News From ACFAS

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ACFAS has reached yet another milestone, with membership achieving an all-time high of 7,000 members! This success comes in part from you, ACFAS members, working hard continuously over the years to help advance the mission and strengthen the values of the College and the profession. The determination, fortitude and intellect members bring to the College have propelled it to the prestigious position it holds today.

Thank you to each and every member for being a part of the College’s strength and growth! The clock is ticking! You have less than a week to submit your research poster for presentation consideration at ACFAS 2014 in Orlando. All poster submissions must be sent by Tuesday, October 15, 2013 (11:59 pm Central Time). Please submit your application and abstract via the online submission system, but be sure to visit acfas.org/asc and read the full Poster Exhibits Guidelines (PDF) before you make your submission final.

Remember:

• Scientific Format posters must be submitted in both paper and electronic (PDF) format.
• At least one of the poster authors (both Scientific Format and Case Study Format) must register for and attend the Annual Scientific Conference in order for their poster to be displayed.

For any last-minute questions, contact Nicole Trefilek, Education Assistant, at (773) 693-9300 ext. 1323. Just released at acfas.org/SLR – six new Scientific Literature Reviews (SLRs) for the month of October. These time-saving summaries are written by podiatric surgical residents and highlight some of the latest foot and ankle surgery studies published in other specialty journals you might not have on your radar. Here’s a sneak peak at some of this month’s reviews:

• Outcome of Ankle Arthroplasty with Preoperative Coronal-Plane Varus Deformity of 10 Degrees or Greater, from the Journal of Bone and Joint Surgery, reviewed by Adam M. Lang, DPM
• A Biomechanical Comparison of One-Third Tubular Plates Versus Periarticular Plates for Fixation of Osteoporotic Distal Fibula Fractures, from the Journal of Orthopaedic Trauma, reviewed by Joseph Genualdi, DPM
• Early Weight-Bearing After Percutaneous Reduction and Screw Fixation for Low-Energy Lisfranc Injury, from Foot and Ankle International, reviewed by Sonia Mvuemba, DPM

To see the full list of SLRs for the month of October, or for past collections, visit acfas.org/SLR.

Foot and Ankle Surgery

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A recent study has found that there are a number of advantages to using arthroscopic surgery to treat patients with ankle joint impingement syndrome. The study examined 23 patients who underwent arthroscopic surgery and had their ankle joint function evaluated before the surgery, one week afterward, and six months afterward. Overall, excellent or good ankle function scores were seen in nearly 87 percent of patients six months after the operation, which was significantly higher than the percentage of patients who had such scores before the operation. The study concluded that arthroscopic surgery is an effective way to treat ankle joint impingement syndrome because it causes little trauma, results in few complications, and allows for quick patient recovery.

In addition to examining the clinical outcomes of patients who underwent arthroscopic surgery, the study also examined the value that three types of MRI sequences--FSE-T2WI, FSE-PDWI, and FS-3D-FISP MRI--had in diagnosing ankle joint impingement syndrome. The study found that FS-3D-FISP MRI displayed a good consistency with arthroscopic examinations and had higher sensitivity and specificity than the other types of MRI sequences in diagnosing ankle joint impingement syndrome.


A recent retrospective review of patients who had undergone Mobility total ankle replacements (TARs) has found that while the overwhelming majority experienced satisfactory outcomes after an average of four years, a significant number had persistent pain. Researchers reviewed 178 Mobility TARs and performed an analysis on the radiological parameters and clinical outcomes in a subgroup of 129 patients. The study found that 86 percent of patients were clinically improved after an average follow-up period of four years. Mean Ankle Osteoarthritis Scale (AOS) pain scores, meanwhile, were 17 at follow-up. But researchers also found that 18 patients had a poor outcome, with AOS pain scores higher than 30. An association was seen between a worse outcome and a preoperative diagnosis of post-traumatic degenerative arthritis. Eight of the patients who reported having persistent pain said the pain was primarily on the medial side. Researchers were unable to determine why these patients had persistent pain or why the pain was primarily on the medial side.


A new study by researchers in South Korea compared the rates of sagittal malalignment in patients who underwent total ankle arthroplasty using either the Mobility or Hintegra total ankle system. The positional stability of the implant components was also examined over time. The study found that the anteroposterior offset ratio intra- and interobserver reliabilities all had good or excellent levels of agreement in patients treated with either type of total ankle system. However, the Mobility system was found to be superior to the Hintegra system in terms of the stability of sagittal translation of the talus. Because the Mobility system had less sagittal malalignment of the talus than the Hintegra system, researchers said, surgeons must pay close attention to sagittal malalignment when performing ankle surgery on osteoarthritis patients using the Hintegra system.

Practice Management

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The consulting firm Accenture has conducted a study that examined how patients felt about electronic health records. The survey found that 84 percent of consumers believed that they should have full access to their medical records, though only 36 percent reported having full access to their EHRs. Moreover, the survey found that consumers were willing to take action to obtain access to their EHRs, with 41 percent saying that they would be willing to change doctors to access their records. Dr. Kaveh Safavi, the managing director of Accenture's North America health business, said that consumers' interest in EHRs is the result of two factors, including the federal government's meaningful use requirements. Physicians and practices are entitled to incentives under the second round of meaningful use when they meet several requirements, including providing patients with the ability to view health information online within four days after that information has been made available to the doctor. Safavi also said that consumers want access to their EHRs because they want to take greater ownership of their medical care.


Doctors' practices should train their employees about how to comply with the Health Information Technology for Economic Clinical Health (HITECH) Act as well as the new and existing Health Insurance Portability and Accountability Act (HIPAA) rules, both of which deal with the security of patients' personal health information. Such training should help employees understand their role in developing a protocol for ensuring the confidentiality, integrity, and availability of any sensitive information held by the practice. In addition, the training needs to make employees aware about the guidelines and protocols they need to follow to comply with HITECH and HIPAA. Doctors should never assume that employees, even those who have worked in the medical field for a long period of time, already know these guidelines and protocols. In addition to employee training, another important step practices should take to ensure compliance with HITECH and HIPAA is to conduct a thorough risk analysis that examines the ways in which sensitive information is vulnerable. Practices should also review their security practices, preferably with the help of another organization, and be sure they know how to respond to a breach of personal health information.

Health Policy and Reimbursement

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Although Congress is focused on passing funding measures to end the federal government shutdown and will soon be embroiled in a fight over raising the debt ceiling, lawmakers say that there is also an ongoing effort to eliminate Medicare's sustainable growth-rate formula (SGR). House Ways and Means Committee member Rep. Tom Price (R-Ga.), whose panel is currently working on SGR reform, says that he expects SGR to be "taken care of" in November or December, just as it has been in the past. Meanwhile, House Energy and Commerce Committee Rep. Phil Gingrey (R-Ga.) said that he was optimistic that Congress would agree on legislation to replace SGR before January. The House Energy and Commerce Committee has already passed a bill that would replace SGR with a new system that ties Medicare reimbursements to how well healthcare providers meet a new set of quality guidelines. The Senate Finance Committee is also continuing to work on its own bill for replacing SGR. A Republican aide working on the Finance Committee's bill said that while no one has "given up" on the effort to replace SGR, there is concern that a "conclusive" end to the government funding and debt limit debates would "take all the energy out of the first session," which in turn could result in lawmakers failing to address SGR.


Steve Zaleznick, the executive director for consumer strategy and development at the health plan ranking service HealthPocket, said Oct. 3 that out-of-pocket healthcare costs are likely to be the next issue of concern for consumers enrolled in plans offered through health insurance exchanges. Zaleznick noted that the percentage of consumers who are enrolled in so-called "bronze" and "silver" plans but never meet their deductibles will be "very high." Consumers who are enrolled in these plans and do not meet their deductibles, Zaleznick said, will be looking for ways to reduce their healthcare expenses. He noted that while the federal government is releasing data on health plans and pricing that will be available to consumers, most consumers will not want to take the time to use that data to bring down their healthcare costs. However, a variety of companies are working to analyze this data for consumers and help them make choices with regard to their healthcare, Zaleznick said. Meanwhile, health insurers are increasingly using claims data to provide accountable care organizations (ACOs) and other new types of coordinated care delivery systems with information on how to improve quality and reduce costs, said Aetna CEO Charles Kennedy. He added that this will help ACOs deliver high quality healthcare at a lower cost and at greater convenience for patients.


Healthcare industry observers say that physicians' practices could face a number of problems when insurance plans offered through health insurance exchanges take effect on Jan. 1. For instance, doctors who treat patients insured by those plans will have to keep track of the varying levels of coverage those plans offer, as well as the different co-payments and deductibles. In Pennsylvania, for example, that will mean that doctors will have to be aware of the differences between the 35 plans offered through that state's health insurance exchange. The large number of plans offered through the exchanges means that there will be a greater administrative burden on doctors' practices to determine a patient's eligibility and benefits before a visit takes place, said Donna Kell, the CEO of a company that provides billing services to a number of independent physician groups. Kell added that the variety of different plans that will be offered could also make it difficult for insurance companies to properly handle claims, since these companies may not have enough employees to handle all the claims that will be filed and may not have enough employees who are knowledgeable about the different plans.


A new study by researchers at Stanford University has found that there is a great deal of variation in the reimbursements private insurance companies pay out to doctors--even among doctors who provide the same types of services. The study analyzed over 40 million insurance claims and found that the lowest-paid 5 percent of doctors received $47 or less for a problem-focused exam that lasted roughly 15 minutes, compared to $86 or more among the highest-paid 5 percent of doctors. The study also found that reimbursements ranged from $103 or less to $257 or more for more complex but identical office visits that lasted longer and involved new patients. Researchers found that only about a third of the differences in reimbursements could be chalked up to differences in geographic location. In addition, researchers pointed out that neither the patients' age, sex, or insurance plan--or the physician's specialty--could explain the different reimbursement rates. Further analyses on differences in reimbursement rates will likely examine factors that this recent study did not take into account, such as the size of physicians' practices.


A KLAS Research survey that asked more than 200 doctors and hospitals about their attitudes toward patient portals has found that providers view the technology as being a "must have" due to the impending implementation of Meaningful Use Stage 2 requirements. However, most of the portals that are currently available are not meeting providers' needs, according to the results of the survey. KLAS noted that patient portals that are designed to simply interface with a variety of electronic health records, such as those from MedSeek and Intuit, are losing customers. One possible reason for this is that providers may be using a single-vendor strategy for portals, much as they are doing for other types of health information technology. Conversely, KLAS found that providers prefer to use patient portals that are designed for and integrated with their EHRs. The most popular EHR vendor, according to KLAS, was Athenahealth. KLAS notes that the company's customers like the ease with which they can upload patient information as well as the patient portal's "flexible" platform for educational content and patient messaging. Athenahealth also scored above average for sending reminders as well as other areas of portal functionality, including prescription refills, online form completion, and patient-entered data.

Medicine, Drugs and Devices

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Researchers in China have performed a study that compared the effectiveness of using hinged ankle-foot orthoses (AFOs) at different times of the day to treat ambulant children with spastic diplegia. The 112 children who participated in the study were divided evenly between two groups: a group that wore AFOs only during the day and one that wore the devices all day and all night. Both groups of patients underwent conventional rehabilitative treatments five times per week for an eight-week period. Researchers observed that patients who wore AFOs only during the day displayed improvements in the 66-item Gross Motor Function Measure that were significantly better than what was seen in the day-night group. This led researchers to conclude that using AFOs during the day is more effective at improving Gross Motor Function Measure scores than wearing AFOs at night. Researchers observed a significant root mean square decrease in gastrocnemius in the day group following the intervention, while the muscles affected in the day-night group were both the gastrocnemius and the tibialis anterior.


The Journal of Clinical Endocrinology and Metabolism has published a study that examined the effects that calcium and vitamin D supplements have on bone health and the risk of osteoporosis in healthy post-menopausal caucasian women. The 120 women who completed the study were given one of four regimens: double placebo, 1200 mg of calcium per day along with a placebo, 4000 IU of vitamin D3 plus placebo, and vitamin D3 and calcium. At the conclusion of the study, researchers determined that the addition of 1200 mg of calcium per day--an amount that is higher than the recommended dietary allowance--brought about significant reductions in bone turnover. Bone turnover was further reduced by a calcium load, researchers said. However, the study found that taking vitamin D in excess of the recommended dietary allowance did not reduce bone turnover or the risk of osteoporosis. But despite the apparent benefit of taking vitamin D supplements over the recommended dietary allowance, researchers said that women need to consider the potential vascular side effects caused by ingesting too much calcium. Researchers also urged women to talk to their doctors to determine if their diet is adequate as well as whether they need to take supplements.


A recent study examined the use of a weight-bearing extremity computerized tomography (CT) study in evaluating the biomechanics of the first metatarsal bone in hallux valgus. The study involved 10 hallux valgus patients and five asymptomatic controls, all of whom were examined with a portable extremity CT to study the forefoot--particularly the first metatarsal bone--while at rest and at weight-bearing. Researchers measured two-dimensional or three-dimensional hallux valgus angles, intermetatarsal angles, and several other types of parameters on CT data and compared the measurements of both groups of patients. Measured angles were also compared to angles measured on plain radiographs. A statistically significant difference was observed in the measured 3D hallux valgus angles at weight-bearing, though not at rest. Researchers said this finding suggests that it is important to conduct weight-bearing CT studies when evaluating hallux valgus. Researchers concluded that the relationships of the forefoot bones, including rotational changes, can be reliably measured using a weight-bearing extremity CT. They also pointed out that this is believed to be the first time that weight-bearing CT data has been presented when evaluating hallux valgus, adding that this offers an alternative to plain radiographs.