News From ACFAS

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The American Medical Association recently released findings from its Allied Health Professionals Survey, designed to study how hospital medical staffs integrate and monitor the activities of “allied health professionals” (an AMA-coined term) with regard to patient care, safety, quality and ethical issues. The survey was conducted by the AMA’s Organized Medical Staff Section and the National Association of Medical Staff Service, with data collected from 439 NAMSS members from May through July 2010.

Highlights include:

• Top four non-physician health professionals practicing in respondent hospitals: nurse practitioners (98%), physician assistants (97%), podiatrists (93%) and dentists (80%)
• Podiatrists (83%), dentists (80%) and doctorate level counselors (59%) most likely to be licensed independent practitioners
• Nurse anesthetists, nurse practitioners, nurse midwives and physician assistants were typically under the supervision of MD/DOs and credentialed and privileged by the medical staff, as were podiatrists and dentists
• Dentists (88%) and podiatrists (86%) most likely to be members of the hospital medical staff compared to other non-physician health professionals at respondent hospitals
• Podiatrists and dentists most likely to qualify for medical staff officer or have voting rights
• Dentists (89%), podiatrists (87%) and chiropractors (55%) have highest entitlement to due process under the medical staff bylaws

For more background and results, visit the AMA website.
Have you ever had a difficult case, one that presented unique medical or management challenges? Submit it by Jan. 15, 2011, for presentation in the “Curbside Consult” at the ACFAS 2011 Annual Scientific Conference in Fort Lauderdale, Fla.

If selected, your case will be discussed by expert clinicians in a forum designed to give you opinions and an unbiased read from your colleagues. Visit the Curbside Consult web page to submit an uncommon case today!
Mac users will be happy to learn that the member login at acfas.org is now working in Safari, as well as in Firefox. We appreciate your patience as we resolved this glitch.

What mobile devices are DPMs using? A recent analysis of mobile operating system use by visitors to acfas.org reveals this top five:

• iPhone (47%)
• iPad (22%)
• Android (18%)
• BlackBerry (7%)
• iPod (3.5%)

Foot and Ankle Surgery

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Researchers performed a study to assess the results of the treatment of congenital pseudarthrosis of the tibia by excision of the pseudarthrosis, transarticular intramedullary rodding, and onlay autogenous cortical bone grafting in a group of children who were tracked until skeletal maturity. Eleven of 38 children treated with this method for over two decades reached skeletal maturity, and union of the pseudarthrosis was facilitated in nine of the 11 children after the index operation, and in two cases after additional surgery.

All 11 patients had a soundly united tibia at final follow-up, although 10 patients exhibited persistent fibular pseudarthrosis; 10 patients had 21 secondary operations for various indications, and at final follow-up anterior or medial bowing of the tibia, ranging from five to 28 degrees, was observed in seven patients, and ankle valgus was seen in five patients. Just three patients who had their transarticular rods extracted exhibited satisfactory ankle motion.

The researchers concluded that excision of pseudarthrosis, intramedullary rodding, and cortical bone grafting effectively unites congenital pseudarthrosis of the tibia, but a percentage of patients will need further surgery to contend with refractures and other complications.



Researchers investigated the potential clinical benefit of tibiotalocalcaneal arthrodesis (TTCA) with an intramedullary nail with a valgus curve, two compression options, and angle-stable locking. Patients who had undergone TTCA at two tertiary hospitals were eligible. Patients who had undergone TTCA before the beginning of the study were evaluated retrospectively, then all following patients were examined prospectively. There were 59 TTCAs; 55 patients were available for analysis. Twenty-eight were evaluated retrospectively, 27 prospectively.

Bony union was obtained in 53 patients. Fifty-one patients were satisfied with the outcome. Fifty-one patients had marked subjective improvement in mobility. The mean AOFAS score of the 55 patients at the latest followup was 66.8. The mean Mazzur score was 68.0. In the prospective group, the scores were significantly improved: AOFAS score by an average of 39.6 points and Mazur score by an average of 43 points. SF-36 physical component summary score and mental component summary score also improved. Radiology showed good hindfoot alignment. The complication rate was 25 percent.

The researchers concluded that compared with the literature, the data obtained in this study show a good outcome and a high rate of bony union, with comparable complication rates. Patient satisfaction was good.



Researchers evaluated current evidence regarding the prognostic value of the Semmes Weinstein monofilament examination (SWME) in predicting foot ulceration and lower extremity amputations (LEAs) in patients with diabetes mellitus (DM). The MEDLINE/PubMed database was searched through November 2009 for articles pertaining to diabetic foot and SWME.

Of the 863 studies identified, nine articles were relevant, involving 11,007 patients with DM. Six studies were identified that assessed the prognostic value of SWME regarding diabetic foot ulceration. The relative risk for patients with a positive SWME result versus those with a negative result ranged from 2.5 (95 percent confidence interval [CI]) to 7.9 (95 percent CI) in the identified studies with follow up between one and four years. Three of the studies assessed the risk of LEA with a positive SWME result. The relative risk for LEA ranged from 1.7 (95 percent CI) to 15.1 (95 percent CI) with follow-up between 1.5 and 3.3 years.

The researchers concluded that all nine studies found SWME to be a significant and independent predictor of future foot ulceration or likely of future LEA in patients with DM. Therefore, SWME is an important evidence-based tool for predicting the prognosis of patients with diabetic foot.

Practice Management

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Researchers described the Facebook activity of residents and fellows and their opinions regarding the impact of Facebook on the doctor–patient relationship. An anonymous questionnaire was e-mailed to 405 residents and fellows at the Rouen University Hospital in France. Of the 202 participants who returned the questionnaire, 147 had a Facebook profile. Among responders, 138 displayed their real name on their profile, 136 their birthdates, 128 a personal photograph, 83 their current university, and 76 their current position. Default privacy settings were changed by 61 percent of users, more frequently if they were registered for more than one year. If a patient requested them as a "friend," 152 (85 percent) participants would automatically decline the request, 26 (15 percent) would decide on an individual basis and none would automatically accept the request. Eighty-eight participants (48 percent) believed that the doctor–patient relationship would be altered if patients discovered that their doctor had a Facebook account, but 139 (76 percent) considered that it would change only if the patient had open access to their doctor's profile, independent of its content.

The researchers concluded that residents and fellows frequently use Facebook and display personal information on their profiles. Insufficient privacy protection might have an impact the doctor–patient relationship.



Approximately 16 percent of family doctors used online scheduling in 2009, up from 6 percent in 2005, according to the American Academy of Family Physicians. Most do it on their own or through health systems in which they work. Some outsource the function.

ZocDoc, which started in New York City in 2007 and entered the Washington market last year, also offers its online doctor scheduling in Chicago and Dallas and aims to add doctors in Boston, Los Angeles, Houston and Philadelphia. About 40 percent of ZocDoc appointments take place within a day of booking. After an appointment is made online, the doctor's office confirms it by e-mail, then ZocDoc sends electronic reminders. Nearly 85 percent of appointments made on ZocDoc are new patients. Patients pay nothing for the service, and doctors pay about $250 a month to be listed.

Another company that helps people schedule appointments online, Health In Reach, started in September but is marketing the feature to new patients only in Los Angeles for now. The company is paid only when the doctor gets an appointment. To reduce no-show rates, patients must pay at least a portion of an insurance co-payment online before the appointment.



Physicians not e-prescribing in 2011 risk a Medicare reduction in payments of 1percent in 2012 and 1.5 percent in 2013. CMS is looking at the first six months of 2011 to determine the penalties for 2012 and 2013. On the other hand, offices who successfully e-prescribe in 2011—meaning they submit the e-Rx code G8553 (at least one prescription created during the encounter was generated and transmitted electronically using a qualified e-Rx system) a minimum of 25 times— will earn a 1 percent payment bonus from Medicare. This incentive, however, does not apply to practices that also apply for the EMR Meaningful Use rebate of up to $44,000 over 5 years. Before choosing which year to submit for Meaningful Use, physicians should look at the impact of their potential e-Rx incentive for 2011.

To avoid any penalties, physicians should:

* Sign up for an e-prescribing system. If you do not have an EMR, there are free alternative e-Rx systems available at www.nationalerx.com.

* Report G8553 on a minimum of 10 eligible e-Rx encounters for dates of service Jan. 1, 2011 - June 30, 2011 when submitting the claim for those encounters (you can’t go back and add a G code later.) These claims must be submitted no later than July 31, 2011.

Health Policy and Reimbursement

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The Centers for Medicare and Medicaid Services (CMS) has launched a portal to help hospitals and eligible medical professionals meet Stage 1 meaningful use criteria. CMS urges users to register through the Medicare and Medicaid EHR Incentive Program Registration and Attestation System portal as soon as possible. Medicaid EHR Incentive Program registration is voluntary and on a state-by-state basis. Professionals in California, Missouri, and North Dakota will be able to register only in February 2011, and some other states will launch their Medicaid EHR programs later this year. CMS is urging users to register for the program even if they do not have a certified EHR. For more information on registration, requirements, and eligibility, visit CMS' EHR Incentive Program page.



A slight majority of residents believe new duty-hour standards that go into effect in July will improve their quality of life, while nearly half said the standards could hinder their medical training, according to a recent survey. Standards adopted by the Accreditation Council for Graduate Medical Education in September 2010 will limit first-year residents to 16-hour shifts; while other residents can work up to 24 hours per shift, plus four hours for transferring patients. The rules will also require training programs to step up supervision of residents, educate them about the signs of sleep deprivation, and revise scheduling to minimize how often patients are transferred from one resident to another between shifts.



Beginning Jan. 1, doctors must disclose their financial interest when referring Medicare and Medicaid patients for certain advanced imaging services, including MRI and CT scans, within their practices, and must also provide patients with a list of alternative suppliers. According to a recent report from the Center for Studying Health System Change, policymakers are concerned that physicians with ownership or other financial interests in medical facilities and equipment may make more referrals than medically necessary. As a result, the report says, lawmakers and CMS have taken action to make physicians' ownership and use of some types of advanced imaging less attractive by cutting Medicare reimbursements.

Medicine, Drugs and Devices

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Triad Group has issued a voluntary recall of its alcohol prep pads, swabs, and swabsticks due to possible bacterial contamination. The products are used for disinfection prior to an injection, and if contaminated could lead to life-threatening infections, the company said. One non-life-threatening skin infection has been reported to date. The products are sold under the labels: Cardinal Health, PSS Select, VersaPro, Boca/Ultilet, Moore Medical, Walgreens, CVS, or Conzellin.



A recent survey of 825 U.S. hospitals by HIMSS Analytics reveals that approximately 33 percent have integrated medical devices and electronic medical records (EMRs) to save time by eliminating manual documentation. The survey reveals that intelligent medical device hubs and physiological monitors are more likely to be interfaced than other devices. While return-on-investment studies have yet to be completed, hospitals say integration has saved time, with a 60 percent time savings reported by St. John's Medical Center in Jackson, Wyo. According to John Daniels, vice president of healthcare organizational services at HIMSS, "The transfer of data directly from a medical device to the EMR can reduce potential medical errors and improve patient care, because no manual transfer of data takes place. Such data integration also improves work flow by saving time for clinical staff, a valuable benefit when looking at nursing shortages in healthcare."



Researchers executed a prospective, observational study to evaluate the impact of various immobilization devices—including a left-foot driving adapter, a controlled-ankle-motion device, and a short leg cast—on brake-response times in 35 volunteers.

The average total brake-response time was substantially increased compared with that of the control group in all three study groups; the average reaction time was significantly increased for the short leg cast and controlled-ankle-motion groups versus reaction time in the control group. The average braking time was significantly higher in the controlled-ankle-motion and left-foot driving-adapter groups in comparison with the control group's braking time.

The researchers concluded that total brake-response time while wearing a controlled-ankle-motion boot or a short leg cast or while using a left-foot driving adapter is significantly increased, or exacerbated, in comparison with the response time while wearing normal footwear. This conclusion may be important to physicians when advising patients on when it may be safe to resume driving.



The success of the Ponseti method for treating idiopathic clubfoot deformity is dependent on the casting techniques and the adherence of the patient to the foot abduction brace protocol. Researchers compared the compliance and treatment outcome using two brace designs, the traditional simple brace of pre-walking shoes attached to a Dennis Browne (DB) bar and the new sophisticated Mitchell brace. The researchers compared the functional outcome and compliance with the post-corrective bracing protocol of 38 children with idiopathic clubfoot treated using two brace designs. Twenty-one chose the DB brace and 17 chose the Mitchell brace.

There was no difference in the compliance rate or in the final clinical and radiological outcomes of the two groups after a minimum of two years of follow-up. A positive correlation was found between the Pirani score at the beginning of treatment and the final functional score for both groups. Both groups were satisfied with the selected brace. Both groups were equally compliant with the brace protocol.

The researchers concluded that new and more expensive brace designs do not necessarily provide better clinical results. Fully corrected foot and a strong family–treating team partnership are crucial to adherence with the brace protocol.