News From ACFAS

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Your favorite one-stop shop for practical tips and tools to better manage the nonclinical side of your career is back! Come to the HUB, March 22–24 in the ACFAS 2018 Exhibit Hall in Nashville, and hear your peers share tried and true advice to help you with:

• The Great Job Hunt and Compensation
• Promoting Yourself in the Digital Age
• Public Speaking and Teaching
• Early Career Finances
• Credentialing and Privileging
• And more!

Each HUB session is 50 minutes long and gives you the chance to participate in open and candid conversations with speakers and attendees. Leave with ready-to-use solutions you can put to work the minute you get home.

Visit acfas.org/nashville for the complete HUB schedule. No preregistration is necessary to participate in HUB sessions. Explore state-of-the-art approaches to cartilage repair in this month’s free clinical session, Next Generation of Cartilage Repair: Staving Off Fusions and Joint Replacements. Six presentations on the latest repair techniques shed light on new treatment options for your patients:

• What’s the Problem with Articular Cartilage? Why Don’t You Heal?
• Marrow Stimulation Techniques: Technique Au Naturel?
• OATS and Fresh Osteochondral Allograft Transplantation: When Do They Work?
• Biologic and Synthetic Scaffolds: Navigating Indications and Outcomes
• PRP, Stem Cells, Hyaluronic Acid: The Quick Facts and Fiction
• Autologous Chondrocyte Implantation: Where Are We with Cost and Outcomes?

Complete a short CME test after you watch the presentations to earn 1.75 continuing education contact hours.

Access this session and many other free resources in the ACFAS e-Learning portal at acfas.org/e-Learning for convenient online education that is always ready when you are. Do you need a few stray CME hours to meet your requirements for the year? Visit the ACFAS e-Learning Portal for a robust catalogue of Clinical Session videos, Surgical Techniques DVDs and e-Books that makes earning CME hours a snap.

Each tool in the e-Learning Portal includes an exam you can submit and pass to obtain your hours. And with new programs added to the portal every six weeks, you always have plenty of options to explore. Access acfas.org/e-learning at your convenience from any location, and never fall behind in fulfilling your requirements.

Foot and Ankle Surgery

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A cohort study was conducted to prospectively evaluate the remission rate of diabetic foot osteomyelitis treated via application of white blood cell (WBC)-single-photon emission computed tomography (SPECT)/computed tomography (CT) as a predictive marker of remission. Forty-five patients with diabetic foot osteomyelitis that was nonsurgically treated between April 2014 and December 2015 were included. All were treated solely with antibiotics, with WBC-SPECT/CT conducted at six weeks and antibiotic treatment discontinued if clinical indicators of soft-tissue infection had resolved and there was no abnormal uptake of labelled WBCs. Treatment was otherwise continued for 12 weeks and then discontinued. For these individuals, another WBC-SPECT/CT was conducted at 12 weeks. The overall remission rate was 84 percent at one year. A six-week course of antibiotics was used in 23 patients, 22 of whom were in remission at one year. A 12-week course was used for 22 patients, 16 of whom were in remission at one year. Sensitivity of WBC-SPECT/CT at 12 weeks was 100 percent, specificity 56 percent, positive predictive value 46 percent and negative predictive value 100 percent.


This cross-sectional study examined the relationship of flat feet with knee pain, disability and physical performance in patients with knee osteoarthritis (OA). Ninety-five orthopaedic clinic participants between the ages of 61 and 91 (68.4 percent women) with Kellgren-Lawrence (K/L) grade greater than or equal to one in the medial compartment underwent evaluation of navicular height and foot length for flat feet. Knee pain intensity, disability and physical performance were evaluated using the Japanese Knee Osteoarthritis Measure, 10-m walk, timed up and go and five-repetition chair stand tests. Of the 95 enrolled patients, 24 (25.3 percent) had bilateral flat feet and significantly higher knee pain compared to patients with no flat feet. An ordinal logistic regression analysis showed that bilateral flat feet were significantly associated with increased knee pain compared with no flat feet, adjusted for age, sex, body mass index and tibiofemoral joint K/L grade, and this relationship is consistent across various different cutoffs of the definition of flat feet. Physical performance was similar between patients with and without bilateral flat feet. The presence of unilateral flat feet was not significantly associated with any outcome measures. These findings indicate that bilateral, but not unilateral, flat feet are associated with worse knee pain. A prospective study investigating a causal relationship between bilateral flat feet posture and knee pain as well as disability would be of particular interest to verify the potential adverse effect of altered foot posture.


In this study, researchers analyzed self-reported outcomes in a prospective cohort of patients treated with ankle arthrodesis or total ankle replacement (TAR) during a time of transition from older to newer-generation TAR implants. They conducted a prospective cohort study comparing outcomes in 273 consecutive patients treated for ankle arthritis with arthrodesis or TAR between 2005 and 2011. Adult patients with end-stage ankle arthritis who were able to walk and willing and able to respond to surveys were included. At baseline and at six-, 12-, 24- and 36-month follow-up visits, participants completed a pain score, a Musculoskeletal Function Assessment (MFA) and a Short Form-36 (SF-36) survey. Researchers found a significant mean improvement in most outcomes after surgery regardless of procedure. In general, the greatest improvement occurred during the first six months of follow-up. Linear mixed-effects regression adjusted for differences at baseline in age, body mass index and surgery type showed improvement in scores at six months. The mean improvements in the MFA and SF-36 PF scores over the three-year follow-up period were significantly better after the TARs than after the arthrodeses. The differences between the two groups were slightly greater when only the newer TAR devices were compared with the arthrodeses. Patients reported improved comfort and function after both surgical treatments, and the average improvement in the MFA and SF-36 PF scores was better after TAR than after arthrodesis, particularly when the TAR had been done with later-generation implants, the researchers found. Younger patients had greater functional improvements than older patients.

Practice Management

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With the U.S. Centers for Medicare and Medicaid Services issuing rules for how Medicare Access and CHIP Reauthorization Act (MACRA) will function in 2018, medical practices must push forward in preparing to address the law's mandates. This can be eased with scorecards that serve as critical tools to help a practice monitor progress toward key goals as defined by the law. Northwell Health Physician Partners (NHPP) has adjusted many of the scorecards it already uses to mirror MACRA's definition of items to be measured and its requirements. In one example, NHPP administrators noted mammography rates among patients appeared lower than the clinicians thought those rates actually were, which was partly due to the fact that the women were getting mammograms outside the system and physicians were not correctly documenting this in the record. Subsequently, management opted to relieve physicians of the task of making sure that outside mammography reports were entered correctly, causing mammography rates to rise. The scorecards need to accurately reflect MACRA regulations, what metrics will be used and the way in which they will be scored.


A new Accenture survey calculates only about 25 percent of healthcare providers can provide cost estimates, even though 91 percent of patients want them and 47 percent would consider changing providers to access that information. Most patients are not using cost estimate data to shop around, but are using it to better plan their budgets, and 60 percent of those who know their medical costs ahead of time opt to proceed with the service. In addition, 46 percent of patients require up-front cost information for budget-planning purposes and 41 percent are worried about their ability to pay, especially in the uninsured and Medicaid segments. Furthermore, 60 percent of patients who know their medical cost in advance go ahead with the service, but 23 percent elect to delay care, rather than canceling or switching to a less expensive provider. The poll also found only 11 percent of patients use this information to shop for better deals, with more price shopping reported for routine services, such as dental and vision, and less reported for diagnostic testing, chronic care and surgery. In addition, Gen X and younger consumers are more than three times as likely to price shop as older generations.


A recent study published in Healthcare IT News described the legal risks of the electronic healthcare record (EHR), some of which are predictable and some of which are not. Among the study's findings is the fact that providers in direct patient care carry ultimate responsibility for the data to which they have access. Practices must therefore review the entire record before executing a treatment plan. A second finding is that when an alert is not followed up and this leads to an adverse outcome, the provider is culpable. Everything done on a modern EHR system is tracked and retained and can be accessed from a forensic standpoint and used against the provider in court. In addition, there should be a ban on copying and pasting, as it spreads "ratty" data to the detriment of patient care. Insurers and the government can identify duplication, and legal counsel will use the same measures to indicate lack of care and failure to accurately and completely document the visit, opening up the provider to fraud as well as malpractice charges. Auto population of notes also can be dangerous, and the EHR's ability to keep track of everything makes data discoverable in a liability claim and can be used both in defense of the provider's actions, as well as against them. Finally, "canned" notes are easily detected and often missed by providers.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) has released a final rule on the Quality Payment Program. The rule includes a comment period about the second year and future years of the Quality Payment Program, an initiative established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to reward physicians for value and outcomes either through the Merit-Based Incentive Payment System and Advanced Alternative Payment Models. Some of the changes are noted in a CMS fact sheet.


The House passed a bill to fund the Children's Health Insurance Program for five years despite objections from Democrats, who oppose how the legislation is underwritten. The bill would charge higher premiums to more affluent Medicare beneficiaries, slash money from the Affordable Care Act's (ACA) public health fund and shorten the grace period for ACA enrollees who fail to make premium payments. The Center on Budget and Policy Priorities estimates that between 259,000 and 688,000 people could lose their insurance due to the shortened grace period. "This Republican bill offers a false choice," warned Rep. Frank Pallone Jr. (D-N.J.). "In one hand, it strips healthcare away from upwards of 680,000 Americans and guts the Prevention Fund...and then in the other hand, it reauthorizes these important programs." The bill was integrated with separate legislation that extends funding for community health centers for two years, while also providing $1 billion over two years to help strengthen Medicaid in Puerto Rico and the U.S. Virgin Islands.


The U.S. Centers for Medicare and Medicaid Services (CMS) has published detailed regulations for the expanded model of the Medicare Diabetes Prevention Program (MDPP) in its final rule for the 2018 physician fee schedule. CMS will add MDPP as a covered benefit for Medicare beneficiaries who satisfy certain criteria, beginning on April 1, 2018. MDPP would provide coaching to prediabetic people to help them shed weight and avoid developing type 2 diabetes. Community health workers and health professionals will supply these services in community and healthcare environments. "The sessions provide practical training in long-term dietary change, increased physical activity and problem-solving strategies for overcoming challenges to maintaining weight loss and a healthy lifestyle," the final rule states. A key objective of MDPP is for beneficiaries to cut their weight by at least five percent from baseline by the end of the first year to qualify for ongoing maintenance sessions in the second year. MDPP services include core sessions for the first half-year, core maintenance sessions in the second half-year and ongoing maintenance sessions in the second year. Sixteen weekly sessions must be done within the first six months. CMS says by making persons eligible for the MDPP benefit only once in their lives, people will likely be more motivated to meet the criteria.


Seven Democratic U.S. senators have introduced legislation designed to slow the "revolving door" between federal agencies and the pharmaceutical companies they regulate. The legislation would bar former officials from the U.S. Food and Drug Administration and the U.S Drug Enforcement Administration (DEA) for two years from assisting pharmaceutical companies with lobbying efforts. The measure also expands the definition of "lobbying contact" to include taking part in activities, such as strategy sessions. It also limits the issues pharmaceutical industry officials can handle if they join the federal government. The proposed legislation follows reports on the opioid industry's influence in Washington. Companies that manufacture or distribute opioids have hired dozens of high-ranking officials from DEA during the past decade, many of them from a division that regulates some of the same companies. Senator Tammy Baldwin (D-WI), who sponsored the legislation, said it would serve as a check on the power the pharmaceutical industry wields on Capitol Hill. Baldwin said she plans to seek out Republican cosponsors.

Medicine, Drugs and Devices

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Deaths by drug overdose in the United States increased by more than 17 percent in 2016, according to a report released Friday by the U.S. Centers for Disease Control and Prevention (CDC). Preliminary data from the 50 states show that from the fourth quarter of 2015 through the fourth quarter of 2016, the rate of fatal overdoses rose to nearly 20 people per 100,000 from 16.3 per 100,000. CDC had previously estimated that about 64,000 people died from drug overdoses in 2016. Robert Anderson, MD, chief of CDC's mortality statistics branch, says in recent years the deaths have been driven by overdoses of synthetic opioids, mostly fentanyl, rather than heroin. The report's results are preliminary. Although the report includes deaths by cancer, heart attack and most other causes through mid-2017, its section on drug deaths covers only 2015 through 2016 because of the complexity of toxicology reports and other information needed to confirm drug overdoses. The number of teenagers becoming addicted to opioid analgesics is going down, notes Andrew Kolodny, MD, director of opioid policy research at Brandeis University. But those in their 20s and 30s who are already addicted are increasingly in danger because of the practice of mixing heroin with fentanyl or fentanyl being sold as heroin. Other government reports show that deaths by fentanyl have increased significantly in three years.


House Republicans are considering repealing a decades-old tax credit designed to spur cures for rare diseases as part of their tax reform efforts. The proposal under consideration would end the tax breaks for development of what are called orphan drugs. Ending the credit used by big and small drug companies could save the government an estimated $54 billion over the next decade, an effort to help offset some of the anticipated losses in revenue if other Republican tax cut provisions become law. The credit has come under scrutiny because critics say that some major drugmakers have exploited it by obtaining the orphan designation for billion-dollar blockbuster drugs. However, the repeal proposal will likely face opposition in the Senate, particularly from Sen. Orrin Hatch (R-UT), who is overseeing tax reform in the Senate and was a leading sponsor of the 1983 Orphan Drug Act. Under current law, companies that develop drugs for rare diseases can receive a tax credit for half of the cost of their clinical trials, and they are also granted seven years of exclusivity, when the drug is protected from competition. Companies are not required to disclose the amounts of the tax credits they receive. In public, the pharmaceutical industry's largest lobbying groups have not said much about the credit.


The defense policy bill currently being negotiated by a conference committee would give the U.S. Department of Defense (DOD), and not the U.S. Food and Drug Administration (FDA), the power to approve drugs and medical devices. Lawmakers backing the bill, including House Armed Services Chair Mac Thornberry (R-TX), say the measure is necessary. "FDA has denied freeze-dried plasma to troops in the field for 10 years," said House Armed Services spokesperson Claude Chafin, referencing a still-unapproved medical product that the Pentagon says is necessary to save the lives of military personnel. FDA officials warn that creating a new pathway to approve drugs is both risky and—in the specific case cited by Thornberry—not needed. "FDA has been working closely with DOD to bring freeze-dried plasma to our troops and anticipates that these products will be fully approved for safe and effective use for our armed forces as early as 2018," said an FDA official. Section 732 of the Senate’s version of the National Defense Authorization Act creates a new regulatory structure that would allow the Pentagon to sign off on unapproved devices and drugs for emergency use on military personnel and others in harm's way. The bill is in conference committee with final language expected as early as this week. FDA currently has sole authority to authorize drugs and devices for emergency use.