News From ACFAS

---

There’s still time to share your thoughts on CME planning. Answer just a few short questions in our CME survey today and have a lasting impact on ACFAS’ educational programs over the next three years.

Check your inbox for an email from ACFAS with the subject line “Shape the Future of Surgical CME!” Respond by September 26 and be eligible to win one of four $200 American Express gift cards. Residents, don’t let your ACFAS membership expire on October 1! Renew by September 30 to continue receiving:

• discount pricing on ACFAS CME offerings, including conferences, courses and e-Learning;
• The Journal of Foot & Ankle Surgery, Student & Resident Update, ACFAS Update and This Week @ ACFAS;
• full access to acfas.org and the PodiatryCareers.org career center;
• regional support through ACFAS Division activities and Division funding support for resident manuscripts and posters;
• and much more!

Resident member dues are just $118. Pay online or fax the invoice you received by mail or email with your payment information to (773) 693-9304.

Remember, first-year residents (PGY-1) receive a complimentary year of membership during their first year of residency courtesy of ACFAS and its Divisions. Second-year (PGY-2) and third-year (PGY-3) residents must pay the annual dues. While some residency programs may pay for annual dues, it is not done automatically.

Questions about your resident membership? Contact ACFAS Membership Manager Jessica Brown. The cost to apply for Recognized Fellowship status has increased to $1,000, which is in effect for the May 1, 2017 application deadline. Applications are considered on an annual basis.

The ACFAS Fellowship Committee approved this increase to bring ACFAS’ processes and fee structure more in line with like organizations, to better support the ACFAS Recognized Fellowship Initiative and to ensure applicants are fully committed to the work level that goes into the creation and support of a successful fellowship program.

Program directors who have already requested an application after May 1, 2016 and are in the process of completing it will be grandfathered in at the 2016 rate. To request an application, contact Michelle Kennedy, ACFAS director of Membership. Earn CME hours at your convenience with ACFAS' e-Learning portal. Available anytime, anywhere, this online resource makes it easy for you to meet your licensure or privileging requirements.

Watch clinical sessions presented by leaders in the profession, listen to podcasts for stimulating discussion with expert panelists or download our Surgical Techniques videos. Then complete an exam and submit it to ACFAS to earn your credit hours. You can also purchase the College’s first e-Book, Arthroscopy of the Foot and Ankle, which features self-assessments after each chapter.

Visit acfas.org/e-Learning to explore our latest offerings and get a headstart on fulfilling your requirements for the year.

Foot and Ankle Surgery

---

Metatarsus adductus may occur in children after successful clubfoot treatment or as an isolated deformity. A retrospective study examines treatment of the forefoot adductus with medial cuneiform opening-wedge osteotomy along with transmetatarsal osteotomy through the base of the second to fifth metatarsals. Researchers analyzed the preoperative and postoperative radiographs of 25 feet in 16 patients who underwent the procedure. Significant differences were found between preoperative and postoperative standing radiographs in measures of the talo-first metatarsal angle, the talo-calcaneal angle, the calcaneal-second metatarsal angle and the calcaneal-fifth metatarsal angle. The lateral subluxation of the talo-navicular joint was partially corrected.


A recent study aimed to determine whether an outpatient visit with radiographs less than three weeks after ankle fracture surgery resulted in a change in patient management. Researchers reviewed 878 ankle fracture patients with an early outpatient clinical-radiological visit. Treatment plans were altered in 9.8 percent of patients. Of the changes in treatment plans, 91 percent were due to clinical findings, and only three patients required a change in treatment plan based exclusively on the findings of the radiographs. Thirty-seven percent of patients requiring treatment change had solicited a visit before the scheduled outpatient appointment due to clinical problems.


A study examined the effect of botulinum toxin on plantar fasciitis through a randomized, controlled and blinded trial involving 50 patients. Twenty-five patients with plantar fasciitis were randomly selected to receive an IncobotulinumtoxinA (IBTA) or saline injection in their affected foot. At six months, the mean Foot and Ankle Ability Measures (FAAM) score increased from 35.9 to 40.9, and the mean pain score decreased from 8.4 to 7.9 within the placebo group. The mean FAAM score increased from 36.3 to 73.8, and the pain score fell from 7.2 to 3.6 within the treatment group. At 12 months after injection, no patients who received IBTA and three patients from the placebo group underwent surgery for recalcitrant plantar fasciitis.

Practice Management

---

The Centers for Medicare and Medicaid Services (CMS) have finalized a rule that requires healthcare providers participating in Medicare and Medicaid to have adequate emergency preparedness plans. CMS officials say previous requirements were not comprehensive enough to ensure patient safety during emergencies and natural disasters. The new rule requires providers to adhere to four best practice standards, beginning with the development of an emergency plan. Practices are advised to conduct a risk assessment and to create a plan that addresses the full spectrum of potential emergencies or disasters specific to the location of a provider. Policies and procedures should be developed and implemented in accordance with the risk assessment and emergency plan. Providers should also maintain a communication plan to ensure patient care is well-coordinated within the facility and with public health departments and emergency systems. Finally, initial and annual training programs and drills should be conducted to test the plan. Healthcare providers affected by this rule must comply and implement all standards within the next year.


Consultant Susanne Madden offers advice on how medical practices can use consultants effectively. Consultants are best used for highly specialized areas, such as insurance contract negotiations, succession planning, strategic business planning, coding audits, practice assessments, practice valuations, mergers, practice start-ups and electronic health record selection, according to Madden. "If you have needs like these, hiring an experienced expert who knows how to do it right will be worth your investment." Madden differentiates between outsourcing and consultant utilization, noting the former is preferable for ongoing daily tasks, such as patient billing or human resource management; the latter typically concentrates on specific, singular issues and they help the practice deploy solutions. Madden recommends that practices find an appropriate consultant by querying colleagues. "You can also call your medical society; many societies have a process for evaluating consultants before they will add them to their referral lists," she notes. The next step Madden suggests is to prepare "a solid outline of your most pressing concerns and the areas you think you need the most assistance in. A good consultant will want to discuss your needs thoroughly before developing a proposal for you." Madden says the contract should clearly state the services to be performed on behalf of the practice, identify clear milestones, develop a set timeline and list any information the practice will need to supply during the engagement. "If you aren't sure why a project is moving in a certain direction or the basis behind certain decisions, ask questions until you have a complete understanding," Madden advises.


Navigating the 12-month moratorium on retrospective denials of unspecified claims using the ICD-10 disease classification system, ending October 1, could be a major hurdle for the healthcare industry. During this moratorium, auditors will not penalize physicians retrospectively for nonspecific codes, provided that codes are in the correct family or group. This only applies to Medicare Part B claims and does not pertain to cases where a specific code is required for medical necessity purposes.

Health Policy and Reimbursement

---

Electronic health records (EHRs) can improve process maps used in failure mode and effects analysis (FMEA) to improve patient safety, according to new research published in the Journal of the American Medical Informatics Association. Process maps identify the people and activities to be included in an FMEA analysis, so more accurate and complete process maps can lead to stronger risk prevention. Researchers studied 34,939 activities across 2,222 encounters at the inpatient cardiology unit at Northwestern Memorial Hospital, comparing process maps to EHR data. The EHR data was more detailed and identified discharge processes not included in the process map. Additionally, 25 percent of activities were completed by providers not accounted for on the process map. The study indicates that EHRs may reveal gaps in process maps and should be leveraged to improve FMEA protocols.


The Centers for Medicare and Medicaid Services have released figures on the performance of accountable care organizations (ACOs) in the Medicare Shared Savings Program and Pioneer ACO program. Thirty-one percent of ACOs participating in the programs received shared savings bonuses for their 2015 performance, edging past the 2014 increase of 27 percent. Participation increased from 330 ACOs in 2014 to 400 last year. Consistent with previous analyses, the 2015 results indicate that ACOs that received shared savings had substantially higher financial benchmarks per beneficiary than those that did not share in savings. The program continues to produce significant variation in performance and quality results. As care transformation can be a long and difficult process, this year’s data confirms that the most experienced ACOs have a greater rate of success in achieving shared savings. Additionally, smaller, physician-led ACOs were more likely to improve quality and decrease costs than larger ACOs.


Six Republican senators have introduced a bill intended to exempt uninsured individuals from Affordable Care Act (ACA) penalties if they live in places where insurers offer one or no plans. The issue of limited ACA competition is gaining attention as insurers, such as UnitedHealth Group and Aetna, have pulled out of some states’ exchanges. The Kaiser Family Foundation estimates that 19 percent of individuals buying plans on ACA exchanges may have only one insurer option to choose from next year. Only Arizona’s Pinal County has been left without any insurer, although the Department of Health and Human Services says the government is working to bring an insurer to the county’s ACA market.

Medicine, Drugs and Devices

---

Japanese startup SHC Design Inc. has developed a 3D printer that can produce custom-made polymer prosthetic limbs faster and at a lower cost than traditional methods. Typically handmade from multiple expensive materials, a prosthetic limb costs an average of $4,200 in Japan. Insurance generally pays for standard prosthetics, but the high cost makes it difficult for wearers to get specialized ones for certain activities or for particular shoes. SHC expects to produce prosthetic legs for about $100 each, making artificial limbs more attainable for people with additional needs or those without access to specialist care. The limbs are made by a printer specially designed to output a soft, elastic polymer and guided by a template created from a scan of the desired leg and foot. SHC Design plans to begin selling its system as soon as next April in Japan and the Philippines for about $2,000. Tom Fise, executive director of the American Orthotic and Prosthetic Association, raises concerns over the legs' durability compared with standard ones, which are made of tougher materials, such as titanium and carbon fiber. SHC Design says it has not observed any durability problems in trials but notes that if a 3D-printed leg wears out, a new one can be made quickly and relatively inexpensively.


Patients who require high-dose opioids to manage chronic pain may have genetic anomalies that impact their ability to metabolize drugs, according to researcher Forest Tennant, MD, DrPH, in a presentation at the Pain Week conference earlier this month. In a survey of 101 chronic pain patients taking more than 1,000 morphine milligram equivalent per day, 96 percent of these patients had between one and three defects in cytochrome P450. Eight percent of patients had defects in all three CYP450 enzymes. Tennant also examined a subset of 45 patients and tested for opioid receptor mu 1 (OPRM 1), which is involved in drug dependence, as well as Catechol-O-methyltransferase (COMT) activity, which plays a role in drug absorption. Nearly 29 percent of patients had intermediate or low OPRM 1 activity, and 62.2 percent had intermediate or high COMT levels. Tennant notes that having a patient on high doses of opioids should be an indication to an insurance company or Medicare and Medicaid that a patient should receive this type of genetic testing.


HCA, the largest chain of for-profit hospitals in the United States, has adopted a regimen of germ-killing soap baths and daily applications of antibiotic nose ointment to reduce infections due to antibiotic-resistant bacteria among intensive care unit patients. Although better healthcare worker hygiene procedures have limited the spread of infections, such as MRSA, infections can also be caused by bacteria normally on the skin or in noses. About a third of people are colonized with staphylococcus bacteria, which can cause serious illness if it enters the body. Since close to half of staph strains are now resistant to antibiotics, researchers are trying to find effective methods to remove the bacteria without increasing antibiotic resistance. A study, published in the New England Journal of Medicine in 2013, took place at 74 HCA hospital ICUs. Researchers found that adding the preventive cleansing and nasal ointment regimen, called universal decolonization, reduced MRSA by 37 percent and all types of bloodstream infections by 44 percent. The approach is estimated to prevent nine bloodstream infections for every 1,000 ICU admissions. No increase in antibiotic resistance was observed during the first trial, but a second phase of testing is now underway in HCA hospitals.