News From ACFAS

---

Register now for tonight’s free webinar, “Take a New Look at Practice Building,” scheduled for 8pm ET/7pm CT, and gain proven strategies for increasing referrals and partnering with other healthcare providers in patient care.

Christopher L. Reeves, DPM, FACFAS; Amber M. Shane, DPM, FACFAS; and John S. Steinberg, DPM, FACFAS will share tried and tested tips for using the marketing materials from the Take a New Look at Foot & Ankle Surgeons campaign to grow your practice.

Melissa Matusek, ACFAS director of Marketing and Communications, will also walk you through the resources available in the ACFAS Marketing Toolbox and will explain how to use them to promote yourself and your practice.

Visit acfas.org/practicebuilding to register now! Book your hotel accommodations for ACFAS 2018 with onPeak, our official housing partner, and receive the best rate for your stay in Nashville. Choose from three hotels:

• Gaylord Opryland Hotel (a Marriott Rewards partner): $229/night (includes a reduced resort fee of $18)
• The Inn at Opryland, A Gaylord Hotel: $179/night
• Hyatt Place Nashville/Opryland: $189/night

If you are planning to fly Delta to Nashville on March 20 or 21, you can enjoy even further savings by using discount code NMR4D when reserving your flight at delta.com/meetings or by calling Delta directly.

Reserve your room now and get once step closer to the fun and excitement awaiting you in Music City, USA!

Should you need any assistance while making your reservation online, click on the "Help" button in the upper righthand corner of onPeak's website to contact an agent by email or phone. The ACFAS Board of Directors election closes Monday, January 22. If you have not yet voted, a reminder email with the subject line: ACFAS Board of Directors Election—We Need Your Vote! was sent to you last Friday (January 12) from acfas.ballot@intelliscaninc.net with your unique link to the election. Members without an email address or whose email system rejected our test email were sent voting instructions by U.S. mail earlier this month. If you do not see the email and did not receive a letter, check your junk mail folder.

Please contact our independent election firm at kwier@intelliscan.com if you have questions about accessing the ballot site.

Foot and Ankle Surgery

---

This study was carried out to describe long-term gait changes after talus fractures, identify patterns associated with poor outcomes and discuss potential treatment options based on dynamic gait analysis. Twenty-seven patients were followed-up clinically and via gait analysis after talus fracture osteosynthesis. Continuous dynamic pedobarography with a gait analysis insole was performed on a standardized parcours consisting of different gait tasks and matched to the outcome. Mean follow-up was 78.3 months, and mean American Orthopaedic Foot and Ankle Society and Olerud-Molander scores were 66 and 54, respectively. Significant correlations between fracture classification and osteoarthritis as well as several gait differences between injured and healthy foot with correlations to outcome were seen: decreased step load-integral/maximum-load; associations between center-of-pressure displacement and outcome as well as between temporospatial measures and outcome. Overall, pressure-distribution was lateralized in patients with subtalar joint injury. The findings indicate that talus fractures lead to chronic gait changes and restricted function. Dynamic pedobarography can identify patterns associated with poor results. The observed gait patterns suggest that changes can be addressed by physical therapy and customized orthoses to improve overall outcome. The presented insole and measurement protocol are immediately feasible as a diagnostic and rehabilitation aid, the researchers concluded.


Researchers in Vienna, Austria, conducted a study to demonstrate the need for extensive training before practicing minimally invasive distal metatarsal metaphyseal osteotomy (DMMO). Although the operation appears to be less complex with a shorter surgical time, it requires great awareness for the risks in the early learning stages, the researchers concluded. They studied 27 patients who were an average of 60.9 years old with a mean follow-up time of 7.2 months. Indication was metatarsalgia, intractable plantar keratosis and the (sub)luxation of the metatarsophalangeal joint. Clinical results were evaluated with the 12-item Short Form (SF-12), Foot Function Index (FFI), Foot and Ankle Ability Measure (FAAM) and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Researchers also obtained radiographs and pedobarographic analysis. Scores were close to standard value (AOFAS 88.07 points; FFI 93 percent; FAAM 36.4 points; SF-12 31.27 points). Pedobarography showed major differences in several forefoot areas, and the researchers found nonunion/malunion and necrosis of the metatarsal head. The results of the study demonstrate that minimally invasive DMMO requires a steep learning curve. Correct handling of the burr is associated with intensive training, while poor handling can lead to nonunion/malunion or necrosis.


Researchers in Norway reviewed clinical and radiographic results for patients who had stabilization of an acutely injured syndesmosis with a suture button (SB) versus those treated with one quadricortical syndesmotic screw (SS). Nearly 100 patients, 18 to 70 years old, with an ankle injury that included the syndesmosis were randomized into SB and SS groups. The main outcome measure was the score on the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale. The secondary outcome measures were the Olerud-Molander Ankle (OMA) score, visual analog scale (VAS) and EuroQol-5D (EQ-5D) Index. Computed tomography (CT) scans of both ankles were obtained. Two years of follow-up were completed for 90 percent of the patients. The researchers discovered the SS group had more injuries to the posterior malleolus than the SB group. At two years, patients treated with an SB had higher median AOFAS, OMA and EQ-5D Index scores than patients in the SS group. The SB group also reported less pain during walking at two years than the SS group, or lower VAS scores, and less pain during rest. In addition, the SB group had less widening seen radiographically at two years than the SS group.

Practice Management

---

Hospital staff are trained to care for and help people, but their jobs often mean they may experience traumatic events in the lives of patients. Hospital administrators note that cases of burnout and symptoms similar to posttraumatic stress disorder are rising. Hospitals are responding by encouraging staff to share experiences or vent their feelings during stressful times. North Hawaii Community Hospital provides aromatherapy and pet therapy for staff as a means to relax. Experts say the need for these programs has become very clear following events like mass shootings and terrorist attacks.


Physicians can use checklists as a tool to connect with patients and improve their emotional care, experts say. Improved physician-patient communication can help patients regulate their emotions, better understand medical information and enable physicians to better evaluate their patients' needs and expectations, according to a 2010 study in The Ochsner Journal. This research inspired Hawaii Pacific Health in 2016 to set up a checklist of steps for physicians to perform during each visit, with the goal of improving patients' emotional well-being and encouraging deeper trust between physicians and patients. Doctors identified new checklist items to practice, from clearing their minds of distractions to listening to the patient for several minutes without interrupting. The result of this change in practice was a more than 20 percent improvement on a physician communication score within a year of implementation. Karen Sibert, MD, president of the California Society of Anesthesiologists and an associate clinical professor of anesthesiology at UCLA Health, has long followed a mental patient well-being checklist. She always begins by addressing her patients formally and establishing herself as a physician in her introduction, which creates "an atmosphere of clear communication" and respect. Other experts note that checklists allow for standardizing practices that can help prevent errors or miscommunications. They also help physicians do things in a logical order and confirm that the task was completed. Although a checklist may sound like an additional task to add to a physician's already full workload, many doctors already have an informal process in place to connect with patients. Making it more formal and consistent can help to ensure consistency and improve patient outcomes.


The U.S. Office of the National Coordinator for Health Information Technology (ONC) has issued a draft for the Trusted Exchange Framework, which aims to improve the exchange of health information for patients, physicians and payers. The framework is mandated by the 21^st Century Cures Act and is one of several initiatives created by Congress to improve the flow of healthcare data. ONC Chief Don Rucker described the proposed framework as a "network of networks" concept that will help link existing entities and allow them to exchange information. Rather than setting up an entirely separate infrastructure, the draft framework reuses existing technology and servers. The framework does not specifically address the provider level, such as allowing one provider to access information from another provider, but will permit networks using the proposed framework to more easily exchange data using an agreed upon standard. Genevieve Morris, ONC's principal deputy national coordinator for health information technology, says they are seeking to establish a single "on-ramp" to interoperability, where a provider can log into one network and get all patient data from any other network. The draft framework will be available until February 18 for public comment. Once the comments are evaluated, ONC will select a Recognized Coordinating Entity that will use the framework to develop a common agreement that health networks and their participants will voluntarily agree to adopt. The final agreement will be released for public comment with the final rule to be approved and published this year.

Health Policy and Reimbursement

---

The Trump administration says it will allow states to test requiring some Medicaid recipients to work or participate in community activities as a condition of eligibility for Medicaid. The U.S. Centers for Medicare and Medicaid Services issued guidance making it easier for states to design and propose test programs that implement such requirements. States must propose such changes through waivers and receive federal approval. Seema Verma, the agency's administrator, says the policy guidance came in response to requests from at least 10 states that proposed requiring some Medicaid recipients to work or participate in activities that may include skills training, education, job search, volunteering or caregiving. Certain Medicaid populations would be exempt from the rules, including those with disabilities, the elderly, children and pregnant women.


Alex Azar, the Trump administration's nominee for U.S. Department of Health and Human Services (HHS) Secretary, has vowed to reduce drug prices, implying a willingness to follow alternative policies that might go further in dealing with drug makers' list prices. "The most important thing we have to figure out is, can we reverse the incentive on list prices?" Azar said. "There's a lot that we all know we can do on the net, the discounted prices. But I want to work with this committee and anyone who is smart and thoughtful about it. Can we create incentives that actually pull down those list prices so that when the [consumer] walks in needing to pay out of pocket at the pharmacy, that they're not hit with those kind of costs?" Azar also reiterated an earlier indication that he is amenable to more government drug price negotiations, modeled after how private Medicare drug plans negotiate prices for beneficiaries. However, he balked at broader drug price negotiations within Medicare, suggesting policies that depend on a national formulary would significantly limit seniors' access to drugs. Azar also repeated his promise to prioritize addressing drug prices if his HHS Secretary nomination is confirmed.


The House Energy and Commerce Committee has released a report outlining issues and recommendations to improve the 340B drug pricing program. "Program participation has more than quadrupled over the past 10 years, yet the Health Resources and Services Administration (HRSA) has remained largely the same size," the report said. "This explosion in program growth has raised concerns about HRSA's ability to effectively oversee the program with its limited resources." Among the main issues the report addressed is the financial incentive for 340B hospitals to prescribe expensive drugs to Medicare Part B beneficiaries. Discounted drug purchases made by covered entities under the 340B program totaled more than $16 billion in 2016—a more than 30 percent increase in 340B purchases in one year, the report said.

Medicine, Drugs and Devices

---

New research indicates that sucrose octasulfate dressing could potentially serve as an option for treating neuroischemic diabetic foot ulcers. Results from a randomized, controlled, double-blinded, 20-week trial are published online in Lancet Diabetes & Endocrinology by Michael Edmonds, MD, of the King's College Hospital Diabetic Foot Clinic, London and colleagues. The potassium salt of sucrose octasulfate acts at the tissue level to inhibit excess matrix metalloproteinases while also restoring growth factor function and tissue formation. In the study, which compared sucrose octasulfate to placebo dressing in 240 patients with neuroischemic diabetic foot ulcers, wound healing was significantly improved among patients given the active dressing. The study was conducted in 43 hospitals with specialty diabetes foot clinics in France, Spain, Italy, Germany and the United Kingdom.


New data from the U.S. Centers for Disease Control and Prevention (CDC) Antibiotic Resistance (AR) Investment Map indicates there is early progress by states to combat AR. The map notes more than 170 state-reported successes, and each state reported multiple successes. These are the first comprehensive reports on state progress made following the first year of Congress' investment in CDC's Antibiotic Resistance Solutions Initiative. CDC Director Brenda Fitzgerald said: "This interactive map showcases the work happening on the front lines of every state and CDC's commitment to keep people safe from drug-resistant infections." CDC made investments in all 50 states, six large cities and Puerto Rico in fiscal year 2016 to expand laboratory and epidemiology expertise and increase public health innovations to combat AR across healthcare settings, food and communities.


The hurricane that left most of Puerto Rico in ruins has also had ripple effects for certain medical devices. Baxter International Inc., a major manufacturer of saline IV bags, had a facility on the island, which was damaged by the storm. In addition, another manufacturer of the bags has been troubled by production problems. The shortage has forced hospitals and staff to administer drugs using less efficient methods. There have also been pauses placed on elective procedures and clinical trials. Baxter, which has two facilities in Puerto Rico, says power remains spotty, but the company expects to return to normal production levels in the coming weeks. Meanwhile, hospital employees warn that the shortage leaves facilities in a precarious state, especially if a catastrophic or viral event occurs.