November 8, 2017 | | JFAS | Contact Us

News From ACFAS

Three Reasons to Come to Nashville Early
The perfect prelude to ACFAS 2018 in Nashville? Three new preconference workshops that will skyrocket your coding and surgical skills to the top of the charts!

Set for Wednesday, March 21, 2018 at the Gaylord Opryland Hotel, these workshops are your backstage pass to ACFAS 2018. Choose from:

Coding and Billing for the Foot and Ankle Surgeon
(7:30am–5:30pm, 8 CE contact hours)
Gain no-nonsense solutions to maximize your surgical billing processes and increase your reimbursement.

Tendon Transfers: Common to Complex
(7:30am–Noon, 4 CE contact hours, includes wet lab)
Master several tendon transfer techniques to better manage common deformities.

Common Corrective/Realignment Osteotomies
(Noon–5pm, 4 CE contact hours, includes wet lab)
Perform common forefoot and rearfoot osteotomies step by step and one on one with expert faculty.

Registration details for these special programs will be available soon—check updates.
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Save the Date: Take a New Look at Practice Building Free Webinar
Do you struggle with generating referrals? Attracting new patients? Cutting through the clutter to build your practice? If so, make plans to participate in ACFAS' newest free practice building webinar—Take a New Look at Practice Building on January 17, 2018, 7pm CT.

Hear from your trusted peers and public relations experts on what tools you need to make practice growth a reality. Plus, gather insight on:
  • How to leverage tools from the Take a New Look at Foot & Ankle Surgeons campaign to generate or strengthen referrals to your practice.
  • The importance of proactive relationship building to encourage referrals.
  • How to use the resources in the ACFAS Marketing Toolbox to attract new patients to your practice through traditional media outreach, social media and community relations.
Make 2018 the best year for your practice by joining the webinar in January. Save the date and watch for more information and registration details!
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Present a Compelling Clinical Case in the Doctors’ Lounge
Have you always wanted to join the ACFAS faculty or speak at the Annual Scientific Conference? Then consider presenting a clinical case at the Doctors’ Lounge during ACFAS 2018, March 22–25 in Nashville. This is a great way to get a feel for what the faculty and speaker roles involve.

Your case should cover an intriguing aspect of foot and ankle surgery and encourage discussion of correct diagnosis. Download and complete the Doctors’ Lounge Case Form from and send it to Marilyn Wallace by January 12, 2018. We will notify you if your case is selected for presentation.
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Watch Your Mail for 2018 Dues Reminder
Associate and Fellow members—if you have not already renewed your ACFAS membership for the 2018 calendar year, you will receive a dues reminder in the mail. You can pay your dues online now or via mail or fax once you receive your reminder. Payment is due by December 31, 2017.

To learn more about the many benefits your ACFAS membership provides, visit the Member Center on
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Foot and Ankle Surgery

Heel-Rise Height Deficit One Year After Achilles Tendon Rupture Relates to Changes in Ankle Biomechanics Six Years After Injury
A study was conducted to define the differences in ankle biomechanics, tendon length, calf muscle recovery and patient-reported outcomes at an average of six years following Achilles tendon rupture (ATR) between two cohorts that, at 12-month follow-up, had less than 15 percent versus greater than 30 percent differences in heel-rise height. Seventeen patients with less than 15 percent and 17 patients with greater than 30 percent side-to-side difference in heel-rise height at one year after ATR were assessed at an average of 6.1 years following ATR. Ankle kinematics and kinetics were sampled through standard motion capture procedures during walking, jogging and jumping. Tendon length was assessed via ultrasonography, and the Limb Symmetry Index (LSI) was calculated for side differences. The researchers found that the less than 15 percent cohort had significantly more deficits in ankle kinetics during all activities versus those in the greater than 30 percent cohort at an average of six years after ATR. The less than 30 percent group, compared with the greater than 15 percent group, also had significantly lower values in heel-rise height and heel-rise work and substantially larger side-to-side differences in tendon length. Achilles tendon length correlated with ankle kinematic factors while heel-rise work correlated with kinetic factors. LSI tendon length correlated negatively with LSI heel-rise height, and no differences were observed between groups in patient-reported outcome.

From the article of the same title
American Journal of Sports Medicine (11/01/17) Brorsson, Annelie; Willy, Richard W.; Tranberg, Roy; et al.
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Imaging Modalities in the Diagnosis and Monitoring of Achilles Tendon Ruptures: A Systematic Review
A systematic review was conducted to ascertain the role of imaging in the diagnosis and monitoring of Achilles tendon ruptures. A total of 56 studies were analyzed, most concerning the use of ultrasound or magnetic resonance imaging. Seven studies supplied data on the diagnostic accuracy of imaging. Most ultrasound studies employed a 7.5 MHz probe and scanned the patient bilaterally in prone position, with recent studies typically using higher frequency probes. Sensitivity for rupture detection ranged from 79.6 percent to 100 percent, and the spread in specificity was large, but two studies had perfect data. Negative and positive probability ratios ranged from 0 to 0.23 and 1.0 to 10 respectively. The researchers recommend primary reliance on clinical examination and assessment, using imaging to exclude other injuries and provide additional clinical information. More high-quality research is justified in the diagnostic accuracy of imaging as well as less conventional imaging modalities' diagnostic and monitoring capabilities.

From the article of the same title
Injury (11/01/17) Vol. 48, No. 11, P. 2383 Dams, Olivier C.; Reininga, Inge H.F.; Gielen, Jan L.; et al.
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Immobilization-Induced Osteolysis and Recovery in Neuropathic Foot Impairments
A study was conducted to determine differences in foot skin temperature, calcaneal bone mineral density (BMD) following immobilization, calcaneal BMD after 33 to 53 weeks of recovery and percentage of feet classified as osteopenic or osteoporotic after recovery in participants with neuropathic plantar ulcers (NPU) versus Charcot neuroarthropathy (CNA). Fifty-five participants with peripheral neuropathy were studied, and 28 had NPU while 27 participants had CNA. Prior to immobilization, skin temperature differences in CNA between their index and contralateral foot were markedly higher than NPU feet. BMD in NPU immobilized feet averaged 486 plus or minus 136 mg/cm2, and CNA immobilized feet averaged 456 plus or minus 138 mg/cm2. Following immobilization, index NPU feet lost 27 mg/cm2 and CNA feet lost 47 mg/cm2 of BMD. After recovery, 61 percent of NPU index feet and 84 percent of CNA index feet were classified as osteopenic or osteoporotic.

From the article of the same title
The Bone Journal (12/01/2017) No. 105, P. 237 Sinacore, David R.; Hastings, Mary K.; Bohnert, Kathryn L.; et al.
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Practice Management

How to Express Sympathy Without Receiving a Malpractice Lawsuit
Physicians often want to express sympathy for a patient who experiences an unexpected adverse outcome despite the physician's best efforts. However, physicians need to curb the risk of patients' attempts to use their statement as evidence of malpractice in a lawsuit. An "admission" of wrongdoing in court can be defined as any oral statement that supports the plaintiff‘s claims, such as falling below the accepted standards of medical care. In approximately 32 states, the general rule of evidence on admissions applies, requiring physicians to be particularly cautious about what they say to a patient or a family member about an unanticipated adverse outcome. Research has shown, however, that a physician who discusses adverse outcomes with his/her patient is significantly less likely to be sued for malpractice than a physician who does not do so. Ideally, physicians should undergo risk management training on how to handle conversations with patients and their families in these situations. Apart from what, how and when to say it, such training advises physicians to have at least one witness present who is on the physician's side when he/she speaks to the patient and/or family members; have available the clinical records that substantiate that what went wrong was a known, unavoidable complication; referring, in a sympathetic fashion, to these records during the conversation and afterward, having the physician and his/her witness document in the clinical record who said what and what otherwise occurred during the conversation.

From the article of the same title
Medical Economics (10/30/17) Alessi, Dennis J.
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One in Five Physicians Ready to Reduce Clinical Work Hours
New research from the American Medical Association (AMA), Mayo Clinic and Stanford University published in Mayo Clinic Proceedings urges a comprehensive approach by national policymakers and healthcare delivery institutions to address the challenge of burdensome work hours faced by physicians. The study estimates about one in five physicians plan to reduce clinical work hours in the next year, while about one in 50 plan to change careers in the next two years. Physicians who were burned out, unhappy with work-life integration and dissatisfied with electronic health records were more likely to intend to reduce clinical work in the next year. Burnout is the largest variable influencing physicians planning to leave medicine in the next two years. "An energized, engaged and resilient physician workforce is essential to achieving national health goals," notes AMA President David O. Barbe. "Yet burnout is more common among physicians than other U.S. workers, and that gap is increasing as mounting obstacles to patients care contribute to emotional fatigue, depersonalization and loss of enthusiasm among physicians." AMA has made burnout prevention a top priority. Working with partners across healthcare, the association is spearheading a shift in medicine that prioritizes physician well-being as critical to the long-term clinical and economic success of the American healthcare system.

From the article of the same title
American Medical Association (11/01/2017)
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When and How to Say Sorry to Patients
There are several legal issues to consider when healthcare providers apologize to their patients. Laws in some states put a time limit on the inadmissibility of an apology from three days to 30 days. The intent is to encourage doctors to communicate to patients sooner and more often. In Ohio, a recent ruling by the state's supreme court means doctors in that state now have special legal protection under what is known as an "apology shield law." The court ruled that a healthcare provider's apology to a patient cannot be admitted as evidence in a civil lawsuit—even if the apology expressed fault or "acknowledgement that the patient's care was substandard." Massachusetts was the first state to enact an apology shield law in 1986, and since then, some three dozen other states have passed similar legislation. Now that doctors are gaining added legal protection when confronted with aggrieved patients, they should consider whether it might be time to say, "I'm sorry," ideally to convey both empathy and an apology. In one case, staff at a hospital fed a child patient with severe food allergies a peanut butter sandwich, and the child died quickly. The child's mother subsequently sued the hospital, and the years-long case ended in a settlement with the family. When hospital representatives later visited her and said they were sorry for the loss of her child, her response indicated that had she received the apology sooner, everyone could have been spared years of expense and stress from the legal process. In general, an estimated 95 percent of all lawsuits are settled out of court.

From the article of the same title
MedPage Today (10/25/17) Sergel, Roger
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Health Policy and Reimbursement

ACA Benchmark Premiums Up 37 Percent in 2018 After Subsidy Cut-Off
The U.S. Department of Health and Human Services' (HHS) Office of the Assistant Secretary for Planning and Evaluation estimates the average monthly premium for benchmark Affordable Care Act (ACA) insurance plans will spike by 37 percent next year. Meanwhile, the average monthly premium for the second lowest-cost "silver" plan for a 27-year-old will climb to $411 monthly in 2018 from $300 monthly this year, and federal tax credits that help individuals purchase coverage also will experience a sharp rise. Consequently, people who qualify for tax credits based on their income may wind up paying less per month for insurance, while middle-class Americans who do not qualify will face much higher prices. "This data demonstrates just how rapidly [ACA's] exchanges are deteriorating with sky-rocketing premiums year after year, more than half of Americans with no more than two insurers to choose from and the taxpayer burden exploding," says HHS spokeswoman Caitlin Oakley. Earlier this month, the Trump administration severed subsidies that insurers use to reduce copays and other out-of-pocket expenses for low-income Americans under the ACA. Insurers are still required to supply discounts on out-of-pocket costs to eligible consumers enrolled in the most popular "silver" plans, even lacking government subsidies. Insurers have hiked premiums on those plans to compensate for those costs.

From the article of the same title
Reuters (10/30/17) Erman, Michael
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Lower ACA Enrollment Forecast in 2018
Affordable Care Act (ACA) exchanges are projected to sign up between 10.6 million to 11.4 million people during the upcoming fifth open enrollment period, according to S&P Global Ratings. "This is about seven percent to 13 percent lower than the 12.2 million that signed up during the 2017 open enrollment season," said S&P credit analyst Deep Banerjee. "We expect that most individuals who maintained ACA insurance for full-year 2017 will reenroll (for 2018), although fewer new enrollees will enter the marketplace." S&P cites several factors for the decreased enrollment, such as reduced outreach at the federal level, a reduced broker presence in the individual market, shorter enrollment periods and higher nonsubsidized premiums. Of consumers who purchased insurance on an exchange last year and paid their premiums for full-year 2017, more than 80 percent likely receive an advanced premium tax credit, which will offset the impact of the 2018 premium increases, S&P said. "As for new enrollees, we are forecasting fewer people signing up in 2018 than during previous open enrollments," according to Banerjee. For 2018, S&P also forecasts that effectuated enrollment will be between 8.3 million and nine million as of year-end 2018, which is flat to eight percent lower than S&P's estimate for 2017 effectuated enrollment of nine million. As for the exchange population beyond 2018, S&P expects enrollment again to jump at the beginning of the year and then gradually decline as the year proceeds.

From the article of the same title
HealthLeaders Media (10/30/17) Commins, John
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No Surgery for Smokers or the Obese: Policy in UK Stirs Debate
The Clinical Commissioning Group (CCG) for Hertfordshire County in the United Kingdom has indefinitely banned patients who are obese or smokers access to nonemergency surgery under the National Health Service until their health improves. However, CCG added "exceptional clinical circumstances (will) be taken into account on a case-by-case basis." CCG says the timeframe given to patients to improve their health is nine months for the obese. Meanwhile, smokers have to go eight weeks or more without a cigarette. The policy is expected to stir controversy, but experts say it is intended "to support patients whose health is at risk from smoking or being very overweight." Experts also say economic, health and ethical arguments are surrounding the ban.

From the article of the same title
CNN (10/31/17) Senthilingam, Meera
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Medicine, Drugs and Devices

Amazon's Push into Pharmacy Business Is Full of Promise and Pitfalls
A successful outcome for Amazon's potential move into the pharmacy business could prove elusive, according to industry analysts. Companies, such as Amazon, may be "sensing there is a significant discontinuity, a shift, about to occur and it is time to jump in," says Pratap Khedkar, who heads the pharmaceuticals practice at consulting firm ZS Associates. However, filling drug prescriptions online would pose very different challenges than what Amazon usually faces, say industry experts. Drugs are highly regulated and can be sold only by a pharmacy with a state-issued license. Importantly, the patient usually does not pay directly for the prescription drugs. "Amazon has built its business dealing with first-party payment—the consumer," says Adam Fein, president of Pembroke Consulting. "It’s a very different business when the consumer is sharing the cost with a third party." The involvement of middlemen would present steep challenges for Amazon if it wanted to bring its seamless, one-click experience to the experience of filling a prescription. For these reasons, many healthcare industry officials believe Amazon, if it opted to enter the market, would probably seek to join with or buy a company with systems already in place for processing prescriptions and then integrate those systems into its online shopping.

From the article of the same title
Wall Street Journal (10/29/17) Rockoff, Jonathan; Stevens, Laura
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CMS Announces New ‘Meaningful Measures’ Initiative
The U.S. Centers for Medicare and Medicaid Services has begun an initiative that aims to streamline quality measures, cut regulations and encourage innovation in the healthcare industry. The Meaningful Measures initiative will "involve only assessing those core issues that are most vital to providing high-quality care and improving patient outcomes,” while adding that CMS “aims to focus on outcome-based measures going forward, as opposed to trying to micromanage processes." Industry reactions to Meaningful Measures have been positive, but there is some reluctance as the industry has been discussing some of the goals of the effort for years.

From the article of the same title
Health Data Management (10/30/17) Slabodkin, Greg
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How HIPAA Information Sharing Regulations Impact the Opioid Crisis
The U.S. Office for Civil Rights (OCR) has released guidance on how the Health Insurance Portability and Accountability Act allows healthcare providers to share information as a way to improve patient care. OCR says that healthcare providers can share information with family members under certain circumstances, and they may not need permission to do so. The new guidance states, "Sharing health information with family and close friends who are involved in care of the patient if the provider determines that doing so is in the best interests of an incapacitated or unconscious patient and the information shared is directly related to the family or friend’s involvement in the patient’s healthcare or payment of care." OCR Director Roger Severino says the new guidance will "give medical professionals increased confidence in their ability to cooperate with friends and family members to help save lives."

From the article of the same title
HealthIT Security (10/30/2017) Snell, Elizabeth
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This Week @ ACFAS
Content Reviewers

Mark A. Birmingham, DPM, FACFAS

Daniel C. Jupiter, PhD

Gregory P. Still, DPM, FACFAS

Jakob C. Thorud, DPM, MS, FACFAS

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This Week @ ACFAS is a weekly executive summary of noteworthy articles distributed to ACFAS members. Portions of This Week are derived from a wide variety of news sources. Unless specifically stated otherwise, the content does not necessarily reflect the views of ACFAS and does not imply endorsement of any view, product or service by ACFAS.

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