News From ACFAS

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Don’t miss out on the opportunity to help shape the future of your profession! Volunteer to serve as an ACFAS committee member, a Clinical Consensus Statement panelist or Scientific Literature reviewer for 2018. Visit acfas.org/volunteer to apply. Submit your application by Monday, December 18, 2017. Save on your registration fee for ACFAS 2018, March 22–25, 2018 in Nashville, by registering before the January 8, 2018 early bird deadline. The biggest annual conference for foot and ankle surgeons will descend upon Music City to bring you the very best in clinical and surgical education.

Don’t miss the cutting-edge sessions, hands-on workshops, networking and special events that play to sold-out crowds every year—register now at acfas.org/nashville. “‘A rising tide floats all boats’ means all of us benefit if DPMs in the VA receive equal pay,” said ACFAS President Laurence Rubin, DPM, FACFAS. “Please write your federal representatives in support of the proposed Caring for Our Veterans Act of 2017 (S. 2193).”

This bill would in part establish that DPMs appointed to the Veterans Health Administration would be eligible for supervisory positions to the same degree as a physician. It would also allow DPMs to practice to the full extent of their education and training, thereby giving veterans full access to providers who can adequately treat their foot and ankle injuries and conditions. ACFAS has also sent letters of support for S.2193.

Visit congress.gov for more information, and watch This Week @ ACFAS for updates as they become available.

Foot and Ankle Surgery

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A study that used weightbearing computed tomography (CT) and a three-dimensional (3D) analysis system was conducted to assess displacement of the intercuneiform 1-2 joint, intercuneiform 2-3 joint and second cuneonavicular joint due to weightbearing in hallux valgus and normal feet. Study participants included 11 women with hallux valgus and 11 women with normal feet. It was determined that relative to the medial cuneiform, the middle cuneiform was displaced by 0.1 and 0.8 degrees on account of dorsiflexion, 0.2 and 1.0 degrees because of inversion and 0.7 and 0.7 degrees due to abduction in normal feet and feet with hallux valgus, respectively, with the latter having significantly greater dorsiflexion and inversion. No significant intergroup difference at the intercuneiform 2-3 joint and second cuneonavicular joint was observed.


A study was conducted to compare the lower extremity mechanics of Achilles tendon (AT) ruptured runners with healthy controls, with 11 participants having history of an AT repair and 11 healthy controls matched on sex, age, type of regular physical activity, mass, height, footfall pattern and lateral dominancy. The chief outcome measures were lower extremity joint angles and instances during stance phase of running and AT lengths. Athletes in the AT group exhibited an affected gastro-soleus complex, while athletes with a history of AT tendon rupture had reduced ankle range of motion during the second half of the stance phase of running, an overextended knee during initial contact and greater affected knee range of motion in the first half of stance phase on their affected limb versus the healthy control group. A 22 percent increase in the maximal hip joint moment on the contralateral side was observed in the AT group compared to the controls. The outcomes suggest a compensation mechanism, relatively extended knee at initial ground contact against the deficit in the muscle-tendon complex of the triceps surae. Overextension during sporting activities may put the knee at risk for additional injury. Avoidance of AT lengthening and plantarflexion strength deficit after surgery and during rehabilitation might aid in managing AT rupture since these variables may be responsible for altered running kinematics.


A study was conducted to identify the rates of chondral injury, soft-tissue impingement and bony impingement in pediatric patients receiving the modified Brostrom procedure with ankle arthroscopy for lateral ankle instability. A retrospective review of all patients undergoing this procedure performed by two surgeons at a tertiary care children's hospital between October 2002 and April 2014 was conducted. All patients exhibited symptoms of ankle instability and had failed nonoperative management prior to surgery. Sixty-nine patients and 75 ankles were reviewed, of whom 54 were female and six underwent bilateral surgery. The average age was 15.2 years, and the average BMI was 23.6 ± 5.0 kg/m2. All patients had preoperative radiography and magnetic resonance imaging. All patients reviewed were administered the Brostrom procedure with Gould modification and routine concurrent arthroscopy. During the operation, anterior soft-tissue impingement was noted in 49 ankles, synovitis in 40, chondral defect in eight, loose body in three and none had bony impingement. Bony impingement and chondral injury are more common in the adult population.

Practice Management

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U.S. Centers for Medicare and Medicaid Services Administrator Seema Verma says the agency will focus on refining its quality and regulatory measures to lighten the burden on providers. Two initiatives, of many, included in this effort to streamline operations are Meaningful Measures and Patients Over Paperwork. The former is designed to make sure quality metrics only evaluate core issues. Meanwhile, Patients Over Paperwork will encourage providers to spend more time interacting with patients to prevent burnout. This program will also strive to decrease regulatory burdens and increase efficiencies. Verma says the agency will also look at how the reporting process can be simplified for providers.


The Journal of Medical Internet Research has published a report that says four factors predict a patient's likelihood to want to share online medical records with healthcare providers. Researchers came to that conclusion after conducting a survey of 1,600 people. They discovered that privacy concerns had the most influence on a patient's decision to share medical records online. Other issues factoring into this decision were found to be patient activation, issue involvement and patient-physician relationship.


To deal with sexual harassment at a physician practice, attorney Ericka L. Adler first suggests always having a witness present at meetings, especially those involving any reprimand, discipline, termination or similar interaction. She also recommends that having a female nurse in the room when a male physician performs an exam be mandatory to minimize exposure. "This is especially true of ob-gyns and those performing exams where there is contact with breasts or genitals (male or female)," Adler writes. Her third suggestion is to take every accusation, allegation or comment suggesting inappropriate behavior seriously, while her fourth piece of advice is to set up a culture in the practice where inappropriate behavior and comments are unacceptable. "The practice should not have to rely on a complaint before action is taken," Adler contends. She also notes claims of sexual misconduct are frequently untrue, which is why an investigation must be conducted and documented. Adler's final suggestion is for the practice to divest itself of any bad actors.

Health Policy and Reimbursement

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U.S. House Ways and Means Committee Chair Rep. Kevin Brady (R-Texas) has expressed a possible willingness to retain specific protections for people facing large medical bills in the GOP's tax bill. Brady noted he has gotten much feedback on Republicans' decision to remove the medical expense deduction, with some of his colleagues emphasizing it is crucial to maintain support for people with "extraordinary" medical cost. "We really stripped down the tax code on the House side and are rebuilding it based on what we're hearing from our representatives," Brady said. "That issue is being raised a lot by our lawmakers as very important." The House tax overhaul eliminated the itemized deduction for medical expenses greater than 10 percent of income, in what Brady has defended as a broader bid to simplify the tax code. Meanwhile, the Senate plan preserves and temporarily broadens the expense deduction at the urging of Sen. Susan Collins (R-Maine). Brady has made no commitments to keeping the deduction nor has he specified what other protections he would advocate for in the final bill, noting only that it would be a key point of discussion for House and Senate negotiators.


Kentucky, New Hampshire, Maine and Indiana are among at least eight Republican-led states seeking federal approval to require Medicaid enrollees to work as a precondition of their health coverage. All four states have been hard hit by drug addiction. Governors say they would exempt people with chronic drug problems or severe mental illness from the Medicaid work requirements, but who would qualify and under what circumstances has not been spelled out. Critics fear that many addicts could lose benefits, particularly if they go in and out of treatment or have relapsed. Employers' resistance to hiring people who have failed drug tests or have criminal records could also put health benefits at risk. Supporters of Medicaid work requirements say they are needed to reduce government dependency as the program has grown to cover more than 70 million Americans. The Trump administration has signaled it will sign off on the state waiver requests, even as it made combating the opioid epidemic a priority.


The market-based system set up by the Affordable Care Act encourages consumers to shop around annually to find the plan that best suits their medical needs and income. Many people, however, end up being forced to shop around when their plans drop out of the local market or eliminate preferred hospitals and doctors from the network. The task of finding new insurance each year can complicate care for some people, particularly those with continuing medical needs or chronic conditions. Fewer than half the people with marketplace insurance in 2014 stayed in the same plan the next year, according to a University of Michigan survey by Marianne Udow-Phillips and colleagues. Nearly a third of marketplace enrollees for 2017 were new customers, meaning they had other types of coverage previously or were uninsured. For the 2018 enrollment season, which began on November 1 and ends December 15 in most states, millions of people will switch coverage. Laws in some states allow patients in active treatment to retain doctors from one plan to the next but do not necessarily ensure stable medical relationships or long-term treatment strategies.

Medicine, Drugs and Devices

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The U.S. Food and Drug Administration (FDA) has announced three new significant policy documents to further the agency's approach to the development and proper oversight of innovative digital health tools. The new guidances—two draft and one final—address, in part, key provisions of the 21^st Century Cures Act that offer additional clarity about where FDA sees its role in digital health and also where the agency does not see a need to be involved. The first draft guidance, "Clinical and Patient Decision Support Software," details the agency's approach to clinical decision support software (CDS). FDA Commissioner Scott Gottlieb notes, "We believe our proposals for regulating CDS and [patient decision support software] not only fulfill the provisions of the Cures Act, but also strike the right balance between ensuring patient safety and promoting innovation." The second draft guidance being issued, "Changes to Existing Medical Software Policies Resulting from Section 3060 of the 21^st Century Cures Act," deals with other digital health provisions of the Cures Act. In particular, this guidance details FDA's interpretation of the types of software that are no longer considered medical devices. According to Gottlieb, "We're making clear that certain digital health technologies—such as mobile apps that are intended only for maintaining or encouraging a healthy lifestyle—generally fall outside the scope of FDA's regulation. Such technologies tend to pose a low risk to patients but can provide great value to consumers and the health care system." Finally, the final guidance FDA is issuing, "Software as a Medical Device: Clinical Evaluation," expands on a draft issued in October 2016. The guidance establishes common principles for regulators to use in evaluating the safety, effectiveness and performance of Software as a Medical Device, providing globally recognized principles for analyzing and assessing such software based on the overall risk of the product. These three guidance documents, said Gottlieb, "will continue to expand our efforts to encourage innovation in the ever-changing field of digital health. Our aim is to provide more clarity on and innovative changes to our risk-based approach to digital health products so that innovators know where they stand relative to FDA's regulatory framework."


The merger of CVS Health and Aetna would combine one of the country's biggest pharmacies with one of its largest health insurers. Executives at the firms say it will create a world where patients will get the "human touch," and that getting high-quality, low-cost medical care will be as close as your community pharmacy. "It's not going to immediately shake up the world, but I think you have two behemoths—two battleships that are slow to turn—and it will at least create an environment by which information can be shared and innovation can take place," says Nadina Rosier, the health and group benefits pharmacy practice leader at the consulting firm Willis Towers Watson. Skeptics say CVS and Aetna entered into the deal not to benefit consumers but to strengthen their competitive positions at a tumultuous time for the industry, in the hopes that the combination will yield new business opportunities. Some worry that the nation's healthcare system will come to resemble a series of kingdoms, where consumers are locked into separate ecosystems of pharmacies, doctors and healthcare clinics depending on their insurance provider.


U.S. Food and Drug Administration (FDA) Commissioner Scott Gottlieb reports the agency is the first in the world to provide a comprehensive technical framework to advise manufacturers creating medical products on 3D printers. 3D printing of medical devices, medications and human tissue is quickly becoming a promising reality. Patients have already benefited from 3D printed medical products through access to personalized devices and innovative drugs that have led to significant health improvements. But FDA is now preparing for a significant wave of new technologies that are nearly certain to transform medical practice. "We're working to provide a more comprehensive regulatory pathway that keeps pace with those advances," says Gottlieb, "and helps facilitate efficient access to safe and effective innovations that are based on these technologies." FDA has reviewed more than 100 devices currently on the market that were manufactured on 3D printers. The agency also approved the first drug produced on a 3D printer, which is used to treat seizures and has a more porous matrix than the drug manufactured in the traditional way, enabling the drug to dissolve more rapidly in the mouth to work faster.