News From ACFAS

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The deadline to apply for support for your research with the 2011 ACFAS Clinical and Scientific Research Grant is coming up fast: Sept. 1, 2011.

Members of the College should not miss the opportunity to receive up to $20,000 for research in podiatric foot and ankle surgery that will be 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 encourages use of a scoring scale, including the ACFAS Scoring Scale. Find the Scoring Scale, its Validation, the application and more information at acfas.org/grant. Don’t take a chance on Lady Luck — come to ACFAS’ “Practice Made Perfect” practice management/coding seminar in Las Vegas, Oct. 14–15, 2011, to gain a competitive edge with insights from respected experts. Sign up for a free coding consultant at the seminar with Douglas G. Stoker, DPM, FACFAS, by contacting kristin.hellquist@acfas.org.

Remember, members of the College can e-mail coding questions to Dr. Stoker any time at coding@acfas.org. Just as ACFAS announced it wants to assist members with integrating into academic health centers (AHCs), the Centers for Medicare and Medicaid Services has announced that 267 teaching hospitals will have their full-time-equivalent resident slots reduced pursuant to the 2010 healthcare reform law, PPACA.

In other regulatory news for surgeon researchers, the Food and Drug Administration (FDA) released a “Strategic Plan for Regulatory Science,” to be used in evaluating the safety of FDA-regulated products. In support of modernization of its existing technology, the FDA says that improved IT infrastructure would allow the FDA to better monitor adverse trends and disease outbreaks; combine data from multiple clinical trials, preclinical work and postmarket studies; conduct large-scale data mining for research purposes; and evaluate and compare the safety and effectiveness of products.

Futurescan™

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Healthcare, especially healthcare financing, is changing day by day. To help provide some basic education on current trends in the U.S. healthcare industry, ACFAS is sharing abstracted articles from the American Hospital Association's publication, Futurescan™ 2011: Healthcare Trends and Implications 2011–2016, in this special eight-week section.

Over the next five years, U.S. health reform can be expected to move in several distinct directions at once, writes health futurist Jeffrey C. Bauer. "Therefore, industry leaders and strategists should approach evolution of the medical care system not as a discrete trend to be rationally discerned and carefully followed, but as an array of possibilities to be enthusiastically harnessed and creatively shaped," he contends. Bauer says it is doubtful that 2010 health reform laws will be implemented as enacted, while Washington is not where true reform is being shaped. "Desirable trends are being established on a daily basis by a small but powerful cadre of creative providers, purchasers, payers, and their business partners who are willing to try new and different combinations of resources and then incorporate successful experiments into daily operations," he writes.

To position the real reformers for success, Bauer recommends that health system leaders and strategists:
1) Pursue a flexible, contingency approach to planning
2) Cautiously assess the net impact of seeking grants or incentives provided by the 2010 statutes; many may have to devise new business models more rapidly than the statutory timetable for federally financed pilots and demonstrations
3) Develop alliances with other medical marketplace stakeholders.

Foot and Ankle Surgery

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Researchers evaluated the effect of anterior epiphysiodesis of the distal tibia on recurrent equinus deformity in patients with clubfeet treated surgically. Twenty-five children (31 feet) with recurrent equinus deformity after surgical treatment of clubfoot were involved in the study. The mean dorsiflexion of the ankle was 2.5 degrees (-5 to 10 degrees) and the anterior distal tibial angle (ADTA) was 85 degrees preoperatively. The plates or staples were removed if the desired effect of around 15 degrees of dorsiflexion was achieved, or the ADTA shifted >15 degrees. Mean follow-up was 22 months. Mean improvement of dorsiflexion was 2 degrees, with a mean of dorsiflexion of 4.5 degrees, and mean radiological changes of ADTA were 13 degrees. No correlation was found between functional dorsiflexion and radiographic changes in ADTA following epiphysiodesis.


Researchers compared the outcomes of open reduction and rigid internal fixation of displaced calcaneal fractures with that of non operative treatment. Seventy two consecutive patients with displaced intra-articular calcaneal fractures were selected for the study and randomly allocated to surgical and non surgical groups. The first group underwent open reduction and internal fixation with reconstruction plate and screws fixation, while the other group were treated with closed reduction and cast immobilization. The results showed significant difference between outcomes of surgical treatment and nonsurgical method (p = 0.001). There were some differences between two methods in terms of decreasing pain [Odd Ratio (OR): 6.72, p = 0.001], swelling (OR: 6.80, p = 0.001), increased range of motion of the joints (p = 0.001), and decreased late osteoarthritis (OR: 2.33, p = 0.22) in favor of the surgical group.

Practice Management

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Sixty-nine percent of medical specialties saw their income rise last year, although those increases were "marginal," according to the American Medical Group Association's 2011 income survey. Primary-care physicians saw a 2.6 pay increase, while doctors in other specialties averaged a 2.4 percent increase and surgical specialists received a 3.8 percent boost. Separately, the survey found that providers in every region of the country were operating at a loss, based on the median operating margin per physician. A majority of practices were able to sustain such losses without going out of business, according to an AMGA spokesman, because most were part of much larger healthcare entities that were covering the shortfalls.


Orthopedic surgeons Dennis McGee and Robert Walker of Boise, Idaho, foresaw a troublesome future for private practice, so they joined local hospital systems. Because of the difficulty and expense of keeping up-to-date with technology, equipment, electronic medical records, changes in privacy rules, and imaging facilities, McGee went to work at Saint Alphonsus Hospital, where he already was seeing most of his patients. Despite enjoying being a business owner, Walker wanted the economies of scale that are not available when working in a small independent group, and also joined a local hospital system.

More than 100 physicians have joined the Saint Alphonsus and St. Luke’s health systems since last summer. At St. Luke's, which has a total employee count of about 10,000, the doctor staff grew by nearly 50 percent in one year. This mirrors a national trend, with hospitals and health systems buying about twice as many physician practices in 2010 as in 2009, according to Irving Levin Associates, which studies healthcare investment trends. Irving Levin says recent healthcare reform may be influencing this trend, and the company expects to see more hospitals acquire physician practices as part of their efforts to create accountable care organizations.

Health Policy and Reimbursement

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Physician organizations, patient proponents, and others are urging the Obama administration to reject at least three recently submitted state Medicaid reform requests from California, Florida, and Utah that could potentially limit access to care. The three states recently submitted waiver requests to the Centers for Medicare & Medicaid Services (CMS) to allow larger co-pays and other fees for Medicaid enrollees, and all are seeking additional flexibility to bring costs under control.


The Government Accountability Office (GAO) is urging the Centers for Medicare & Medicaid (CMS) to strengthen its approach to physician quality reporting, and for CMS to be more methodical in making reports more reliable. The GAO also recommended that CMS determine why some physicians may not have read the reports, and that it should ask a sample of physicians about the reports' usefulness and reliability. The Medicare Improvements for Patients and Providers Act of 2008 instructed the Department of Health and Human Services (HHS) to create a program to provide physicians with confidential feedback on the resources used to provide care to Medicare beneficiaries.

To achieve this, CMS, an HHS agency, implemented the Physician Feedback Program by distributing feedback reports to an increasing number of physicians that provided data on resources consumed and the quality of care. The GAO found methodological challenges CMS has encountered in developing feedback reports, the methods CMS has used to address those challenges, and other challenges CMS faces in distributing feedback reports.


Physician-hospital alignment is complicated by a number of factors, according to Kenneth Cohn, MD. One factor is individualistic physicians in an environment that requires collaboration, while hospital employment of physicians offers no guarantee that engagement in strategic initiatives and cost-cutting measures will readily move forward. Cohn also notes that physicians frequently perceive meetings as a waste of time and a distraction from their duties, based on the fact that physicians are usually not meeting participants but merely figureheads. Physicians and hospital administrators also take different problem-solving approaches, with physicians trained to take a large volume of data and distill it into a single diagnosis, while many administrators employ data to create different options. Variable definitions of "long-term" is a complicating factor as well, with Cohn recommending that administrators employ "chunking" to supply doctors with a two- to three-week roadmap of outcome measures for long-term projects. Under-utilization of physician mentors is additionally cited by Cohn, as is the fact that hospitals may not clarify their expectations for physicians upfront.

Medicine, Drugs and Devices

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Medical professionals often hold themselves to an extremely high standard, and when they make a mistake they can feel isolated and guilty. The sense of guilt can make sharing the ordeal of a medical mistake the last thing some physicians want to do, but some are sharing their experiences in the hope that future mistakes can be prevented.

One, orthopedic surgeon David C. Ring, realized he had performed a carpal-tunnel release on a patient who was supposed to receive a trigger-finger release when he was dictating a report on the last of his six operations that day. A change in the operative room's location meant a nurse who sat in on a preoperative assessment was not present to catch the mistake, and another nurse mistook Ring's conversation in Spanish with the patient as a preoperative timeout. The marking on the site for the operation was washed away during a preoperative cleaning.

"I knew that the biggest mistake of my life and the worst event in my life was also an opportunity," says Ring. "In my role as a teacher and mentor, if I make a mistake in diagnosis, a mistake in surgery or a mistake in judgment, it's always been a teaching opportunity. There's always been something to discuss. It's not something to sweep under the rug." Despite the risk to his reputation, Ring believes going public was worth it to spread the idea that safety checks are needed to help prevent mistakes, and that even the most accomplished physicians can err.


A study was held to devise a clinical prediction rule to help identify individuals with patellofemoral pain syndrome (PFPS) who are most likely to be benefit from foot orthoses. Sixty PFPS patients were issued with noncustomized prefabricated foot orthoses equipped with arch supports and 4° rear foot varus wedging. Fourteen (25%) participants reported marked improvement at 12 weeks. The number of participants with marked improvement increased to 78% if three of the following four criteria were met: footwear motion control properties score of <5.0 (indicative of less supportive footwear), usual pain <22.0 mm, ankle dorsiflexion range of motion (knee flexed) <41°, and reduced single-leg squat pain when wearing the orthoses.


Assessing the effectiveness of tolerability of pegloticase in managing refractory chronic gout was the purpose of two replicate, randomized, double-blind, placebo-controlled trials performed at 56 rheumatology practices in the United States, Canada, and Mexico in 225 patients with severe gout, allopurinol intolerance, or refractoriness, and serum uric acid concentration of 8 mg/dL or higher. One hundred and nine patients participated in trial C0405 and 116 in trial C0406. The intervention regime consisted of 12 biweekly intravenous infusions containing either pegloticase 8 mg at each infusion, pegloticase alternating with placebo at monthly successive infusions, or placebo. In trial C0405 20 out of 43 patients in the biweekly group reached the primary end point, as did eight of 41 patients in the monthly group and no patients in the placebo group. In trial C0406, 16 of 42 patients treated with pegloticase in the biweekly group reached the primary end point, along with 21 of 43 patients in the monthly group. The number of patients in C0406's placebo group that achieved the primary end point was zero. The pooling of data in the two trials revealed that the primary end point was reached in 36 of 85 patients in the biweekly group, 29 of 84 patients in the monthly group, and 0 of 43 patients in the placebo group. Seven deaths were recorded between randomization and closure of the study database.