic assessment of medial malleolar reduction, effects of a surgical career on a woman’s childbearing and fertility, the influence of knee position on ankle dorsiflexion and much more.

Each SLR includes podiatric relevance, methods, results and conclusions and highlights a topic you may have been wanting to learn more about but just haven't found the time. Visit our complete archive of SLRs dating back to 2009 to catch up and be sure to check the site monthly for newly released reviews.

Foot and Ankle Surgery

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Questions are being raised about the safety of ambulatory surgery centers amid the increased popularity of these facilities for procedures such as joint repairs and the aftermath of the death of Joan Rivers at an outpatient surgery center. Former Ambulatory Surgery Center Association President David Shapiro said cases such as Rivers', who died as the result of a "therapeutic complication" while undergoing a procedure at an outpatient surgery in New York City that was later found to be in violation of a number of regulations, is unusual. Shapiro notes that outpatient surgery centers have an "exceptional" success rate and that they are "very, very tightly regulated." The findings of at least two studies indicate that the rate of complications in patients at these facilities is low. For example, an analysis of 244,000 outpatient surgeries performed between 2005 and 2010 found that the overall rate of complications was 0.1 percent. But Lisa McGiffert, the director of Consumers Union's Safe Patient Projects says an insufficient amount of detailed information exists about outcomes and quality measures at outpatient surgery centers. McGiffert also pointed out that such facilities are generally regulated differently by each state. For example, some states do not require outpatient surgery centers to report post-operative infections.


Minimally invasive reduction and percutaneous fixation (MIRPF) is superior to open reduction and internal fixation at managing displaced intra-articular calcaneal fractures, a new study has found. The finding may help settle the controversy over the best way to manage such fractures. The study's authors examined the outcomes in 45 displaced intra-articular fractures treated with either ORIF or MIRPF. Participants were followed up with clinically and radiologically for at least a year after surgery. The study found that seven of the 23 heels in the ORIF group had wound-healing problems, which was the primary outcome measure, while none in the MIRPF group did. Median time to return to work was two weeks earlier in the MIRPF group than it was in the ORIF group. In addition, patients treated with MIRPF had better Creighton Nebraska Health Foundation scale scores, which were used to measure functional outcomes, after one year compared to patients treated with ORIF.

Practice Management

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Practice management consultant Nick Hernandez, MBA, FACHE, says physicians need to have good communications skills to lead their practices effectively. Hernandez says benefits of effective communications between physicians, staff and patients include more positive and productive interactions and higher levels of motivation and productivity among employees. One way physicians can improve their communications skills and realize these benefits, Hernandez says, is by projecting an image of being approachable when there is a problem. Hernandez says employees should not be afraid that they will be treated harshly by a physician for reporting a problem within the practice since the presence of such fear will make employees less likely to discuss problems with physicians. Physicians can convey approachability by listening closely to employees, making eye contact and smiling during conversations, and asking open-ended questions. Another recommendation Hernandez has for physicians is to explain the reasoning they use to arrive at their decisions, as this will increase the chances that staffers will follow their requests. Finally, Hernandez says physicians should pay close attention to staffers' body language during conversations to determine if they understand what they are being told. If physicians have doubts that employees understand what is being said, Hernandez says, they should make a clearer restatement or ask the employee to restate what was said.


Physicians' practices may want to consider offering their patients the option to pay their balances online to reduce their outstanding accounts receivable. Practices have several different options for implementing online bill payment, including using a standalone system or one that is integrated into the electronic health record system or patient portal. Any of these types of systems can help reduce outstanding accounts receivable because patients expect to be able to pay all of their bills in this fashion. But physicians' practices should also take several other steps to ensure they collect the money they are owed by patients, including designating a staffer or a group of employees who will be responsible for discussing financial policies with patients. These individuals can include front desk employees or someone in the billing department. Regardless of who is chosen, the designated employee or employees should give patients a written copy of the practice's financial policy with the most important information highlighted or circled. Employees should also develop a relationship with patients to help make the process of contacting those with past-due balances easier. In addition, patients should be told whether the practice sends out statements before the patient's financial responsibility has been determined by his or her insurer or after.

Health Policy and Reimbursement

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The percentage of Americans who are uninsured is at the lowest level ever recorded and is expected to continue to fall in the year ahead, according to the White House Council of Economic Advisers (CEA). CEA released a study that showed that the percentage of Americans without insurance fell from 14.4 percent before the Affordable Care Act's exchanges went online last year to 11.3 percent as of the first half of this year. The decline in the percentage of uninsured consumers is due to the fact that 9.7 million people have obtained health insurance in the first year of the exchanges, CEA says. In addition, the number of Medicaid beneficiaries has increased by almost 20 percent since summer 2013. CEA predicts that the number of Americans who lack health insurance will continue to fall in the year ahead, partly because at least 2.5 million people have signed up for new insurance coverage in the current enrollment period.


Vermont Gov. Peter Shumlin issued a statement Dec. 17 saying he will no longer move forward with his effort to create Green Mountain Care, a quasi single-payer health system, by 2017. Shumlin said now is "not the right time" to move forward with such a plan due in part to what he said are the heavy tax increases that would have been necessary to fund it and because not as much federal money is available to fund the creation of the program as previously expected. Green Mountain Care was billed by some as the first state-based, single-payer system but was not actually single-payer because large companies with some types of self-insured plans would have been exempt and because Medicare would likely have continued to operate independently. Shumlin's decision is coming under fire from single-payer advocates who say the 2011 law that calls for the creation of a single-payer system remains in effect.


American College of Physicians (ACP) President David A. Fleming, MD, MA, MACP, is criticizing Congress for failing to take action on the Medicare sustainable growth rate formula (SGR) and other issues related to Medicare payments to physicians during its lame-duck session. Fleming says it is imperative that the next Congress address these issues after it is seated in January. Failing to patch SGR or repeal it altogether by March 31, when the current patch is scheduled to expire, means physicians could see their Medicare payments cut by 21 percent. Other organizations besides ACP are also calling on Congress to repeal SGR.


The Department of Health and Human Services (HHS) released a report on Dec. 2 to tout the achievements of its efforts to transition from fee-for-service to a pay-for-performance payment model. HHS noted that its efforts, along with those of its healthcare partners, helped save 50,000 lives, reduced the number of iatrogenic patient injuries by 1.3 million and saved $12 billion in health spending. Some say these findings highlight the usefulness of compensation bonus agreements between physicians and facilities that collaborate on efforts to improve patient outcomes. These agreements, which are also known as comanagement pay-for-performance agreements, allow physicians and facilities to share performance bonuses if they achieve certain outcome metrics or benchmarks. One reason why comanagement agreements are praised by some is because they highlight the fact that physicians can take an active role in reducing bad patient outcomes and that they should receive incentives for implementing quality-of-care initiatives. However, comanagement agreements need to be structured carefully to be as effective as possible. For instance, the agreements must include a guaranteed, fixed payment per year and a potential annual performance-based payment equal to an annual maximum.


House Energy and Commerce Committee Chair Fred Upton (R-Mich.) and House Rules Committee Chair Pete Sessions (R-Texas) recently voiced their support for keeping the upcoming deadline for ICD-10 transition as Oct. 1, 2015. Upton and Sessions voiced their support for the transition deadline in a joint statement saying they intend to "continue our close communication with the Centers for Medicare and Medicaid Services to ensure that the deadline can successfully be met by stakeholders," calling it a "milestone in the future of healthcare technology." Upton and Sessions say they heard from several interested parties worried about falling behind after the latest delay of ICD-10 and say that moving forward with the transition is a priority. The statement is a further indication of a lack of congressional support for further ICD-10 delays. Groups like the American Medical Association are pushing for a two-year delay but failed to have the delay included in the recently approved spending bill.

Medicine, Drugs and Devices

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The findings of a study recently published in the journal Arthritis & Rheumatism could affect how gout patients are treated, according to the study's lead researcher, Hyon K. Choi, MD, DrPH. Choi and a team of researchers used data from a separate study to examine the relationship between the risk of gout attacks and the time of day and also recruited 724 gout patients and asked them to report the time of day they experienced attacks for a one-year period. Participants were also asked to report medication use and possible risk factors for gout attacks, including the consumption of alcohol or seafood during the one- to two-day period before an attack took place. Researchers found that the risk of gout flares was 2.36 times higher overnight than it was during the day and 1.26 times higher overnight than in the evening. Overnight was defined as being from 12 a.m. to 7:59 a.m. The higher risk of a gout attack during the overnight period compared to other times of the day persisted even among patients who did not drink alcohol and had low purine intake during the 24 hours preceding an attack. The study also noted that these associations remained after taking into consideration factors such as patients' use of diuretics, gout medications and non-steroidal anti-inflammatory drugs. Choi said the findings show that prophylactic drugs used to prevent gout flares, particularly those with short half-lives, are likely to be more effective if taken at night.


Orthopaedic surgeons in China have published a study that sought to help answer the question of what is the best way to treat displaced intraarticular calcaneal fractures, a condition for which there is no uniform method of treatment. The study's authors attempted to answer that question by treating 42 intraarticular fracture patients with either locking or nonlocking plates and then comparing the radiological and functional outcomes in the two groups. All patients experienced healing of their fractures regardless of the type of plate used, although patients treated with locking plates had significantly better Bohler's and Gissane's angles than did their counterparts in the nonlocking plate group. None of the patients in the locking plate group experienced complications, while three patients in the nonlocking plate group experienced implant loosening that resulted in loss of reduction. In addition, the locking plate group had an average American Orthopaedic Foot and Ankle Society hindfoot score that was significantly higher than that of the nonlocking plate group. The study's authors said their findings suggest that locking plates could provide better stability and functional recovery in the treatment of intraarticular calcaneal fractures.


A recent randomized control trial (RCT) and open-label extension (OLE) study examined the safety and effectiveness of treating patients with active rheumatoid arthritis with certolizumab pegol (CZP) and methotrexate (MTX) for five years. The RCT phase lasted one year, followed by the OLE, during which patients initially received 400 mg of CZP along with MTX every other week for as long as 204 weeks in some patients. After six months or more, the dose of CZP was reduced to 200 mg every other week although it was still taken in conjunction with MTX. The study found that the overall event rate (ER) per 100 patient years of adverse events was 290.4, with the most frequent adverse events being urinary tract infections, nasopharyngitis and upper respiratory tract infections. ER of serious adverse events, meanwhile, was 20.3. In addition, 21 of the 958 patients from whom safety data was collected experienced a fatal adverse event. The study also found that Disease Activity Score (DAS)28 remission rates and improvements from baseline were maintained until week 256 in the 508 patients who completed the RAPID1 study and subsequently enrolled in the OLE. This was also observed in the 783 patients who were randomized to receive CZP, whether they finished the RCT or not. The study concluded that a five-year course of treatment with CZP and MTX has a favorable risk-benefit profile.