News From ACFAS

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When in the Exhibit Hall at ACFAS 2020, don't miss the HUB—your one-stop shop for practical learning for practically everyone.

The HUB is the spot for real-world advice and a fresh lineup of topics! The small 50-person theater allows for candid, interactive discussions between attendees and speakers in an intimate setting during hourly presentations. This year’s HUB topics include:

• Exit Strategies for Leaving a Practice
• Why Should I Do Research?
• Early Career Finance
• Peer to Peer Insurance Review
• And more!

Pre-registration is not required to participate in HUB sessions. Visit acfas.org/sanantonio to download the ACFAS 2020 conference program and see the complete HUB schedule. Get the latest from ACFAS with the newest issue of Update—coming straight to your mailbox this week! This issue kicks off ACFAS 2020 with hotel reservations and this year’s lineup of Pre-Conference Workshops. You will also find advice on advice on raise and contract negotiation, get an inside look at the July ACFAS Board of Directors Meeting, new patient resources and more!

If you can’t wait to get your hands on the latest issue, visit acfas.org/update to read it now. You can also check out all past issues in the Update archives. We’re well into fall and approaching the holiday season, which means traveling for many of us. ACFAS wants to know where your feet take you on your holiday travels. Share with us and be part of the ACFAS #KeepYouOnYourFeet social media public awareness campaign to show how foot and ankle surgeons keep the world “on their feet."

Whether it’s photos of your feet relaxing on vacation, enjoying time with family or during your normal daily routine, we want to see them! Share your photos with us and use #KeepYouOnYourFeet so we can follow along on your journey. Get your patients involved and encourage them to post photos of their feet on the move using the hashtag, too. Plus, we also want to see them here at headquarters—send your photos for us to post on the ACFAS social media accounts. Just email them to erin.morrison@acfas.org and include your name, location of the photo and where you practice.

Show the world the impact foot and ankle surgeons have on our lives. Follow the #KeepYouOnYourFeet campaign on the ACFAS Instagram, Facebook and Twitter accounts and keep sharing your life journeys with us!

(ACFAS Staffer Erin Morrison patiently waits for your #KeepYouOnYourFeet photos.)

Foot and Ankle Surgery

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The distal lower extremity poses certain reconstructive challenges due to the durability it requires for the load-bearing plantar surface and for thin, pliable contour in the dorsal foot and ankle region. The authors conducted a retrospective review of soft tissue free flaps used for traumatic foot and ankle defects. Outcomes included repeat procedures, partial flap failure, total flap failure and wound complications. A total of 165 cases met inclusion criteria, with muscle flaps accounting for the majority of these cases. Defects involving the non-weight bearing surface were more common than those of the weight-bearing surface.

Complications occurred in 56 flaps (33.9 percent of flaps), including 11 partial losses and six complete losses. There were no differences in repeat procedures, partial flap failure, or total flap failure between muscle and fasciocutaneous flaps, but fasciocutaneous flaps had significantly fewer wound complications compared with muscle flaps. Defects of the weight-bearing surface had significantly increased risk of wound breakdown compared with those in the non-weight bearing surface. The authors conclude that muscle flaps demonstrated higher rates of wound complications than fasciocutaneous flaps.


Researchers sought to assess whether systematic inflammatory response syndrome (SIRS) is correlated with outcomes in diabetic foot infections (DFIs). In a retrospective review of 137 diabetic patients admitted to a hospital with moderate and severe DFIs, the authors used SIRS criteria to define severe infection based on the presence of at least two of the following: heart rate above 90 beats per minute, temperature between 36 degrees and 38 degrees Celsius; respiratory rate above 20 breaths per minute and white cell blood count under 4,000 cubic millimeters (mm³) or above 12,000 mm³. Patients with severe DFI were significantly younger and less likely to have type 2 diabetes or a history of previous amputation.

There were no differences in patients with severe SIRS-defined infections versus moderates infections in the need for surgery, any amputation, duration of antibiotics or healing within one year. The only outcome variable to differ significantly was the length of hospital stay, with a median of 12.7 days for severe infections versus 7.8 days for moderate infections. Foot-related readmission was more common in moderate infections (46.2 percent versus 25 percent, p =. 02). In conclusion, SIRS criteria for severe infections in diabetic patients with skin and soft tissue infections were not associated with a difference in outcomes other than longer hospital stay.


This Level 1 study compared the rate of malreduction after high fibular fractures associated with syndesmosis injury were treated with open reduction and internal fixation, using either two screws or one knotless TightRope device. Drawing from 11 hospitals across Canada, the trial examined 103 patients with OTA/AO 44-C injuries with demonstrated radiographic syndesmosis diastasis or instability after malleolar bony fixation. In all cases, open reduction of the syndesmosis was performed in all cases, with standardized surgical techniques and rehabilitation. Fixation was randomized to either TightRope (one knotless TightRope device, group T) or screw fixation (two 3.5 millimeter cortical positional screws placed across three cortices, group S). Follow-up was performed at two and six weeks and at three, six, and 12 months.

Overall, the rate of malreduction using screw fixation was 39 percent, compared with 15 percent using TightRope fixation. Patients in group T had greater anterior translation compared with the contralateral limb or group S. Group T syndesmoses also had greater diastasis compared with control limb and less fibular medialization compared with group S. Functional outcome measures demonstrated significant improvement over time, but there were no differences between fixation groups. The reoperation rate was higher in the screw group compared with the TightRope, with the difference driven by the rate of implant removal.

Practice Management

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The U.S. District Court in the Southern District of New York on Wednesday struck down a Trump administration rule that would have let medical providers opt out of participating in medical procedures based on their religious or moral objections. Nineteen states and family planning groups had sued to block the U.S. Department of Health and Human Services regulation that sought to expand enforcement of protections for medical workers with moral or faith-based objections to medical procedures such as abortion, assisted suicide or sterilization at hundreds of thousands of health organizations. The court vacated the rule, which was set to take effect on November 22, in its entirety. "The court's finding that the rule was promulgated arbitrarily and capriciously calls into question the validity and integrity of the rulemaking venture itself," U.S. District Judge Paul Engelmayer wrote in his decision.


Although the number of malpractice lawsuits has been declining in recent years, there were still more than 11,500 filed in 2018, and malpractice payouts rose nearly 3 percent from the year before. Understanding why lawsuits happen can help doctors minimize the chances of being sued and improve the odds of a favorable outcome if they are. Experts say the main point to remember is that most malpractice suits are not about money, but are rather the result of injured patients or their families wanting to establish what happened, who was responsible for it and to see that it does not happen to others. Doctors can reduce their legal exposure by first striving for trusting, open relationships with patients while practicing strong communication, both oral and written. Patient visit documentation is especially important and should occur as soon as possible, as these documents are incredibly important for malpractice defense.

There is also the fact that a practice or organization's culture is critical in ensuring patient safety and thus affects the frequency of malpractice suits. Experts note that environments where physicians treat other members of the care team as equals are less prone to malpractice. Primary care physicians should also be sure to make referrals when warranted and to document that they made the referral and followed up with the patient. Moreover, there are some cases where primary care doctors who continue to treat a patient for the problem for which they referred the patient to a specialist can be held to the medical standard of the specialist in a malpractice suit, even if the patient does not see the specialist, so it is important to document patient noncompliance.


The article outlines a few potential risks associated with the growing field of telemedicine. The first risk is litigation, which could stem from a variety of issues. Some claims will likely contribute to existing issues, such as miscommunication, while others could involve the very nature of telemedicine. Some claims might argue that an exam should have been done in person rather than remotely, and there could be privacy and security allegations around the technology used. There are also risks around state laws and licensing, as with telemedicine, it is not always possible to assume that the patient and the provider are in the same state. Providers should consult with an attorney as state laws vary and continue to evolve regarding telemedicine.

Policies and procedures for telemedicine should address all aspects of handling virtual care, such as patient identification, what constitutes a patient encounter and which patients and symptoms are appropriate for a telemedicine visit. Documentation is as critical when delivering telemedicine services as when providing any other kind of healthcare service. In addition to following documentation protocol to the letter, providers should consider privacy and security risks, as using telemedicine and electronic health records can leave them vulnerable to malware and hacks. Informed consent is another issue, as patients must be made aware of the risks of telemedicine, how the process works and who will be in charge of their care. When working with other organizations to provide telemedicine services, it is important to have solid contracts in place.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) reports that more than 177,000 people signed up for Affordable Care Act plans during the first two days of open enrollment, which began Nov. 1. Of the 177,082 people who selected plans on HealthCare.gov from Nov. 1-2, nearly 49,000 were new customers. During the first week of open enrollment last year — which spanned three days instead of two — 371,676 people signed up. CMS indicates that enrollment numbers likely are slightly lower this year due to technical issues that occurred on the site Friday. The agency says the error messages received by some consumers have been addressed.


The U.S. Centers for Medicare and Medicaid Services has issued a final rule that includes updates to payment policies, payment rates and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS). Under the 2020 PFS final rule, payment is made for services furnished by physicians and other healthcare practitioners. Payments are based on the relative resources typically used to furnish the surface in the form of relative value units, which become payment rates after a conversion factor. The 2020 rule makes updates to a number of areas, including: rate-setting and the conversion factor; Medicare telehealth services; evaluation and management services; physician supervision requirements for physician assistants; review and verification of medical record documentation; care management services; Medicare coverage for opioid use disorder treatment services; and therapy services. Other provisions include ambulance services, ground ambulance data collection and the open payments program.


A Kaiser Family Foundation analysis finds that the average Medicare beneficiary spent $5,460 out-of-pocket on insurance premium, cost-sharing and other heatlhcare costs in 2016. This includes spending by beneficiaries living in the community, who spent an average of $4,519, as well as the 5 percent of Medicare beneficiaries living in long-term care facilities, who spent an average of $1,014. Researchers said out-of-pocket spending varied across groups of beneficiaries. For example, Medicare beneficiaries ages 85 and older spent $10,307 out of pocket on average, compared to $5,021 for beneficiaries between 65 and 74. Women, people with multiple chronic conditions, and those who had been hospitalized were also likely to spend more out-of-pocket.

Medicine, Drugs and Devices

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Some of the newest, most expensive brand-name medicines have been plagued by quality and safety concerns during production, according to a Kaiser Health News (KHN) analysis. Even when U.S. Food and Drug Administration (FDA) inspectors flagged the potential danger and raised red flags internally, KHN reports those problems were resolved quietly with the agency without a follow-up inspection and the drugs were approved for sale. FDA has repeatedly found a way to approve brand-name drugs despite safety concerns at manufacturing facilities that had prompted inspectors to push to reject those drugs' approval, according to an ongoing KHN investigation. For example, inspectors found that facilities making immunotherapies and migraine treatments did not follow up when drug products showed evidence of bacteria, glass or other contaminants.

Without a follow-up inspection to confirm drugmakers corrected the problems inspectors found, these medicines eventually were approved for sale. Janet Woodcock, director of FDA's Center for Drug Evaluation and Research, said an inspector's recommendation to withhold approval can be "dealt with" without a follow-up. Woodcock said the agency cannot comment on specifics, and companies are reluctant to discuss them because the details of the resolution are protected as a corporate trade secret. "That doesn't mean that there's anything wrong with the drug," Woodcock said.


The U.S. Food and Drug Administration (FDA) released a draft document on best practices in drug and biological product postmarket safety surveillance. According to Janet Woodcock, MD, director of FDA's Center for Drug Evaluation and Research, the "draft best practice document outlines our approach for timely postmarket analyses of drugs and biologics and includes a high-level overview of tools, methods and signal detection and evaluation activities, using varied data sources, for drug safety surveillance to provide a broader context and a general overview of our overarching effort and commitment in this area." The draft document stems from the 21st Century Cures Act, which eliminated the requirement in the Federal Food, Drug and Cosmetic Act for periodic summary analyses of adverse drug reaction reports and includes a new requirement that FDA make its best practices for drug safety surveillance public available online. "We are constantly seeking new methods for improving our surveillance practices, and we invite the public to comment on the draft document released today," FDA said.


Emily Silverman, an internal medicine doctor at the Zuckerberg San Francisco General Hospital, critiques the electronic health records system Epic, which has been or will soon be adopted by many top medical centers. Epic offers a single, centralized system with modern-feeling graphics, and its ubiquity makes it easier for doctors to see healthcare data from other institutions, but it has many downsides. Many physicians have written about Epic's overwhelming complexity and unintelligible medical notes filled with superfluous text. Epic often makes abrupt requests mid-documentation to "assign" patients diagnoses from a list of highly specific options, which can feel premature and intrusive. Epic's voice is another one of its flaws. For example, the system is obsessed with identifying "deficiencies" in providers, and instead of deleting an incorrect diagnosis on a patient's list of medical problems, you can only "resolve" it.

These softer issues evince a greater lack of empathy with healthcare providers. Many people in the medical field want external validation and often struggle with deep guilt and a sense of inadequacy. Doctors suffer from disproportionately high rates of burnout, depression and suicide, but Epic's voice does not seem designed with this in mind. Some physicians have pointed out that Epic may not care about this, as its goal is not make users feel good: its goal is to maximize productivity, keeping physicians checking boxes and churning through patients as quickly as possible. Regardless, its voice will continue to contribute to the medical profession's growing sense of despair.