News From ACFAS

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Last Friday, January 5, ACFAS eligible voting members received an email from the College’s independent election firm with a unique link to the 2018 Board of Directors Election website. If you are a Fellow, Associate, Life or Emeritus member, please take a few minutes to cast your vote for your elected leadership. Your vote is important to advancing our profession and surgical specialty.

If you have not yet voted, two more reminder emails will be sent to you in the next few weeks. If you do not have a valid email address on file with the College or your email system blocked the email from our election company, watch your U.S. mail for voting instructions. Voting remains open until January 22. Register now for the free webinar, “Take a New Look at Practice Building,” set for January 17 at 8pm ET/7pm CT, and learn how to increase referrals to your practice while helping other healthcare providers become more aware of your expertise.

Hear your colleagues Christopher L. Reeves, DPM, FACFAS; Amber M. Shane, DPM, FACFAS; and John S. Steinberg, DPM, FACFAS discuss how they have used the Take a New Look at Foot & Ankle Surgeons campaign marketing materials to drive practice growth.

Melissa Matusek, ACFAS director of Marketing and Communications, will also outline the resources available in the Marketing Toolbox to promote your practice to patients and other healthcare professionals.

Don't miss out on these free tips and takeaways—register today at acfas.org/practicebuilding. Head to the HUB in the ACFAS 2018 Exhibit Hall for fresh takes on timeless sessions, including Imagine Them Naked: Public Speaking and Teaching, Employing a PA or NP and Perfecting Your PowerPoint Presentation, plus brand-new additions to the lineup, such as:

• JFAS—How to Get Published
• Preparing Your Office for Medical Emergencies
• Working with Industry
• Are You Tomorrow’s ACFAS Leadership?
• And more!

Each 50-minute HUB session encourages open and candid discussion between you and the speakers. Gain practical tips for handling the nonclinical side of your practice and meet a few new friends along the way.

Download the ACFAS 2018 conference program at acfas.org/nashville to view the complete HUB schedule and to decide which sessions you would like to attend.

Foot and Ankle Surgery

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This study was conducted to assess the prognostic value of a high or immeasurable ankle-brachial index (ABI) at baseline for major amputation and amputation-free survival (AFS) in patients with critical limb ischemia (CLI). Data from two recent trials in patients with CLI and proven infrapopliteal arterial obstructive disease were pooled. Patients were allocated to the low (<0.7), intermediate (0.7-1.4) or high (>1.4)/immeasurable ABI subgroup. Major amputation and AFS rates were compared. Hazard ratios for major amputation and death were calculated. The net reclassification improvement of incorporating high/immeasurable ABI in the Project of Ex-Vivo vein graft Engineering via Transfection III (PREVENT III) prediction model was derived. There were 146 patients (56.2 percent) who had a low ABI, 81 patients (31.2 percent) who had an intermediate ABI and 33 patients (12.7 percent) who had a high/immeasurable ABI at baseline. Patients with high/immeasurable ABI showed higher five-year major amputation (52.1 percent) and lower five-year AFS (5.0 percent) rates than the intermediate (25.5 percent and 41.6 percent, respectively) and low ABI patients (23.5 percent and 46.9 percent, respectively). This same trend was observed in subgroup analysis of patients living with and without diabetes. Adjusted hazard ratio of high/immeasurable ABI for major amputation/death risk was 2.93. Adding a high/immeasurable ABI as model factor to the PREVENT III model yielded a net reclassification index of 0.38. The researchers found that a high/immeasurable ABI in patients with CLI and infrapopliteal arterial obstructive disease was an independent risk factor of major amputation and of poor AFS, in patients living with and without diabetes. Incorporating high/immeasurable ABI in the PREVENT III prediction model improves its performance, they concluded.


Researchers conducted a randomized clinical trial to examine if antibiotic prophylaxis with a single preoperative dose of intravenous cefazolin (1,000 mg) reduces the risk of surgical site infection (SSI) following removal of orthopaedic implants used for treatment of fractures below the knee. Researchers conducted a multicenter, double-blind, randomized clinical trial including 500 patients aged 18 to 75 years with previous surgical treatment for fractures below the knee who were undergoing removal of orthopaedic implants in 19 hospitals in the Netherlands (November 2014–September 2016), with a follow-up of six months (final follow-up, March 28, 2017). Exclusion criteria were an active infection or fistula, antibiotic treatment, reimplantation of osteosynthesis material in the same session, allergy to cephalosporins, known kidney disease, immunosuppressant use or pregnancy. Researchers administered a single preoperative intravenous dose of 1,000 mg of cefazolin (cefazolin group, n=228) or sodium chloride (0.9 percent; saline group, n=242). Among 477 randomized patients (mean age, 44 years; women, 274; median time from orthopaedic implant placement, 11 months), 470 patients completed the study. Sixty-six patients developed an SSI (14.0 percent): 30 patients (13.2 percent) in the cefazolin group versus 36 in the saline group (14.9 percent). The researchers concluded that a single preoperative dose of intravenous cefazolin did not reduce the risk of surgical site infection within 30 days following removal of orthopaedic implants used for treatment of fractures below the knee.


The objective of this study was to compare the preoperative diagnostic accuracy of plain radiographic findings with the accuracy of magnetic resonance imaging (MRI) findings for diabetic foot osteomyelitis in hospitalized patients who underwent first-time partial foot amputations with confirmed histopathological specimens positive for osteomyelitis. Researchers also sought to determine whether certain variables within the initial clinical presentation and preoperative laboratory findings were associated with more accurate diagnosis of diabetic foot osteomyelitis in this study population. Another goal was to determine the most common bacterial organisms found in bone and soft-tissue cultures taken intraoperatively and to determine how often the same organism was found in both. After applying the inclusion and exclusion criteria to the initial 329 patients identified through chart review, the final sample size for further analysis was n=107. In this study, after adjusting for the effects of covariates, such as age, erythrocyte sedimentation rate (ESR) and C-reactive protein, plain radiographs seemed to have statistically more significant power than MRI in predicting and diagnosing diabetic foot osteomyelitis. Moreover, the higher ESR values were confirmed to predict a higher chance of positive diagnosis for diabetic foot osteomyelitis. The presence of positive bacterial identification from intraoperative bone cultures did not always indicate true osteomyelitis on histopathological examination, the researchers found.

Practice Management

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Trends toward more patient involvement, proactive population health management and inventive use of digital health in chronic care management are influencing tomorrow's healthcare technologies, while a conflict between the desire for greater access to information and pressure to more securely protect healthcare data also is significant. Among the anticipated 2018 tech trends is voice recognition to elevate the quality of care and patient experience. For example, new technologies are coming that will translate the distorted speech of patients with Parkinson's disease or those who have been affected by stroke. A second expected trend is cloud-based applications in physician practices. As healthcare security threats grow, practices are especially vulnerable because they often lack the resources to keep up with security updates or the IT staff to manage their response to potential threats. Cloud technology addresses the risk potential both effectively and economically. Also predicted for next year is the growing use of patient-generated health data capabilities by providers, driven by the federal government's recognition of the value of such data in supplementing medical information collected by providers. Meanwhile, the fast increase in options for healthcare wearables and use-at-home medical devices signals a growing consumer desire to capture and share health information with physicians.


Telemedicine is emerging as an effective way for doctors in urban areas to connect with patients. For example, the Mary's Center, in Washington D.C., has a pilot program to provide primary care to Medicaid patients who cannot reach clinics for various reasons. Experts say telemedicine has the benefits of building stronger relationships with doctors and reducing the number of nonemergency hospital visits. Furthermore, it opens up opportunities to help doctors extend additional treatments, such as flu shots or nutritionist appointments, to patients. However, barriers can prevent telemedicine from being effective. Doctors need to be licensed in the same state as a patient to complete a visit.


BuildMyBod Health CEO Jonathan Kaplan writes price transparency can be a valuable lead-generation tool for medical practices. "A lead is important, no matter where they are in the [sales] funnel," he notes. "Better to capture and nurture as many leads as possible because eventually, statistically, they'll be paying patients." Price transparency, as manifested by a "Get a Quote Now" button on the practice's website, guarantees that the practice will generate many leads. "With this Price Estimator type of call to action, consumers submit a 'wish list' containing their procedures of interest along with their contact info," Kaplan says. "The consumer immediately receives a cost estimate and the provider receives the consumer's contact info—the lead." Patience is required by practices in terms of waiting for leads to convert into clients. Kaplan cites the BuildMyBod Health price transparency website's finding that consumers who submitted three or more "wish lists" to a physician waited an average of 41.4 days between submitting each of their wish lists. "Capturing leads is critical to provider success," Kaplan contends. "And hopefully, by now, you'll agree there's no better way to capture leads than through price transparency."

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) has unveiled plans for an expanded bundled payment model that calls for participants to take on risk in both inpatient and outpatient settings and that will qualify providers for additional incentives under the 2015 Medicare Access and CHIP Reauthorization Act. The Bundled Payments for Care Improvement (BPCI) Advanced model is the next generation of the BPCI models already operating around the country. BPCI Advanced comes after CMS canceled an Obama-era proposal for mandatory bundled payments in cardiac care, as well as a mandatory expansion of a program in joint replacements.


U.S. District Judge Rudolph Contreras ruled the Trump administration can make sharp cuts to 340B subsidies Medicare pays some hospitals for pharmaceuticals. The American Hospital Association and two other healthcare groups had filed a lawsuit against the U.S. Department of Health and Human Services in an attempt to stop the cuts. But Contreras dismissed the case, saying the plaintiffs cannot sue before exhausting other avenues to challenge the cuts, as required by law. The other plaintiffs were the Association of American Medical Colleges and America's Essential Hospitals. Judge Contreras’s ruling means Medicare can proceed with the cuts, which were scheduled to start January 1. The administration estimates the cuts will reduce annual drug spending by Medicare and beneficiaries—who pick up some of the cost of certain drugs—by about $1.6 billion. Officials with the trade groups said the ruling left open the possibility hospitals could return to court to challenge the reduced subsidies. The 340B program requires pharmaceutical companies to sell some drugs at a steep discount to hospitals and clinics that care for large numbers of low-income or uninsured patients. Medicare has paid hospitals slightly more than the average sales price for the drugs. Hospitals have argued the difference helps pay for expanded services for patients. Medicare will now slash what it pays hospitals eligible for the program, under a new rule the administration released in November.


The Trump administration has issued a proposed rule that would allow more small businesses and self-employed workers to band together to buy health insurance. Experts say the rule to expand access to "association health plans"—part of the administration's goal to encourage competition in the health insurance markets and lower the cost of coverage—actually could weaken the individual health insurance market. These plans are not subject to the same regulations and consumer protections as other health plans sold under the Affordable Care Act (ACA). The proposed rule would broaden the definition of an employer under the Employee Retirement Income Security Act of 1974 to allow more employers to form association health plans and bypass ACA rules.


Consumers in the United States typically use about the same amount of healthcare as do people in other wealthy countries, but they pay significantly more for it, according to a 2003 paper in Health Affairs. "What was true in 2003 remains so today," says Harvard University's Ashish Jha. A recent study in JAMA by scholars from UCLA and the Institute for Health Metrics and Evaluation cited prices as a likely culprit. The study suggests that more is done for patients during hospital stays and doctor visits, but they are charged more per service or both. Potential ways to curb high healthcare prices include an all-payer system, such as that seen in Maryland, which regulates prices so that all insurers and public programs pay the same amount. A single-payer system could also regulate prices. Higher prices are not all bad for consumers because they could potentially lead to increased innovation. Although it is reasonable to push back on high healthcare prices, there may be a limit as to how far the country should, say researchers Austin Frakt and Aaron E. Carroll.

Medicine, Drugs and Devices

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The U.S. Food and Drug Administration announced that it will permit the marketing of the first shock wave device intended to treat diabetic foot ulcers. The Dermapace System (Sanuwave, Inc.) is intended to treat chronic, full-thickness diabetic foot ulcers with wound areas measuring no larger than 16 cm² that extend through the epidermis, dermis, tendon or capsule but without bone exposure. The external shock wave system uses pulses of energy to mechanically stimulate the wound. The system is intended for adults, aged 22 years and older, presenting with diabetic foot ulcers lasting for more than 30 days, and it should be used in conjunction with standard diabetic ulcer care. According to the U.S. Centers for Disease Control and Prevention, an estimated 30.3 million people in the United States have been diagnosed with diabetes. Approximately one quarter of those individuals will experience a foot ulcer in their lifetime.


For years, China's drug industry concentrated on replicating Western medicines, but the country is now pushing to play a bigger role in the global drug industry. Millions of people in China have cancer or diabetes, and the government has made pharmaceutical innovation a national priority. Officials have promised to speed up drug approvals and to reverse a brain drain by luring scientists back home. The authorities are providing land, grants and tax breaks and investing in research. China's drug development is in the earliest stages compared with the broader industry. Some experts say, however, that it is only a matter of time before China’s medical companies stand alongside major international pharmaceutical firms.


The pharmaceutical industry lobby spent 2017 working to redirect public anger about drug prices to pharmacy benefits managers (PBMs), in the process bringing a long-simmering feud between two big health industry players into the open. The drug companies' fight with PBMs and insurers has helped thwart any real action on the issue of drug pricing—splintering the problem into a multi-industry echo chamber of accusations that is hard to comprehend, much less solve. "This has been a year of finger-pointing," says Steven Pearson, president of the Institute for Clinical and Economic Review, a nonprofit organization that receives funding from insurance and drug companies. "They're flooding the zone—with 'they' being pharma—with efforts to diffuse and deflect the focus on their role in drug pricing. Part of the policy challenge is they have a point." PBMs say they typically pass along 90 percent of the savings they negotiate to customers and point to data showing no link between drug price growth and rebates. "It is so convoluted and so complicated," says Gerard Anderson, a professor at Johns Hopkins Bloomberg School of Public Health. "The PBMs have grown in power and profitability over the last 10 years and are becoming a huge force. The drug companies, they're the ones that raise prices. It's definitely a synergistic relationship."