News From ACFAS

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Apply to attend this unique skills course Total Ankle Arthroplasty, set for May 19–21 in Aurora (Denver), Colorado, and implant six FDA-approved systems (four primary and two revision TAA) in one weekend.

Expert faculty who specialize in total ankle replacement will guide you through implantation of each system and will share their own experiences to help you improve patient outcomes. Gain a better understanding of total ankle arthroplasty’s role in managing ankle arthritis while learning how to select patients, choose between total ankle arthroscopy and ankle fusion and evaluate complications.

This course is worth 17.5 continuing education contact hours and includes three cadavers for each registrant. Visit acfas.org to apply. Revitalize your practice’s marketing efforts with the spring issue of FootNotes, now available for download in the ACFAS Marketing Toolbox. Articles in this latest edition of our patient education newsletter include:

• Watch for Heel Pain After Coming Out of Hibernation
• Keep Kids’ Feet & Ankles Safe During Spring Sports
• Foot Fractures Can Signal Osteoporosis

Customize page 2 of FootNotes with your office’s contact information then post the issue on your practice’s website, distribute printed copies to your patients or bring FootNotes to any upcoming speaking engagements and health fairs on your calendar.

Visit acfas.org/marketing often for many other free resources to help promote your practice year round, such as infographics, PowerPoint presentations, healthcare provider referral tools and fill-in-the-blank press releases. This year’s poster competition at ACFAS 75 in Las Vegas featured 255 case study and scientific entries, each providing a glimpse into the profession’s latest research. View these posters, as well as this year’s award-winning entries, at acfas.org. If these posters inspire you to share the results of your own study, check acfas.org this summer for details on next year’s poster competition at ACFAS 2018, March 22–25, 2018 in Nashville.

Foot and Ankle Surgery

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The objective of this study was to investigate the role of circulating microRNA-21 (miR-21) in vascular restenosis of lower-extremity arterial occlusive disease (LEAOD) patients after interventional therapy. A total of 412 LEAOD patients were enrolled randomly in this study. According to computed tomography angiography (CTA) and ankle-brachial index (ABI), patients were assigned into the restenosis group and the nonrestenosis group. miR-21 expression was detected with quantitative real-time polymerase chain reaction (qRT-PCR) before and after patients underwent interventional therapy. Researchers found that after a follow-up period of six months, patients were older in the restenosis group than in the nonrestenosis group. The percentages of patients living with diabetes and hypertension were higher in the restenosis group than in the nonrestenosis group, and the Fontaine stage differed significantly between the two groups. In addition, miR-21 expression was higher in the restenosis group than in the nonrestenosis group. The findings also suggest that miR-21 expression level was related to age, diabetes and hypertension in the restenosis group. Using miR-21 to predict vascular restenosis yielded an area under the curve (AUC) of 0.938 with Youden index of 0.817, sensitivity of 83.5 percent and specificity of 98.2 percent. Logistic regression analysis revealed that diabetes and miR-21 expression were the major risk factors for vascular restenosis of LEAOD. The researchers concluded that miR-21 can be used as a predictive indicator for vascular restenosis of LEAOD after interventional therapy.


Platelet-rich plasma (PRP) injections have shown mixed results for treating Achilles tendinopathy, but they continue to be the most commonly used biological treatment for this condition. Recent findings suggest that stromal vascular fraction (SVF) within adipose tissue may counteract impaired tendon homeostasis. Researchers conducted a study to prospectively compare the efficacy of PRP and SVF injection for the treatment of noninsertional Achilles tendinopathy. Forty-four patients were recruited in the study, of whom 23 were assigned to the PRP group and 21 to the SVF group. The patients were treated unilaterally or bilaterally for a total of 28 tendons per group. All patients (age 18 to 55 years) were clinically assessed preoperatively and at 15, 30, 60, 120 and 180 days from treatment, using the VAS pain scale, the VISA-A, the AOFAS Ankle-Hindfoot Score and the SF-36 form. The patients were also evaluated by ultrasound and magnetic resonance before treatment and after four (U.S. only) and six months. Both treatments allowed for a significant improvement with respect to baseline. Comparing the two groups, VAS, AOFAS and VISA-A were significantly better at 15 and 30 days in the SVF compared to the PRP group. Both PRP and SVF were found to be safe, effective treatments for recalcitrant Achilles tendinopathy. Patients treated with SVF obtained results more quickly, indicating that such a treatment should be taken into consideration for patients who require an earlier return to daily activities or sport.


End-stage hallux rigidus can be treated surgically by arthrodesis, excisional arthroplasty and implant arthroplasty. However, little attention has been given to health-related quality of life and the use of patient-reported outcome measures. An evaluation was undertaken in a community-based podiatric surgery service. Patient-reported outcomes were captured on the day of surgery and six months post operation in the form of the Manchester Oxford Foot Questionnaire (MOXFQ) and the PASCOM PSQ-10 patient satisfaction questionnaire. Between November 1, 2011 and October 31, 2014, there were 157 admissions for treatment of end-stage hallux rigidus; 61 implant arthroplasties; 53 Keller's arthroplasties; and 43 arthrodeses. The age range was 45 to 89, and 72 percent of patients were female. MOXFQ scores improved across all domains for all procedures, the score change exceeded the minimal clinically important change threshold of 13 points and large effect sizes were achieved. Patient satisfaction was good for all procedures with mean PSQ-10 scores of 81.89 for arthrodesis, 82.36 for implants and 81.89 for Keller's. Few serious complications were encountered, although the overall incidence of complications was high for the implant group. This evaluation found all three procedures are clinically effective with high levels of patient satisfaction and improved quality of life. Although the implant arthroplasty is associated with a higher incidence of complications, this is not reflected in the outcomes achieved.

Practice Management

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Ongoing privacy and security healthcare audits may be making the transition from training to enforcement, and providers must make sure their compliance and operational teams are cooperating on vulnerability detection. Although the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has said the second round of Health Insurance Portability and Accountability Act (HIPAA) audits are intended to be educational, healthcare attorney Alisa Chestler reports a shift is probable. "It's my understanding that, dependent on what they find, they'll be taking enforcement actions on these audits," she notes. Chestler points to the likelihood of the OCR finding compliance vulnerabilities and taking enforcement action because of increasingly complex healthcare IT. The goal of the compliance audits is to ascertain whether healthcare organizations and their contractors are adhering to HIPAA privacy and security regulations. Healthcare attorney Colin Zick says although future HIPAA audits will always have an educational aspect, the period when a bad audit result will not lead to an enforcement action is over. "That's why self-auditing is so important, just as it has become in the billing context, because these problems must be found and corrected before the government finds them," he notes.


Healthcare reform is forcing post-acute care (PAC) providers to computerize and is urging more hospitals to prioritize information exchange with senior care communities. When doctors are able to access vital data across these care settings at a faster clip than they do now, experts say they will find it easier to care for people dealing with complex illnesses and those recovering from recent hospital stays. "If physicians have improved access to [PAC] data, hopefully they can make better decisions," Mike Seiser, director of the healthcare practice at Chicago-based Huron Consulting Group, remarks. "As they move to value-based care and population health, they will need that kind of data."


There is some evidence supporting the efficacy of mobile health (mHealth) interventions for patients with diabetes, but the quality of past studies is substandard and additional research is needed, according to a new study published in the journal PLoS ONE. The study was designed to critically appraise and consolidate evidence from multiple systematic reviews on the effectiveness of mHealth interventions for patients living with diabetes. Researchers conducted a comprehensive search of multiple databases to identify relevant systematic reviews published between January 1996 and December 2015, independently identified 15 for inclusion in the study, extracted data and assessed the methodological quality of those reviews. They discovered that, “on average, mHealth interventions improve glycemic control (HbA1c) compared to standard care or other non-mHealth approaches by as much as 0.8 percent for patients with type 2 diabetes and 0.3 percent for patients with type 1 diabetes, at least in the short-term (up to 12 months)." Still, Spyros Kitsiou from the University of Illinois-Chicago's College of Health Sciences and colleagues believe mHealth interventions represent a promising approach for patients who want to manage their diabetes. Further research should explore the use and impact of diabetes mobile apps that are publicly available through the Apple and Google Play stores.

Health Policy and Reimbursement

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The Health Transformation Alliance (HTA), a U.S. alliance formed last year by more than three dozen companies, is announcing its first plans aimed at lowering the companies’ healthcare spending. The blueprint includes group contracts to purchase prescription drugs through units of CVS Health and UnitedHealth Group, the creation of specialized doctor networks and a deal to use IBM’s Watson software to analyze their healthcare data. Each company must still decide whether to participate in the prescription drug contracts, after comparing the alliance-negotiated deals with their existing prescription arrangements, according to the alliance. HTA Chief Executive Robert Andrews said the alliance expects at least 20 members to participate, and estimates they will save a combined $600 million over three years compared with their current drug benefit contracts.


The Medicare Access and CHIP Reauthorization Act is encouraging more and more accountable care organizations (ACOs) to sign risky contracts with Medicare to qualify as participating in advanced alternative payment models. However, the majority of Medicare ACOs still follow upside-only payment models. Those that make the change face financial risks, but they benefit from being able to offer flexible treatment options for patients. Steven Shortell, professor of health policy and management at the University of California at Berkeley, believes the trend will gain momentum, but it will not be an immediate change.


The American Nurses Association (ANA) has criticized the healthcare proposal from Republican House lawmakers, saying their approach to repealing and replacing the Affordable Care Act (ACA) does not "improve care for the American people." ANA wrote, "The American Health Care Act threatens healthcare affordability, access and delivery for individuals across the nation." The group pointed out that nonpartisan experts, such as the Congressional Budget Office and the Government Accountability Office, have not weighed in on the plan. "ANA strongly urges Congress to allow opportunity for considered public and stakeholder feedback in the face of reforms that would have a far-reaching and personal impact on the lives of millions of people," the letter said. ANA President Pamela Cipriano wrote in a March 8 tweet that the GOP proposal fails to fulfill the promise that it would be better than the ACA. The American Hospital Association and the American Medical Association have also spoken against the GOP plan. In December 2016, ANA wrote a letter to President Trump urging him to keep certain provisions of the ACA, including allowing children to stay on their parents' health plans until they are 26 and preventing individuals with preexisting conditions from being denied health insurance coverage, according to a Forbes report.

Medicine, Drugs and Devices

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The Medicare Payment Advisory Committee (MedPAC) wants to change the way physicians are paid for administering drugs under Part B of the Medicare program. However, not all committee members agree on how to revamp the program's payment model. The chair of MedPAC presented his recommendations for reforming the payment program to commissioners during a recent meeting. The recommendations include improving average sales price (ASP) data reporting, modifying the payment rate for drugs that are paid for based on wholesale acquisition cost, limiting payment rate increases for drug payments based on ASP, instituting consolidated billing codes for biosimilar drugs and transitioning the payment system over to a drug value program. Commission members overall seemed pleased with the recommendations. The commission also discussed ways to help physicians transition from Medicare's Merit-Based Incentive Payment System (MIPS), which several commissioners have said probably will not deliver much value to Medicare, to advanced alternative payment models (A-APMs). Strategies suggested by commission staff included limiting the potential advantages of MIPS, implementing a "quality adjustment" program and increasing the advantages of A-APMs.


The number of narcotic pain pills prescribed by doctors at Dartmouth-Hitchcock Medical in New Hampshire declined by 53 percent after they were told to limit painkillers, according to a study that was recently published in the journal Annals of Surgery. Richard J. Barth, chief of general surgery at the medical center, and colleagues came up with a painkiller recommendation after surveying people who underwent one of five outpatient surgeries: partial mastectomy, partial mastectomy with a lymph node biopsy, gall bladder removal and two kinds of hernia repair. The team discovered that patients consumed only 28 percent of the opioids they were prescribed and that there was a wide range in prescribing habits on the part of the doctors. Barth and colleagues then suggested that surgeons limit the number of narcotic pills to five and 10 for the two breast operations and 15 for the other three. They also told patients they would most likely be able to manage their pain with nonnarcotic painkillers such as acetaminophen or non-steroidal anti-inflammatory drugs such as ibuprofen. Only one patient came back for a prescription refill. A survey of 148 patients revealed that the group had been prescribed 1,913 pills but only took 656.


President Donald Trump castigated the U.S. Food and Drug Administration (FDA) for having a "slow and burdensome" drug approval process, during his first speech to Congress. However, former and current agency officials say the attack was unfair, and point out that reviews for new prescription drugs have sharply accelerated in recent decades. Today, FDA routinely beats other regulators around the world and sometimes comes under criticism for moving too quickly to approve products. The improvement in review time for drug approvals came after years of frustration among manufacturers and patient groups, which resulted in a decades-long effort from both Congress and pharmaceutical companies to get more money, and thus more staff, for the agency. Still, critics say it is time to overhaul the way FDA operates. Supporters worry about the damage that could be caused by easing some agency rules. “The competitiveness of the U.S. pharmaceutical industry is based on the fact that the drug is validated as safe and effective by FDA,” says David Kessler, who was the agency's commissioner chief during the administrations of George H.W. Bush and Bill Clinton. “Any proposal that doesn't require both will set back the industry's competitiveness by 50 years.”