News From ACFAS

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Back by popular demand, make plans now to attend the Musculoskeletal (MSK) Ultrasound Workshop to be held twice, February 15 and February 16, during ACFAS 2019, February 14–17, 2019 in New Orleans.

This addition to the conference lineup will take a systematic approach to sonographic evaluation of foot and ankle. Learn how to use MSK ultrasound technology to:

• Confirm clinical diagnosis of foot and ankle pathology
• Identify soft-tissue pathology, including ligaments, tendons, nerves and capsular tissues
• Evaluate the ankle, medial ankle, lateral ankle and posterior ankle as well as the hindfoot, midfoot and forefoot

Faculty will demonstrate the latest imaging techniques and show you how to assess difficult structural anatomy. You will also practice recommended injection procedures using silicone and see how MSK ultrasound is used in aspiration and biopsy.

Stay tuned for more details on this and other new conference sessions and workshops as they become available. Help your patients recognize the signs and symptoms of a gout attack and understand what is involved in gout treatment. Download the new free PowerPoint presentation, Got Gout? How to Find Relief & Reduce Flare-Ups, from the ACFAS Marketing Toolbox and use it when speaking at local health events this fall or prerecord the presentation and share it on your practice website or social media sites.

The presentation outlines why too much uric acid causes gout and why this condition typically affects the big toe. A customizable slide is included in the PPT file for your practice’s contact information, and an accompanying script helps keep your conversation on point.

Access the complete library of PowerPoint presentations at acfas.org/marketing, and be sure to check out the many other free resources in the Toolbox, such as the seasonal FootNotes patient newsletter, infographics and healthcare provider referral tools, to amplify your practice marketing efforts. The Residency Directors Forum will be back in 2019 with a focus on best practices in resident education and learning.

This year’s Forum will be held in advance of ACFAS 2019 in New Orleans on Wednesday, February 13 from 1:30–5:30pm and cohosted by the Council of Teaching Hospitals (COTH). The Forum will provide time for open Q&A with all of the residency-related organizations, including AACPM, PRR, COTH, CPME, ABFAS, ABPM and ACFAS.

The Forum will also include the following sessions:

• CPME vs. ACGME: Best Practices in Resident Education
• Slaying the Three-Headed Monster: Patient Safety, Physician Well-Being and Resident Remediation
• Research: The Next Frontier
• Get on Board! Preparing your Residents for In-Training Exams and How this Correlates with ABFAS Board Qualification Rates
• Mix It Up Like Jambalaya: Organizational Oversight Updates

Residency program directors, codirectors and faculty are invited to attend, with up to two attendees per program. School deans are also invited. Watch your email and mailbox for more details and instructions to register. The application deadline to be considered by the Nominating Committee for the ACFAS Board of Directors election ballot has been extended to Sunday, September 16. For more information, visit acfas.org/nominations.

Foot and Ankle Surgery

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Charcot neuroarthropathy often results in a rocker-bottom foot deformity, which leads to ulceration, infection and amputation. Surgical techniques to reconstruct the medial column include intramedullary beaming and plantar plating, with disagreement over which approach provides a stronger construct with superior stability and fixation. The purpose of this cadaveric study was to compare the construct rigidity and strength of beaming and plantar plating of the medial column of five paired bilateral feet.

Cannulated titanium beams and plates were implanted in the right and left feet, respectively. The specimens underwent interval testing to generate load-displacement and load-strain curves, cyclic loading at low loads and then were loaded to failure. The beamed and plated specimens had statistically similar stiffness with a mean of 11.1 ± 3.9 N/mm and 11.3 ± 5.9 N/mm, respectively. The beamed and plated specimens had a statistically similar mean strain of -164 ± 75.1 µe and -208 ± 87.8 µe on the dorsal and 92 ± 90.4 µe and 221 ± 100.5 µe on the plantar surfaces of the first metatarsal. Three beamed specimens failed from talus fracture and two beams plastically deformed. Two plated specimens failed from talus fracture and three experienced screw pullout. The beamed and plated specimens withstood a mean load to failure of 234 ± 111.4 N and 140 ± 68.9 N, respectively, with the difference statistically significant.

The researchers concluded that beaming was stronger than plantar plating because it was less sensitive to specimen size and bone quality.


The aim of this study was to determine whether nonunion rates after tarsometatarsal (TMT) arthrodesis were influenced by either the use of screw versus plate fixation or the addition of bone graft versus no bone graft.

All patients older than 18 years undergoing arthrodesis for TMT arthritis between July 1991 and July 2016 were identified retrospectively. Exclusion criteria included less than 12 months' follow-up, prior midfoot surgery, any added procedure beyond TMT arthrodesis using plates or screws and acute foot trauma. All patients with radiographic or clinical nonunion, including those requiring revision surgery, were identified. Demographic data and associated risk factors were recorded via chart and radiographic image review. Eighty-eight patients with a total of 189 joints and who met enrollment criteria were treated with arthrodesis by nine different surgeons.

The overall nonunion rate was 11.4 percent. Significant independent risk factors associated with nonunion were arthrodesis using plate fixation with all screws through the plate, smoking during the perioperative period and postoperative nonanatomic alignment. Bone graft utilization significantly lowered the rate of nonunion.

The researchers concluded that isolated plate fixation, smoking and postoperative nonanatomic alignment appear to significantly increase the rate of nonunion among patients undergoing TMT arthrodesis for midfoot arthritis. Concomitant use of autogenous bone graft significantly decreased this risk.


The goal of this study was to determine whether patient outcomes and adverse events after surgical repair of acute Achilles tendon rupture (ATR) are related to delayed time from injury to surgery (TTS). Researchers retrospectively examined 228 patients with ATR who were treated with uniform anesthetic and surgical techniques within 10 days after injury. Patients were assigned to one of three groups: short TTS (<48 hours), intermediate TTS (48–72 hours) and long TTS (>72 hours). Patient-reported outcome at one year was assessed with the validated Achilles tendon Total Rupture Score, with scores higher than 80 on a 100-point scale indicating an overall good outcome.

Short TTS was significantly associated with increased rate of good outcome and reduced risk of adverse events. Seventy-one percent of the patients with short TTS attained a good outcome versus 44 percent of patients with long TTS and 63 percent of patients with intermediate TTS. The incidence of adverse events was significantly reduced for patients with short TTS at 1.4 percent, versus 11 percent for those with intermediate TTS and 14.8 percent for those with long TTS. The risk of sustaining a deep venous thrombosis was not statistically significantly different among the three groups.

The researchers concluded that patients with acute ATR undergoing operation within 48 hours after injury had better outcomes and a lower number of adverse events compared with patients undergoing operation after 72 hours. These results align with evidence-based recommendations from other surgical disciplines and should be used as guidelines for optimizing ATR treatment protocols.

Practice Management

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Inaccurate coding is a leading cause of lost revenue for medical practices, highlighting the need for an on-staff professional coder. Since skilled coders are in high demand, recruiting and retaining the right candidate can be a challenge. Practices should first consider investing in training current staff to get those coding skills. If searching for a coder externally, practices should determine their coding needs based on their size and revenue. For example, having a joint biller and coder role can be valuable to a practice.

In addition, consider limiting the scope of the search to candidates with professional certification, which ensures they have passed an exam showing competency. Recruit everywhere from social media to job boards specific to coders, such as the AAPC healthcare job database. Furthermore, identify both the qualifications a coder must have to be successful in the coding position and the soft skills needed to work effectively with the team. It is important for a coder to have interpersonal skills and to be able to communicate reasoning behind a code selection.

Finally, offer competitive compensation in line with what other practices provide, which can be assessed using the AAPC salary survey calculator, or provide relevant perks. Coding especially lends itself to remote work. Think about covering the cost of the coder's continuing education units that are required to maintain certifications or membership dues to professional organizations.


Physician burnout may jeopardize patient care, according to a study published in JAMA Internal Medicine. In a meta-analysis of 47 studies with more than 40,000 physicians, researchers found that physicians experiencing burnout were twice as likely to have patient safety incidents, poorer quality of care due to unprofessionalism and low patient satisfaction.

The link between burnout and unprofessional behavior was strongest among residents and physicians in the beginning of their careers. In addition, the results were significantly influenced by whether patient safety incidents and professionalism were reported by physicians or systems, suggesting that assessment standards need to be improved, according to the study. "Physician burnout has taken the form of an epidemic that may affect core domains of healthcare delivery," the researchers wrote. They called for investments in organizational strategies to jointly monitor and improve physician wellness and patient care outcomes as well as funded interventions aimed at improving the culture of healthcare organizations.

An accompanying editorial called the findings "worrisome," but noted that some questions are still left unanswered. For example, it remains to be seen if reducing physician burnout will improve outcomes for patients and how successful efforts can be to reduce burnout given that regulations and complex medical record systems have created new challenges. The editorial called for larger and more rigorous studies.


Electronic health records (EHRs) have become a leading cause of physician burnout, according to a recent article published in the American Journal of Medicine. "The hours spent cloning notes in a mandated doctor-computer relationship leaves the physician unable to experience the best part of being a doctor. No humanistic physician gets up with zeal in the morning, hopeful for a chance to have a meaningful relationship with Epic or MEDITECH," the researchers wrote.

However, physicians can combat EHR-related burnout by writing shorter case notes without compromising the quality of the information, according to the article's lead author. "Shorter notes do not imply incomplete or partial notes," said Andrew Alexander, MD, associate dean at the University of California's Riverside School of Medicine in Riverside, California. He offered several best practices for taking shorter case notes.

First, the physician should focus on the patient's presenting complaint and record all relevant data that helps the doctor formulate the differential diagnosis (DDx) and a plan for concluding the visit. Such data can include testing, consultation, procedures or medications. Further documentation can degrade the quality of care, Alexander warned. In addition, take notes as the questions are being asked and look at the patient while inputting information into the EHR. Finally, physicians should explain the rationale behind preferred and alternative diagnoses, which will help explain diagnosis reasoning in future viewings of the record.

Health Policy and Reimbursement

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The U.S. House Committee on Energy and Commerce is asking the Medicare Payment Advisory Commission (MedPAC) to report on how hospital consolidation trends are affecting Medicare costs. Committee Chair Sen. Greg Walden (R-Ohio) and others on the committee sent a letter to MedPAC citing the increasing trend of hospital merger and acquisition activity. A report by the U.S. Government Accountability Office found that the number of vertically consolidated hospitals increased 21 percent from 2007 to 2012. Lawmakers from both parties have long been concerned about whether Medicare policies are actually driving hospital consolidation and affecting the program. "It is imperative that the committee receive additional analysis from MedPAC regarding the degree to which current Medicare payment policies may encourage hospital consolidation and may also lead to higher drug spending for the program and patients," the letter stated.


Senators will soon vote on a bipartisan package to address the opioid epidemic. The deal would authorize new funding for states to fight drug addiction, expand access to medication-assisted treatment, grant the National Institutes of Health more authority to research and develop nonopioid pain therapies and require the U.S. Postal Service to crack down on shipments of illicit fentanyl.

States would receive a total of $500 million a year through 2021 for grants created under the 21^st Century Cures Act to fight drug addiction. The bill would also create new comprehensive opioid recovery centers offering a range of treatment services, and it would require the U.S. Department of Health and Human Services to develop guidelines for recovery housing. In addition, the bill would mandate a study on the effect that federal and state opioid prescribing limits have had on patients and specifically whether such limits are associated with higher suicide rates.

Regarding the health technology sector, the bill would promote sharing of behavioral health data and the use of telemedicine for substance use disorder. However, it would not specifically target a longstanding federal regulation that requires a patient's direct consent to share behavioral health records. The final deal largely matches an opioid response package passed by the House earlier this year, but does not include provisions requiring Medicaid to cover treatment at more inpatient facilities or easing privacy restrictions for substance abuse patients' medical records.


The Senate has passed a bill that would ban Medicare insurers from enforcing "gag clauses" that prevent pharmacies from telling customers about cheaper ways to buy drugs. The Know the Lowest Price Act is intended to help patients covered under Medicare find out if their prescription would cost less if they paid for it out of pocket rather than through their insurance plan.

"Passing this bill and eliminating gag clauses give patients more power to lower their healthcare costs," said Sen. Bill Cassidy (R-La.), who helped introduce the plan. "It makes prices transparent so patients can save money with less expensive prescriptions." The new rules explicitly apply to Medicare Part D, which pays for prescription drugs, and to Medicare Advantage, a healthcare plan managed by private insurers. In the complexity of the system, patients can sometimes end up paying more while others in the chain pay less. Private health insurers and pharmacy benefit managers use "gag clauses" in their contracts to prevent pharmacists from informing customers that they can save money if they do not go through their health plans.

Another bill passed in committee, the Patient Right to Know Drug Prices Act, would offer the same protections for people who have private health insurance coverage. The White House has urged Congress to scrap the gag clauses and to pass other measures to help reduce what patients pay for drugs.

Medicine, Drugs and Devices

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A new pilot program unveiled by the U.S. Food and Drug Administration (FDA) seeks to slash the time needed to review moderate-risk medical devices from 90 days to 60 days. The Quality in 510(k) or "Quik" Review Program will enable sponsors of moderate risk medical devices from about 40 eligible product codes to electronically download, fill out and submit their 510(k)s using FDA's free "eSubmitter" software. The agency says the products eligible for the program are "well-understood" and include devices, such as electronic stethoscopes, surgical wire and cameras used by ophthalmologists.

"As technology evolves, patients have the opportunity to access more innovative medical devices that can help improve their health. To advance that progress, FDA must also modernize its own review and submission process to make sure that our programs continue to be efficient, consistent and scientifically rigorous," said FDA Commissioner Scott Gottlieb. He does not anticipate the agency will need to change any statutory or data requirements to reduce its review time. In addition, Gottlieb said the efficiencies gained through the program will permit the agency to direct more resources toward reviewing high-risk devices.


The U.S. House Committee on Ways and Means passed a modified version of a bill supported by the medical device industry to clarify and make the U.S. Centers for Medicare and Medicaid Services' (CMS) local coverage determination (LCD) process more transparent. The bill, which device makers say should boost patient access to devices, comes as the U.S. Food and Drug Administration (FDA) works with CMS and private payors to accelerate coverage of FDA-approved devices.

Committee Chair Kevin Brady (R-TX) said the original version of the device coverage bill included a provision that would have required each Medicare Administrative Contractor (MAC) to independently evaluate another MAC's scientific evidence for a coverage decision before implementing it for their region, but the language was removed to advance the legislation forward.

The Advanced Medical Technology Association (AdvaMed) lauded the legislation. "This bill builds on provisions to improve the LCD process in the 21^st Century Cures Act and will foster greater transparency, consistency and objectivity in the process, which will ultimately benefit Medicare beneficiaries," the group said.


A group of major American hospitals has launched a not-for-profit generic drug company, Civica Rx, to take some control over the drug supply. Backed by seven large health systems and three philanthropic groups, the new venture will focus initially on establishing price transparency and stable supplies for 14 generic drugs used in hospitals, without pressure from shareholders to issue dividends or push a stock price higher. "We're trying to do the right thing—create a first-of-its-kind societal asset with one mission: to make sure essential generic medicines are affordable and available to everyone," said Dan Liljenquist, chair of Civica Rx and chief strategy officer at Intermountain Healthcare in Utah. The consortium collectively represents about 500 hospitals.

Liljenquist said that the initial governing members have already committed $100 million to the effort. The business model will ultimately rely on the long-term contracts that member healthcare organizations agree to—a commitment to buy a fixed portion of their drug volume from Civica. Elie Bahou, chief pharmacy officer of Providence St. Joseph Health, a 51-hospital system spread across seven states and one of the consortium members, said the criteria include drugs that underwent price increases of 50 percent or more between 2014 and 2016 and essential medicines that were on national shortage lists.