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This Week's Headlines

News From ACFAS
Foot and Ankle Surgery
Practice Management
Health Policy and Reimbursement
Technology and Device Trends

News From ACFAS

Congratulations to Newly Elected Board of Directors Members

In balloting that concluded on January 22, ACFAS members elected two new members to the Board of Directors and re-elected one incumbent:
• Thomas S. Roukis, DPM of Tacoma, Wash. for a three-year term
• Jerome K. Steck, DPM of Tucson, Ariz. for a three-year term
• Douglas G. Stoker, DPM of Salt Lake City, Utah re-elected for a two-year term.

At the March 6 Honors and Awards Ceremony during the Annual Scientific Conference, these new directors will join the continuing members of the 2009-10 Board of Directors:
• President Mary E. Crawford, DPM of Everett, Wash.
• President-Elect Michael S. Lee, DPM of Des Moines, Iowa
• Secretary-Treasurer Glenn M. Weinraub, DPM of Danville, Calif.
• Immediate Past-President John M. Giurini, DPM of Boston, Mass.
• Director Michelle L. Butterworth, DPM of Kingstree, S.C.
• Director Jordan P. Grossman, DPM of Akron, Ohio
• Director Jerome S. Noll, DPM of Naples, Fla.
• Chairman, Division Presidents Council Marc A. Kravette, DPM of Seattle, Wash.
Peer Reviewers Essential to Success of JFAS

Within the scientific publishing field, the process of peer review is both time-honored and effective. Peer reviewers serve as the voice of a journal’s readership, providing constructive criticism related to the scientific merit and overall interest a manuscript conveys.

Without the efforts of volunteer reviewers, we would not be able to assure the high standards of the content published in the Journal of Foot & Ankle Surgery. Over 200 reviewers participated in evaluation of manuscripts in 2008; a list of their names may be viewed by clicking the Web Link at the bottom of this item.

If you have an interest in contributing to the podiatric literature by serving as a peer reviewer, please contact Editor Scot Malay, DPM,

CMS Issues Determinations Regarding Preventable Errors

The Centers for Medicare and Medicaid Services (CMS) issued three national coverage determinations (NCDs) to establish uniform policies that will prevent Medicare from paying for certain serious, preventable errors in surgical care (“never events”). These NCDs affect physicians and other health care providers involved in erroneous surgeries.

The three newly issued NCDs are:

1. Wrong Surgical or Other Invasive Procedure Performed on a Patient
2. Surgical or Other Invasive Procedure Performed on the Wrong Body Part
3. Surgical or Other Invasive Procedure Performed on the Wrong Patient

By issuing the three NCDs, CMS further promulgates the necessity for quality improvements among all health professionals.

Click on the Web Link at the bottom of this item for full details.

Foot and Ankle Surgery

Study Ties Shorter Surgeries to Fewer Infections
American Medical News (01/19/09)

The length of a surgical procedure impacts infection rates, according to a new study by researchers who examined 33 hospitals across the country, of which 20 had low infection rates. Surgeries at these low-infection hospitals lasted for an average of 103 minutes, compared to 128 minutes at the 13 hospitals with high infection rates. The low-infection hospitals administered blood transfusions in 5.1 percent of surgeries, compared to 9.7 of the time in high-infection hospitals. The low-infection hospitals were also found to be smaller and more efficient and had less turnover among operating room staff. Lead author Darrell A. Campbell Jr., MD, recommends that physicians and hospitals try to finish surgeries as quickly as possible and curb the number of blood transfusions used.

Parkinson's Disease Puts Bones, Joints at Risk
Reuters Health Information Services (01/13/09)

People with Parkinson's disease have a higher chance of developing fragile bones and fractures over time, researchers say. Parkinson's also makes it harder for people to recover from surgery intended to repair such injuries. Dr. Lee M. Zuckerman, an orthopedic surgeon at the State University of New York Downstate Medical Center in Brooklyn, says patients tend to lose bone mass because they walk less compared to those without the disease. They also tend to spend less time in the sunlight, restricting the natural synthesis of vitamin D that helps maintain bones. Zuckerman advocates that those who suffer from the disorder try to manage their symptoms without medication to the greatest extent possible, which includes physical therapy and taking calcium and vitamin D supplements. He also recommends the use of bone-mass boosting medications.

Revision Arthroplasty May Be Useful for Failed Total Ankle Arthroplasty Cases
Orthopedics Today (01/09) Brockenbrough, Gina

A study by researchers in Switzerland suggests that revision arthroplasty may be a good alternative for failed total ankle arthroplasty. Co-authors of the study, Beat Hintermann, MD, and Alexej Barg, MD, conducted a prospective study that evaluated the ankles of 37 patients who had a failed total ankle arthroplasty. A total of 19 women and 18 men underwent revision arthroplasty using a three-part ankle prosthesis at an average of 4.4. years after their initial arthroplasty. Causes for the revision arthroplasty included loosening of one component (29 ankles), loosening of both components (7), granuloma (1) formation, and pain (9). Surgeons used 20 standard components for the talus and 19 standard components for the tibia for the revision arthroplasty. A mean follow-up of three years revealed that nearly 65 percent of the ankles were pain-free, there was a 33-point increase in AOFAS scores, and 78 percent satisfaction. “The hindfoot score improved from 39 to 72 at the mean follow-up of 3 years,” Hintermann says.

Practice Management

HHS Adopts New Rules to Coordinate Health Care Technology (01/22/09) Nagesh, Gautham

The U.S. Department of Health and Human Services has announced new interoperability standards for health care information technology in a bid to pave the way for a nationwide rollout of electronic health records. The three sets of IT standards took effect on January 16, according to a January 21 notice in the Federal Register. The three sets use XML tags to define searchable data elements common to all medical records. "We recognize that if we want interoperable health care and want [President] Obama's vision of e-health records by 2015, we don't need islands of hardware and software; we need a coordinated health care system," says Dr. John Halamka, chief information officer for Harvard University's Medical School and chairman of the Healthcare Information Technology Standards Panel, which established the standards. "The notion that there will be a single medical record system for the country won't work. ... But we want a network of networks, where single hospitals and doctors can communicate with each other and send stuff back and forth over the wire. That's really what a nationwide health care network is all about."

Billing and Collections: Plug Revenue Leaks
Medscape (01/20/09) Kane, Leslie R.

Physicians may not realize that their practices are hemorrhaging revenue as the economy gets tougher and patients face more difficulty in paying their bills, but there are steps they can take to shore up their bottom line. "Doctors need to develop benchmarks for billing and accounts receivable," says consultant Robert C. Scroggins. "To discover any problems, doctors need to monitor billing activity and accounts receivable each month." Physicians must first create a spreadsheet that displays key revenue benchmarks, including each month's accounts receivable compared with the month before and with the prior year at the same time, along with the amount of time from the date of the service to claim submission, the number of denials each month, the number of denied claims resubmitted and the time required for denied claim resubmission. By classifying the denials by type and by biller to ascertain the cause, doctors can work with the proper personnel to enhance their performance. When devising benchmarks, it can pay to consult with a practice management professional who can help examine accounts receivable, while a Web-based claims management company can study a practice's claims acceptances and denials to spot problems.

Physician Documentation Is Still Lacking (12/04/2008) Youngstrom, Nina

Most physicians tend to give too little attention to Medicare coding, concentrating on direct patient care and rarely seeing a connection between the two. However, with the threat of Medicare audits looming large, they must ensure their records are accurate and useful enough to cover all aspects of a patient’s diagnostic and treatment plan. Physicians should “think in ink,” according to Lynn Myers of physician management organization Medical Edge Healthcare Group, who notes that auditors cannot read minds and might lack the necessary clinical experience to make educated assumptions. She says the patient record should tell the patient's entire story even when the doctor is not present to fill in the blanks. This is a particular problem with established patients, as the physician tends to remember the patient’s conditions and does not always feel the need to document. Myers notes that younger physicians who started their careers in an environment of heavy compliance and enforcement tend to have the opposite problem and write too much, and they should focus instead on providing information in the most efficient way. "It's not the most verbose person who gets a good audit. It's the person who has the best information in their charts," she says.

Health Policy and Reimbursement

Obama Team Puts New, Pending Regulations on Hold; Review Planned
Modern Healthcare (01/21/09) Lubell, Jennifer

Implementation of International Classification of Diseases, 10th Revision (ICD-10) and other rules issued recently by the U.S. Department of Health and Human Services could potentially be delayed as the Obama administration proceeds with a review of new and pending regulations issued under the former administration. A memo released by White House Chief of Staff Rahm Emanuel has "put a hold on all regulations that have either not been published or those that have not yet taken legal effect," says a Centers for Medicare & Medicaid Services spokesperson. "We will be working with the new administration in their effort to review actions and regulations subject to the memo." The final rule for implementation of ICD-10 CM (Clinical Modification) and ICD-10 PCS (Procedure Coding System) was issued on January 15 and is not scheduled to become effective until March 17, which means it could fall under the mandate of the review. Other rules that could also be delayed include an interim final rule to identify protected classes of prescription drugs under Medicare Part D and an interim final rule that addresses steps to restart the CMS' competitive bidding program for durable medical equipment, prosthetics, orthotics and supplies.

Gifts to Doctors Must Be Disclosed Under Bill
Reuters (01/22/09) Richwine, Lisa

A new bill sponsored by Sens. Charles Grassley (R-Iowa) and Herb Kohl (D-Wis.) would require drug and medical device makers to publicly disclose all doctor payments and gifts exceeding $100 per year, under risk of a penalty as high as $1 million. The effort aims to bring transparency to a practice critics have said can impact the decisions of physicians. A similar measure that would have applied to payments exceeding $500 per year did not advance in the previous congressional session. "The goal of our legislation is to lay it all out, make the information available for everyone to see, and let people make their own judgments about what the relationships mean or don't mean," says Grassley. The Physician Payment Sunshine Act, as the measure is called, will require information on payments to be posted online for public perusal.

Lawsuit Filed Over Prosthetics Law
Associated Press (01/17/09)

A provider of artificial limbs, orthopedic braces and prosthetic devices in Louisiana is suing the state over a new law that requires companies providing such services to be accredited in order to receive reimbursement from the state Medicaid program. Lambert's Orthotics and Prosthetics Inc. is not accredited by the American Board for Certification in Orthotics, Prosthetics and Pedorthics as a provider, though its president, George H. Lambert Jr., is. Louisiana Department of Health and Hospitals Secretary Alan Levine says that it is not unusual for states to have such requirements in place. The new law took effect on January 1.

Technology and Device Trends

Prosthetic Ankle-Foot Mechanism Capable of Automatic Adaptation to the Walking Surface
Journal of Biomechanical Engineering (03/09) Vol. 131, No. 3, Williams, Ryan J.; Hansen, Andrew H.; Gard, Steven A.

A conceptual design for a prosthetic ankle-foot mechanism with the ability to automatically adapt to the slope of the walking surface has been produced, and a prototype mechanism was designed, developed and tested on three subjects with unilateral transtibial amputations walking on level and ramped surfaces as a proof of concept. The device can automatically adapt to the surface by switching impedance modes at key points of the gait cycle, and it mimics the behavior of the physiologic foot and ankle complex by boasting a low impedance in the early stance phase and then shifting to a higher impedance once foot-flat is reached. The "set-point" at which these impedance changes take place is reset on every step so that proper alignment for the surface can be achieved. The user's bodyweight is tapped by the mechanism to help change impedance modes, and no active control is necessary. It was theorized that the mechanism would cause a shift in the equilibrium point of the ankle moment and the ankle dorsiflexion angle in order to accommodate the walking surface, and this behavior was verified for two of the three test subjects.

Researchers' Work From University of Naples Focuses on Ischemia
Medical Devices & Surgical Technology Week (01/25/09) P. 254

Research appearing in the journal "Bone Marrow Transplantation" (Long-term effects of repeated autologous transplantation of bone marrow cells in patients affected by peripheral arterial disease, 2008;42(10):667-672) confirms that autologous bone marrow transplantation is an effective therapeutic strategy in coping with critical limb ischemia. Researchers at the University of Naples studied the long-term effects of autologous mononuclear bone marrow cell transplantation in patients with severe peripheral arterial disease and critical limb ischemia. Ten patients with end-stage disease were infused twice with autologous bone marrow cells and completed the year-long follow-up study. "Substantial improvement of blood flow and increasing capillary densities were seen when compared with a concomitant control group comprising patients who did not enroll in the study," wrote G. Cobellis and colleagues. "The ankle-brachial index (ABI) and pain-free walking distance improved significantly in treated patients. The improvement was sustained 12 months after treatment."

Studies from S. Nasir and Co-researchers Yield New Data on Plastic Surgery
Medical Device Law Weekly (01/18/09) P. 354

Research appearing in the "Annals of Plastic Surgery" (Reconstruction of Soft Tissue Defect of Lower Extremity With Free SCIA/SIEA Flap, 2008;61(6):622-626) concludes that free tissue transfer is the best approach to soft tissue reconstruction for the lower extremity, though cosmetic results and donor site morbidity are only of secondary concern in the procedure. "Based on our results, free SCIA/SIEA (superficial circumflex inferior artery/superficial inferior epigastric arteryflap) has the following advantages in soft tissue reconstruction of lower extremity: (1) large flaps may be harvested for extensive, defect and/or to reach recipient artery for passing zone of injury; (2) if necessary, final flap debulking may be performed by surgical procedure using local anesthesia; (3) the donor site is closed in a similar manner to abdominoplasty incision so that excellent cosmetic result may be achieved," wrote S. Nasir and colleagues. "Although secondary debulking procedure was performed for some flaps, most flaps had acceptable thickness for functional and esthetic outcomes especially in the pretibial, ankle, and foot defect reconstruction with an average of one-year follow-up."

Operating on the Virtual Human
BBC News (01/12/09) Lever, Anna-Marie

Oxford University physiologist Dr. Peter Kohl believes surgeons will be using virtual reality to simulate alternative operations within 10 years. Computer models will enable surgeons to experiment on a virtual surgical table, discover the best way to proceed with a procedure, and also lead to faster operations. The European Union has been funding an effort to create biomedical models that simulate the human body structurally and functionally. "We have developed better tools to look at smaller parts of the puzzle in terms of structure and function," says Kohl, one of the principal investigators of the Virtual Physiological Human (VPH) initiative. "We now need to understand how the pieces interact with each other and the environment." Kohl acknowledges that some people will have their doubts about using a quantitative computer model to assess patients' surgical options. He says a thorough assessment of the computer predictions used for medical procedures will be needed to determine VPH's reliability.

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January 28, 2009