News From ACFAS

Looking for a Journal of Foot & Ankle Surgery article that you recall reading in past years? Researching references for an article you’re writing?

ACFAS members can now access every article from each issue of JFAS from January 1995 to the present on jfas.org.

“This enhanced availability of earlier scientific works will allow greater access to our journal’s body of literature,” says Allen M. Jacobs, DPM, Chairman of the ACFAS Council for Journal Management. “It will also increase the citation of these published works by others engaged in research, leading to enhanced prestige of the journal, the College, and our profession.”

Use the web link below for seamless access to the Journal web site, and then go to “Previous Issues” on the jfas.org navigation bar.

The ACFAS Board of Directors welcomed newly elected directors Thomas S. Roukis, DPM, PhD and Jerome K. Steck, DPM when it met just prior to the 2009 Annual Scientific Conference on March 4 in Washington, D.C. It also bid a fond farewell to retiring directors Troy Boffeli, DPM and past president Daniel J. Hatch, DPM.

Highlights of the business accomplishments included the approval of:

• A new position statement on History & Physical Privileges for Podiatric Foot and Ankle Surgeons to help members in securing full and unfettered hospital privileges, pursuant to CMS regulations and Joint Commission guidelines,
• The 2009 Business Plan and revised Strategic Compass,
• Subsidizing membership dues for first-year resident members in partnership with the ACFAS regional divisions,
• Totally new Web sites for acfas.org and FootPhysicians.com,
• Starting work on a new Ankle Disorders Clinical Practice Guideline in 2009 and a new Arthritis CPG in 2010,
• Eight new section editors for the Journal of Foot & Ankle Surgery,
• Expanded student programs and services,
• International affiliate application and procedures, and
• Volunteer recruitment and committee appointment policies.


Legislation (H 2044/S875) was introduced in the Massachusetts House and Senate that would expand podiatrists’ scope of practice to include diagnosis and treatment of the ankle. Passage of this legislation would expand the definition of podiatry to include the “diagnosis and treatment of the structures of the human foot and ankle by medical, mechanical, surgical, manipulative and electrical means, including, but not limited to, the treatment of the local manifestation of systemic conditions as they present in the foot and ankle, partial amputation of the foot, and tendon surgery in the foot and ankle, including the Achilles tendon.”

For more information, contact the ACFAS Health Policy Department at (773) 693-9300.

Foot and Ankle Surgery

The Role of Pantalar Arthrodesis in the Treatment of Paralytic Foot Deformities

A study to assess the long-term effects of pantalar arthrodesis with regard to its impact on the adjacent joints and the walking ability of patients with paralytic foot deformities involved the reevaluation of 24 patients who underwent a one-stage pantalar arthrodesis between 1953 and 1973 for the treatment of sequelae of poliomyelitis. Development of immediate postoperative complications was seen in 11 patients, but long-term results were on the whole positive. Sixteen patients experienced repeated episodes of ipsilateral knee pain, with 15 experiencing a gradual onset of pain starting at an average of 20.8 years postoperatively. The position of the fused ankle did not seem to have a significant effect on the development of ipsilateral knee pain or the period between the pantalar arthrodesis and the beginning of the pain. These observations led to the conclusion that the ankle, hindfoot and midfoot in patients with severe paralytic deformities are effectively stabilized by pantalar arthrodesis.



Effect of Cultural Factors on Outcome of Ponseti Treatment of Clubfeet in Rural America

The Ponseti method is the accepted initial form of treatment for clubfoot, and a group of researchers compared early recurrence after Ponseti treatment between rural and urban ethnically diverse North American populations to study whether distance from the site of care impacts compliance and whether certain patient demographic traits predict recurrence. The test involved monitoring 100 consecutive infants with a total of 138 clubfeet treated with the Ponseti technique for at least two years from the start of treatment. Early recurrence was categorized as the need for subsequent cast treatment or surgical treatment, while compliance was defined as strict adherence to the brace protocol described by Ponseti. These two factors were analyzed with respect to the distance from the site of care, age at presentation, number of casts needed for the first correction, need for tenotomy, and family demographic variables. Fourteen of 18 infants from a rural region who had early recurrence were Native American, and the families of these children, like those of all of the children with early recurrence, discontinued orthotic use earlier than was advised by the doctor. This discontinuation was associated with recurrence, with an odds ratio of 120 in patients living in a rural region. Additional significant recurrence risk factors for rural area patients included Native American ethnicity, unmarried parents, public or no insurance, parental education at the high-school level or less, and a family income of under $20,000. The researchers concluded that compliance with the orthotic regimen after cast treatment is critical to the success of the Ponseti method, and the dramatic disparity in outcome in rural Native American patients versus the outcomes in urban Native American patients and children of other ethnicities suggests specific problems in communicating to families in this subpopulation the importance of bracing.



Children's Shoes Are Too Small and Causing Deformities, a New Study Finds

A new study of 250 children in Switzerland presented by the American Academy of Orthopaedic Surgeons (AAOS) found that a vast majority of young children are wearing shoes that are too small, increasing the risk of foot deformities. "The most striking finding was that more than 90 percent of children's shoes were too small," says Norman Espinosa, MD an orthopaedic surgeon at the University of Zurich. Overly-tight shoes are the leading cause of Hallux Valgus, a condition that occurs when the big toe begins to angle sideways in the direction of the second toe, causing a bump or bunion on the side of the foot.



Study May Lead to Diabetes Vaccine

Two teams of British researchers have found evidence that enterovirus infection can trigger an immune reaction that can lead to insulin-dependent diabetes. The virus family often shows no symptoms but can attack insulin-producing beta cells in the pancreas, triggering an immune response and causing type 1 diabetes. A vaccine against these viruses could prevent the infection, but scientists do not yet know which of the 100 strains to target. According to one of the researchers, Professor Noel Morgan of the Peninsula Medical School in the southwest of England, this study marks the first time that scientists have so extensively linked the enterovirus with type 1 diabetes. The viral infection may also be linked to type 2 diabetes. The study was reported in the journal Diabetologia.

Practice Management

E-prescribing to Soar With New Spending

Up to three-quarters of American physicians will be prescribing medicine electronically within five years because of federal funds to promote e-prescribing and other health care information technology included in the economic stimulus bill recently signed by President Obama. "Broader health IT [information technology] adoption will create a safety revolution in American health care," says Pharmaceutical Care Management Association President and CEO Mark Merritt in an interview. U.S. e-prescribing network operator Surescripts estimates that about 13 percent of U.S. doctors currently prescribe drugs electronically, and a report from Visante projects that that percentage will rise to 75 percent in five years and to approximately 90 percent by 2018. The study estimates that the money saved through e-prescribing would more than cover the cost of the stimulus package's $19 billion health care IT promotion budget. The savings would be derived from higher use of less expensive generic drugs and the prevention of medical errors such as patients receiving the wrong medicine because a pharmacy misreads a physician's handwriting. The Visante report also predicts that more use of e-prescribing will prevent 3.5 million medication errors and 585,000 hospitalizations by 2018. In January Medicare started offering financial bonuses to doctors who use e-prescribing. More than three-quarters of American retail pharmacies support e-prescribing, but many doctors are reluctant to adopt the technology because of costs.



Chart Audit: Is Your Practice Billing What It Should?

A chart audit can save practices a great deal of money lost from incorrect billing by helping them understand how well charges are captured for all services; how well denied claims are followed up by staff; the accuracy of code selection, charge entry, claims submission and payment processes; and the cause of any problems found in the above. Potential areas of concern should be identified by the practice's physicians and office manager prior to the audit. Once the areas of concentration have been identified, a single day must be selected for the review to increase the probability that all, or almost all, of the charges for that date have been paid and allow the review of denials, appeals and the follow-up work associated with these charges. Following this, an accurate appointment list for the date of service the practice has chosen to review must be printed, and then the data for each encounter should be entered on a worksheet. The listed services should then be compared so that any discrepancies can be reviewed, while out-of-office procedures should be considered separately. Upon the audit's completion, the practice leader should share the results with the other doctors and personnel, address any patterns that are costing the practice revenue, and discuss solutions to improve the process. Common problems include preventable denials, denials stemming from incorrect processing by the insurer, unbilled lab and other ancillary services, unbilled or incorrectly billed minor surgical procedures, one provider's charges repeatedly not billed, unbilled office visits and medications billed with incorrect units. Should the chart audit reveal fraud, the practice should first review its compliance policy, and practices that still lack a compliance plan should prepare one.



What Older and Younger Doctors Can Learn From Each Other

Gordon Cotell, MD, a 70-year-old founding partner of the Chicago-area practice Doctors of the North Shore, says that the mix of older and younger doctors at his practice provides an interesting and useful mix of perspectives. "When I started practice, I was on call two nights a week and every other weekend," he says, adding that nobody questioned this as a standard arrangement. Cotell says he has benefited from the younger doctors' comfort with technology, saying that it has helped him improve his computer skills and electronic medical records skills. Another doctor at the practice, 35-year-old Daniel Berman, MD, says that the elder doctors in the practice have helped him improve how he relates to patients. "In practices, each person brings a different skill set and different perspective," says Jennifer Zarate, president and CEO of Professional Medical Staff Associates. "No one person can know everything, and by exchanging new ideas, everyone wins—especially the patients." Among the factors that have changed over the years are the desire for greater work/life balance and a greater interest in being salaried employees rather than becoming a partner or running a practice. Jim Hay, MD, a 62-year-old founder of North Coast Family Medical Group in Encinitas, Calif., says the key to harmony is flexibility and communication, including coordinating work hours through a staff member, staying in touch via twice-monthly meetings and through e-mail, and sharing weekend call responsibilities equally.

Health Policy and Reimbursement

HHS Names Federal Coordinating Council for Comparative Effectiveness Research

The U.S. Department of Health and Human Services (HHS) has named the 15 members of the Federal Coordinating Council for Comparative Effectiveness Research. The council was authorized by the American Recovery and Reinvestment Act (ARRA) to help coordinate research and guide investments in comparative effectiveness research funded by ARRA. "Comparative effectiveness research can improve care for all Americans and is an important element of President Obama's health reform plan," says HHS spokeswoman Jenny Backus. The council will focus on determining the effectiveness of various medical interventions in a bid to provide clinicians and patients with valid information to help them make decisions. The council will not however make recommendations pertaining to clinical guidelines for payment, coverage, or treatment. The Recovery Act authorizes $300 million for the Agency for Healthcare Research and Quality, $400 million for the National Institutes of Health, and $400 million for the Secretary of Health and Human Services for comparative effectiveness research.



Bill Aims for Coverage for Pre-existing Conditions

Sen. Jay Rockefeller (D-W.Va.) and Rep. Joe Courtney (D-Conn.) have pledged to introduce a bill on March 17 that establishes a blanket requirement for all insurance companies to cover the more than 133 million Americans who suffer from pre-existing medical conditions such as heart disease and diabetes. "That's what insurance companies are meant to be doing, that's what they're in business for," said Rockefeller, chairman of the Senate Finance Committee's Health Care Subcommittee, at a conference call. "They are in business in order to pay for people who are sick." More than 75 cents of every dollar spent in the American health care system goes toward patients who suffer from multiple conditions, according to the Partnership to Fight Chronic Disease. Rockefeller and Courtney said their measures would collectively reduce the overall expenditure, which currently stands at approximately $2.2 trillion annually. The legislation also would deter insurance firms from inflating coverage costs for patients with chronic illnesses. Rockefeller drew a connection between the legislation and an overarching initiative to reform the delivery and payment of health care in the United States.



Bill Aimed at Improving Private Insurance Coverage of Prosthetics

The Amputee Coalition of America (ACA) is backing a proposed measure in Pennsylvania under which private insurance companies would have to offer amputees the same benefits that federal healthcare offers to them. Right now, children who need prosthetics can get replacements and upgrades as they grow if they are covered by federal healthcare programs, but private insurance offers frequently cover just one limb per lifetime or pay only a small part of the prosthetic device's full price. Dr. Jeffrey Cain, chairman of the ACA's advocacy committee, compares this to telling parents of newborns that they could only ever buy one pair of shoes for their children, even as the children constantly grow. Similar legislation has been passed in 11 states and is being considered in another 30, according to Cain, although he notes that state regulations do not cover companies with more than 5,000 employees who self-insure, and this type of company accounts for half of the U.S. private workforce.



Aetna Lets More Patients See What Doctors Are Being Paid

Aetna has expanded an online tool that allows members in 57 markets throughout the United States to view how much the company has agreed to pay specific doctors for care. Members are allowed to see prices for Aetna network doctors in more markets in Rhode Island, upstate New York and New Jersey, and the price transparency tool also lists negotiated prices for care delivered by nonphysician health professionals, including podiatrists, chiropractors and optometrists. The American Medical Association (AMA) and others are worried that the company could be sharing inaccurate data and that the reimbursement rates in some areas are presented without quality measures. "If the insured is looking at the negotiated rate and it's not accurate, that patient is going to be confused," warns AMA President-elect J. James Rohack, MD. Plan members who wish to view rates for specific types of visits or procedures for in-network physicians can log on to Aetna's Navigator Member Web site and choose either medical, dental or hospital care, and the displayed figures are supposed to reflect Aetna's current negotiated fee schedule with that doctor, facility or health care professional. However, Rohack cites AMA research indicating that the rates that health plans agree to pay are not always what they actually pay. The AMA's 2008 National Health Insurer Report Card found that insurers' "allowed amount" listed on reimbursement records and the rate specified in a doctor's contract matched about 70 percent of the time, but this figure was beaten by the match rates for Humana and Anthem. But even where there is accurate data, there are some markets where Aetna has yet to post clinical quality information. "That sets up a situation where you're rewarded for possibly cutting corners, and that's just not an environment I think is healthy," says Mark Jarvis of the Ohio State Medical Association.

Technology and Device Trends

False Start on a Laser Remedy for Fungus

The use of lasers to treat onychomycosis, or toenail fungus, could one day be as popular as the technology's use in cataract surgery, dental work, and hair removal. Currently, there is no cure for the fungi that causes the infection. Popular antifungal drugs are completely successful less than 50 percent of cases and carry a slight risk of liver damage, and prescription lacquer painted on infected toenails daily for 48 weeks has a complete cure rate of less than 10 percent. While some pharmaceutical giants are banking on the next-generation of lacquers, pills and ointments to treat the disease, some podiatrists and patients are pinning their hopes on lasers, which allow for the selective irradiation of fungi with no damage to the nail or surrounding tissue. Nomir Medical Technologies of Waltham, Mass., is developing a laser called Noveon that utilizes two different wavelengths of near-infrared light to selectively target and kill toenail fungi. According to the results of a clinical trial of the technology, approximately half of the volunteers tested no longer had active nail infections after four treatments, and about three-quarters had clear nail growth within six months after the first treatment. "We will be able to reach people who have heretofore stayed away from treatment because of the toxicity or the costs or other reasons," says Richard F. Burtt, CEO of Nomir, which is preparing to submit the results of the trial to the U.S. Food and Drug Administration (FDA) for approval to market the technology. Meanwhile, another company, PathoLase, is already marketing its PinPointe laser device despite not having gained FDA approval to do so specifically for the use in curing toenail fungus; the device was cleared by the agency in 2001 for use in dentistry. An estimated 10 percent of adults in the United States suffer from toenail fungus, which can lead to serous health problems in those suffering from diabetes or immune disorders. Americans spend about $1.26 billion each year on oral and topical prescriptions for onychomycosis. Analysts say that a more effective treatment could boost the market for treatments to up to $3 billion a year.



Study: Save Limbs With Stents

Researchers have found that the use of drug-eluting stents can reduce the rate of repeat procedures for treating critical limb ischemia related to peripheral arterial disease (PAD). Via a balloon angioplasty, an interventional radiologist opens a clogged blood vessel and inserts the drug-eluting stent, which holds the narrowed artery open while time-releasing a drug for several weeks to prevent the re-growth or proliferation of cells. The new study is available at the Society of Interventional Radiology's Web site.



Imaging Technology Guides Treatment of Ankle Injuries

Roughly 300,000 ankle sprains occur each day in the United States, of which many are not first-time incidents. Recurring ankle injuries are linked to subsequent arthritis in some people as well as the need for ankle replacement surgery. Researchers at Duke University have turned to an imaging technology to improve the correction of ankle injuries. Dr. James Nunley, a Duke University Medical Center orthopedic surgeon, and his research team have merged X-ray technology with magnetic resonance imaging (MRI) to examine the mechanics of injured ankle joints. Researchers are able to see three-dimensional images of torn or weak ligaments, which cause abnormal bone movement. In a study, Nunley used the imaging as a guide for aligning bones as well as repairing tendons. This technology, if proven successful, may eventually become a standard tool for the treatment of ankle injuries and preventing osteoarthritis.



Abstract News © Copyright 2009 INFORMATION, INC.

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