News From ACFAS

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Download, print or post our newest patient education infographic, Back-to-School Shoe Shopping Tips, from the ACFAS Marketing Toolbox and help kids start the new school year on the right foot. This handy guide explains how to find the proper fit, when to replace worn-out shoes and what kind of shoes to buy for children with flat feet.

Visit acfas.org/marketing for a complete library of infographics you can share with your patients. Take advantage of the many other free resources available in the Toolbox, such as PowerPoint presentations, press release templates and the seasonal FootNotes newsletter, to get the most mileage from your patient education and practice marketing efforts. See how much foot and ankle surgery has evolved since the College’s start in 1942 and how members like you are revolutionizing patient care. Mark your calendar for ACFAS 75 in Las Vegas February 27–March 2, 2017 to celebrate 75 years of influence and ingenuity in the profession.

Enjoy clinical sessions and workshops with renowned faculty, hundreds of exhibits, award-winning posters, papers and case studies, and exciting special events. Come to Vegas on February 26 for in-depth preconference workshops designed to challenge your skills and whet your appetite for the learning that lies ahead.

Visit acfas.org/asc and This Week @ ACFAS for the latest updates on our biggest conference ever! This month’s Scientific Literature Reviews (SLRs) on acfas.org bring you up close and personal with the newest developments in foot and ankle surgery. Read concise summaries of studies on pediatric flatfoot, treatment of acute gout, perioperative vitamin D levels and other topics that apply to your own surgical cases.

Each SLR is written by a podiatric surgical resident and includes podiatric relevance, methods, results and conclusions. New SLRs are posted monthly at acfas.org/SLR so you’ll always be one step ahead of the latest research.

Foot and Ankle Surgery

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A cross-sectional pilot study was conducted to compare quality of life in subjects with partial foot amputation or transtibial amputation secondary to peripheral vascular disease and to determine factors influencing quality of life in these groups. The SF-36v2 Health Survey and an adapted version of the demographic section of the Trinity Amputation and Prosthesis Experience Scales-Revised were sent to people enlisted via a large metropolitan hospital. Both the SF-36v2 mental health component summary and physical component summary scores were comparable in the partial foot amputation and transtibial amputation cohorts. A multivariate linear regression demonstrated that age, time with diabetes and the presence of retinopathy significantly affected either the SF-36v2 mental health component summary or physical component summary while the amputation level did not. The results support existing descriptive data indicating quality of life is comparable in cohorts with partial foot and transtibial amputation. The researchers conclude that quality of life need not be considered when choosing between partial foot and transtibial amputation for persons with vascular disease. Surgeons and patients may wish to weigh other factors, such as the relative risk of ulceration and subsequent amputation, when deciding between partial foot and transtibial amputation.


A primary operation with on-top plasty for lengthening short-type postaxial polydactyly was detailed, with four patients undergoing the procedure. Ray transfer was conducted at the proximal phalangeal level. Resection of the lateral distal and middle phalanges was undertaken, and the medial ray was transferred on top of the remaining lateral proximal phalanx. Preoperative and postoperative toe lengths and complications were assessed by comparison with the contralateral side on x-ray. All toes were lengthened by an average of 115.1 percent from the tip of the distal phalanx to the bottom of the proximal phalanx relative to contralateral side. Appearances were quite natural without valgus deformity and hypertrophic scar. No remaining dysfunction in walking was observed after an average of 21.5 months follow-up.


A study was conducted to translate the Achilles tendon Total Rupture Score (ATRS) to Dutch and to assess its reliability and validity in the Dutch population. The researchers performed a forward-backward translation procedure based on the guidelines of cross-cultural adaptation process. The Dutch ATRS was evaluated for reliability and validity in patients treated for a total Achilles tendon rupture from January 1, 2012, to December 31, 2014, in one teaching hospital and one academic hospital. Reliability was assessed by the intraclass correlation coefficients, Cronbach's alpha and minimal detectable change (MDC). Construct validity was evaluated via calculation of Spearman's rho correlation coefficient with domains of the Foot and Ankle Outcome Score (FAOS), Victorian Institute of Sports Assessment-Achilles questionnaire (VISA-A) and Numeric Rating Scale (NRS) for pain in rest and during running. The Dutch ATRS exhibited a good test-retest reliability and a high internal consistency. MDC was 30.2 at individual level and 3.5 at group level. Construct validity was supported by 75 percent of the hypothesized correlations. The Dutch ATRS correlated strongly with NRS for pain during running and all the five subscales of the Dutch FAOS. A moderate correlation was observed with the VISA-A-NL and NRS for pain in rest.

Practice Management

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Kaiser Permanente attending cardiologist Payal Kohi writes that talking with patients about prescription drug costs is becoming a necessity for physicians. She says she usually waits until the end of the office visit to bring up drug costs and makes an analogy to explain the concept. In Kohi's case, she uses the analogy of cars. "If given a choice, would you rather choose a Toyota, a Tesla, a BMW or a Porsche?" she usually asks in such a scenario. "Immediately, their response provides me with great insight into their approach to cost vs. benefit ratio," Kohi says. "The Toyota driver may feel that a car's purpose is to transport from one location to another in the most cost-efficient way and may be willing to tolerate a lower-cost vehicle that requires more frequent repairs (i.e., frequent INR checks with warfarin, a generic low-cost drug). The Tesla driver, on the other hand, favors luxury over cost and may be willing to pay the upfront cost of a more expensive vehicle in exchange for the convenience of fewer maintenance visits and better performance (i.e., eliquis, which is more expensive but does not require INR check and has a slightly better safety to efficacy profile)." Discussing costs with patients requires physicians to familiarize themselves with the costs of new drugs and incorporate that into their decisions of which drug to select for which patient, according to Kohi. For cases of unaffordable drugs, it pays to combine one's knowledge of a drug's cost with knowledge of its effectiveness and safety from its clinical trials.


A new study published in JAMA Surgery focused on what surgeons disclose to patients about adverse events and how those discussions can have an impact on the doctor. “For a long time in the field, people thought that the primary reason that physicians have trouble reporting adverse events is that they were worried about being sued, but there are other barriers that are more important,” says University of Washington Professor Thomas Gallagher. “This paper helps highlight how embarrassing and upsetting these events are for clinicians...[and] makes it difficult for the physician to admit to the patient, 'Here is exactly what happened.'” The researchers utilized surveys of surgeons who reported adverse events at three Veterans Affairs medical centers. About 90 percent of the surveys revealed that doctors said they had reported the event to patients or their families within 24 hours, communicated concern for the patient's welfare, explained why the event occurred, expressed regret and discussed with patients steps to treat subsequent problems. However, only about 50 percent of polls showed the doctors discussed whether the event was preventable and 33 percent reported they talked about how it could be avoided in the future. Slightly more than 50 percent gave the patient an apology. Moreover, surgeons who find an event very or extremely serious and who had problems discussing that event are more likely to suffer anxiety. This also was apparent with surgeons concerned about negative reaction from patients, an impact on their reputations, bad publicity or a malpractice suit.


Technologies that clinicians and researchers say are most likely to transform how physicians practice in 10 years include virtual visits and telehealth. "I can see physicians using [smartphones] to engage the patient, especially patients in remote locations or those who can't come to the office due to physical issues," says the Medical Group Management Association's Todd Evenson. Another technology is wearable and remote patient monitoring. By collecting biometric data directly from the patient and allowing that data to be used to personalize treatment and generate real-time alerts, wearables can give patients the tools and education to self-manage their health and stay out of hospitals. Smartphones and associated apps also are expected to have an impact. "As we get more aligned with value-based payments, physicians get more and more interested in these kinds of tools because they start to understand they will [improve care and reduce costs] by spreading the human resources in their practice across more patients, and these kinds of tools enable that," says Connected Health's Joseph Kvedar. Machine learning and artificial intelligence may be incorporated into clinical decision support tools for physicians, helping them analyze and make sense of vast volumes of data. Meanwhile, the waiting room experience could be transformed into a more effective and efficient tool by reinventing scheduling, billing, connecting with staff and meeting special needs, Evenson says. Finally, easily accessible personal health records could enable more effective control by patients over their healthcare.

Health Policy and Reimbursement

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U.S. antitrust enforcers have rejected a pair of proposed deals that would consolidate the nation's five biggest health insurers into three. The Justice Department has sued to block Anthem's $48 billion takeover of rival health insurer Cigna and Aetna's $37 billion bid for Humana, saying the deals would raise healthcare costs and reduce choice for consumers. Three of the companies said they would fight the lawsuits, which could tie them up in months of litigation.


The Centers for Medicare and Medicaid Services (CMS) saved about $42 billion in fiscal years 2013 and 2014 through program integrity efforts, according to a report to Congress released Wednesday. CMS attributed the savings to increased provider enrollment and screening standards as well as fraud prevention efforts established by the Affordable Care Act.


In Phase 2 of the Department of Health and Human Services' Office for Civil Rights (OCR) audit program, covered entities and business associates will be reviewed for Health Insurance Portability and Accountability Act compliance. Starting this fall, 167 health plans, providers and clearinghouses will be subject to desk audits. The aim of this phase will be to review individual policies and procedures for adherence to standards of the Privacy, Security and Breach Notification Rules. Healthcare attorney Daniel Gottlieb contends that the Phase 2 audit will focus on areas of greatest security risk and pervasive noncompliance, rather than conducting a comprehensive review. However, OCR may initiate a full review if the audit raises serious concerns. To ensure that covered entities and business associates are prepared for a potential audit, Gottlieb recommends organizations conduct risk assessments and review breach notification and data security policies.

Medicine, Drugs and Devices

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A Wall Street Journal review of corporate filings and conference call transcripts found that drug companies are still able to raise the price of medicine despite criticism from the public and legislators. Specifically, the review found that more than two-thirds of the 20 largest drugmakers said price increases boosted sales of some or most of their biggest drugs in the first quarter. While companies continue to increase prices, Congress has taken little action to address the issue. Adding to the problem of monitoring rising drug prices is a complex healthcare market combined with a complex drug rebate and discount system. Furthermore, experts say drug companies often mislead outsiders about the true costs and earnings of the drugs they make.


A study published in Clinical Infectious Diseases found that an infection control program can lower the spread of most of the bacteria that can carry the superbug MCR by 40 percent. However, the infection control program was designed to stop the spread of MRSA. The program was created in 2007 at the Veterans Administration Health Care System. The program called for hospitals to check new patients for MRSA, isolate patients who were found to have it, improve hand washing and make infection prevention a priority. Research showed that by focusing on MRSA, the hospitals were also able to improve overall infection control. As a result, the infection control program also proved beneficial for the hospital in the long run despite the cost increases.


The U.S. Centers for Medicare and Medicaid Services and Food and Drug Administration (FDA) are advocating for the use of unique identification numbers in billing records for medical devices. In a letter to the Accredited Standards Committee (ASC) X12, Medicare's acting administrator, Andrew M. Slavitt, along with FDA Commissioner Robert M. Califf, encouraged the use of the ID number in medical bills and claims, called a unique device identifier, saying the change "would allow for evaluation of product performance and identification of safety concerns for devices at the model level." They said the change also would help providers and certain payers calculate and compare total costs and outcomes based on the device model used, among other benefits. Ultimately, whether the change occurs depends on a decision from the ASC X12, a committee of the medical billing industry. The panel is scheduled to make specific recommendations to the industry by December.