October 2, 2013

News From ACFAS

ACFAS Launches New Informational Videos
The College recently released several new videos designed to inform referring physicians and patients on the education and training of foot and ankle surgeons. Developed with assistance from the ACFAS Professional Relations Committee, these videos are available for members to share with intended audiences to help promote the specialty and their practices. Video topics include:
  • What Is a Foot and Ankle Surgeon?
  • Board Certification for Foot and Ankle Surgeons
  • Collaboration Between Foot and Ankle Surgeons and Medical Doctors
  • Scope of Practice for Foot and Ankle Surgeons
  • Misconceptions About Foot and Ankle Surgeons
The videos are available for members to view and download at in the Physician to Physician Marketing Tools section. They are also available for public viewing on ACFAS’ YouTube page at or at Patients can also view select videos on the patient education website,
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New Division Presidents Council Chair Elected
The Division Presidents Council (DPC) recently elected Aksone Nouvong, DPM, FACFAS, as its new Chairperson for a two-year term.

As the DPC Chair, Dr. Nouvong leads the Council and also holds a seat on the ACFAS Board of Directors as representation of the Divisions at the Board level. Her term commences at the DPC Meeting at the 2014 Annual Scientific Conference in Orlando when she succeeds outgoing Chair, Randal Wraalstad, DPM, who served a two-year term as Chairperson.

Dr. Nouvong is the Past President of ACFAS Division 1 “Pacific,” and her platform statement focuses on maintaining the mission and vision of ACFAS. She hopes to achieve this through local grassroots efforts, which is one of the key goals of the 14 ACFAS Regional Divisions, as well as connecting with members through local seminars, meetings and labs.

The College extends its appreciation to Dr. Wraalstad for his service and commitment to the DPC and the Board of Directors and offers congratulations to Dr. Nouvong!
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The College Expands its Social Reach
Now you can find ACFAS in two more social network arenas, Google+ and on a new ACFAS YouTube page. These new outlets add to our communications strategy to keep members informed and to continue to educate patients and referring audiences on the expansive and important role of foot and ankle surgeons in the full healthcare continuum.

Share these new links on your website and on your social media pages. Each can be found at or click here to access the ACFAS Google+ profile.
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Foot and Ankle Surgery

Management of Degloving Injuries of the Foot with a Defatted Full-Thickness Skin Graft
A new study has found that both children and adults suffering from degloving injuries of the foot with involvement of the heel and sole can be successfully treated with a defatted full-thickness skin graft followed by conventional dressings. The study examined 13 adults and eight children who were treated for a degloving injury of the foot with an immediate defatted full-thickness skin graft. The graft was subsequently reattached to the original anatomical site, secured with a number of sutures, and fenestrated to improve skin graft incorporation. Traditional dressings were then applied. Ten of the adults and seven of the children displayed complete incorporation of the skin graft. The wounds of 81 percent of all patients were stable after an average follow-up period of 32.8 months. All patients obtained at least protective sensation, and none reported experiencing cold intolerance of the foot. Finally, Maryland Foot Scores were good to excellent in 17 patients at final follow-up.

From the article of the same title
Journal of Bone and Joint Surgery (American) (09/18/13) Yan, Hede; Liu, Shen ; Gao, Weiyang; et al.
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Intraoperative Positioning of the Hindfoot with the Hindfoot Alignment Guide: A Pilot Study
Orthopaedic surgeons in Switzerland have developed a technique that they say is superior to the use of visual means in the intraoperative positioning of the hindfoot. The novel hindfoot alignment (HA) guide developed by the surgeons projects the mechanical axis from the tibia down to the heel. The guide also makes it possible to position the hindfoot in the necessary varus/valgus position and in plantigrade position in the lateral plane. A comparison of the HA guide to the use of visual means in positioning the hindfoot found that accuracy with the HA guide was 4.5 +/- 5.1 degrees, while accuracy without the guide was 9.4 +/- 5.5 degrees. The HA guide also made it possible for two patients out of a group of 11 to avoid osteotomies, while five others needed additional osteotomies. The surgeons concluded that not only did the HA guide allow for the hindfoot to be positioned with greater precision, it was particularly useful for multilevel corrections in which the need for and the amount of a simultaneous osteotomy needed to be evaluated intraoperatively.

From the article of the same title
Foot & Ankle International (09/18/2013) Frigg, Arno; Jud, Lukas ; Valderrabano, Victor
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Practice Management

How Physicians Can Increase Employee Satisfaction at Their Medical Practice
Experts say that there are several steps that doctors can take to manage their practices' staff and to improve the performance of sub-par employees. Accomplishing both of these goals requires practices to create an environment that motivates staff members. For instance, doctors should find ways to motivate individual employees, since different staff members are motivated by different things. When an employee does well, doctors should give them some type of reward that he or she finds motivating, and they should be sure to do this in front of other employees so that they are motivated to improve their performance as well. In addition, any type of praise that is given to an employee should be given publicly so that others can hear. Conversely, employees whose behavior needs to be corrected should be pulled aside for a private conversation in which the doctor informs the employee about the potential negative ramifications that the behavior could have on patients or the practice. Doctors should be sure to communicate to the employee that they care about his or her success, and conclude by politely asking the employee to try to do better. Doctors should not be hesitant to fire problematic employees if their behavior is serious enough to warrant termination, since keeping poorly-performing employees hurts morale and brings down the performance of the entire staff.

From the article of the same title
Medical Economics (09/25/13) Zaenger, H. Christopher
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AMA Says Physician Exodus to Hospitals is Overrated
The American Medical Association (AMA) has released a report that disputes the notion that large numbers of doctors are leaving private practice to work for hospitals. The 2012 Physician Practice Benchmark Survey found that 60 percent of doctors work in physician-owned practices and that roughly 53 percent of physicians run their own practices. The survey found that only 23 percent worked for practices partially owned by hospitals, while less than 6 percent worked only for a hospital. AMA says that its findings contradict those of other studies that found that doctors are leaving private practice because its study does not leave out specialists. AMA found that more than 50 percent of surgeons, anesthesiologists, radiologists and gynecologists own their own practices, though ownership rates are lower in other fields. AMA added that it remains unclear whether new payment and healthcare models focused on collaborative and team-based care, which some have blamed for encouraging doctors to work for hospitals, are part of a national trend or if they are more of a localized phenomenon.

From the article of the same title
Medical Economics (09/23/13) Marbury, Donna
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Group Meetings Turn Doctor Visits Inside Out
The predicted increase in the number of Americans who will have health insurance once the Affordable Care Act fully takes effect is expected to accelerate the trend towards shared medical appointments. During such appointments, a group of patients dealing with the same health conditions watch relevant demonstrations and share stories with their fellow patients about how they are managing their health. Doctors also chat individually with each patient to discuss topics such as recent lab work and any medications they may be taking. Some physicians say they like such appointments because they eliminate the need for them to repeat the same information over and over again to different patients with the same health conditions. In addition, some doctors say that the peer pressure created by a group setting is effective in encouraging patients to live healthier lifestyles. Research has shown that can help reduce emergency visits. Supporters of group appointments also say that they allow patients to get appointments faster and spend more time with their doctors. But some have raised concerns about the privacy implications stemming from doctors sharing patients' confidential medical information in front of others. Critics say that could result in an increase in lawsuits, though patients and their family members who participate in shared appointments are typically required to sign confidentiality agreements in which they promise not to talk about other patients afterward.

From the article of the same title
Los Angeles Times (09/16/13) Gorman, Anna
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Health Policy and Reimbursement

Federal Marketplaces Will Offer Average of 53 Health Plans, Lower Premiums Than Projected
The Department of Health and Human Services released a report on Sept. 25 that found that premiums for insurance plans offered through health insurance exchanges will be significantly lower than had been anticipated. According to the report, the premiums for plans offered through the exchanges will be more than 16 percent lower nationwide than had been projected before subsidies are included. For example, so-called "silver" tier plans, which will cover 70 percent of the insured's medical costs, will cost $768 less per year, or 16 percent less than original estimates made by the Congressional Budget Office, said HHS Secretary Kathleen Sebelius. Some people who sign up for insurance coverage may pay nothing at all, the HHS report found. For example, a family of four living in Anchorage, Alaska, would be able to obtain the lowest cost "bronze" plan for free after tax credit subsidies are taken into consideration. Gary Cohen, the director of HHS' Center for Consumer Information and Insurance Oversight, said that premiums will be lower in states that have more competitive insurance markets as well as robust rate review systems. HHS' report also found that consumers who live in states where the federal government will operate health insurance exchanges will have an average of 53 plans to choose from. Meanwhile, congressional Republicans have responded to the report by saying that they believe that Affordable Care Act will cause insurance premiums to rise, not fall.

From the article of the same title
BNA Health Care Policy Report (09/25/13) Hansard, Sara
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Win-Win Payments for Providers and Payers
Healthcare providers and payers are increasingly drawing up new contracts that include reimbursement models designed to reward quality care and value. One such arrangement exists between the Hawaii Medical Service Association (HMSA), which is an independent licensee of the Blue Cross Blue Shield Association, and its network of hospitals throughout the state. Under the arrangement, which was created in 2011, HMSA ties 15 percent of reimbursements to outcomes at all hospitals except for small critical access facilities. Data about outcomes is sent to the Premier healthcare alliance, which scores the data on a number of quality metrics. The scorecards of all the hospitals are then sent out to all the facilities so that each hospital is able to see how others perform on the metrics, which has the effect of putting pressure on poorly-performing hospitals to improve. HMSA Chief Health Officer Hilton Raethel says that this transparency has been an important part of the program's success, which has included a 12.5 percent decline in hospital readmissions and a 43 percent drop in hospital-acquired infections. Another reason the program has been successful, Raethel says, is because it creates shared goals and objectives for healthcare providers and payers, rather than forcing them to assume an adversarial role with one another as does the fee-for-service model. The success of the program has convinced HMSA to tie outcomes to up to 30 percent of reimbursements beginning next year.

From the article of the same title
Health Leaders Media (09/26/2013) Letourneau, Rene
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More Than 100 House Members Ask CMS to Delay 'Two Midnight' Rule
Over 100 U.S. House members from both parties have sent a letter to Centers for Medicare & Medicaid Services (CMS) Administrator Marilyn Tavenner asking her to delay the implementation of the so-called "two midnight rule" for outpatient observation care by six months. The rule, which is scheduled to take effect on Oct. 1, states that patients who are expected to be hospitalized for more than two days should be admitted to inpatient care rather than outpatient observation care. CMS says that the rule is needed to reduce the number of long observation stays in hospitals. But Rep. Allyson Schwartz (D-Pa.) and the other House members who wrote to Tavenner say that the rule will force many Medicare patients to pay higher out-of-pocket costs for hospitalization and post-acute skilled-nursing care because Medicare observation care requires 20 percent per-service co-payments and does not cover post-acute care. Schwartz and the other lawmakers say that the implementation of the rule needs to be delayed to allow CMS to consider possible changes to the criteria that Medicare hospitals should use when deciding whether to admit a patient.

From the article of the same title
Modern Healthcare (09/24/13) Carlson, Joe
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5 EHR Vendors Lead Pack in Ambulatory-Care Niche
Data released by the Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services show that most doctors are relying on one of a handful of electronic health-record (EHR) system vendors to help them achieve meaningful use under Medicare's electronic health record incentive payment program. Of the more than 257,000 doctors and other eligible professionals who are meaningful users of a complete EHR in an ambulatory-care setting and have been given Medicare incentives, nearly 53 percent use the software of one of five EHR developers. The three developers with the biggest share of the EHR market are Epic Systems, Allscripts, and eClinicalWorks. The remainder of the market is controlled by 439 EHR vendors who have had at least one customer achieve meaningful use and have been paid incentives. The data also show that the top EHR vendors for the nearly 4,600 eligible professionals who have received Medicare incentive payments for complete EHR systems in inpatient settings include Epic Systems, GE Healthcare, and Cerner. The latter is the dominant vendor among the 2,359 eligible professionals who have been paid Medicare incentive payments for using modular EHRs in inpatient settings, the data show.

From the article of the same title
Modern Healthcare (09/24/13) Conn, Joseph
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Medicine, Drugs and Devices

Older Adults May Be Getting Too Many Bone Mineral Density Tests, Study Suggests
Screening older people at risk for osteoporosis through a bone mineral density (BMD) test every two years to determine the probability that they may suffer fractures in the near future may be unnecessary, according to a new study published Sept. 24 in the Journal of the American Medical Association. The researchers studied a group of adults who were 75 years old on average, and found a second bone mineral density test taken as much as four years after the first did not provide any meaningful information on fracture risk. BMD testing uses low-dose x-rays in an imaging scan known as Dual-energy X-ray absorptiometry (DEXA). Data was compiled from 310 men and about 500 women enrolled in an osteoporosis study of adults recruited between 1987 and 1999 who received BMD screening every four years. Subjects were tracked through approximately 12 years after they received their second BMD test, and only 113 people developed one or more major fractures, and the second test offered little, if any, additional predictive value for their injuries. Still, Chad Deal with the Cleveland Clinic's Center for Osteoporosis and Metabolic Bone Diseases cautions that this study's findings should not obscure the fact that many individuals, such as menopausal women, smokers, alcohol users, women who took aromatase inhibitors to treat breast cancer and anyone taking a medication for bone loss, require frequent BMD tests.

From the article of the same title
CBS News (09/24/13) Jaslow, Ryan
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Comparison of Autologous Conditioned Plasma Injection, Extracorporeal Shockwave Therapy, and Conventional Treatment for Plantar Fasciitis
A new study has found that treating plantar fasciitis with either autologous conditioned plasma (ACP) or extracorporeal shockwave therapy (ESWT) in conjunction with conventional treatments brings about better pain and functional outcomes than the use of conventional treatments alone. Fifty-four unilateral chronic plantar fasciitis patients between the ages of 29 and 71 were recruited for the study and were randomized into three groups: an ACP and conventional treatment group, an ESWT and conventional treatment group, and a conventional treatment only group. All groups displayed significant improvements in Visual Analog Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, and ultrasound plantar fascia thickness. However, the ACP group displayed significant VAS pain score improvements compared to the conventional treatment group after one month, while significant improvements in VAS pain scores were seen in the ESWT group compared to the conventional treatment group after one, three, and six months. Improvements in AOFAS ankle-hindfoot scale scores were seen in the ACP group at months three and six compared to the conventional treatment group, and similar improvements were seen in the ESWT group at months one and three. The ACP group displayed greater reductions in plantar fascia thickness than did the ESWT group.

From the article of the same title
PM&R (08/22/2013) Chew, Kelvin Tai Loon; Leong, Darren; Lin, Cindy Y.; et al.
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Effect of Tocilizumab Combined with Methotrexate on Circulating Biomarkers of Synovium, Cartilage, and Bone in the LITHE Study
A recent study that examined the effects of tocilizumab (TCZ) on joint tissue remodeling in patients with moderately to severely active rheumatoid arthritis (RA) has found that the drug actively suppresses key pathobiological processes at the site of inflammation in RA patients. Patients who participated in the study were given either four or eight milligrams of TCZ along with methotrexate and had their biomarkers measured at five different times to measure the dose-dependent effect of TCZ. Participants were divided into three groups: early non-responders, those who experienced a 50 percent improvement in tender or swollen joint counts along with a 50 percent improvement in three of the other five American College of Rheumatology criteria (ACR 50 responders), and non-responders. Researchers found that the eight milligram dose of TCZ strongly inhibited the biomarkers of joint tissue remodeling; for example, it brought about significant reductions in matrix metalloproteinase-mediated C-reactive protein (CRPM), matrix metalloproteinase-mediated degradation of type II collagen (C2M), matrix metalloproteinase-mediated degradation of type III collagen (C3M) and citrullinated and matrix metalloproteinase-degraded vimentin (VICM) from baseline to week 52. Differences were also observed in the biomarker profiles of responders and non-responders, which was seen as being an indication that there are specific responder profiles.

From the article of the same title
Seminars in Arthritis & Rheumatism (08/06/2013) Bay-Jensen, Anne C.; Platt, Adam; Byrjalsen, Inger; et al.
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