News From ACFAS

---

Tomorrow, all eligible voters will receive an e-mail with special ID information and a link to the election website. After logging in, members will first see the candidate biographies and position statements, followed by the actual ballot, pursuant to the bylaws. Eligible voters without an e-mail address will receive paper instructions on how to log in to the election website and vote. There will be no paper ballots.

Please feel free to review the nominees' profiles before voting. Are you a coding expert? ACFAS is seeking members with coding expertise who are interested in providing coding advice and guidance to ACFAS members. The individuals sought may provide answers to coding questions, speak at coding courses or serve as a consultant to ACFAS. If you are interested in learning more about this opportunity or if you have any questions, please contact ACFAS’ Director of Health Policy, Practice Advocacy and Research, Dawn Brennaman, via email at dawn.brennaman@acfas.org or phone (773) 444-1322. Listen to this free podcast to hear five bright minds from ACFAS come together to discuss and debate their methods for diagnosing and treating osteomyelitis. Not every method is the same; hear how these foot and ankle surgeons differ in their strategies, from testing to reconstruction. Some of the topics discussed include:

• Opinions on the most clinically effective and cost-effective lab and diagnostic testing
• The use of and reasons for MRI
• Are bone biopsies still considered the clinical “gold standard” in diagnosis?
• Dealing with infectious disease specialists: understanding their concerns and helping them understand yours
• Using beads to locally treat infection – in what circumstances would you use them and how?
• Debate on debridement

Visit acfas.org to tune in to this free podcast and perhaps you’ll consider practicing new tactics you’ve never done before! These days, patients have the ability to review your practice online in a matter of minutes. Join ACFAS tonight for a complimentary practice management webinar, Improving Your Reputation: How to Defend against Bad Online Reviews. ACFAS and our benefits partner Officite will teach you take control of the way patients view your practice online. You will learn how to proactively monitor your online image and encourage positive reviews from patients, as well as how to leverage mobile technology to acquire reviews before the patients even leave the office, and more!

If you’ve been too busy to register, you still have time. Register now to reserve your seat and participate in this free, 45 minute webinar tonight at 8pm CST to learn how to be one step ahead in managing your practice’s reputation.

Foot and Ankle Surgery

---

It has been demonstrated that intravenous prostacyclin and bisphosphonates can help achieve a reduction in bone-marrow oedema (BME) with a significant improvement in the attendant symptoms, and researchers compared the results of both intravenously applied prostacyclin and bisphosphonate in treatment of BME of the knee and foot, in 20 patients evenly divided into two groups. A substantial improvement of WOMAC score, SF-36 score and VAS three months and one year following intervention was evident in both the prostacyclin and the bisphosphonate groups. Magnetic resonance imaging scans identified a distinct reduction of BME in 47 percent of cases and a full regression in 40 percent. Although improvement of the scores was higher in the prostacyclin group than in the bisphosphonate group, the difference was insignificant.


Researchers have conducted a study to evaluate the outcome and preoperative risk factors of the diabetic foot reconstructed with free flaps. The study included a review of 121 cases of reconstructed diabetic feet in 113 patients, aged 26 to 78 years. Free flaps used included anterolateral thigh, superficial circumflex iliac artery perforator, anteromedial thigh, upper medial thigh, and other perforator free flaps. Ten cases involved total loss and 111 free-tissue transfers were successful, with a flap survival rate of 91.7 percent. Limb was eventually lost in 17 patients, with an overall limb salvage rate of 84.9 percent and a five-year survival rate of 86.8 percent. Preoperative risk factors for flap loss included a history of previous angioplasty, peripheral arterial disease, and taking immunosuppressive agents.


Cellular allograft with mesenchymal stem cells is becoming more popular for augmenting foot and ankle arthrodesis. Patients with underlying comorbidities -- such as diabetes, Charcot osteoarthropathy, suppressive medication, or higher body-mass index -- may be more likely to require surgical revision procedures, with a greater rate of nonunion compared to counterparts without such comorbidities. Researchers conducted a study to determine if use of a mesenchymal stem cell graft will make a successful fusion during the primary procedure more likely. Investigators reviewed the use of stem cell grafting in hindfoot and ankle surgery and the healing times in high-risk patients. Successful fusion was defined as bridging across three cortices. For these patients, average interval to radiologic union was 11.1 weeks. Interval to partial weightbearing was an average of 5.5 weeks, to full weightbearing was 8.4 weeks on average, and to shoe wearing was about 13.6 weeks.


Researchers recently completed a study to provide more data on the mechanical strength of fifth metatarsal osteotomies. The study mechanically tested five osteotomies to failure using a materials testing machine, comparing them with an intact fifth metatarsal using a hollow saw bone model with a sample size of 10 for each construct. Tested osteotomies were the distal reverse chevron fixated with a Kirschner wire, the long plantar reverse chevron osteotomy fixated with two screws, a mid-diaphyseal sagittal plane osteotomy with two screws, and an additional cerclage wire and a transverse closing wedge osteotomy fixated with a box wire technique. Analysis found a statistically significant difference among the data. The chevron was statistically the strongest construct at 130 N, then the long plantar osteotomy at 78 N. The chevron compared well with the control at 114 N; both fractured at the proximal model to fixture interface. The other osteotomies were significantly weaker, and had no statistically significant difference among them at 36, 39, and 48 N. Researchers concluded that the chevron osteotomy was superior in strength to the sagittal and transverse plane osteotomies and similar to the intact model.

Practice Management

---

Baylor College of Medicine Professor Bryan Vartabedian notes that physicians "are being completely redefined" by forces that include social media. A 2011 survey by the American College of Surgeons estimated that 20 percent of surgeons were using Twitter. "Half of those surgeons were using it only rarely, which you and I know means they weren't using it at all," Vartabedian says. The survey did not show what kind of information was being circulated. Vartbedian points to the growing difficulty for physicians to keep their personal and professional lives separate online because of the spread and popularity of social media. "When we think about social media, and when your institution talks to you about social media, almost invariably it will be viewed from the perspective of risk," he observes. "All we see is the risk associated with it, and all your orientation and your programs, everything will center on risk and nothing will center on opportunity."


A majority of Americans looking up health information online are no longer merely researching symptoms. Instead, they are going online to determine which physicians to see, what treatment to get, and what services a hospital or pharmacy might provide. According to Manhattan Research, which surveyed 5,210 adults who use the Internet as a health resource, 54 percent of respondents said they did online research to decide what services they might need and who should provide them. The findings reflect the trend of people becoming more comfortable with using the Internet for other aspects of their life and the natural progression they have made to using it for health-related decisions, according to Maureen Malloy, senior research analyst for Manhattan Research.

Physicians may need to put more effort into beefing up their online presence so they can have greater control over it, allowing them to communicate who they are and what they do. Howard Luks, MD, an orthopaedic surgeon in Hawthorne, N.Y., who consults on digital media and medicine issues, says physicians who are not managing their online presence are missing out on attracting new patients. "People want to trust you as a person," he said. "They are going to pick you over the best hospital in the country because of the way you humanize your existence and your presence using tools like YouTube or Vimeo or a simple webcam."


Some healthcare centers now use palm vein pattern recognition to identify and manage patients more effectively. However, some consumer advocates suggest that it could violate patients' privacy for the sake of convenience, suggesting that vein patterns should be treated with the same care as other genetic samples. New York University Langone Medical Center began implementing biometric systems to address problems such as similar names among multiple patients and multiple records among different affiliates for the same patient. The center added photography and palm-scan technology to give each patient two unique identifying features, using the system PatientSecure, marketed by HT Systems of Tampa. However, the concern with privacy advocates is that the center does not have formal consent, and does not inform patients that they can opt out of the photos and scans. NYU Medical Center recently experienced losses or thefts of devices that contained unencrypted patient data. However, the palm scan system turns vein measurements into encrypted binary numbers for storage on a separate NYU server. Whether or not a medical center obtains patient consent or not, some experts see little current value in using patient palm scans, unless they also enhance patient privacy.


Several major academic medical centers have been fairly successful collecting electronic patient-reported data to help manage care and improve outcomes, but they still struggle to integrate the information with clinical information systems and physician workflow. Such data can automate patient check in, assist with triage, lessen waiting time and get at health issues that might otherwise have gone unnoticed. "The patient is the gold standard for reporting," said Dr. Deborah Miller, a social worker in the Mellen Center for Multiple Sclerosis Treatment and Research at the Cleveland Clinic. The Cleveland Clinic has collected patient-reported outcomes (PRO) data on more than 720,500 patient visits since 2007, including upwards of 83,000 in its Epic MyChart patient portal, according to neurologist Dr. Irene Katzan, director of the clinic's Center for Outcomes Research and Evaluation. When patients arrive for appointments at several Cleveland Clinic departments, they enter information on tablets or on touchscreen kiosks in the waiting areas. The clinic uses the PRO data to provide insight into issues relevant to patients, to identify areas in need of quality improvement, for comparative effectiveness research and for showing outcomes. Cleveland Clinic has connected the PRO system, called Knowledge Program, with the Epic EHR through a Web-based interface. Others are not so far along. Claire Snyder, co-chair of the Cancer Outcomes and Health Services Research Interest Group at Johns Hopkins Bloomberg School of Public Health, helped develop a system called PatientViewpoint. "At its heart, PatientViewpoint is an electronic questionnaire delivery device," Snyder explained. It is similar to a form where physicians can order lists of patients with a specific range of laboratory values to participate in disease management programs and clinical trials. "It also helped us identify problems that otherwise might have gone unnoticed," Snyder added. "That's really what we're hoping to accomplish with PatientViewpoint." PRO studies have also been conducted with oncology patients at Mayo Clinic in Scottsdale, Ariz., who reported on their feelings before and after radiation treatment, and of a screening system at the University of Pittsburgh. Since 2003, the University of Pittsburgh Medical Center health system has used tablet computers to allow select patients to complete history forms electronically at check-in. The results go to a medical assistant in the exam room, who prints out an assessment for the physician.

Health Policy and Reimbursement

---

Co-chair of the House GOP Doctors Caucus Rep. Phil Gingrey (R-Ga.) expects Congress to pass a 12-month freeze in Medicare physician pay rates during the lame duck session. The pay rates are scheduled to be hit with a 27.5 percent cut on Jan. 1, and Gingrey promises that "during the lame duck, there will be a patch." He expresses confidence that Congress will be able to secure the $18 billion needed to compensate for the cost of a one-year payment freeze and suggests using savings from slashing programs included in a yearly report on wasteful government spending by Sen. Tom Coburn (R-Okla.). Gingrey says the 12-month sustainable growth-rate (SGR) formula patch will obtain congressional approval during the lame-duck session of Congress, irrespective of whether lawmakers furnish only a several-month freeze in other major spending reductions. Gingrey's caucus plans in 2013 to concentrate on finding a replacement to the SGR and a way to cover the $300 billion cost of permanently replacing it.


The Department of Health and Human Services (HHS) recently announced that Medicare Part B premiums will increase in 2013 while Part A premiums will decrease. The standard premium for Medicare Part B will rise 5 percent next year to $104.90, and the deductible for Part B services will total $147, a $7 hike from this year. In the meantime, premiums for Part A will decline $10 to $441 for 2013, and Part A deductibles will climb $28 to $1,184. The Centers for Medicare and Medicaid Services forecast earlier this year that Medicare Part B premiums would increase by more than $9 instead of by the $5 per month announced by HHS. The announcement should serve as a reminder to lawmakers during deficit-reduction negotiations that elderly and disabled persons already pay a substantial amount for healthcare, according to the Medicare Rights Center. "The average person with Medicare spends $4,500 for healthcare per year," reports Medicare Rights Center President Joe Baker. "In the last five years of life, beneficiaries spend an average of $38,688 per year, and for 25 percent of beneficiaries, out-of-pocket costs average $101,791 during this period." Baker concludes that "this harsh financial reality makes clear that any proposal to find savings in the Medicare program should not force people with Medicare to pay more for less health security."


U.S. Reps. Tom Price (R-Ga.) and Ron Kind (D-Wis.) on the House Ways and Means Health Subcommittee are advocating for the Department of Health and Human Services (HHS) to maintain a state-based structure for Quality Improvement Organization (QIO) contracts as HHS embarks on the deployment of QIO provisions included in a 2011 trade bill. In a letter to HHS Secretary Kathleen Sebelius, Price and Kind cited issues about the Medicare Quality Improvement program provisions bundled into the Trade Adjustment Assistance Reauthorization bill. Both lawmakers have co-sponsored legislation that would rescind the provisions of that bill and would guarantee that QIOs keep a state-based focus. The trade bill permits QIOs to be regional or even national, which proponents such as the American Health Quality Association say would undermine QIOs' working relationships with their local communities. "The trade bill permits a QIO's discrete functions (e.g., hospital and nursing home technical assistance, investigation of beneficiary complaints) to be broken up among different organizations instead of integrating the functions within one state-based QIO," wrote Price and Kind in their letter. "Improving quality requires a comprehensive and integrated approach—not a fragmented one—and this is best carried out by a single, locally focused organization."


Although the Affordable Care Act's repeal is unlikely thanks to President Barack Obama's reelection, there are still unresolved issues about implementation of coverage expansions and payment reforms for physicians, particularly when it comes to payment from both public and private payers. Analysis by Avalere Health projected that at least 20 states would be operating their own health insurance exchanges by 2014, with 13 states opting for partnership exchanges. Any state that does not select one of those options would default to a federal exchange. As states prepare to develop exchanges, plans moving into these marketplaces will seek to offer lower-cost options to consumers, notes consultant Laura Jacobs. Insurers that wish to keep spending down might move toward more restrictive networks of health professionals who will accept reduced negotiated pay rates. Jacobs says physicians must devise tactics on what health plans they want to participate in, whether they could accept lower rates and how they will manage collecting deductibles. Other major issues for physicians in the post-election environment concern Medicare's sustainable growth rate (SGR) formula and the law's Medicaid expansion. Primary care physicians will get higher rates starting next January for supplying primary care services to Medicaid patients, but not every physician is eligible for this pay hike, and physicians who see few Medicaid patients may be hesitant to take more since there is no assurance that Medicaid pay parity will continue. Meanwhile, physicians facing a substantial SGR cut on Jan. 1 will work to acquire a payment patch during the lame-duck congressional session.

Medicine, Drugs and Devices

---

A study was held that focused on 13 patients exhibiting distal tibial hypertrophic nonunion with angular deformity treated with fixator-assisted acute deformity correction and locking compression plate fixation. Five patients were originally treated by interlocking nail, three received plate and screws fixation, four received conservative treatment and one had deformity secondary to fracture of a lengthening regenerate. The healing of all osteotomies was completed within three months, and all patients were capable of work within an average of 2.3 months. The upper ankle joint exhibited unrestricted function in 12 cases, while a mild functional deficit was demonstrated in one case. Average follow-up was 60 months, and both frontal plane alignment parameters and sagittal alignment parameters were within normal values postoperatively. There was no observation of deep infection or fixation failure.