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This Week's Headlines

News From ACFAS
Foot and Ankle Surgery
Practice Management
Health Policy and Reimbursement
Medicine, Drugs and Devices

News From ACFAS

Health Policy News and Notices

Get Out the Vote and Get Ready for 2011
As the midterm elections draw near, ACFAS members should keep in mind the goal of passing legislation to include podiatrists in Title IX. Unfortunately, current bills H.R. 1625 and S. 654 will have to be re-introduced in the new Congress to be seated in 2011, as efforts in 2010 have once again stalled.

Free Webinar on Reducing Infections
Calling all administrative/clinical leaders and policymakers interested in patient safety. Register now for a webinar on opportunities to reduce healthcare-associated infections through collaboration among health systems, hospitals, and government organizations. Speakers include leaders from the U.S. Department of Health and Human Services and hospital leaders of the Texas Medical Institute of Technology's (TMIT) “Greenlight Program.”
The webinar will take place Oct. 28, 2010, 1:00 p.m.–3:00 p.m. ET. For more information and to register, visit the SafetyLeaders website.

Florida Looks Toward New Standard of Care for Office Surgery
There is a proposed rule of the Florida Department of Health, Board of Medicine, amending the regulations under FAC 64B8-9.009 regarding the standard of care for office surgery. The rule addresses the adoption of the American Society of Anesthesiologists' most recent guidelines for office-based anesthesia. Comments are due Nov. 5, 2010. Contact: Larry McPherson, Jr., Executive Director, Board of Medicine/MQA, 4052 Bald Cypress Way, Bin #C03, Tallahassee, FL 32399-3253.

Colorado Approves Amendments
Colorado has approved several new regulations for podiatrists effective Oct. 30, 2010, and central to this is amendments to 3 CCR 712-13, Rule 290, on the scope of practice of podiatrists. The rule expands the scope of podiatric practice, sets forth related guidance, and defines terms. For more details, visit the ACFAS web page on recent state regulations.
AAOMS Challenges AMA Dentistry Scope Document

In 2007, podiatry was the first shot across the bow in the American Medical Association’s Scope of Practice Data Series. The AMA podiatry scope document was so flawed with outdated or inaccurate data that it was retracted. Now the American Association of Oral and Maxillofacial Surgeons (AAOMS) has challenged the 2009 AMA data series on oral surgeons and dentistry in general. Sound familiar?

AAOMS President Ira D. Cheifetz, DMD, in a guest editorial in the June 2010 issue of the Journal of the American Dental Association, says, “The document’s contents revealed numerous errors, inaccuracies, and basic misrepresentations related to every area of the specialty, including education, training, and the scope of OMS practice. In fact, the AMA Scope of Practice document impugns dental education as a whole, questions the authority of the profession to oversee and accredit its training programs, and casts doubts on the ADA’s Definition of Dentistry.”

“Welcome to the club, dentistry!” says ACFAS President Michael S. Lee, DPM, FACFAS. “Clearly the AMA Scope of Practice initiative is all about economic turf protection, not patient access to legally recognized and licensed healthcare professionals. DPMs who are challenged in hospital privileging matters with the AMA’s podiatry document can now reference the AMA’s attack on dentistry as even more evidence of AMA’s self-interest trumping objectivity.”
Get Involved to Shape Your Profession

You can help shape the advancement of your profession, the future of the College and, ultimately, the care of patients. The College is looking for talented, dedicated ACFAS members to serve on 2011–12 committees.

Visit the ACFAS website for more information on getting involved, including committee descriptions and application information. Applications are due Dec. 15, 2010.
Recent Research at Your Fingertips

You’re just one click away from current research at ACFAS’ Scientific Literature Reviews. The latest journal articles, abstracted for foot and ankle surgeons by podiatric residents, include:

Radiofrequency Coblation for Chronic Foot and Ankle Tendinosis, from the Journal of Orthopaedic Surgery.
Reviewed by Jacqueline Monroe, DPM, OCPM/UHHS Richmond Medical Center.

Treadmill Exercise and Resistance Training in Patients with Peripheral Arterial Disease With and Without Intermittent Claudication: A Randomized Controlled Trial, from the Journal of the American Medical Association.
Reviewed by Stephanie Ouhadi, DPM, OCPM/UHHS Richmond Medical Center.

Drop by to browse the entire online archive at Scientific Literature Reviews.

Foot and Ankle Surgery

Lateral Ligament Repair and Reconstruction Restore Neither Contact Mechanics of the Ankle Joint nor Motion Patterns of the Hindfoot

Researchers set out to determine the effect of lateral ligament injury, repair, and reconstruction on ankle joint contact mechanics and hindfoot motion patterns. Combined compressive (200-N) and inversion (4.5-Nm) loads to the hindfoot at 0° and 20° of plantar flexion were applied to eight cadaveric specimens.

The researchers found that ligament sectioning decreased contact area and caused a medial and anterior shift in the center of pressure with inversion loads relative to those with the intact condition. There were no significant differences in inversion or coupled axial rotation with inversion between a Broström repair and the intact condition. The medial translation of the center of pressure, however, remained elevated after the Broström repair relative to the intact condition. A Broström-Gould procedure provided additional support to the hindfoot relative to the Broström repair, reducing inversion and axial rotation with inversion beyond that of intact ligaments. There were no significant differences in center-of-pressure excursion patterns between the Broström-Gould repair and the intact ligament condition, but this repair increased contact area beyond that with the ligaments intact. Graft reconstruction more closely restored inversion motion than did the Broström-Gould repair at 20° of plantar flexion but limited coupled axial rotation. Graft reconstruction also increased contact areas beyond the lateral ligament-deficient conditions but altered center-of-pressure excursion patterns relative to the intact condition.

The researchers concluded that no lateral ankle ligament reconstruction completely restored native contact mechanics of the ankle joint and hindfoot motion patterns. They state that the results provide a rationale for conducting long-term, prospective, comparative, in vivo studies to assess the impact of altered mechanics following lateral ligament injury, as well as its nonoperative and operative treatment, on the development of ankle osteoarthritis.

From the article of the same title
Journal of Bone and Joint Surgery (American) (10/20/10) Vol. 92, No. 14, P. 2375 Prisk, Victor R.; Imhauser, Carl W.; O'Loughlin, Padhraig F.; et al.
Web Link - May Require Paid Subscription | Return to Headlines

Reliability and Validity of Radiographic Measurements in Hindfoot Varus and Valgus

Clinical decision-making in the treatment of foot deformities is based primarily on the results of the physical examination and the radiographic findings. Researchers sought to determine the validity and reliability of commonly used radiographic measurements of hindfoot valgus and varus deformities. Seventy-two patients with hindfoot deformity (36 hindfoot valgus, 36 hindfoot varus) were evaluated. Nine representative indices on weight-bearing radiographs were assessed. The researchers found that naviculocuboid overlap, anteroposterior talonavicular coverage angle, anteroposterior talus-first metatarsal angle, calcaneal pitch angle, and lateral talus-first metatarsal angle showed excellent reliability. Naviculocuboid overlap, anteroposterior talonavicular coverage angle, and anteroposterior talus-first metatarsal angle showed excellent discriminant validity (in terms of effect-size r) and convergent validity (in terms of correlation coefficients with pedobarography).

From the article of the same title
Journal of Bone and Joint Surgery (American) (10/06/10) Vol. 92, No. 13, P. 2319 Lee, Kyoung Min; Chung, Chin Youb; Park, Moon Seok; et al.

The Role of Foot Collateral Vessels on Ulcer Healing and Limb Salvage After Successful Endovascular and Surgical Distal Procedures

Researchers analyzed the influence of collateral distal vessels on ischemic ulcer healing and limb salvage after successful distal procedures, according to an angiosome model. Retrospective analysis of 76 ischemic ulcers revascularized by surgical (41) and endovascular (35) distal procedures was performed. All interventions were primary procedures with single outflow vessel that remained patent during follow-up. Ulcers were classified according to an angiography angiosome study as direct revascularization (DR), indirect revascularization (IR), and IR through collaterals (IRc). Healing rates and limb salvage were compared according to the type of revascularization

Ulcer healing rate at 12 months was higher in DR than in IR (92 percent vs. 73 percent) but similar to IRc (92 percent vs. 85 percent). Limb salvage at 24 months was higher in DR than in IR (93 percent vs. 72 percent) but similar to IRc (93 percent vs. 88 percent). The researchers concluded that ulcer blood flow restoration through collateral vessels may give similar results to those obtained through its specific source artery.

From the article of the same title
Vascular and Endovascular Surgery (11/10) Vol. 44, No. 8, P. 654 Varela, César; Acín, Francisco; de Haro, Joaquín; et al.

Practice Management

Association Between Implementation of a Medical Team Training Program and Surgical Mortality

Researchers analyzed the success of a Veterans Health Administration Medical Team Training program established in 2006 that encourages teamwork and emphasizes safety procedures in surgery. The program includes two months of preparation and planning with the surgical team, plus a one-day learning session on site, which is followed by four quarterly follow-up phone calls with the team for a year.

Over three years, the researchers followed 108 facilities; 74 received the training and 34 did not. Observed deaths declined 18 percent in the trained facilities and 7 percent in the untrained facilities. For every quarter of training, mortality rates went down 0.5 per 1,000 procedure deaths.

Almost half of the trained facilities said that communication improved among their operating room staff, while 46 percent said there was better OR staff awareness and about 65 percent said they noticed an improvement in OR teamwork.

From the article of the same title
Journal of the American Medical Association (10/20/10) Neily, Julia; Mills, Peter D.; Young-Xu, Yinong; et al.
Web Link - May Require Paid Subscription | Return to Headlines

In-House vs. Outsourced Billing Operations: Which Is Best?

Medical billing is one of the most challenging and important aspects of a medical practice. When choosing whether to keep billing in-house or not, there are several things to consider. In-house billing is generally better at collecting on smaller outstanding bills, which billing companies may not pursue because the balance is not large enough to be worth their effort. Outsourcing billing is generally good for practice owners who do not want to manage an administrative team. A reputable medical billing company should have a team of well-trained certified billers knowledgeable in billing and sending claims. Billing companies are often the best choice for smaller practices because they have specialized medical billing tools and technologies that would be prohibitively expensive for smaller firms. The average cost of a medical billing firm ranges from 5 percent to 10 percent of a practice's collections.

From the article of the same title
Physicians Practice (10/19/10) Alpers, Adam

The Doctor Will See You Eventually

The average time patients spend waiting to see a healthcare provider is 22 minutes, according to a 2009 report by healthcare consulting firm Press Ganey Associates. Some steps to reduce patient wait times are as simple as leaving a few "catch-up" slots empty each day or stocking the same supplies in the same place in every exam room. Other options include open-access scheduling; minimizing office visits by handling follow-ups through phone, email, or video chat; and having patients complete registration forms, medication lists, and other paperwork in advance via computer or mail.

From the article of the same title
Wall Street Journal (10/18/10)
Web Link - May Require Paid Subscription | Return to Headlines

Health Policy and Reimbursement

California First to OK Insurance Exchange Outlined Under Health System Reform

California has become the first state to create a health insurance marketplace as envisioned under the federal healthcare reform law. Under the law, exchanges must be operational by Jan. 1, 2014; HHS must certify them by Jan. 1, 2013. If states do not create an insurance exchange, the federal government will offer one in the state. Startup costs will be paid by the federal government. HHS awarded planning grants of up to $1 million per state on Sept. 30, for a total of nearly $49 million. The exchanges must be self-sufficient by January 2015.

From the article of the same title
American Medical News (10/18/10) Trapp, Doug

Docs on Pharma Payroll Have Blemished Records, Limited Credentials

More than 17,000 doctors and other healthcare providers have taken money from seven major drug companies to talk to other healthcare professionals about their products, according to an investigation by journalism group ProPublica, including more than 380 who took in more than $100,000 in 2009 and 2010. The investigation showed that doctors were sometimes urged to recommend "off-label" prescriptions of drugs and that hundreds of doctors receiving payments had been accused of professional misconduct, were disciplined by state boards, or lacked credentials as researchers or specialists. For the study, ProPublica created a comprehensive database that allows users to enter a doctor's name to find payment information.

From the article of the same title
ProPublica (10/18/2010) Ornstein, Charles

U.S. Sues Michigan Blue Cross Over Prices

The U.S. government has filed suit against Blue Cross Blue Shield of Michigan, the state's largest health insurer, alleging that it abused its market power to inflate healthcare costs and impede competition. The suit alleges that the insurer negotiated contracts that prohibited hospitals from granting bigger price discounts to other insurers. In some cases, Blue Cross contracts required hospitals to charge other insurers significantly more than they charged Blue Cross, while at other times, Blue Cross agreed to increase the prices it pays hospitals—boosting costs for its own customers—in return for commitments that other insurers would be charged no less.

From the article of the same title
Washington Post (10/19/10) Hilzenrath, David S.

Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era

In 2004, The Joint Commission introduced a three-step "universal protocol" to prevent errors before surgical procedures, which includes a time-out immediately before the procedure. Researchers examined data collected by an insurance company that provided liability coverage to 6,000 doctors in Colorado from Jan. 1, 2002, to June 1, 2008. During the study period, 25 wrong-patient and 107 wrong-site procedures were reported.

According to the researchers, the main factors behind wrong-patient medical mistakes were errors in diagnosis (56 percent) and errors in communication (100 percent). Errors in judgment contributed to 85 percent of wrong-site medical errors and the lack of performing a "time out" before starting the surgical procedure was cited as the cause in 72 percent of these mistakes.

From the article of the same title
Archives of Surgery (10/01/10) Vol. 145, No. 10, P. 978 Stahel, Philip F.; Sabel, Allison L.; Victoroff, Michael S.; et al.

Medicine, Drugs and Devices

Effect of Ankle Taping on Knee and Ankle Joint Biomechanics in Sporting Tasks

Prophylactic taping is commonly used to prevent ankle injuries during sports. However, unnatural constraint of the ankle joint may increase the risk of injury to proximal joints such as the knee. Researchers sought to measure changes in knee and ankle kinetics and kinematics during dynamic athletic activities undertaken with and without ankle taping. A kinematic and inverse dynamics model was used to determine ankle and knee joint motion and loading in 22 healthy male participants undertaking running and sidestepping tasks. Both tasks were randomized to planned and unplanned conditions and undertaken with and without the use of ankle tape.

At the knee, peak internal rotation moments and peak varus moments were significantly reduced during all running and sidestepping trials when undertaken with ankle tape. Internal rotation impulse was reduced for sidestepping tasks. Varus impulse during unplanned sidestepping maneuvers was reduced with the use of ankle tape. However, there was a trend toward increased valgus moments and impulse for planned sidestepping trials undertaken with ankle tape. Taping reduced the range of motion at the ankle in all three planes. Peak inversion was reduced for running trials only. Average eversion and peak dorsiflexion moments were significantly reduced in sidestepping tasks by use of taping.

The researchers concluded that by limiting motion at the ankle, taping increased mechanical stability at this joint. Ankle taping also provided protective benefits to the knee via reduced internal rotation moments and varus impulses during both planned and unplanned maneuvers. Medial collateral and anterior cruciate ligament injuries may, however, occur through increased valgus impulse during sidestepping undertaken with ankle tape.

From the article of the same title
Medicine and Science in Sports and Exercise (11/10) Vol. 42, No. 11, P. 2089 Stoffel, Karl K.

New Real-Time Blood Monitoring May Lessen the Need for Transfusions During Surgery

Researchers have developed a noninvasive device that takes real-time measurements of a patient's red blood cells (specifically, hemoglobin levels). The technology could drastically cut the need for blood transfusions during surgery. The device, attached to a sticker that is placed on a patient's finger, employs near-infrared light to measure hemoglobin levels, relying on several different wavelengths to assess the relative quantity of red blood cells circulating in the body. In a clinical trial of elective orthopedic surgery procedures, researchers found that standard protocol resulted in about 4.5 percent of patients receiving blood transfusions during surgery, whereas for those relying on the new device, only 0.6 percent required extra blood.

From the article of the same title
Scientific American (10/18/10) Harmon, Katherine

Secondary Use of Electronic Health Record Data: Spontaneous Triggered Adverse Drug Event Reporting

Computerized patient records could be used to improve lax reporting of serious drug side effects, say researchers. At study at Massachusetts General and Brigham & Women's hospitals in Boston showed a large increase in reporting of adverse events to the FDA once doctors used an automated tool. Over five months in 2008 and 2009, 26 doctors at the hospitals reported 217 side effects to regulators, compared with zero reports in the same group in the previous year, according to the study.

When doctors in the study recorded discontinuing a medicine because a patient experienced an adverse event, the hospitals' electronic patient record system generated an alert. The system asked the doctor whether the side effect was serious and submitted a report to regulators.

From the article of the same title
Pharmacoepidemiology and Drug Safety (10/10) Linder, Jeffrey A.; Haas, Jennifer S.; Iyer, Aarthi; et al.

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October 27, 2010