November 28, 2018 | | JFAS | Contact Us

News From ACFAS

Residents' Day: Stuff Your Residency Director Can’t Tell You
Residents, want to be a rock star as you transition from residency to practice? Then come to our first-ever Residents' Day on Wednesday, February 13, 2019 before ACFAS 2019 kicks off in New Orleans!

Experienced foot and ankle surgeons will share inside tips on everything from interview preparation to hospital privileging to managing difficult cases. Also learn how to decide which practice option is the best fit for you and how to make the most of those first five years. Lunch plus an informal networking event with open Q&A are included.

Visit to view the full agenda and to register now.
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Sign Up for Media Training at ACFAS 2019
A little media savvy can go a long way in helping you promote your practice. Learn PR basics plus how to speak to the media on behalf of the College during a free, formal training program held at ACFAS 2019, February 14–17 in New Orleans.

Your personalized one-hour training session with a professional media trainer will include:
  • One-on-one media training
  • On-camera training with feedback
  • ACFAS media training tips
Slots are limited, so reserve your session now by contacting Melissa Matusek, ACFAS director of Marketing and Communications, at
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Foot and Ankle Surgery

Hallux Valgus Correction with Rotational Scarf Combined with Adductor Hallucis Tendon Transposition
A prospective cohort study was conducted to gauge the effectiveness of treating patients with hallux valgus and to compare the outcomes of innovative and standard surgeries. Data was analyzed on 78 patients with hallux valgus treated surgically between March 2010 and December 2015 using either an innovative method, which included rotational scarf osteotomy with bone fragment impaction and adductor hallucis tendon reinsertion, or classical scarf osteotomy. X-ray examination was conducted preoperatively and three and 36 months afterward. Comparative analysis of the outcomes revealed no significant difference in mean radiographic data between the two cohorts preoperatively and three months following surgery. However, the mean intermetatarsal angle 36 months post surgery in standard and innovative groups was 9.7 plus or minus 0.7 degrees and 9.0 plus or minus 0.8 degrees, while the mean metatarsophalangeal angle was 13.6 plus or minus 0.9 degrees and 13.2 plus or minus 1.1 degrees, respectively.

From the article of the same title
Journal of Foot & Ankle Surgery (11/15/18) Boychenko, Anton V.; Solomin, Leonid N.; Belokrylova, Maria S.; et al.
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Sodium Glucose Cotransporter 2 Inhibitors and Risk of Serious Adverse Events: Nationwide Register-Based Cohort Study
An observational study of nearly 35,000 Scandinavian patients with type 2 diabetes (T2D) has found sodium-glucose cotransporter 2 (SGLT2) inhibitors, a class of prescription drugs used to lower blood sugar in adults with T2D, may almost double patients' risks of lower-limb amputation and diabetic ketoacidosis compared to glucagon-like peptide 1 (GLP1) receptor agonists. Researchers evaluated the potential risks of the drug class by comparing data from 17,213 patients living with diabetes in Sweden and Denmark who had just started taking SGLT2 inhibitors to that of 17,213 patients living with diabetes and taking GLP1 receptor agonists. The researchers looked for outcomes that included limb amputation, bone fracture, ketoacidosis, acute kidney injury, urinary tract infection and venous thromboembolism during an average 270 day follow-up period. After adjusting for factors like disease history, socioeconomic status and other medications, the team found that the use of SGLT2 inhibitors was associated with a twofold increased risk of both lower-limb amputation and diabetic ketoacidosis compared to GLP1 receptor agonists. No significant link was found between SGLT2 inhibitors and elevated risk for bone fracture, acute kidney injury, serious UTI, thromboembolism or acute pancreatitis.

From the article of the same title
The BMJ (11/14/2018) Ueda, Peter; Svanström, Henrik; Melbye, Mads; et al.
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Comparison of Arthroscopic to Open Tibiotalocalcaneal Arthrodesis in High-Risk Patients
The purpose of this study was to compare the complication rates of open versus arthroscopic tibiotalocalcaneal arthrodesis (TTCA) in high-risk patients. A total of eight open and 15 arthroscopic TTCAs were included. Three open and four arthroscopic TTCAs presented preoperative plantar ulceration. Fusion rates were similar (75 percent versus 67 percent). Major complications occurred in 63 percent of open [80 percent surgical site infections (SSI)] and 33 percent of arthroscopic (100 percent nonunions) TTCA. Preoperative plantar ulceration did not affect major SSI in open TTCA (67 percent versus 60 percent) but resulted in a significant increase of nonunion rates for arthroscopic TTCA (75 percent versus 18 percent. In patients without plantar ulceration, the union rate was 80 percent for both open and arthroscopic TTCA. The researchers concluded that arthroscopic TTCA significantly reduced major SSI and that patients without preexisting ulceration had excellent union rates for open and arthroscopic TTCA.

From the article of the same title
Foot and Ankle Surgery (11/05/18) Baumbach, Sebastian Felix; Massen, Felix Kurt; Hörterer, Severin; et al.
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Practice Management

'I Had Not Kept Up': A Physician Reeducation Story
With five decades of experience under his belt, San Diego physician Jeoffry Gordon, MD, long prided himself on being able to treat his patients without referring them out. But he came under criticism for his prescribing practices this summer after one of his pain patients was hospitalized with a heroin overdose. Following a period of anger and embarrassment, Gordon accepted his director's suggestion that he go through Physician Assessment and Clinical Education (PACE), a set of physician reeducation classes offered by the University of California San Diego (UCSD). He found it worth his time and the $3,000-plus cost.

"Treatment protocols have evolved," Gordon said. "But I had not kept up." He found that the course leaders treated the students with dignity and respect, and the atmosphere was educational rather than punitive. Among other things, he learned not to give the same patient benzodiazepines and opioids simultaneously because they are both respiratory depressants. He also learned how his recordkeeping could be improved to document not just the multiple diagnoses and drugs for each patient, but to be precise about his assessment and treatment plan. "I generally went to both classes thinking I was more knowledgeable than most about hustling patients, proper charting and regulatory oversight," he said. "I was wrong on all counts."

Going forward, Gordon does not feel he should be taking care of chronic pain. "I feel compelled, given all the information in this class, to refer them to pain management, or psychiatry, or somebody else." He added, "I will recommend that my managers develop a competent team within our clinic for pain management, or my clinic should designate a specialist to see them all."

From the article of the same title
MedPage Today (11/02/18) Clark, Cheryl
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Coding Changes in the New Year
Portions of the "Patients Over Paperwork" initiative will go into effect at the beginning of 2019. Bill Dacey of The Dacey Group, Inc., a consulting firm dedicated to coding, billing, documentation and compliance concerns for physicians, helps clarify just how reduced some of the history documentation will be. According to the U.S. Centers for Medicare and Medicaid Services announcement on November 1, for established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not rerecord the defined list of required elements if evidence exists that the practitioner reviewed the previous information and updated it as needed. Dacey notes it may be prudent to not change much for the time being. In addition, Medicare is requiring these changes, while commercial payers still follow either the American Medical Association's CPT E/M guidelines, federal guidelines or some combination of these.

Another issue is whether to time stamp progress notes to support Medicare's time-based billing purposes. Dacey says for overall E/M coding by time purposes, a statement recording the time spent on the visit with the percent of face-to-face "counseling/coordinating" care is sufficient. However, Medicare has specified that for "prolonged service" codes 99354 and 99355, the time in and out—or actual times spent in that activity—must be documented. Dacey says he would apply this to 99358 as well. Medicare's changes to the outpatient E/M codes will affect the way time-based coding is documented starting in 2021.

From the article of the same title
Physicians Practice (11/12/18) Dacey, Bill
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Burnout Plagues One in Three Residency Program Directors
In 2016, a third of medicine residency directors were burned out and roughly half had considered resigning in the preceding year, according to a recent study published in the American Journal of Medicine. Residency director burnout and turnover have negative consequences ranging from lower educational program effectiveness to long-term negative effects on physicians in training. "Turnover of a residency program director affects not just the physician and clinical practice, but the residency program and residents in it. Over the past two decades, the proportion of program directors in the role three or fewer years has ranged from one third to one half; since 2009, the median tenure of an internal medicine program director has ranged from four to six years," researchers wrote.

For residency program directors, the level of support from department chairs and hospital leaders is likely a significant contributor to burnout, said Alec O'Connor, MD, MPH, the study's lead author. "Ultimately, if the program director feels like he or she has to fight with the department chair every time a critical issue has to be addressed—and loses some or all of these critical issue fights—then frustration and feelings of being put into an impossible position will outstrip feelings of accomplishment, leading to burnout and resignation," O'Connor said. Maintaining time for residents to pursue academics can also be a draining challenge for residency program directors, he said. O'Connor suggested that mentoring new program directors could be helpful in reducing burnout. Mentoring efforts could ease navigation of stressful duties, such as dealing with a struggling resident as well as striking a healthy balance between work and home life, he said.

From the article of the same title
HealthLeaders Media (11/23/18) Cheney, Christopher
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Health Policy and Reimbursement

CMS Tells Congress Federal Law Inhibits Use of Telehealth for Seniors
Laws regulating telehealth restrict it as a healthcare option, the U.S. Centers for Medicare and Medicaid Services (CMS) informed Congress in a recent report. Under the 21st Century Cures Act, Congress mandated that CMS compile a report on the number of Medicare enrollees using telehealth services. It also asked about barriers to expanded use, but it did not seek any suggestions on how to fix those legislative barriers. Medicare currently pays for telehealth services only if the beneficiary is in a rural area with a shortage of health professionals or in a county outside of a metropolitan area. It also places limits around which providers can bill for such services. Those provisions are "the greatest barriers to expansion of Medicare telehealth," the agency said.

Nearly 90,000 Medicare beneficiaries, or just 0.25 percent of all fee-for-service Medicare beneficiaries, used telehealth services in 2016. Telehealth could play an important role in achieving quality goals under value-based models if federal laws were amended, according to CMS. "Emerging evidence indicates that telehealth can be a tool for empowering healthcare providers and patients to offer the best approaches to care," CMS said in the report. Many patients face long waits to see a provider, and telehealth could be a way of improving that trend.

From the article of the same title
Medscape (11/15/18) Dickson, Virgil
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Politics Could Drive 2019 Congressional Action on Rural Health
Advocates hope that House Democrats and Senate Republicans see strengthening rural healthcare access as a key area for bipartisan action in Congress next year. They say moves to stabilize embattled rural hospitals and offer communities alternative payment and delivery models could be smart politics for both parties, as well as for President Donald Trump, heading into the 2020 elections.

Several bipartisan rural health bills in the Senate and House went nowhere this year, despite the steadily rising number of rural hospital closures. While rural health long has been a second-tier issue in Congress, legislative action to address it could prove an easier and less risky political lift than tackling contentious top-tier issues, such as reducing prescription drug costs and stabilizing the Affordable Care Act insurance markets. One reason advocates are cautiously upbeat for action next year is that Republican Sen. Chuck Grassley of Iowa will become chair of the powerful Senate Finance Committee in January. His bipartisan bill, the Rural Emergency Acute Care Hospital Act, would let small rural hospitals continue to receive Medicare payments if they dropped inpatient care and shifted to providing only emergency and outpatient services on a 24/7 basis.

Instead of waiting for legislation, Congress could also nudge federal agencies to take helpful steps. For instance, the U.S. Federal Communications Commission could expand broadband in rural areas to promote telehealth services. In addition, the U.S. Centers for Medicare and Medicaid Services and the U.S. Center for Medicare and Medicaid Innovation could launch rural demonstrations to promote accountable care organizations and improved information technology.

From the article of the same title
Modern Healthcare (11/21/18) Meyer, Harris
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Sanders Unveils Aggressive New Bill Targeting Drug Prices
Sen. Bernie Sanders (I-VT) and Rep. Ro Khanna (D-CA) have introduced legislation aimed at aggressively slashing drug prices by stripping monopolies from drug companies if their prices are deemed excessive. The bill would strip the monopoly from a company, regardless of any patents, and allow other companies to create cheaper generic versions of a drug if the price for that drug is higher than the median price in Canada, the United Kingdom, Germany, France and Japan. "No other country allows pharmaceutical companies to charge any price they want for any reason they want," Sanders said. Drug companies argue that other countries, with price controls, lack the innovation that exists in the United States. The measure does not have a clear path forward in the next two years given that Republicans will still control the Senate.

From the article of the same title
The Hill (11/21/18) Sullivan, Peter
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Medicine, Drugs and Devices

Ulcers From Diabetes? New Shoe Insole Could Provide Healing On the Go
A new shoe insole is being explored to determine its efficacy in healing diabetic foot ulcers. Purdue University researchers used lasers to sculpt silicone-based rubber into insoles and then produce reservoirs that release oxygen only at the part of the foot where the ulcer is located. In simulation, the insole can deliver oxygen at least eight hours daily under the pressure of a wearer weighing about 53 to 81 kilograms. The insole can also be tailored to bear any weight. The team suggests a manufacturer could send a patient a pack of prefilled insoles customized to their wound site, based on a "wound profile" gained from a doctor's prescription and an image of the foot.

From the article of the same title
Medical Xpress (11/15/18)
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Amazon Expands Catalog of HIPAA-Eligible AI Services
Amazon's cloud business, Amazon Web Services (AWS), recently announced that three of its most popular services—Amazon Translate, Amazon Comprehend and Amazon Transcribe—are now HIPAA-eligible. These services allow entities that are subject to HIPAA to use the secure AWS environment to process, maintain and store protected health information. The trio brings the number of HIPAA-eligible AWS machine learning services up to six, after Amazon Polly, Amazon SageMaker and Amazon Rekognition. The move marks Amazon's latest effort to be more relevant to healthcare workers and comes as it expands its footprint in healthcare. The company recently secured a patent for a feature that would enable Alexa, Amazon's voice-activated technology, to detect when a user is sick and suggest an over-the-counter remedy.

Natural language processing and accurate transcription are currently top priorities for doctors. According to a Medscape survey, 70 percent of physicians feel burned out, depressed or both as a result of increasing administrative burdens. A number of tech firms are seeking to address that space with new tools. For example, Google is searching for talent in voice technology with the aim of improving the doctor-patient experience. Meanwhile, Epic partnered with Nuance Communications to leverage voice assistance technology in electronic health records. Doctors using the systems will be able to retrieve schedules, call up patient information and check lab results and medication lists.

From the article of the same title
Healthcare Dive (11/12/18) Bryant, Meg
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Medical Device Safety Action Plan: FDA Sets Measure of Success Amid Funding Issues
The U.S. Food and Drug Administration (FDA) has updated its medical device safety action plan with "an important and ambitious new goal" and explained the path forward for its planned nationwide device surveillance system. The new goal to propel the safety action plan—released in April—is centered around ensuring that the agency is "consistently first among the world's regulatory agencies to identify and act upon safety signals related to medical devices," FDA Commissioner Scott Gottlieb and Center for Devices and Radiological Health (CDRH) Director Jeff Shuren said.

The agency prioritized regulatory reforms to shift away from a passive approach toward an active surveillance system as it has come under growing pressure to reform its postmarket oversight approach. Gottlieb and Shuren said "delivering on the goal to be first in the world to consistently identify and act on medical device safety signals will rest in part" on whether the agency is able to "fully leverage" the intended benefits of the currently underdeveloped National Evaluation System for Health Technology (NEST) and resolve the funding issues that could hamper its success. "Funding is the principal barrier to establishing this system," Gottlieb and Shuren said. A total of $46 million was requested under the president's budget for fiscal year 2019 in support of NEST's development and related postmarket studies to tackle device-specific safety concerns.

The agency has already seen improvements in manufacturers' readiness in submitting clinical evidence and answering postmarket questions that would have been difficult to address in the past, according to Gottlieb and Shuren.

From the article of the same title
Regulatory Focus (11/20/2018) Mulero, Ana
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This Week @ ACFAS
Content Reviewers

Brian B. Carpenter, DPM, FACFAS

Caroline R. Kiser, DPM, AACFAS

Britton S. Plemmons, DPM, AACFAS

Gregory P. Still, DPM, 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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