News From ACFAS

---

ACFAS President Glenn M. Weinraub, DPM, FACFAS, has written New York legislative leaders in support of podiatry scope-of-practice reforms that have thus far been approved by the New York state senate. Action by the state house is pending.

In his letter Weinraub says, "New York law is out of step with 37 other states, including all of your neighboring states, by not including the ankle in the podiatric scope of practice act. Since many conditions which affect the foot originate in soft tissue beyond the permissible treatment zone, the current law should be amended to remove this stumbling block which impedes proper podiatric service. This impediment to prompt treatment usually proves frustrating to the patients whom the podiatrists are forced to advise to go elsewhere for more treatment of the suspected conditions ranging above the patient’s foot."
The ACFAS Clinical and Scientific Research Grant application is now available for members seeking funding for the study of foot and ankle surgical medicine. Research should have either direct or indirect impact on issues of interest to ACFAS members. Projects capable of obtaining EBM Levels of Evidence 1, 2 or 3 will be given preference, but beginning this year, cadaveric, animal or bench-top studies will also be considered.

The ACFAS Research Committee is also encouraging use of a scoring scale, including the ACFAS Scoring Scale, which was recently fully validated by a volunteer ACFAS task force. Their article, which will publish in the July/August issue of the Journal of Foot & Ankle Surgery, can be accessed online now:

• Visit acfas.org/jfas and click on "Read current and past issues online"
• Log in when prompted with your ACFAS member information
• When you reach the JFAS home page, click on "Articles in Press" and scroll to read "Validation of the American College of Foot and Ankle Surgeons Scoring Scales."

The application deadline is Sept. 1, 2011. Find out how to apply at acfas.org/grant.

Foot and Ankle Surgery

---

Research was conducted to assess the types and rates of complications associated with contemporary ankle arthroscopy that involves noninvasive ankle distraction and a padded foot strap, through retrospective review of 294 consecutive arthroscopies. The overall complication rate was 6.8 percent, and four non-neurologic complications and 16 neurologic complications were observed; when analyzed as a group the subjects receiving Workers' Compensation had a higher complication rate than those not receiving Workers' Compensation. Although contemporary ankle arthroscopy performed with a noninvasive distraction method was deemed to be safe, the complication rate was lower than reported in a previous benchmark study. A key advantage of contemporary ankle arthroscopy involving the use of small-joint arthroscopic instruments and noninvasive distraction is a significant reduction in the rate of non-neurologic complications.



Researchers investigated the efficiency of platelet-rich plasma (PRP) on the healing of chronic diabetic ulcers in comparison with platelet-poor plasma (PPP). The study included 24 patients with chronic diabetic ulcers who were systematically randomized into two groups: PRP group (n = 12) and PPP group (n = 12). The results showed that healing in PRP group was significantly faster (P < 0·005).



Identifying structures which may be at risk of injury when using a minimally invasive method for the osteosynthesis of the lateral malleolus and how the implant's size influences the frequency of injury to these structures was the goal of a study involving the percutaneous insertion of 40 plates within 20 cadaveric legs. In 55 percent of the cases of the 10 hole plates the superficial peroneal nerve was in direct contact with the plate, and the researchers identified just one instance of the superficial peroneal nerve skirting the proximal edge of a 6 hole plate. The researchers note that careful attention should be applied to the dissection of soft tissues in both the proximal and distal incisions, and they point out that the plate's length may be checked with intraoperative imaging prior to its insertion, and the site of both proximal and distal incisions may be marked on the skin. Following cautious dissection down to the bone, saving nerves and tendons, the periosteal elevator should be introduced both from the proximal and the distal incisions to ready the extra-periosteal tunnel for the insertion of the plate, in order to avoid the entanglement of the superficial peroneal nerve with the metal work, especially in plates of longer than six holes.

Practice Management

---

Medical practices that fail to pay close attention to financial management go out of business. Managing finances is more than just balancing books. It's also figuring out how to grow the organization profitably, using tools to recover money owed, attracting new patients, adhering to government regulations, and much more.



Reporting services for foot and ankle procedures, especially surgery on the toes, can be challenging. Payer rules related to modifiers further complicate the claims submission process and increase the challenges faced by the appeals team. Click here for some coding tips.



MGMA lists eight tips for collecting at the time of service:

1. Always begin by asking for the balance in full.
2. Develop a sense of urgency with the patient concerning the need for full payment at the time of service.
3. Politely explain that the medical group does not carry accounts without specific prior arrangements.
4. When establishing a new patient in the practice, get the name and full contact information of the financially responsible party prior to providing a major surgery, medical or ancillary procedure.
5. Obtain, with proper signatures, all credit information.
6. If the patient cannot pay at the time of service, obtain the date on which the account will be paid in full. Try not to go beyond 30 days.
7. Instruct patients on how to use the e-commerce system of online payment.
8. Consider isolating a call center, separate from the front desk staff, to handle appointments.

Health Policy and Reimbursement

---

A new survey of U.S. regional health information organizations (RHIOs) published in the Annals of Internal Medicine concludes that health information exchange between physicians and hospitals has been slow to catch on, and that few organizations responsible for coordinating the digital exchange of patient records are financially viable, while only a small number support the type of information exchange that the government designates as necessary. "A lot of the value comes from having complete patient information at the point of care, and not all patients see the same doctor for their whole lives," says study co-author Julia Adler-Milstein from Harvard Business School. The survey found that a mere 13 of the 75 operational U.S. RHIOs could perform the type of information exchange that doctors must use to receive some of the $30 billion in government incentives reserved to promote health information exchange.



Since the government released its proposed rules for establishing accountable care organizations (ACOs) in March, the plan has hit numerous roadblocks. The most recent came when seven influential Republican senators wrote a letter to Health and Human Services Secretary Kathleen Sebelius and Medicare Chief Don Berwick demanding that the proposed ACO rules be withdrawn. The senators argued that the rules are "unworkable" and that the proposed ACO regulation would fail to accomplish its purpose.



The advisory panel to the HIT Policy Steering Committee has taken a step closer to pushing back stage 2 of meaningful use, hoping to grant providers more time to incorporate other deadline-driven health IT projects, most notably ICD-10 conversion, into their agendas. The committee has detailed three options of late, the third of which is pushing stage 2 back until 2014. “Option three gives the opportunity to sync up your upgrades for ICD-10 and meaningful use stage 2,” said Paul Tang, chairman of the meaningful use work group. The intent is plausible, according to Mandy Willis, an ICD-10 expert in Seattle. “ICD-10 is a mandate with a hard cut-over date. ... We need to focus on getting it done and doing it well.” While meaningful use is an incentive program, ICD-10 is a federal mandate. The Centers for Medicare & Medicaid Services has said that the Oct. 1, 2013, compliance deadline is firm and will not be altered. The panel said it will present its recommendations, including extending stage 2, to the HIT Policy Committee in June. A Notice of Proposed Rulemaking will follow by year’s end, and the final rule would be handed out in mid-2012.

Medicine, Drugs and Devices

---

IBM's Watson computer, which is best known for defeating the world's best "Jeopardy!" players, is being prepared to work as a medical tool. IBM says Watson's ability to understand plain language enables the computer to digest questions about a person's symptoms and medical history and quickly suggest diagnoses and treatments. Watson could also link to the electronic health records the federal government wants hospitals to maintain. A marketable medical Watson is still about two years away, according to IBM.



A Northwestern University survey of 350 medical device developers says that the FDA's device approval process has become stricter, with more layers of expensive clinical requirements added over the past three years. The poll reports that 58 percent of respondents have experienced broader FDA requirements for clinical studies and analyses in recent years, which mirrors other recent industry opinion reviews that the device approval process has become more stringent and less predictable.



A new study reveals that a pro-inflammatory protein called tumor necrosis factor (TNF) can also suppress aspects of inflammation. Researchers say they have identified the mechanism of how this occurs, potentially leading to new treatments for diseases like rheumatoid arthritis. In test tube studies, the researchers treated human monocytes and macrophages, which play a key role in inflammatory diseases, with TNF and then challenged these cells with lipopolysaccharide (LPS), a prototypical inflammatory factor. They found that TNF suppressed the inflammatory response of the macrophages and monocytes. The mechanism by which TNF suppressed the inflammatory response involved a protein known as GSK3 (glycogen synthase kinase 3-alpha) and a gene known as TNFAIP3 that encodes the A20 protein. The study was published May 22 online in advance of publication in the journal Nature Immunology.