News From ACFAS

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Three candidates have been recommended by the Nominating Committee for two vacancies on the ACFAS Board of Directors: Michael Cornelison, DPM, FACFAS (Incumbent); Michael D. Vaardahl, DPM, FACFAS; and Eric G. Walter, DPM, FACFAS. One candidate has been nominated by petition: Brian B. Carpenter, DPM, FACFAS.

Candidate profiles and position statements are now viewable at acfas.org/nominations. Electronic voting will be conducted November 30–December 17. Watch This Week @ ACFAS for balloting details over the next month. Early birds, don’t let exclusive savings on your ACFAS 2019 registration fee sail away like a steamboat on the Mississippi! Register before December 12, 2018 to receive a reduced rate on the year’s biggest educational event for foot and ankle surgeons.

Set for February 14–17, 2019 at the Ernest N. Morial Convention Center in New Orleans, ACFAS 2019 will bring you everything you have come to expect from the Annual Scientific Conference, plus a new lineup of preconference workshops and our first-ever Residents’ Day on February 13.

Visit acfas.org/neworleans to register now and be part of something spectacular! The Residency Directors Forum will be back in 2019 with a focus on best practices in resident education and learning. This year’s Forum will be held in advance of ACFAS 2019 in New Orleans on Wednesday, February 13 from 1:30–5:30pm and is cohosted by the Council of Teaching Hospitals (COTH).

The Forum will provide time for open Q&A with all of the residency-related organizations, including AACPM, PRR, COTH, CPME, ABFAS, ABPM and ACFAS. New this year: the Forum will offer attendees 2.5 CME hours.

Forum sessions will include:

• CPME and ACGME: Sharing Best Practices in Resident Education
• Slaying the Three-Headed Monster: Patient Safety, Physician Well-Being and Resident Remediation
• Research: The Next Frontier
• Get on Board! Preparing Your Residents for In-Training Exams and How This Correlates with ABFAS Board Qualification Rates
• Mix It Up Like Jambalaya: Organizational Oversight Updates

Residency program directors, codirectors and faculty are invited to attend, with up to two attendees per program. School deans are also invited.

Visit acfas.org for further details and to register. Need holiday gift ideas for your colleagues, friends or office staff? Head to the ACFAS Logo Store and get inspired!

Browse through shirts, jackets, pullovers and scrubs in a wide range of colors and sizes, drinkwear, pens and other items perfect for even the pickiest person on your shopping list.

Place your order by Monday, December 3 to ensure you receive your shipment before the holidays. Visit acfas.org/logostore now to shop the full collection of ACFAS-branded merchandise.

Foot and Ankle Surgery

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The purpose of this study was to analyze the characteristics, treatment and local recurrence of chondroblastoma (CB) of the foot at a single institution. A total of 40 patients were diagnosed and treated for CB of the foot from 1975 to 2012. The mean follow-up visit was 55 months. The main symptom was pain (100 percent) accompanied by swelling (35 percent), with median duration of 12 months. The talus (50 percent) and calcaneus (37.5 percent) were the most affected bones. All patients underwent surgery, which included 10 cases of curettage, 15 cases of curettage and bone graft, 13 cases of curettage and cement, one case of wide resection and one case of Chopart amputation. Ten patients had secondary aneurysmal bone cyst, and one patient had local recurrence after surgery. The researchers concluded that patients with CB of the foot are typically older than 20 years and that males are most affected. The hindfoot is the most affected area. Surgical treatment is required, and intralesional curettage and packing with cement or graft is curative in most cases. Local recurrence in the foot is lower than in other locations.


A study involving 122 consecutive patients who underwent a calcaneal osteotomy for hindfoot realignment treatment was conducted to compare the effectiveness of traditional open incision and percutaneous techniques. Fifty-eight patients had procedures using an open incision technique and 64 patients, or 66 feet, underwent percutaneous surgery. Clinical and radiologic assessments were performed preoperatively at six weeks and at 12 months postoperatively. Both groups showed postoperative improvement in American Orthopaedic Foot and Ankle Society scale scores and visual analog scale pain scores, with the difference between cohorts rated as insignificant. Outcomes of the radiologic measurements pre- and postoperatively were not significantly different, and no pseudarthrosis transpired in either group. Comparison also identified a significantly lower risk for wound healing problems in the percutaneous group, as well as a significantly shorter period of hospitalization.


A retrospective review of 121 patients with ankle fractures treated via open reduction internal fixation (ORIF) was conducted, with 58 undergoing follow-up of at least 24 months. Time between injury and surgery greater than 14 days was categorized as "delayed." Demographic variables, injury characteristics, length of surgery and postoperative stay were recorded. Comparison of demographic variables, wound complications and functional outcome ascertained by Foot and Ankle Outcome Score (FAOS) was performed.

The duration between injury and surgery was six days in the "early" cohort and 19 days in the "delayed" cohort. No significant differences in demographic variables, injury characteristics and length of surgery were observed between the groups. Wound complications in the early and delayed groups were 5 percent and 11.8 percent, although this difference was statistically insignificant. Among 58 patients who had a follow-up of at least 24 months, the average follow-up time was 38 months. Each subscale of FAOS showed a significant difference. Ankle ORIF performed more than 14 days after injury did not significantly heighten the rate of wound complication, nor did it hinder ultimate functional outcome in this group.

Practice Management

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Key performance indicators (KPIs) can help practices spot revenue opportunities across all internal workflows and find useful data that might be hiding in practice management, revenue cycle management and electronic health record systems. Front desk staff must verify the eligibility of every single patient for every appointment and confirm how much of a patient's deductible has been met so they know how much to collect. Should a payer need authorization and fail to obtain it, the claim will be denied. Practices should examine their denial codes to see what percentage of denials are caused by a lack of authorization, correct them and change the behavior causing them.

Reviewing the cancellation rate also is valuable, with the practice assigning the appropriate reason for every visit to identify trends feeding into decreased productivity and lost revenue. Afterward, analysis can zero in on what behavior modification is necessary to decrease cancellations. The next KPI strategy is to reduce bill lag, with practices comparing the bill rate to the date of service to determine that lag. Practices should have denials be less than 2 percent of the claims that go out the door. The first pass resolution rate, in addition to denial percentages, is an important KPI for boosting revenue. Finally, practices ought to reduce days in accounts receivable.


As health systems continue to acquire physician practices, providers are seeking fully integrated, customizable electronic health records (EHRs) and practice management (PM) and revenue cycle management (RCM) systems to help them succeed under value-based care. In a new Black Book Market Research survey, 36 percent of hospital leaders said finding a high-performing integrated EHR, PM and RCM is a top priority. Among large hospital systems, 40 percent said their organizations are budgeting to replace existing patchwork systems with consolidated and integrated ambulatory technologies compatible with their EHRs and RCMs, with a goal of having the new systems in place by the end of 2020. In addition, 80 percent of integrated delivery network executives said aligning hospital and physician IT supports value-based care models. Nine out of 10 hospital execs believe nonintegrated EHRs and PM systems undermine those goals.

"With over 50 percent of U.S. doctors receiving their pay directly or indirectly from a hospital system organization, CFOs and CIOs are seeing the value-based care model potential, reimbursement improvements and resources expenditure savings to be gained by implementing a fully integrated healthcare information technology system," said Doug Brown, managing partner of Black Book Research. A recent Physicians Foundation survey also suggests that better integrating hospital and practice IT systems could increase satisfaction and lead to better cost and patient outcomes.


Electronic health records (EHRs) can be optimized for combined clinical decision making and operational effectiveness by following seven tips, starting with conducting clinical end user interviews. Having a solid comprehension of providers' perception of how the system functions is a good beginning before studying the specifics of system use, workflows, information storage and providers' direct system interactions. The second step involves assessing data collection processes because guaranteeing the workflow enables the provider's view of data aggregation. This is also closely linked to monitoring providers interacting with the system.

The third practice requires the performance of usability studies. For clinical optimization post evaluation, the practice should look for documentation points where data should be switched from either discrete to free form or vice versa. The next steps are designed to optimize EHRs financially, beginning with compiling a list of authorization numbers per major health plan. Afterward, the practice needs to ensure consistent copay collection, and then it must conduct assessments on common claim denials. Finally, data from the EHR should be harnessed to reduce the charge entry lag time.

Health Policy and Reimbursement

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Republicans are working to push through some key healthcare measures during the lame-duck session of Congress, which include drugmaker contributions to the Medicare Part D "doughnut hole," the CREATES Act and the medical device tax. Yet Democrats, who are poised to take over the House, have little incentive to help them out. Congress could advance these initiatives by including them in a must-pass government funding bill, but lobbyists say they are pessimistic that anything substantial will happen.

Three health policy initiatives are worth paying attention to. First, drugmakers are fighting part of a February spending bill that requires them to give deeper discounts to Medicare enrollees whose spending on drugs is high enough to reach a coverage gap known as the "doughnut hole." The discount is currently 50 percent for brand-name drugs but is set to increase to 70 percent next year. Lawmakers are also discussing passing the CREATES Act, which has unusually strong bipartisan support. The bill would allow generic drug developers to sue branded pharmaceutical companies for failing to provide them with samples needed for testing. Legislators have proposed passing this measure as a way to get Democrats on board with making the doughnut-hole fix that drugmakers desire.

Another point of discussion is the medical device tax, which the device industry is fighting to repeal. The 2.3 percent sales tax was included in the Affordable Care Act as a way to help pay for its insurance subsidies, but Congress has delayed its implementation until 2020. Because that is still a year away, the long timeline might remove a sense of urgency that could otherwise push Congress to repeal it.


Rep. Frank Pallone Jr. (D-N.J.), who is set to become the next chair of the House Energy and Commerce Committee, said his top priorities in his role overseeing drug prices are permitting Medicare to negotiate prices and accelerating the approval of cheaper generic drugs. Pallone cited President Trump's support for those two policies in expressing hope for a bipartisan deal. Trump has previously backed letting Medicare negotiate drug prices, a top Democratic priority, but has since backed off the idea. Democrats are hoping to get him back on board and they see drug prices as an area of potential bipartisan cooperation.

Pallone also mentioned bipartisan legislation called the Creates Act that would crack down on stalling tactics used by drug companies to prevent cheaper generic competition from entering the market. That bill has been delayed all year despite support from members of both parties. House Democrats say drug pricing legislation will be one of their top priorities next year in the majority. They are hopeful that if Trump supports legislation, he can help get it through the GOP-controlled Senate. Passing drug pricing legislation would be an uphill climb given the clout of pharmaceutical companies in Washington.


U.S. Department of Health and Human Service Secretary Alex Azar announced in a recent address that Medicaid may soon permit hospitals and health systems to directly pay for housing, healthy food or other solutions for the "whole person." He noted that U.S. Center for Medicare and Medicaid (CMS) Innovation officials are seeking to move beyond current initiatives to partner with social services groups and to try to manage social determinants of health as they see appropriate.

"We believe we could spend less money on healthcare—and, most importantly, help Americans live healthier lives—if we did a better job of aligning federal health investments with our investments in non-healthcare needs," Azar said. CMS has approved pilots for housing relating services through Medicaid in California, Illinois, Minnesota and New York, but none of them covers rent due to federal prohibition, said the U.S. Center on Budget and Policy Priorities' Peggy Bailey. "Paying for these services on a wider scale would be breaking new ground for sure," she concluded.

Medicine, Drugs and Devices

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The U.S. Centers for Medicare and Medicaid Services' (CMS) 2019 final payment rule for hospital outpatient surgery departments and ambulatory surgical centers (ASCs) included an average 2.1 percent reimbursement rate increase per procedure for ASCs, as well as a new code for nonopioid pain management drugs. CMS will now make separate payments for nonopioid pain management drugs for ASCs. The only HCPCS code falling into this category is Exparel, from Pacira Pharmaceuticals, which will now receive separate payment when used in the ASC.

"Current payment policy serves as an impediment to using nonopioids for post-surgical pain, so this provision addresses our concerns by allowing ASCs to get paid for nonopioid pain relief drugs when used in a surgical procedure," said ASCA CEO William Prentice in response to the proposed payment update in August. Prior to the final rule's release, Aetna expanded coverage for Exparel to select ASCs in Florida and New Jersey on October 30. The pilot program will reimburse for physicians who use nonopioid therapy for postsurgical pain management at ASCs. The company began reimbursing for Exparel in 2017 for select impacted wisdom tooth instructions. The payer also updated its online provider directory to identify surgeons who are trained to administer Exparel.


A study has assessed nitric oxide's foot-ulcer healing efficacy under diabetic and normal conditions in human dermal fibroblast cells. The researchers have built a nitric oxide-measuring device in partnership with Zysense to produce commercial nitric oxide measurement devices that would enhance their research. To construct a nitric oxide bandage with personalized healing power, the team plans to work with the UP Portage Health System to collect cell samples from local patients. By increasing their cell samples and using the technology on real-world patients, the researchers will continue to expand their database as well as their knowledge of nitric oxide mechanisms. The working bandage prototype would eliminate the cumbersome nitrite proxies and nitric oxide dumps, enabling people with diabetic foot ulcers to heal much faster than six months or more.


A systematic review looked at the occurrence of medication mistakes in the context of general anesthesia, which have been reported more frequently in the last two decades. The researchers examined 31 narrative reviews and 20 case studies and found that errors related to the preparation, dosing, administration or substitution of a drug are most common, while the biggest culprits are narcotic medications, vasopressors and antibiotics. The medical repercussions include potential adverse events, significant adverse events, serious adverse events and potentially fatal adverse events. The investigators also discovered correlations between specific medications and certain types of errors. Substitution missteps, for example, seem to plague phenylephrine, while administration and preparation mistakes often come into play with narcotics.

"It's insightful to know that different types of errors can happen in different ways, depending on the type of medication in question," says lead researcher Amir Abrishami, MD, an assistant professor of anesthesia at Canada's McMaster University. "This kind of information can help us develop strategies to deal with these issues." Ultimately, he hopes, medication errors can be mitigated for patients undergoing anesthesia. "My next step would be looking at clinical review articles on strategies to reduce medication errors and see how effective they are," he speculates. "The answer could lie in electronic dispensing machines, double-checking strategies or coming up with a checklist system."