News From ACFAS

---

ACFAS partnered with The Joint Commission, the U.S. Centers for Disease Control and Prevention (CDC) and other healthcare specialty organizations on a three-year initiative, Adaptation and Dissemination for Outpatient Infection Prevention (ADOPT) Guidance, to help ensure patients are provided care in environments that minimize or eliminate the risk of healthcare-associated infections.

As the only podiatric surgery organization involved in the initiative, ACFAS helped develop two free outpatient infection control guides specific to podiatry, Guide to Infection Prevention for Outpatient Podiatry Settings and Pocket Guide to Infection Prevention for Outpatient Podiatry Settings.

The guides were not only developed with input from the healthcare project partners, but also with the help of in-depth interviews and onsite visits with podiatry, orthopaedic and pain management outpatient facilities to gather setting-specific scenarios, challenges and examples for inclusion in the guides.

ACFAS member Barry I. Rosenblum, DPM, FACFAS, was part of a task force that assisted the CDC and The Joint Commission with the podiatry-focused guides. “Foot and ankle surgeons who are in private practice and not in hospitals or surgery centers can use this guidance to enhance infection control procedures already in place,” he says. “The ADOPT Guidance can help identify injection and sterilization practices that could potentially prevent infection in outpatient settings.”

Download the guides now at acfas.org/ADOPT or for more information, visit cdc.gov. Protect your patients’ private health information and achieve deidentification in accordance with the HIPAA Privacy Rule by using ACFAS’ newest infographic, Know Your HIPAA Identifiers, in your practice.

Created by the ACFAS Practice Management Committee, the infographic is intended to be shared with your staff and other physicians or displayed in your office as an ongoing reference to help ensure compliance with HIPAA Privacy Rule requirements. Log into acfas.org/marketing to download the infographic now. The final 90-day reporting period for fulfilling Merit-Based Incentive Payment System (MIPS) requirements for this current performance year starts October 1. Participation in the MIPS’ Clinical Practice Improvement Activities and Promoting Interoperability categories during this period will help you meet the MIPS performance threshold and avoid a payment penalty in 2020. Visit qpp.cms.gov for more on MIPS and its requirements. Starting October 1, 473 ICD-10 diagnostic code changes will go into effect, of which numerous will have a direct or indirect impact on podiatry.

The changes include 279 new codes, 143 revised codes and 51 deactivated codes. Be sure to share this information with your office staff, and visit cms.gov for further details on the code changes.

Foot and Ankle Surgery

---

Over the last decade, surgical decompression procedures have been commonly used in the treatment of diabetic peripheral neuropathy (DPN). However, the effectiveness of them remains to be proved.

Researchers conducted a comprehensive literature search of databases, including PubMed-Medline, Ovid-Embase and Cochrane Library to collect the related literatures. The Medical Subject Headings used were "diabetic neuropathy," "surgical decompression" and "outcomes."

A total of 12 literatures, including eight prospective and four retrospective, encompassing 1,825 patients with DPN were included in the final analysis. Only one literature was identified as a randomized-controlled trial. The remaining 11 literatures were observational studies; seven of them were classified as upper-extremity nerve decompression group and four were classified as lower-extremity nerve decompression group. Meta-analysis shows that Boston questionnaire symptom severity and functional status of upper extremities, as well as distal motor latency and sensory conduction velocity of median nerve of DPN patients, are significantly improved after carpal tunnel release. Visual analog scale and two-point discrimination are considered clinically and statistically significant in lower extremities after operation.

The findings showed the efficacy of surgical decompression procedures in relieving the neurologic symptoms and restoring the sensory deficits in DPN patients. As few high-quality randomized-controlled trials or well-designed prospective studies exist, more research is needed to elucidate the role of surgical procedures for DPN treatment.


Arthrodesis of the first metatarsal-phalangeal joint is a reliable procedure for correction of both hallux limitus/rigidus and severe hallux abducto valgus deformities. However, a possible contraindication to the procedure is the extended period of nonweightbearing immobilization that is typically associated with it. The purpose of this study was to perform a systematic review of the incidence of nonunion after early weightbearing in patients who underwent arthrodesis of the first metatarsal-phalangeal joint.

Researchers performed a review of electronic databases with the inclusion criteria of retrospective case series, retrospective clinical cohort analyses and prospective clinical trials with 15 feet, a mean follow-up of 12 months, a defined postoperative early weightbearing protocol, a clear description of the fixation construct, a reported incidence rate of nonunion and patients who underwent primary surgery for hallux abducto valgus or hallux limitus/rigidus deformities. Seventeen studies met the inclusion criteria, with a total of 898 feet analyzed. Of these, 57 were described as developing a nonunion.

This would likely be considered an acceptable crude, heterogeneous incidence of nonunion when considering this procedure. It might also indicate that arthrodesis of the first metatarsal-phalangeal joint does not always require an extended period of nonweightbearing postoperative immobilization.


The purpose of this study was to examine the clinical outcomes of acute, limited open Achilles tendon repair using modified ring forceps and to analyze functional results using foot and ankle-specific outcome measures.

The clinical records of 32 consecutive patients with 33 acute Achilles tendon ruptures were retrospectively reviewed. All patients underwent limited open repair with modified ring forceps through a 2- to 3-cm midline incision. Suture placement into the tendon stumps was guided using a pair of ring forceps bent 30°. Three No. 2 nonabsorbable sutures were placed in the proximal and distal segments, the tendon ends were reapproximated and the sutures were tied to secure the tendon. Outcomes from a 10-cm visual analog scale (VAS), the Foot and Ankle Ability Measure (FAAM) and the Victorian Institute of Sport Assessment-Achilles (VISA-A) were assessed.

At final follow-up, 31 of 32 patients reported no pain in their Achilles, with a mean Achilles VAS score of 0.7 ± 4.2 of 100. The mean postoperative VISA-A score was 82.3 ± 19.5 of 100. The mean FAAM activities of daily living and sports subscores were 96.5 percent ± 5.2 percent and 85.1 percent ± 21.2 percent, respectively. Regarding current functional level, 19 of 33 tendons were rated as "normal," 10 as "nearly normal" and four as "abnormal," with none rated as "severely abnormal." One case had a superficial infection; no cases had deep infections, sural neuritis or reruptures. The cost of the modified ring forceps technique is 5.3 to 12.1 times less than commercially available devices.

The researchers concluded that limited open Achilles repair with modified ring forceps provides an economical repair with excellent pain relief, favorable functional outcomes and a very low complication rate at midterm follow-up.

Practice Management

---

Surveys indicate that about 30 percent to 60 percent of physicians report symptoms of burnout, and EHR documentation ranks high among physicians as a leading source of dissatisfaction. At Brigham Health in Boston, certain changes have been made to reduce the burden of EHR documentation, says Brigham Health's chief information officer, Adam Landman, MD. He says these changes must involve continual iterative improvements, such as ways to reduce notifications and remove clicks from the medication refill process.

One improvement came after Brigham's informaticists turned off three clinical decision support alerts with very low acceptance rates. Brigham also rolled out a one-to-one support program in which an expert trainer meets physicians in their practices and helps them with their work flow. Each session is 90 minutes to two hours long, and providers are offered one or more follow-up sessions. In addition, Brigham has made voice recognition tools and training available to physicians. Two-hour training sessions are mandatory for those interested in using them, with additional personalization sessions also available. Finally, informaticists have partnered with departments to build department-specific order sets.


JAMA recently published two major studies on physician burnout. The first study, a systematic review, summarizes existing research on physician burnout. It found that researchers do not use a consistent definition of burnout, and estimates of how common it is vary widely. The second study followed doctors in training over six years and tracked how they felt about their work. They discovered that women and doctors in certain high-stress specialties were more likely to experience symptoms of burnout, such as emotional exhaustion and regret about career choice.

Dr. Katherine Gold, coauthor of an editorial accompanying the studies, points to a problem with this study and with media reports on doctor burnout. She says that the main questionnaire used to measure burnout was not designed for doctors, but for professionals like social workers and therapists who need to cope with trauma their patients experience. According to Gold, doctors may be facing stress related to mounting administrative tasks—a different problem with a different solution.

In a separate interview with NPR, Gold says burnout is a word people seem to have latched on to, but she thinks this feeling would more aptly be described as stress. She also notes that burnout is less stigmatized than depression; people are just more willing to say they are burned out. Furthermore, physicians are often given personal solutions—such as practicing mindfulness—but Gold suggests the stress people are feeling is much more about external demands, like the EHR and paperwork, and thus requires a larger systemic fix. Gold says what has helped protect her from burnout is spending time with patients, which allows her to refuel and gives her joy in her work again.


For practices to improve their billing and collections procedures, one solution is going paperless. A recent survey conducted by HIMSS Analytics found that nearly all medical providers still use paper to invoice patients, yet more than half of patients surveyed said they would prefer to be billed electronically and pay their bills online as well. Practices should also be able to collect money at the time of visit. The chance of collecting a payment decreases by almost 20 percent once the patient leaves the office, according to the American Physical Therapy Association's Nancy White. It is essential to ensure compliance with Payment Card Industry Data Security Standards.

Barbie Hays, coding and compliance strategist for the American Academy of Family Physicians (AAFP), notes that keeping patients' credit card information on file is no longer recommended. In addition, eligibility verification software—which is generally an add-on to an electronic health record—allows practices to check a patient's eligibility, copay and coinsurance. "It saves time because you don't have to call to check verification for each patient individually," says Brennan Cantrell, commercial health insurance strategist for AAFP. The software does not work for all plans, but it should work for major national payers.

Health Policy and Reimbursement

---

In a proposed rule, the U.S. Centers for Medicare and Medicaid Services announced it would relieve the burden on healthcare providers and save them more than $1 billion a year by removing Medicare requirements considered unnecessary, obsolete or excessively burdensome. The rule would remove requirements for ambulatory surgical centers to perform presurgical assessments and instead defer to the operating physician's judgment to ensure that patients are assessed appropriately.

Another provision would eliminate a duplicative requirement on transplant programs to submit data and other information more than once for "reapproval" by Medicare. A third proposal would allow multihospital systems to have a unified and integrated quality assessment and performance improvement program for all of their member hospitals instead of having individual staff for each separately certified hospital. An emergency preparedness proposed rule, meanwhile, would revise requirements for annual reviews to allow facilities to review their plans at least every two years.


On September 18, a bipartisan group of U.S. senators introduced a plan to safeguard patients from surprise bills and high charges from hospitals or doctors who are not in their insurance networks. The draft legislation focuses on three areas. The first is treatment for an emergency by a doctor who is not part of the patient's insurance network at a hospital that is also outside that network. The second area of focus is treatment by an out-of-network doctor or other provider at a hospital that is in the patient's insurance network. The third area is mandatory notification to emergency patients, once they are stabilized, that they could run up excess charges if they are in an out-of-network hospital.

Under the legislation, patients would be required to pay out-of-pocket the amount required by their insurance plan. The hospital or doctor could not bill the patient for the remainder of the bill, a practice known as "balance billing." The hospital and doctor could seek additional payments from the patient's insurer under state regulations or through a formula established in the legislation. Patients would be required to sign a statement acknowledging that they understood that their insurance might not cover their expenses and they could seek treatment elsewhere.

Medicine, Drugs and Devices

---

A year-long telehealth study by Humana suggests that physicians using a virtual care platform provided more effective treatment. The Humana-Doctor On Demand study compared roughly 5,500 patient cases in 2016 and 2017, matching in-person treatment against the Doctor On Demand platform. The study found that doctors using a connected care platform prescribed antibiotics in 36.4 percent of the visits, compared to 40.1 percent of in-person visits.

The study also found that referrals and follow-up care were slightly higher for virtual visits over the first two weeks after an initial visit, although those numbers declined after two months. This suggests that doctors were more likely to refer challenging or uncertain cases to other treatment, such as an urgent care clinic or emergency room. For more common cases, doctors were more likely to decide on a diagnosis and treatment and continue with that plan, finishing the treatment more quickly. In addition, telehealth visits cost an average of $38 compared to an average of $114 for a visit to the doctor's office.

The telehealth platform encourages doctors to be more decisive because they are not in the same room as the patient, follow evidence-based protocols and order tests to be sure or refer patients to other care providers, says Ian Tong, MD, chief medical officer for telehealth provider Doctor On Demand, which conducted the study with the insurer.


Beginning October 2, healthcare providers in California will be required to check a prescription drug history database. Prescribing physicians will log into the Controlled Substance Utilization Review and Evaluation System (CURES), which will allow them to easily see if a patient has been "shopping" for prescription drugs. With that information, physicians can provide drug safety warnings, deny the patient's request for prescriptions and offer help when drug abuse is suspected.

"I wrote SB 482 to require that doctors and others consult the CURES system before prescribing these powerful and addictive drugs," said state Sen. Ricardo Lara (D-Bell Gardens), who drafted the legislation in 2015. "This tool will help limit doctor shopping, break the cycle of addiction and prevent prescriptions from ever again fueling an epidemic that claims thousands of lives."

The law generally requires all healthcare practitioners to consult the database before issuing new prescriptions to patients or once every four months if a prescription remains a part of the patient's treatment plan. However, emergency departments and surgical teams can prescribe a nonrefillable five-day supply without consulting the database. The law covers prescriptions for Schedule II-IV drugs; hospice care is not included.


The Senate has passed a comprehensive opioids bill that aims to prevent illicit fentanyl trafficking, account for drug diversion in opioid manufacturing quotas and boost access to addiction treatments through telemedicine. Here is a look at what is in the bill, what is not and what ideas might be added back in the coming weeks and months.

First, the Senate bill gives the U.S. Drug Enforcement Administration more authority to reduce manufacturing quotas for controlled substances, including prescription opioids when the agency suspects diversion. The bill also directs the U.S. Department of Health and Human Services to issue regulations allowing doctors to remotely prescribe medication-assisted treatments. Furthermore, the bill includes a measure that aims to prevent the illegal importation of illicit fentanyl through the international mail system.

The Senate version of the bill does not include language from the House version providing for more methadone treatment. It also excludes hard limits on first-time opioid prescriptions for acute pain. The Senate's package also does little to improve enforcement of parity laws requiring that employers and insurers comprehensively cover treatment for behavioral health conditions, including addiction.

Some aspects might get added back in conference, including a controversial patient privacy law. Advocacy groups are divided over a House provision that gives providers more freedom to share information about a patient's history with substance use and nonfatal overdose with families, caregivers and other health professionals. The Trump administration has also recommended that the federal government waive the IMD exclusion, which restricts Medicaid payments to addiction treatment facilities with more than 16 beds. Advocates say the exclusion limits the nationwide capacity for inpatient addiction treatment.