News From ACFAS

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Now available for download – the 2013 ACFAS Annual Scientific Conference Mobile App! Go digital this year with the app that puts ACFAS 2013 at your fingertips. Download the app, then check your inbox for an email you'll receive next week from ACFAS containing a personal code so you can populate your app with your personal schedule and contact information. Conference-going will never be the same!

Simply download the conference app to your iPhone, iPad, Droid or Blackberry and you’ll instantly be able to:

• Review all the conference happenings
• Find your way around with convenient maps
• Find the vendors you don’t want to miss
• Keep track of your pre-selected sessions
• Read the latest conference happenings in the Twitter feed
• Receive the latest conference alerts
• App will automatically upload changes and updates

Download today through one of three ways:
1. Visit acfas.org on your mobile device for a link to download the app.
2. On your mobile phone web browser, type http://crwd.cc/acfas2013. Your phone will automatically detect and download the app you need!
3. Search the Apple App Store on your iPhone or iPad for ACFAS 2013 and hit download.

Watch your inbox, ACFAS Update and future issues of This Week @ ACFAS for further details and download reminders! Why trust Lady Luck to get you in to the programs you’d most like to attend at ACFAS 2013 when you can register for them now?

A pre-conference workshop and one program within the Annual Scientific Conference are already sold out, but there are still many opportunities for quality education. Courses at ACFAS 2013 are first-come, first-served; so check out the course brochure at acfas.org/vegas and register now to ensure your attendance to your preferred courses.

Remember, discounted registration for ACFAS 2013 is still available until January 25, 2013. After this date, all registrations will need to take place on site. Plus, ACFAS is passing along savings we received from our hotel partners to members on significantly-reduced hotel rates, so book now to take advantage of these rates. Congratulations to Shelly Larson, DPM, AACFAS, of Butler, Pennsylvania! Of all the new ACFAS Associate Members, she is the lucky winner of a new Apple iPad. The ACFAS Membership Committee sponsored this contest to celebrate residents who have recently passed the ABPS Board Qualifying exam and upgraded their membership to “Associate Member” with ACFAS.

Again, congratulations, Dr. Larson, and welcome to you and all of our new Associate Members to ACFAS.

Foot and Ankle Surgery

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The outcomes of open and arthroscopic ankle arthrodesis were assessed in a comparative case series of patients managed at two institutions and followed for two years. The Ankle Osteoarthritis Scale (AOS) score was the primary result, while secondary results included the Short Form-36 physical and mental component scores, duration of hospital stay and radiographic alignment. Each group was comprised of 30 patients, and both groups demonstrated significant improvement in the AOS score and the Short Form-36 physical component score at one and two years. The arthroscopic arthrodesis group exhibited significantly greater improvement in the AOS score at one year and two years, while its hospital stays were shorter. The two groups showed similarities in terms of complications, surgical time and radiographic alignment.


A comparison of the clinical results and complications following reconstruction of the lower leg, ankle and heel via transfer of a perforator pedicle-based sural neurocutaneous flap (P-NCF) or a fascia pedicle-based sural neurocutaneous flap (F-NCF) was performed, focusing on 92 patients with a distal soft-tissue defect treated between March 2007 and December 2010. Forty-eight patients treated with P-NCF were compared with 44 patients receiving F-NCF therapy, and the etiology, size and operation time were recorded. In terms of clinical results, age, sex, defect etiology, duration of surgery and area of flaps did not expose significant disparities. Approximately 20.5 percent of the F-NCF group and 6.25 percent of the P-NCF group exhibited minor flap necrosis, while patient satisfaction, aesthetic appearance and functional outcome were comparable in both groups.


Evaluating the accuracy of syndesmosis reduction with different rotational vectors of forceps placement was the purpose of a study involving 10 through-the-knee cadaveric specimens. Markers were placed on the specimens' tibia and fibula to generate consistent clamp placement and radiographic assessment. A computed tomographic (CT) scan of the ankle was performed to function as a control, followed by a stepwise destabilization of the anterior inferior tibiofibular ligament, syndesmosis, deltoid ligament, small posterior malleolus fracture and large posterior malleolus fracture. Clamps were applied to compress the syndesmosis at varying angles following each step in the procedure, and CT was carried-out to measure the alignment of the syndesmosis as compared with that on the control scan.

The researchers noted a small but consistent amount of overcompression of the syndesmosis in all degrees of induced instability, and for all vectors of clamp placement. The average overcompression and standard deviation for all samples was 0.93 plus or minus 0.70 mm. Both obliquely oriented clamp arrangements consistently induced fibular malreductions in the sagittal plane. Positioning the clamp in the neutral anatomical axis reduced the syndesmosis with the greatest precision, with an average displacement of 0.1 plus or minus 0.77 mm versus control through all degrees of instability.

Practice Management

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When reporting information required by a federal audit, it is important that a medical practice reports all of the medically necessary information for the level of service billed. The administrator of a medical practice should conduct a self audit to make sure they are reporting the correct information to federal authorities in order to remain in compliance. The first step to doing this is to print the codes from the practice management system for the levels of care that are in question, and then compare them with those sent by the requester. If the numbers do not match and the source information for the data is unclear, the administrator should request a patient list.

Administrators should then check to make sure the patient names on the list actually belong to a doctor in the practice. The second step is to review the coding and billing practices to make sure they are in compliance with the requester. Administrators should make sure all services performed are medically responsible and necessary, and they should make sure all necessary documentation is complete before a service is performed. They should look for common mistakes in the charts. One of these mistakes is insufficient information reported, most commonly associated with not reporting a history of medical decision-making.

The charts should also include any medically indicated details of physical examinations. Any information added to a chart should be distinctly labeled with the date and time it was added, and all charts should be signed electronically or manually, but never with a stamp. The federal government has become increasingly focused on signatures, and third-party payers are likely to follow with the government's methods. After the self audit is complete, the administrator should be sure to appeal any penalties that the requester stated by showing that the levels of service are correct. The administrators should be sure to conduct self audits on a regular basis so as to reinforce the habit and keep the practice in compliance with federal regulation.


Effectively managing staff is key for success in any business venture, but doing so in a medical challenge often brings unique challenges. Practice managers are different from many other business leaders, in that their attention is often turned to the business of patient care rather than the management of their staff, but there are a number actions an administrator can take to improve staff management.

The first is to invest in training, which can be as simple as setting expectations and standards. This can be accomplished through the introduction of operations manuals and checklists, but also by hands-on observation of staff performance accompanied by appropriate praise, punishment and correction. Management systems are another good way to improve the work quality of the practice staff. Avoidance, detection and warning systems need not be expensive or computerized, and can be as simple as regularly reviewing records such as staff absences, scheduling and productivity goals for patterns of behavior that can be corrected or built upon. Finally, it is important to have help in improving staff management. Much of the actual management functions can be handled directly by a nurse or medical assistant, while it may be helpful to work with a consultant to craft management strategies.


Disruptive employees in the workplace can put a drag on the overall atmosphere of a medical practice and even drive patients away if their actions and attitude are left unchecked. When one employee treats another employee badly, the mistreated employee is more likely to quit than to say anything or report the behavior, say experts. Research has shown that up to 12 percent of workers leave their jobs because of poor treatment by another employee. A disruptive employee can also cause decreased productivity in the workplace. Keeping disruptive employees on staff can also paint the practice manager as an ineffective leader that condones bad behavior.

When moving to fire such an employee, practice managers should make sure they follow consistent disciplinary and termination policies so as to reduce the risk of a lawsuit. These can be placed inside of an employee handbook so all employees are properly informed. Firings should not come out of the blue; practice managers should have evidence that they tried to improve the employee's work ethic before letting them go. When the termination comes about, a practice manager should keep the meeting brief and stay to the point. Perhaps most importantly, no matter how disruptive the employee was, the practice manager should treat him or her with respect as he or she leaves.

Health Policy and Reimbursement

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For a third year in a row, U.S. healthcare spending in 2011 grew at its lowest rate in the 52 years. The Department of Health and Human Services says that the nation spent $2.7 trillion on healthcare in 2011, an increase of just 3.9 percent over the previous year. The low rate of growth in healthcare spending is not fully understood, as some have said that it is the result of the weak economy while others have attributed it to the effectiveness of cost controls implemented by the federal government and employers. Meanwhile, Medicare spending grew at a faster rate in 2011, though Medicaid spending slowed, the Department of Health and Human Services said.


The popularity of Performance Improvement Continuing Medical Education (PI CME) for physicians has grown significantly since its introduction in the early 2000s, and more physicians are employing this model as they face mounting pressure to show performance improvement. Although the model constitutes less than 1 percent of the more than 132,000 CME activities offered nationwide, demand for PI CME is expected to increase as the country migrates to a pay-for-performance system of care that favors quality over volume. “Physicians increasingly are going to be required to look at their practice and find ways to improve it," says American College of Physicians’ Center for Quality Director Laura Lee Hall. "PI CME is a way to help busy physicians approach this whole science of quality improvement.” The approval of PI CME standards in 2004 by the American Medical Association (AMA) and the American Academy of Family Physicians (AAFP) came in the wake of broad advisories for greater emphasis on patient safety and quality of care, according to Council of Medical Specialty Societies CEO Norman B. Kahn, Jr.

PI CME is a three-step process entailing evaluation of the physician’s practice using identified evidence-based performance measures, deployment of an intervention and reassessment of those performance measures to gauge improvement, the AMA says. A key benefit of the model is its ability to allow physicians to compare patient outcomes with national benchmarks, says Mindi McKenna with the AAFP's CME division. “For a patient whose physician is engaging in PI CME, it ensures more systematic, evidence-based care,” she notes. The equivalent of PI CME for osteopathic physicians is the American Osteopathic Association's Clinical Assessment Program, which boasts the same three-step structure as PI CME. PI CME also functions as a way for physicians to comply with quality improvement requirements stipulated by the Centers for Medicare & Medicaid Services and many private insurers.


A provision of the fiscal cliff bill that President Barack Obama signed Wednesday, January 3, will give Medicare officials the ability to take back an estimated $500 million in payments made to hospitals and physicians since 2007. The provision gives Medicare contractors five years to collect on errors in Medicare payments. Previously, the statute of limitations on nonfraudulent Medicare overpayments was only three years. But last May, the U.S. Department of Health and Human Services inspector general's office wrote that the three-year limit had prevented the Centers for Medicare & Medicaid Services from collecting as much as $332 million in overpayments that had already been identified by investigators because the auditing process takes so long.

Medicine, Drugs and Devices

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The Centers for Medicare & Medicaid Services missed its own 2012 deadline to issue the final rule for a regulation that aims to make financial relationships between healthcare providers and manufacturers more transparent. The Physician Payments Sunshine Act—a provision of the Patient Protection and Affordable Care Act—requires drug and device companies to report payments or gifts given to physicians and teaching hospitals. It also mandates that manufacturers and group purchasing organizations disclose physician ownership and investment interests. However, multiple delays in the rulemaking process mean that data collection is not likely to begin until well into this year and that the data will not be publicly available until 2014. The original statute called for draft regulations on data reporting and collection to be issued in October 2011, for data collection to begin in January 2012 and for data to be made public starting in 2013.


Some health organizations are opening physicians' clinical notes to patients via online portals in response to increased demand for patient engagement and more transparency, and experts say the initial step in such a process is to determine what information should be made available and whether this availability is technically feasible. Information should offer ease of use for patients, and the key to that is to make such information more accessible. Most organizations that opt for an open-notes environment will begin with a basic patient portal to which more capabilities and information will be added, and one expert recommends that organizations study the electronic elements of the patient record to decide which ones patients would benefit from seeing. Another expert says each organization has to decide whether to limit access to certain patients, while another option is to suppress specific notes until the physician can consult with the patient. Physicians also may adjust how they write notes, depending on the purpose; some view notes as only a record of a patient exam, while others consider notes to be a form of physician-patient communication.


The Journal of Clinical Endocrinology & Metabolism has published a study that examined the effects of tripotassium citrate (TPC) on the bones of healthy older adults. More than 200 participants, all of whom were aged 65 and up, took either 60mEq/d of alkalizing TPC or placebo for 24 months, as well as 500 mg of calcium and 400 IU of vitamin D3. Those who took TPC experienced a 1.7 percent increase of lumbar spine at areal bone mineral density, as well as significant increases of trabecular densities in both radii and both tibiae. Fracture prediction scores declined in the TPC group as well.