News From ACFAS

---

We’re back, and we’re coming to a city near you with Fixing a Flat: Comprehensive Approach to Pes Valgus. Join us for more small group discussions, quick lectures and hands-on training starting in November.

This two-day workshop provides 12 hours of Continuing Contact Hours and are a perfect opportunity for lecturers and attendees to roll up their sleeves, put their heads together and learn from each other. Over two days you will participate in a “Complications and Challenging Cases” presentation, challenge faculty and review problematic cases in a panel discussion, talk one-on-one and learn valuable tips and techniques you can take back to the office with you.

We can’t wait to get on the road again! This year’s tour kicks off November 1-2, 2019 and continues through May. Visit acfas.org/comingtoyou to see the schedule and register. What do you want to do before you die? While it’s a question often mused during a daydream or while sitting in horrendous traffic, chances are we’re too busy to give it more than a passing thought. That’s the bad news. The good news is, this year’s ACFAS 2020 Keynote Speaker, New York Times bestselling author Ben Nemtin, has made it his mission in life to not only help people answer that question, but to live it.

Ben’s message of radical possibility combined with his ‘5 Steps to Make the Impossible Possible’ will ask you to look at your day-to-day life through a different lens. He’ll discuss the ripple effect of healthcare, the impact you as healthcare professionals have on communities, and the importance of putting yourself first. Ben will share his personal experiences and remind us that in order to take care of others we must first take care of ourselves.

Don’t miss this opportunity to see Ben Nemtin at ACFAS' Annual Scientific Conference, February 19-22, in San Antonio. If you haven’t renewed, your ACFAS membership will expire on October 1. Double-check that your membership is up-to-date to avoid a lapse in benefits:

• Electronic access to and printed copies of the The Journal of Foot and Ankle Surgery,
• Detailed information on ACFAS Recognized Fellowships,
• Access to peer-reviewed research, scientific literature reviews, and recorded clinical sessions, and
• Resident-only discounts of as much as 50 percent on registration fees for ACFAS Surgical Skills Courses and the Annual Scientific Conference.

Renew online until September 30 at acfas.org/paymydues.

Not sure if you’ve renewed? Need an invoice to submit to your office? Email membership@acfas.org or call (773) 693-9300. We’re closing out summer and heading into fall with your Fall FootNotes—now available in the ACFAS Marketing Toolbox. This edition includes:

• Tell Injuries to Take a Hike this Fall
• Combating Diabetes is a Family Affair
• Make Heading Back to School Painless for Feet

All issues of FootNotes are customizable to add in your office’s contact info into the editable box on the second page. Take advantage of this free resource to promote your practice and educate your patients!

Log into acfas.org/marketing to access the latest issue. While you’re there, check out all our freely available resources. The Marketing Toolbox has everything you need, right at your fingertips.

Foot and Ankle Surgery

---

Between 2001 and 2017, researchers followed 109 consecutive patients operatively treated for a displaced intra-articular calcaneal fractures. A lateral subtalar approach was used, with a cast for eight weeks and full weightbearing allowed after 12 weeks. Researchers assessed gait abnormality, subtalar and ankle range of motion, stability and alignment, which was analyzed on standard radiographs. The American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score was also calculated. The study found a mean AOFAS score of 87 (range, 32-100), and "excellent" and "good" results, as well as hindfoot motion with "normal/mild" and "moderate" restrictions, were seen in 80 percent of patients. The main disadvantage was the high rate of heel screw removal, which was performed in 49 percent of patients.


The article presents results with the use of modified percutaneous Achilles tendon repair under local anesthesia performed from 1991 to 2005 with a two- to 10-year follow-up. There were 270 procedures in 247 male patients and 20 female patients, all treated within seven days after acute total rupture. Postoperative care consisted of a cast, soft cast or functional immobilization for six weeks. Overall, there were 25 major and minor complications, with no cases of increased postoperative dorsiflexion, deep infection or necrosis. Forty-four patients had a slightly decreased range of ankle motion, and 216 patients, including all high-caliber athletes, resumed all previous activities. The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score was 96.10 points. Long-term results suggest a reasonable treatment option for acute total Achilles tendon ruptures.


Researchers compared the clinical outcomes of total ankle replacement (TAR) involving the HINTEGRA prosthesis (Integra LifeSciences), arthroscopic ankle arthrodesis (AAA) and open ankle arthrodesis (OAA) in patients with isolated, non-deformed end-stage ankle arthritis. They identified and retrospectively analyzed 229 patients (mean age of 18 years) who underwent TAR, AAA or OAA from 2002 to 2012 with a minimum follow-up of two years. All patients had symptomatic COFAS Type-1 end-stage ankle arthritis without intra-articular or extra-articular deformity or surrounding joint arthritis. The analysis included 238 ankles (88 TAR, 50 AAA and 100 OAA); the TAR group had more female patients and a higher mean age, while preoperative pain, disability, and total scores were similar for all groups.

Improvements in AOS total score and AOS disability score were significantly larger for TAR and AAA compared with OAA, but the improvements did not meet the minimal clinically important difference. The TAR group underwent more reoperations than AAA and OAA groups, and revision rates were similar for all groups. The study indicates that AAA and TAR involving the HINTEGRA prosthesis were not significantly different surgical options in terms of short-term outcomes. The authors note that patients should be counseled regarding higher reoperation rates for TAR.

Practice Management

---

The Association of American Medical Colleges (AAMC) projects that the U.S. will see a shortage of 46,900 to 121,900 physicians by 2032 in both primary and specialty care. One-third of all doctors currently working will be older than 65 in the next decade, and retirements will squeeze supply as demand spikes for an aging American population that requires more medical care. The number of Americans over the age of 65 will increase by almost 50 percent within the next 15 years. The need for primary care physicians is particularly intense and varies by state. For example, Arizona has the fourth-fastest-growing population in the country, but it ranks 44th of 50 for total active primary caregivers.

Researchers estimate that the state currently needs about 600 primary caregivers, and the number is expected to reach nearly 2,000 by the year 2030. In response, one Arizona program has launched two new graduate medical education programs in underserved areas with growing populations, hoping to retain graduates in these communities. Moreover, Arizona recently enacted a groundbreaking Universal Licensing Recognition law to make it easier for people licensed in other states to move to Arizona and gain similar accreditation. While changes in licensing laws may help in the state, AAMC says that the shortage will require a layered solution, including team-based care, better technology use and expanded Medicare funding for residency programs.


The first step to preventing phishing attacks is educating all levels of employees on what an attack looks like. Busy doctors are often the most at-risk for these scams, as they are usually scanning emails quickly and may not pause to think about whether an email seems legitimate. It is also prudent to work with an IT security company to send out fake phishing scams to employees, see who responds to them, and offer those identified further guidance. A multifactor authentication process can help prevent unauthorized network access by combining a traditional username/password login with another layer of verification. This could be a code, sent by text or to another email address, or a physical object such as a key fob. Finally, it is worth noting that the average forensic investigation into a phishing attack costs more than $84,000, with larger investigations running into six figures. This means that a breach could cost much more than defense measures like multifactor authentication and staff training, so more security is worth the investment.


A strong governance agreement for a private practice explicitly outlines the structure of the board, including directorship qualifications and the duties and needs of any board committees. This should entail an executive committee that includes the practice administrator if a practice has eight or more physicians. The governance agreement should outline responsibilities and succession plans for the managing partner and should lay out a process for evaluating their performance. The agreement must also detail the frequency and requirements of board meetings and the rules around decision-making and voting procedures.

The governance agreement should further address issues related to transitioning physicians, as the average age of a surgeon in the United States is more than 54 years old, and many are beginning to plan their retirement. A good governance agreement will also address departmental oversight and facilitate collaboration between physicians and managers. Practices are advised to include an addendum to the governance agreement entitled The Physician Rights and Responsibilities, which spells out the practice's expectations around physician participation in coding, operations and management as well as the managing partner's conduct.

Health Policy and Reimbursement

---

Groupon and other coupon sites are offering discounted imaging scans, which experts say is symptomatic of a healthcare market where patients desperately want bargains, or at least the means to better specify their costs prior to obtaining care. Saint Louis University's Steven Howard contends such services help drive down prices while simultaneously marketing medical companies. However, skeptics warn such deals may be leading patients to get unnecessary initial scans, which can result in unneeded tests and radiation.


According to federal census data released September 10, both the number and proportion of Americans without insurance grew significantly last year for the first time since 2009. This reverses a trend begun by the Affordable Care Act (ACA) even as the economy's strength pushed down the poverty level to its lowest point since 2001. The change was primarily driven by a decrease in public insurance for the poor, with Medicaid enrollment dropping by 0.7 percent. The census data shows a falling poverty rate and a low unemployment rate combined with high inequality and a growing number of people, especially foreign-born Hispanic adults and Hispanic children who are naturalized citizens, do not have health coverage.

The uninsured rate grew from 7.9 percent in 2017 to 8.5 percent in 2018, compared to the nine million Americans who gained coverage between 2013 and 2014, when Medicaid expanded in many states and ACA insurance marketplaces opened for individuals and families unable to get affordable health plans through work. This has to do with escalating premiums and a tax change eliminating the requirement that most Americans carry health insurance. While Medicaid enrollment fell, the proportion of Americans covered through employer-based insurance did not change significantly, and enrollment in Medicare grew slightly, likely due to the aging American population.


Rigorous evaluations of health policy are rare, as less than 0.1 percent of total spending on American healthcare is devoted to evaluating which policies work. As a result, there is little solid evidence to inform government decision-making. Earlier this year, the Foundations for Evidence-Based Policymaking Act was signed into law, intended to improve the collection of data about government programs by requiring agencies to develop ways to evaluate them. While nearly 80 percent of studies of medical interventions are randomized trials, only 18 percent of studies of U.S. healthcare policy are randomized. Because rigorous health policy studies are rare, those that do occur wield disproportionate influence, like the 1970s RAND experiment, which has driven healthcare insurance design for decades.

Most of the pilot studies conducted by the U.S. Center for Medicare and Medicaid Innovation, created by the Affordable Care Act, lack randomized designs and rely on voluntary participation by healthcare organizations. Promising programs suffer from diminishing participation as healthcare organizations drop out, and a lack of randomized assignment greatly limits what can be learned from a program. Solving these biases can be difficult, as mandatory participation poses its own set of political and practical challenges, and randomization can be complex and hard to maintain.

As in clinical care, there are examples of incorrect thinking based on low-rigor studies that are later overturned by more rigorous ones. Moreover, a 2017 Government Accountability Office report found that the vast majority of federal program managers not aware of any recent evaluation of the programs they oversaw. Taken together, this information suggests a need for more rigorous policy evaluations across the board.

Medicine, Drugs and Devices

---

Google, Microsoft and Amazon are vying to control healthcare and cloud-computing markets, through agreements to store data and develop hospital software. Google announced a 10-year deal with the Mayo Clinic to store the hospital system's medical, genetic and financial information, while Microsoft also has forged a data-storage agreement with Providence St. Joseph Health. Meanwhile, Amazon Web Services agreed to store data from the Cerner electronic-health-record firm in the cloud.

Certain hospital-system and company officials expect to co-develop new software, by merging data and expertise of healthcare companies with technology providers' computing power and engineering knowledge. Mayo's Chris Ross said data analysis can spot unidentified patterns to gain insights into disease, and many algorithms under development aim to accelerate or improve accuracy of disease screening.


A study by Lehigh University researchers detailed a virtual mechanical test for ascertaining the length of recovery from a tibial fracture. Lehigh's Hannah Dailey and Peter Schwarzenberg recruited adults with tibial shaft fractures after standard reamed intramedullary nailing, who underwent low-dose computed tomography (CT) scans after surgery. The researchers employed commercially available software to construct three-dimensional mechanical structural models that identified area of bone and new bone, then ran the models via finite element analysis software to virtually apply force and observe degree of flexion.

Dailey and Schwarzenberg then digitally replicated a healthy version of each patient's leg with the CT scans, and subjected it to the same torsion test, which helped determine the fractured bone's stiffness compared with healthy bone. The virtual test's results significantly correlated with each patient's duration of healing.


To date, 33 states have enacted a total of 51 laws this year to curb drug prices and enhance drug access and affordability. Those figures surpass the previous record of 45 laws enacted in 28 states last year, according to the nonprofit National Academy for State Health Policy. More laws could be forthcoming before year's end. In New Jersey alone, some 20 proposed prescription drug bills are under consideration. At the federal level, more than a dozen bills targeting drug costs have been proposed but are not expected to gain momentum due to a busy congressional schedule, political discord and the upcoming election year. At least 16 states have enacted 20 laws affecting pharmacy benefit managers (PBMs), adding to the 28 passed in 2018.

Most of the new laws prohibit "gag clauses" that certain PBMs impose on pharmacists. Colorado, Florida, Maine and Vermont this year enacted measures to create programs to import prescription drugs from Canada and potentially other countries in Florida's case. However, a 2003 law lets states import cheaper drugs from Canada only if HHS approves a state's plan and certifies its safety. Maryland and Maine enacted laws to form state agencies to review the costs of drugs and take action against those whose price increases exceed a certain threshold.