News From ACFAS

---

Did the sessions and workshops at ACFAS 2018 in Nashville inspire you to join the College’s faculty? Take that next step and consider applying as a faculty member or instructor and help grow our Surgical Skills courses, On the Road programs, e-Learning products and Annual Scientific Conference sessions.

If you are an active Fellow member of the College, have attended our educational programs within the past three years and have been in practice for five or more years, complete a Faculty Application and fax it to the ACFAS Education Department at (800) 382-8270. You may also email your application to Mary Meyers, ACFAS director of Education Curriculum and Alliances. FootHealthFacts.org, the College’s consumer website, is available 24/7 to help you enhance your practice website and also attract new patients and referrals to your office. To make the most of FootHealthFacts.org’s resources:

• Add a link to FootHealthFacts.org on your practice website’s homepage and direct patients there for valuable foot and ankle health information
• Link to specific articles, condition pages and videos featured on FootHealthFacts.org
• Encourage patients to use the Where Do You Hurt? interactive foot diagram
• Remind patients to follow FootHealthFacts.org on Twitter and Facebook

FootHealthFacts.org is free to use and continually updated with new content. If you have any questions about how to make FootHealthFacts.org work for you, contact Jolinda Cappello, ACFAS communications manager, at (773) 444-1320. With podiatric medicine advancing at lightning speed, keeping up with the newest research can seem like an impossible task. Luckily, ACFAS’ monthly Scientific Literature Reviews (SLRs) are just a click away to help you stay up to date on the latest breakthroughs.

Written by podiatric surgical residents, SLRs provide short summaries of studies from prominent medical journals and include podiatric relevance, methods, results and conclusions. Read the April SLRs now at acfas.org/SLR, and be sure to also browse through the complete SLR archive to catch up on any studies you may have missed.

Foot and Ankle Surgery

---

The spring ligament is an important medial arch stabilizer. However, when disrupted, it does not cause planovalgus deformity until the foot is cyclically loaded. Researchers proposed in this study that the tibionavicular (TN) ligament plays an important role. However, this ligament is not imaged in routine magnetic resonance imaging sequences. A prospective case-control study used a novel MRI sequence to image the TN ligament in 20 normal feet creating a baseline appearance of the ligament. The investigators then scanned 20 patients with adult acquired flatfoot deformity (AAFD). The normal ligament was reliably identified on the novel sequences. It had a reproducible appearance in two views and consistent length and width. The study adds to the evidence that AAFD is multifactorial. With this imaging technique, researchers were able to reliably image the TN ligament.


Researchers conducted a study to determine the reliability of numerous radiographic measurements of the skeletally immature ankle joint, timing of ossification of medial malleolus, appearance of tibial incisura and differences in the values of radiographic measurements based on age and sex. This study included 590 subjects, who underwent ankle AP, lateral and mortise radiographs. Presence of the medial malleolus and incisura fibularis was recorded. All radiographic measurements showed good to excellent intraobserver and interobserver reliability. The timing of ossification of medial malleolus and appearance of tibial incisura did not differ between boys and girls. Tibiofibular clear space on mortise views, medial clear space on AP and mortise view significantly decreased by age. For skeletally immature patients, the criteria for absolute radiographic values used in adults to assess distal tibiofibular syndesmosis or deltoid ligament injury cannot be applied, but comparison of both sides of ankle joint could help physicians to predict the need for additional evaluations.


A randomized clinical trial of close contact casting versus the usual practice of surgery for treating unstable ankle fractures in older adults found equivalent ankle function outcomes at six months. Higher rates of radiological ankle malunion and nonunion in the casting versus surgical groups suggested that equivalence between the two groups may be lost if symptoms or functional limitations from posttraumatic arthritis manifest later. A follow-up at least three years after randomization was conducted to determine if equivalence persisted over time. That study found that equivalence in function between casting and immediate surgery strategies was maintained at three years. In post hoc analysis, participants with radiological malunion and medial malleola nonunion at six months had lower Olerud-Molander ankle scores at three-year follow-up.

Practice Management

---

Several communication strategies can enhance the patient/customer experience, which can lead to better outcomes, fewer return visits, more compliance and better overall satisfaction. Because likeability is key, physicians should talk slowly and begin with open-ended questions, such as, “How can we work together to accomplish your goals?” Avoiding medical jargon is also recommended, as it will lessen fear and distrust by patients and reduce the odds of less compliance and misunderstanding. Physicians should speak in simple language, check for understanding, talk in a relatable voice and give patients index cards to write down any questions they may be too timid or confused to ask at that moment. Being empathetic and humane toward patients is a third recommendation, and using compassionate, nonjudgmental language and tone helps build a relationship and work toward shared goals. Physicians also need to acknowledge that patients may have many questions and are overwhelmed by all of the information they are given. It is therefore wise to let them feel they are part of a group that has felt the same way.


A large body of research supports the finding that people who depart from traditional heterosexual norms feel disrespected and marginalized in healthcare environments. "[Physicians] just need to be aware of this population and get the basics of how to approach the patient," says Northwell Health's Tochi Iroku-Malize. To clarify that lesbian, gay, bisexual, transgender, queer, intersexual or asexual (LGBTQIA) patients will be treated with the same respect and high-quality care as any other patients, physicians should first ask two basic questions to answer how patients identify their gender and what sex they were assigned at birth. The second step is to quickly resolve the issue of how to address the patient, using the patient's preferred pronoun consistently and making sure other staff do as well. In addition, Iroku-Malize says the physician "must be confidential, acutely sensitive and aware that there are places where this [being a queer person] could lead to job loss or to the patient's family members being ostracized." Furthermore, the provider should be sufficiently self-aware to recognize if their own discomfort or disapproval disqualifies them from caring for LGBTQIA patients and then refer those patients to clinicians who will give them the appropriate respect and treatment. The last step is to make the waiting room a friendly and welcoming environment.


According to a study from the Mayo Clinic, doctors who receive negative online reviews do not receive negative responses in rigorous patient satisfaction surveys. The study comes as online doctor reviews have become popular among patients seeking medical advice or help. The researchers studied online reviews of 2,148 physicians, 113 of whom had negative online reviews. However, when they compared these doctors' scores in a formal patient satisfaction survey with the scores of other Mayo Clinic doctors, there was no statistical difference in their overall scores. Researchers note the study was small and time spent collecting data was limited, but one study author says patients need to be aware of these differences when they make decisions related to their health.

Health Policy and Reimbursement

---

The U.S. Department of Health and Human Services' Office of the National Coordinator for Health Information Technology (ONC) has issued the ONC Guide to Getting and Using your Health Records, an online resource for individuals, recipients and caregivers. The guide notifies consumers about the value of health information and offers individuals clear, actionable advice on how to access their health records, including offering tips through the process of accessing their records electronically; checking their record to ensure it is complete, correct and up-to-date and using their electronic health records, such as sharing their records to better coordinate their care and using apps and other digital technologies to better manage and improve their health. "It's important that [consumers] and their caregivers have access to their own health information so they can make decisions about their care and treatments," says National Coordinator for Health Information Technology Don Rucker. "This guide will help answer some of the questions that [consumers] may have when asking for their health information." Nearly half of Americans in 2017 who were offered access to an online medical record did not access it, often listing a perceived lack of need as one reason. Consumers may not understand their right under the HIPAA Privacy Rule to access their health data or be aware of the benefits of accessing such information.


The U.S. Centers for Medicare and Medicaid Services (CMS) has expanded the definition of "primarily health-related" benefits insurers can include in their Medicare Advantage policies, which would be added on top of traditional benefits. "Medicare Advantage beneficiaries will have more supplemental benefits making it easier for them to lead healthier, more independent lives," said CMS Administrator Seema Verma. Advantage plans limit members to a provider network, and similar limitations may apply to the new benefits. CMS says insurers will be allowed to provide care and devices that prevent or treat illness or injuries, compensate for physical handicaps, address the psychological effects of illness or injuries or reduce emergency medical care. Besides transportation to doctors' offices or better food options, some insurance experts note supplemental benefits could include modifications in beneficiaries' homes, such as installing grab bars in the bathroom, or aides to help with daily activities.


The Trump administration reported that 11.8 million people enrolled in health insurance through the Affordable Care Act (ACA) marketplaces for 2018, down about 400,000 from last year, which is a relatively small decrease given that the administration significantly cut federal outreach efforts and halved the open enrollment period. Nearly all of the decrease was from the 39 states using HealthCare.gov, as enrollment held steady in the 11 states selling ACA coverage through their own marketplaces. The report showed that new enrollees accounted for 27 percent of total enrollment, down from 31 percent last year, the share of customers younger than 35 fell slightly, and the share of customers older than 55 grew slightly. Overall, 83 percent of enrollees qualified for subsidies to lower premiums. Meanwhile, the report shows that monthly premiums for federal marketplace customers before any subsidy was applied jumped 30 percent to $621 from $476 last year, and subsidies cover an average of 86 percent of the premium cost for those who qualify.

Medicine, Drugs and Devices

---

About 5 percent of U.S. adults obtain a significant portion of their daily calcium from supplements, but many individuals are taking higher doses than necessary, according to a recent study in Bone. Researchers studied nationally representative survey data on dietary habits and vitamin and supplement use collected between 1999 and 2014 from approximately 42,000 adults. In the study's first year, 2.5 percent of supplement users got more than the estimated daily amount of calcium necessary. This reached a peak of 6.7 percent from 2003 to 2004, then fell to 4.6 percent from 2013 to 2014. "Supplemental calcium has potential benefits, particularly in relation to bone health; however, it may also put people at increased risk of kidney stones, cardiovascular disease and adverse gastrointestinal symptoms," said senior study author Pamela Lutsey of the University of Minnesota. By the end of the study period, only 0.3 percent of supplement users were taking more than the upper tolerable limit of calcium supplementation, down from 1.2 percent in 2007 to 2008.


Massachusetts, which led the nation in expanding health insurance coverage, is now trying to address the growth of prescription drug spending for low-income people on Medicaid. However, its proposals have so far met an icy reaction from patients and drug companies. The state has asked the Trump administration for permission to limit the number of drugs that will be covered in its Medicaid program, seeking to exclude "drugs with limited or inadequate evidence of clinical efficacy." Consumer advocates and drug manufacturers have mobilized a campaign to block the proposal, telling the administration that it would deprive Medicaid beneficiaries of access to innovative, lifesaving treatments. To manage the increased drug spending, Massachusetts says it wants to use the same tools that have been widely employed by commercial insurers. State officials want to establish a list of covered drugs, which they say will enable them to negotiate better deals with drug manufacturers, guaranteeing them additional sales for the drugs it does cover, in return for larger discounts or rebates.


The U.S. Centers for Medicare and Medicaid Services (CMS) issued a final Medicare Part D rule to expand access to more affordable drugs and also outlined new opioid limits. The drug cost revisions should lower cost-sharing for some beneficiaries and may provide some savings for taxpayers, but they will not directly affect the prices drug companies charge. The final rule for the 2019 Medicare prescription drug program mandates plans must lower maximum co-payments for biosimilar drugs for people who receive low-income subsidies. CMS says this change should save beneficiaries $10 million in 2019, without changing what plans pay for the biosimilars. The rule also allows Part D plans to immediately substitute newly released generics for brand-name drugs at the same or lower cost-sharing if they come on the market during the plan year. The rule also implements provisions in the Comprehensive Addiction and Recovery Act of 2016, allowing Part D plans to deploy drug management programs that can limit at-risk beneficiaries' access to frequently abused drugs, including opioids and benzodiazepines. Plans can require that at-risk beneficiaries receive the drugs from only one selected provider or pharmacist.