News From ACFAS

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ACFAS wants to know what kind of work-related foot and ankle injuries you treat most often in your office. Cast your vote in our new poll at right and let us know which type of injury is most common among your patients. Visit acfas.org throughout November for real-time results. Thank you for sharing your input! Early birds, register now for the 75^th Anniversary Scientific Conference in Las Vegas at our exclusive low rates and join a community of innovative problem-solvers who will inspire you and energize your career!

Scheduled for February 27–March 2 at The Mirage Hotel, this dazzling celebration of the College’s history will feature a winning combination of clinical sessions, interactive workshops plus:

• the Exhibit Hall featuring hundreds of industry vendors, the fourth annual ACFAS Job Fair and the popular headshot booth
• a new twist on the HUB theater
• award-winning papers, posters and case studies
• networking with experts in your field during social opportunities
• and much more!

Connect with your colleagues the first night during the Premier Connection opening reception in Siegfried & Roy’s Secret Garden & Dolphin Habitat then close out the week with a VIP-worthy wrap party in the LINQ entertainment promenade.

Visit acfas.org/vegas to register before the December 12 early bird deadline and watch your mailbox for our official ACFAS 75 program book. Help advance the profession, patient care and the future of the College by volunteering to serve on an ACFAS committee, a Clinical Consensus Statement panel or as a reviewer of Scientific Literature.

To volunteer, visit acfas.org/volunteer. The application deadline is November 23, 2016. Get a firsthand look at the newest industry products and services, take a lunch break with your colleagues and friends, win prizes and browse through hundreds of scientific posters and case studies—all in the ACFAS 75 Exhibit Hall at The Mirage in Las Vegas.

We’ll cut the ribbon to the Exhibit Hall on Monday, February 27, the first day of the 75^th Anniversary Scientific Conference. Come by immediately following the opening general session to jumpstart your conference experience. Chat with vendors and poster authors, update your professional photo in our headshot booth (Booth No. 1419) and be sure to scan your badge each day the Exhibit Hall is open so you can earn CME.

Register for ACFAS 75 today at acfas.org/vegas and also book your hotel room with our official housing parter, onPeak. Have you downloaded your 2014 PQRS report and your 2014 and midyear 2015 Quality and Resource Use Reports from the CMS Enterprise Portal?

Although these reports differ from the data you will be asked to submit for the Merit-Based Incentive Payment System (MIPS), you can see your historical performance under the federal quality reporting programs. Use this information to identify different measures to report and to reduce resource use within your practice.

Direct your questions about MIPS or MACRA to Sarah Nichelson, JD, ACFAS director of Health Policy, Practice Management and Research.

Foot and Ankle Surgery

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Researchers compared the effect of two positions of a sciatic nerve catheter within the popliteal fossa on local anesthetic consumption and postoperative analgesia in patients undergoing hallux valgus repair. Eighty-four patients received a sciatic nerve catheter between the tibial and peroneal components or medial to the tibial nerve. Postoperative median local anesthetic consumption was 126 milliliters in the sciatic group, compared with 125 milliliters in the tibial group. Fourteen patients in the sciatic group and one patient in the tibial group experienced incidence of insensate limbs. Foot drop was reported by six patients in the sciatic group.


The use of nonabsorbable suture tape fixed to bone to augment Brostrom repairs of the anterior talofibular ligament (ATFL) has been proposed, but data regarding the arthroscopic modified Brostrom operation with an internal brace was lacking. Eighty-five patients underwent arthroscopic modified Brostrom operations; 22 patients were in the internal brace group, and 63 were in the group without an internal brace. Improvement of mean American Orthopaedic Foot & Ankle Society (AOFAS) score in the internal brace group two weeks following surgery was statistically significant. After 24 weeks, the anterior drawer test showed grade 0 laxity in 19 patients and grade 1 in three patients. The AOFAS score in the group without an internal brace six weeks after surgery did not see statistically significant improvement. At the 24-week follow-up, the anterior drawer test showed grade 0 laxity in 54 patients and grade 1 in nine patients.

Practice Management

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Six percent to 17 percent of adverse events in hospitals and 10 percent of patient deaths are due to diagnostic errors, according to a 2015 report from the Institute of Medicine. A paper published in Annals of Internal Medicine offers physicians strategies to prevent hospital diagnostic errors. Research suggests allocating time to communicate more effectively with patients can improve diagnosis. Providers are also encouraged to work closely with lab personnel and radiologists to interpret complex test results and clarify whose responsibility it is to follow up on abnormal results. All members of a healthcare team should be on the same page about a diagnosis. Finally, patients should be encouraged to engage in the diagnostic process and examine their own medical notes for inconsistencies.


Better image quality may make handheld devices a better solution for teleconsulting than laptop computers, according to a report published in Emergency Medicine Journal. Twenty-three emergency medicine specialists and four burn surgeons were asked to compare the perceived quality of 18 images shown on a smartphone, tablet and laptop computer. Images included both clinical and nonclinical subjects. The accuracy of diagnoses for specific conditions using handheld devices was not measured. Participants rated the images as good or very good in 83.1 percent of pictures displayed on smartphones, 78.2 percent on tablets and 70.6 percent on computers. Nearly all participants say they would feel comfortable using smartphones or tablets for image-based teleconsultation.


Failing to update computer systems, third-party contracts and electronic health record (EHR) programs after an employee leaves or changes status within the practice can lead to claim denials, out-of-network processing and Health Insurance Portability and Accountability Act (HIPAA) violations. If former providers are not removed from the EHR system, practices may end up purchasing unnecessary licenses. Practices should also monitor changes of status and update the EHR accordingly. For example, students who worked with the group, graduated and are rehired will require updated documentation. To manage employee access controls, practices should create an employee exit checklist. Before the employee departs, the practice manager should ensure that the employee is removed from all email and software applications and that all facility keys are returned. The employee’s workstation login and voicemail must both be changed. Third-party vendors and medical insurers should also be notified that the employee has left the practice.


Integrated physician and patient workflow has become vital for practices seeking to compete with the resources of hospitals and large healthcare systems. An integrated workflow consists of practice management tools, electronic health records (EHR) and patient engagement strategies. By purchasing these solutions from different vendors, practices create an uneven user experience for themselves and their patients, disrupting the workflow. With an integrated workflow, one common database lets data move seamlessly between applications. The integrated workflow begins with patient acquisition, allowing patients to schedule an appointment online and complete all necessary paperwork and intake forms prior to the appointment. During the visit, physicians can access all necessary patient information on a mobile tablet to make a diagnosis and determine treatment options. If medication or lab work is needed, the physician can send prescriptions electronically to the pharmacy or lab. Patient information is also integrated into the EHR system, and the appropriate information is sent to the insurance company. This approach improves both the patient and physician experience by increasing efficiency and supporting real-time documentation. Improved patient satisfaction and a reduction in medical errors are additional benefits. As workflow becomes more efficient, practices can manage higher patient volumes while improving patient care.

Health Policy and Reimbursement

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A year after a study about U.S. hospitals marking up prices by 1,000 percent generated outrage, 20 of the priciest hospitals have not bowed to the public shaming. A new study published in the Journal of Health Care Finance compared 20 Florida hospitals’ charges before and after the negative publicity. Researchers found no evidence that the damage to their reputations resulted in any reduction in charges. Instead, overall charges were significantly higher in the year following the publicity. The main factors leading to overcharging are believed to be insufficient market competition, hospital transparency and government regulation of prices. Only Maryland and West Virginia set hospital rates. Patients covered by private or government insurance do not pay full price because insurers are able to negotiate lower rates, but millions of Americans without insurance or those using out-of-network providers are more likely to be charged the full rate.


To prevent upcoding violations and scrutiny from auditors, healthcare organizations must keep high-quality electronic health records (EHR) documentation. The U.S. Centers for Medicare and Medicaid Services are especially concerned with balancing medical necessity with meaningful use. When examining EHR documentation, auditors will look for contradictions between the history of present illness and review of systems. Auditors will be attuned to wording or grammatical anomalies and medically implausible documentation. Code-generating software and templates also should be assessed for compliance. Hospitals should consider whether their code generator has been programmed to account for policies specific to the Medicare contractor and how it distinguishes between different levels of decision making. Excessive copying and pasting of notes can easily be spotted by auditors, but the practice does not always indicate wrongdoing. A JAMA Internal Medicine paper by University of Wisconsin researchers notes that data replication is a feature of EHRs and can create time savings when used correctly. The American Health Information Management Association released guidelines for proper use of copying and pasting in 2014 and recommends that providers, vendors and policymakers develop further standards for monitoring clinical compliance.


The federal government reports that premiums for midlevel health plans under the Affordable Care Act will increase by 25 percent in 2017. In addition, consumers in certain states will see fewer insurance companies offering coverage. However, officials say three-fourths of consumers would be able to find plans for less than $100 if they use government subsidies. The 25 percent increase is a sharp rise from the two percent and seven percent increases seen in 2015 and 2016, respectively. The fewer options and cost increases are also expected to become an issue for the next president to address. The open enrollment period begins on November 1. Consumers who do not sign up for a plan face $700 or more in tax penalties.

Medicine, Drugs and Devices

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Infections acquired in hospitals are a growing cause of concern for the healthcare industry, affecting one in 25 hospitalized patients in the United States every day, according to the U.S. Centers for Disease Control and Prevention. Pathogens can spread from sick patients in a hospital to the scrubs of healthcare workers and to items in patient rooms, a new study finds. To track the spread of these bacteria, researchers monitored 167 hospitalized patients and 40 nurses over the course of three separate 12-hour shifts in the intensive care unit. Nurses used a new set of scrubs for each shift. Nurses’ scrubs, patients and samples from patients’ rooms were tested for bacteria. Six types of bacteria were transmitted, including methicillin-resistant Staphylococcus aureus. Researchers found six instances of bacterial transmission from patient to nurse and six from room to nurse. Ten percent of transmissions were from patient to room. The pockets and sleeves of the nurses’ scrubs were the parts of clothing most likely to be contaminated, and the bed rails were the most contaminated items in patients' rooms. Researchers did not find evidence that bacteria had spread from a nurse to a patient. The new findings have not been published in a peer-reviewed journal.


The U.S. Food and Drug Administration and U.S. Centers for Medicare and Medicaid Services (CMS) say that their parallel review pilot program will continue indefinitely. The program allows device manufacturers to request a simultaneous, overlapping review from the two agencies. The program is intended to lower the time it takes between premarket approval, the granting of a de novo and a national coverage determination from CMS. Currently, it takes CMS six to eight months to grant a national coverage determination. The agencies are encouraging companies to apply to the program, although the agencies note they are prioritizing innovative devices that are “expected to have the most impact on the Medicare population.”


Advances in blood storage allow blood to be kept for up to 42 days before transfusion, and the typical practice is to first use the blood that has been in storage the longest. However, the biochemical, structural and functional changes that occur in blood during storage have raised concerns about the use of older blood. A study by McMaster University researchers recently published in the New England Journal of Medicine examined whether transfusions of fresh blood are more beneficial than stored blood. The study included 31,500 patients at six hospitals in Australia, Canada, Israel and the United States. The mortality rate was 9.1 percent among patients receiving the freshest blood and 8.7 percent among those receiving the oldest blood. "Our study provides strong evidence that transfusion of fresh blood does not improve patient outcomes, and this should reassure clinicians that fresher is not better,” says lead author Nancy Heddle.