September 5, 2018 | | JFAS | Contact Us

News From ACFAS

Two New Infographics Available in Marketing Toolbox
Give your practice marketing efforts an A+ this fall. Download the new infographics, 5 Signs of Kids’ Foot Problems and Foot & Ankle Injuries in Young Athletes, from the ACFAS Marketing Toolbox and use them to educate your patients on children’s foot health as the new school year gets underway.

New! Now each infographic includes a customizable box in the lower righthand corner for your practice’s contact information. Post the infographics on your practice’s website and social media channels, distribute copies to your patients and referring physicians or display the infographics in your office.

Free marketing products are added to regularly. Visit often for easy, ready-to-use tools to help you promote your practice and educate your patients any time of year.
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Free Webinar: Tips to Finding the Perfect Residency for YOU
Students, don’t forget to register for the next free webinar:

Residency Director Discussion: Keys to Getting into the Residency of Your Choice
Thursday, September 20
8pm CDST
Register Now

Do you know how to maximize your chances of getting into your chosen residency program? Want to learn what program directors look for in a potential resident? Listen in to this informative panel discussion with plenty of time for open Q&A to get your important questions answered, including:
  • How do I make the most of my externship experience?
  • What factors are important to consider when selecting a program? Location, type of training, number of cases, etc.?
  • How can I stand out during interviews? How can I become the next "Resident Idol"?
  • What impresses residency directors, and even more important, what doesn’t?
  • The matching game, are you in? How can I make the CASPR/CRIPs process work in my favor?
Speakers: Bryan Sagray, DPM, FACFAS; Mike Vaardahl, DPM, FACFAS
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12 Fellowship Programs Receive Status with ACFAS
The ACFAS Fellowship Committee recently determined the following fellowships exceed the minimal requirements to be upgraded to Recognized Status with the College after their first successful year:

Orthopedic Center of Florida Foot and Ankle Fellowship, Fort Myers, Florida
Program Director: Andrew Belis, DPM, FACFAS

Palo Alto Foundation Medical Group, Santa Cruz Foot and Ankle Fellowship, Santa Cruz, California
Program Director: Timothy Blakeslee, DPM, FACFAS

Reconstructive Foot and Ankle Surgery Fellowship, Louisville, Kentucky
Program Director: Paul Klutts, DPM, FACFAS

Foot and Ankle Specialists of Central Ohio Foot and Ankle Surgery Fellowship, Newark, Ohio
Program Director: Daniel Logan, DPM, FACFAS

Penn Presbyterian Podiatric Research Fellowship, Philadelphia
Program Director: D. Scott Malay, DPM, MSCE, FACFAS

Active Orthopedics and Sports Medicine Podiatric Fellowship, Hackensack, New Jersey
Program Director: Ralph Napoli, DPM, FACFAS

Foot and Ankle Specialists of Central Ohio Foot and Ankle Surgery Fellowship, Smyrna, Georgia
Program Director: Allen Raphael, DPM, FACFAS

Emory Midtown Foot and Ankle Surgical Fellowship, Atlanta
Program Director: Mohammad Sharif, DPM, FACFAS

The following fellowships have been granted Conditional Status with ACFAS since the programs are new to the College and have not yet had a fellow matriculate through:

Portland Foot and Ankle Reconstructive Fellowship, Portand, Oregon
Program Director: Michael Gentile, DPM, FACFAS

UT Southwestern Medical Center Wound Surgery Fellowship, Dallas
Program Director: Lawrence Lavery, DPM, FACFAS

Northern Illinois Advanced Foot and Ankle Fellowship, Sycamore, Illinois
Program Director: Douglas Pacaccio, DPM, FACFAS

Pediatric Foot and Ankle Fellowship, Cedar Knolls, New Jersey
Program Director: Mark Solomon, DPM, FACFAS

All Conditional Status programs are considered for Recognized Status with ACFAS after they have received status and the first fellow completes the program.

ACFAS highly recommends taking on a specialized fellowship for the continuation of foot and ankle surgical education after residency. If you are considering a fellowship, visit to review a complete listing of programs and minimal requirements.
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Foot and Ankle Surgery

Analysis of the Changes in the Clinical Outcomes According to Time After Arthroscopic Microfracture of Osteochondral Lesions of the Talus
Arthroscopic microfracture can effectively treat osteochondral lesions of the talus (OLTs). However, very few studies have reported on symptomatic improvement duration and time when symptomatic improvement ceases. This study aimed to investigate the clinical outcome changes after arthroscopic microfracture in patients with OLTs.

The analysis included 64 patients who underwent arthroscopic microfracture for OLTs and were available for follow-up for more than three years. To analyze and compare the clinical outcome changes according to time, the visual analog scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were evaluated every three months up to one year postoperatively and every one year thereafter.

The preoperative and final follow-up VAS scores significantly improved from 6.2 ± 1.1 to 1.2 ± 1.1 and the AOFAS score from 63.1 ± 7.3 to 91.0 ± 7.3. The overall success rate for arthroscopic microfracture in this study was 88.6 percent. The postoperative VAS and AOFAS scores showed significant improvements for up to two years. After two years, the symptoms did not improve but were maintained at a certain level for up to three years. No clinical outcome differences based on the lesion size, lesion containment, presence of cyst and bone marrow edema, age, sex and obesity were observed.

The researchers concluded that symptomatic improvement early after arthroscopic microfracture for OLTs was observed continuously for up to two years postoperatively. Symptom improvement was maintained without worsening for up to three years after surgery. Determining the final outcome of microfracture at least after two years would be reasonable, the researchers said.

From the article of the same title
Foot & Ankle International (08/29/2018) Kim, Tae Yong; Song, Seung Hyun; Baek, Jong Hun; et al.
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Arthroscopic All-Inside ATFL Repair with Suture Augmentation Gives Excellent Results in Case of Poor Ligament Tissue Remnant Quality
An increasing role of arthroscopy as the definitive treatment for ankle instability has been reported, and assisted or all-arthroscopic techniques have been developed. However, treatment of chronic ankle instability with poor remnant ligament-tissue quality is still challenging. The aim of this study was to describe the technique and report the results of the arthroscopic anterior talofibular ligament (ATFL) all-inside repair with suture augmentation to treat patients with poor remnant ligament-tissue quality.

Fifteen patients with chronic ankle instability and poor remnant ligament-tissue quality were treated by arthroscopic means after failing nonoperative management. Median follow-up was 18 months. Through an arthroscopic all-inside technique, and using a suture passer and two knotless anchors, the ligament was repaired. Then, the anchor's residual suture limbs were not cut but recycled and used for augmentation of the ligament repair.

Arthroscopic examination demonstrated an isolated ATFL injury with poor remnant ligament-tissue in the 15 patients. All patients reported subjective improvement in their ankle instability after the arthroscopic all-inside ligaments repair and suture augmentation. The median American Orthopaedic Foot and Ankle Society score increased from 66 preoperatively to 100 at the final follow-up.

The researchers concluded that chronic ankle instability with poor remnant ligament-tissue quality can be successfully treated by an arthroscopic all-inside repair and suture augmentation of the ligament. The clinical relevance of the study is the description of the first arthroscopic all-inside anatomic ATFL repair with suture augmentation that offers the benefit of maintaining the native ligament while reinforcing the repair, especially in patients with poor remnant ligament-tissue quality.

From the article of the same title
Knee Surgery, Sports Traumatology, Arthroscopy (08/20/18) Vega, Jordi; Montesinos, Erik; Malagelada, Francesc; et al.
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Prospective Evaluation of Utilization Patterns and Prescribing Guidelines of Opioid Consumption Following Orthopaedic Foot and Ankle Surgery
The purpose of this study was to prospectively assess opioid consumption patterns following outpatient orthopaedic foot and ankle procedures. Researchers reported postoperative opioid utilization for 988 patients undergoing outpatient orthopaedic foot and ankle procedures. The morphine equivalent dose was calculated for each prescription and then converted to the equivalent of a 5-mg oxycodone "pill." Univariable analyses were performed to identify variables with a statistically robust association with opioid consumption for inclusion in a multivariable linear regression. A stepwise backward regression was then performed to identify independent predictors of opioid consumption.

Overall, patients consumed a median of 20 pills while the median number of pills prescribed was 40. This resulted in a utilization rate of 50 percent and 20,631 pills left unused. Independent factors associated with higher opioid consumption were anesthesia type, age <60 years, preoperative visual analog scale (VAS) pain report of >6 and bony procedures; residual standard error was 16.73.

This study concluded that patients who underwent orthopaedic foot and ankle procedures were overprescribed narcotic medication by nearly twice the amount that was actually consumed. Although researchers identified four independent factors associated with opioid consumption, the large residual standard error suggests that there remains a substantial degree of unexplained variance of opioid consumption observed in the patient population. Physicians face a challenging task of setting appropriate protocols when balancing pain relief and generalizable guidelines.

From the article of the same title
Foot & Ankle International (08/19/2018) Saini, Sundeep; McDonald, Elizabeth L.; Shakked, Rachel; et al.
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Practice Management

Avoiding a Compliance and Coding Tug-of-War at Your Practice
Developing the right coding and compliance infrastructure can be tricky for many physician groups, which might struggle to maximize revenue without compromising compliance with professional fee billing. For an organization to successfully balance cost and benefit for its coding and compliance program, it must recognize the importance of the functions provided by its revenue cycle teams.

First, to drive consistent professional fee coding, practices should consider prebill coding activities—which include developing consistent coding policies and practices across the organization—as well as reviewing audit and compliance activities and examining coding education and feedback loops.

For most organizations, it is impracticable to have certified coders abstract and/or review every professional encounter. Thus, the optimal operational structure is a function-based model, where coders are deployed to support critical activities based on their skill sets and expertise, while providers maintain a high degree of responsibility in the coding process for more routine encounters. In this model, the production team and the audit team provide trends and feedback to the education team, which acts as a resource for providers by communicating issues and opportunities for improvement.

The final step is to review the staffing model to ensure that the appropriate number of resources are working together to complete the coding and compliance activities required and that the work is structured in a way that allows for a streamlined and consistent approach to the workday. Taking such steps can ultimately protect your organization from compliance-related risks and increase reimbursement in a cost-effective manner.

From the article of the same title
Medical Economics (08/27/18) Colton, Ben; Gaspard, Chris
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How EHR Use, Care Coordination Promote Safe Opioid Prescribing
An opioid roadmap recently released by the U.S. Centers for Medicare and Medicaid Services (CMS) lists several strategies for reducing opioid overuse through prevention, treatment and health data utilization. An increasing number of hospitals and health systems connect to state prescription drug monitoring programs (PDMPs) through electronic health record (EHR) systems, which provide prescribers with complete patient prescription histories. EHRs can also help promote safe opioid prescribing practices by streamlining communication between providers, care teams and prescribers for better-informed clinical decision-making.

One of the most commonly used EHR functionalities is computerized prescriber order entry (CPOE). Through CPOE, providers must utilize standardized order sets to fill prescriptions. This baseline standardization ensures providers across care settings can access, view and prescribe medications using similar terminology and values for more efficient communication between clinicians. EHRs can also bolster communication by allowing clinicians to engage in concurrent charting. "With concurrent charting, you have everyone looking at the same patient at the same time," says Nurse and Director of Clinical Applications at HSTPathways Maura Dent Cash. "You can be aware of their pain assessment, their vital signs, what medication was administered, when it was—it's all right in front of you on the screen."

Concurrent charting is especially important in the fast-paced ambulatory surgery center setting. Different members of the patients care team, from anesthesiologists to prescribers, can communicate quantifiable values and indicators of pain more effectively and precisely through EHR systems.

From the article of the same title
EHR Intelligence (08/20/2018) Monica, Kate
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New Report Envisions Key Role for Joint Commission in EHR Safety
A new report issued by the American Medical Association (AMA), the nonprofit Pew Charitable Trusts and hospital operator MedStar Health offers recommendations on steps that can help keep patients safe as health systems upgrade and modify their electronic health records (EHRs). The report also suggests the Joint Commission—which accredits and certifies thousands of healthcare organizations and programs in the United States—could help spread the use of practices intended to make EHRs safer by having its inspectors verify whether certain steps are taken.

The report's recommendations include establishing methods for personnel to report health IT-related safety hazards and permitting access for automated surveillance to detect misconfigurations. The report also emphasizes a need to demand clear justifications and use cases when a healthcare system seeks to make customization within an EHR. Current federal testing processes do not address the circumstances in which customized changes are made to an EHR, the report states. Instead, current rules focus only on the design and development stage of the EHR.

The report also proposes healthcare systems prioritize training by "making clear it's an institutional priority." Meanwhile, developers of EHRs need to document the potentially high risks to patients from customizations that contradict developer guidance and communicate these dangers to their clients, the researchers say. They also recommend that developers have dedicated personnel with credentials in patient safety and risk management on watch for potential issues and able to act on them.

From the article of the same title
Medscape (08/30/18) Dooley Young, Kerry
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Health Policy and Reimbursement

GOP Eyes Another Shot at ACA Repeal After McCain's Death
Senate Republicans say they would like Gov. Doug Ducey of Arizona to appoint a successor to the late Sen. John McCain (R-Ariz.) who, unlike McCain, would support legislation to repeal the Affordable Care Act (ACA). Republican lawmakers say they will not have time to hold another vote to repeal the law in 2018 but vow to try again next year if they manage to keep their Senate and House majorities.

"If we reengage in that discussion in some point in the future, it would be nice to have members who enable us to pass it," Senate Republican Conference Chairman John Thune (SD) said when asked about the possibility of ACA repeal legislation coming up for a future vote. Sen. Bill Cassidy (R-La.) said he does not know whether the Senate will move another comprehensive healthcare reform package, but he expects Republican leaders will push "piecemeal efforts to make affordable once more that which has not been affordable since ACA passed." Republicans want Ducey to appoint someone who will be a more reliable vote on healthcare in case they retain their congressional majorities.

From the article of the same title
The Hill (08/29/18) Bolton, Alexander
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Next Generation ACOs Save Money, Report Finds
A report from the U.S. Centers for Medicare and Medicaid Services (CMS) determined that Medicare's Next Generation model of accountable care organization (ACO) appears to be saving money for participating ACOs. The 18 ACOs that participated in the Next Generation program saved Medicare an average of $18.20 per beneficiary per month (PBPM) in the program's first year. CMS said this decrease "is similar to the decrease noted in the first two years of the Pioneer ACO model, and larger than the decrease noted for Medicare Shared Savings Program ACOs in the early years. However, wide variation in spending existed across ACOs. Seven ACOs showed Medicare [cost savings of] $30 PBPM, while two showed [cost increases of] $30 PBPM."

The report noted the new ACO model assigns ACOs "nearly complete financial risk sharing (either 80 percent or 100 percent risk) and must take on downside risk ... unlike predecessor ACO models, including the Medicare Shared Savings Program and Pioneer models. In addition, there are no minimum savings or loss requirements." In general, CMS estimated a net savings for Medicare of $62.12 million, or 1.1 percent, versus what Medicare would have spent on the same beneficiaries without the ACO.

From the article of the same title
MedPage Today (08/28/18) Frieden, Joyce
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Trump Administration Moves to Give Medicare Drug Plans More Control Over Their Offerings
The Trump administration is pushing to give Medicare drug plans more options in the products they can offer beneficiaries in an attempt to increase their purchasing power and reduce drug prices. The U.S. Centers for Medicare and Medicaid Services (CMS) announced that, beginning in 2020, Medicare prescription drug plans can leverage an indication-based formulary that expands the choices of offerings they can cover, letting plans choose cheaper drugs in certain cases.

"This is a significant step in modernizing the successful Medicare Part D program by giving plans the tools that serve [beneficiaries] well in the private sector," said U.S. Department of Health and Human Services Secretary Alex Azar. Currently, no limits exist on which drugs can be covered on a Part D plan's formulary, and CMS said "if a Part D plan includes a particular drug on its formulary, the plan must cover that drug for every [U.S. Food and Drug Administration]-approved indication, or [beneficiary] condition, even if the plan would otherwise instead cover a different drug for a particular indication."

The agency noted that, starting in 2020, the indication-based formulary will allow plans to tailor their formularies to include different drugs for different clinical indications. Earlier in August, CMS permitted plans on Medicare Advantage to deploy the step therapy method to save costs. This option entails giving a beneficiary a cost-effective treatment first and then transitioning them to a costlier treatment if it does not work. However, the American Cancer Society's Cancer Action Network warned step therapy could hinder people with cancer from receiving needed therapy.

From the article of the same title
Washington Examiner (08/29/18) King, Robert
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Medicine, Drugs and Devices

Spurred by Opioid Epidemic, New Pain Drugs May Lower the Risk of Overdose and Addiction
Scientists have stepped up their efforts to develop safer and less addictive pain medications in the wake of the opioid epidemic. Now, multiple research groups are claiming progress in devising novel opioid alternatives that seem to offer pain relief with far less risk of addiction or respiratory depression.

At a July meeting of the American Chemical Society, researchers at Nektar Therapeutics, a biotech firm in San Francisco, unveiled a drug called NKTR-181. It is a version of oxycodone to which researchers have linked a molecular tail called polyethylene glycol, a common pharmaceutical strategy for extending the life span of medicines in the blood. In animal studies, they found NKTR-181 crosses the blood-brain barrier 70 times more slowly than oyxcodone. Instead of a spike in both pain relief and euphoria, NKTR-181 triggers a slower release of dopamine that produces flatter, more sustained pain relief and less euphoria. In clinical studies of more than 600 patients taking the compound, Nektar researchers discovered far fewer signs of addiction than in patients given oxycodone, as well as fewer side effects.

Another compound developed by Astraea Therapeutics, a biotech company in Mountain View, California, hits two brain molecules simultaneously. In the latest issue of Science Translational Medicine, researchers report that rhesus monkeys given AT-121 experienced 100-fold greater pain relief than the same dose of morphine provided. Yet the drug did not trigger respiratory depression, addictive-like behaviors or even tolerance. AT-121 even appears to counteract addiction to standard opioids, such as oxycodone, says Nurulain Zaveri, Astraea's founder and chief scientific officer.

From the article of the same title
Science (08/29/18) Service, Robert F.
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Study: CDC Guidelines Associated with Declines in Opioid Prescribing
Opioid use declined significantly from 2012 to 2017, which could be in part due to the U.S. Centers for Disease Control and Prevention's publication of its 2016 guidelines for prescribing opioids for chronic pain, according to a new study published in the Annals of Internal Medicine.

The analysis of prescribing practices found prescriptions had begun to fall before the release of the CDC guidelines, dropping 36 percent from 2012 to December 2017. This represented a decline of 23 prescriptions each month per 100,000 people from 2012 to 2016 and a decrease of 56.74 each month per 100,000 from March 2016—when the guidelines were published—to 2017. The rate of high-dosage opioid prescriptions fell by 3.5 a month per 100,000 people from January 2012 to January 2016 and decreased by eight a month per 100,000 from March 2016 to December 2017.

Researchers also found decreases in the rate at which clinicians prescribed opioids to patients who were also using benzodiazepines, the combination of which were found in 2015 to be the cause of nearly a quarter of overdose deaths. The study found the percentage of patients prescribed opioids who had overlapping benzodiazepines declined faster after March 2016 when the CDC guidelines were released compared to before that time.

"Clinical practice guidelines, including those for which compliance is voluntary, may be able to change clinician behavior," researchers wrote. "Our findings demonstrated that the CDC guideline release was associated with decreases in key metrics of inappropriate opioid prescribing patterns."

From the article of the same title
Modern Healthcare (08/28/18) Ross Johnson, Steven
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The Senate Could Soon Pass an Opioids Package. But a New Law Is Still a Long Way Away.
The Senate could pass a comprehensive bill to address the opioid epidemic in the coming weeks, but there is plenty of work left to do. Lawmakers have left untouched many of the bill's most contentious issues, and lawmakers, congressional aides and lobbyists say a final vote likely will not come until the lame duck session this November.

Worse yet, many addiction treatment and prevention advocates warn the legislation lacks substance. The Senate bill reportedly outlines a number of proposals that advocates are likely to support, including provisions that expand access to the addiction treatment drug buprenorphine and step up screenings for fentanyl being illegally imported by mail. The bill would also give patients easier access to some addiction treatments via telemedicine, fund new tools to train providers about pain treatment and screening for substance use disorders and encourage better disposal of unused prescription opioids.

But the bill does little to fundamentally alter the way addiction is treated in the United States, where evidence-based care that includes counseling and medication remains the exception and not the norm. Sticking points include whether to repeal the so-called IMD exclusion, a regulation that prevents addiction treatment facilities with more than 16 inpatient beds from receiving Medicaid dollars. Another unresolved issue is the debate over whether medical providers should have much broader access to information about a patient's history with substance use disorders. Complicating matters further is a contentious November midterm election in which Democrats could seize control of the House.

From the article of the same title
STAT (08/30/2018) Facher, Lev
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This Week @ ACFAS
Content Reviewers

Brian B. Carpenter, DPM, FACFAS

Caroline R. Kiser, DPM, AACFAS

Britton S. Plemmons, DPM, AACFAS

Gregory P. Still, DPM, FACFAS

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This Week @ ACFAS is a weekly executive summary of noteworthy articles distributed to ACFAS members. Portions of This Week are derived from a wide variety of news sources. Unless specifically stated otherwise, the content does not necessarily reflect the views of ACFAS and does not imply endorsement of any view, product or service by ACFAS.

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