News From ACFAS

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The ACFAS Nominating Committee is looking for the best and brightest to participate in the upcoming election to serve on the College’s Board of Directors. If you are an ACFAS Fellow, believe you are qualified and would like to help lead the profession, submit your nomination application by Friday, September 23, 2022. Visit acfas.org/nominations for more information, including complete details on the recommended criteria for election candidates.

The Nominating Committee will announce recommended candidates to the membership on October 26. Online voting for members will start no later than November 28 and will end on December 14. The elected directors will be announced shortly thereafter and will start their term of service at the ACFAS 2023 Scientific Conference on February 9-12, 2023 in Los Angeles. We’re here to help! Join us in October for the new ACFAS Practice Management Webinar Wednesdays. This three-part series highlights important practice management topics to help enhance your efficiency, simplify administrative burdens, and improve your quality of care -- all while earning up to 4.5 CME.

Register for each webinar individually or save when you register for all three.

Insurance Reviews: Get the Inside Scoop for Proper Reimbursement
Get paid for your surgeries! Maryellen Brucato, DPM, FACFAS, David Wander, DPM, FACFAS and Kyle Berger, CPB share the dos and don’ts of surgical billing.
October 12 | 7:00 pm CT

How Do I Know If My Practice is Doing Well?
Bela Pandit, DPM, FACFAS and Heraj Patel, DPM, FACFAS help you do a deep dive analysis to evaluate your practice by accurately determining and measuring your top revenue makers…and losers…and how to adjust accordingly—all without hiring an outside consulting company!
October 19 | 7:00 pm CT

Malpractice Preparation – Because it Happens to Everyone
Hear tips on documentation, peri-operative management and discussions on complications with patients from Ross Taubman, DPM of PICAGroup; Al Ng, DPM, FACFAS; Barry Rosenblum, DPM, FACFAS; Ellianne Nasser, DPM, FACFAS and Maryellen Brucato, DPM, FACFAS.
October 26 | 7:00 pm CT

Register now to get expert advice and real-world tips in October! Visit acfas.org/practicemanagement to register and for more information. There’s a new virtual course in town! Join us November 19 from the comfort of your home or office for the ACFAS First Ray Virtual Symposium!

During this live, interactive event you’ll hear expert faculty discuss surgical options to correct first ray deformity, along with complication and revision options. After the symposium ends, extend your learning experience as you interact with peers and faculty through the online discussion forum.

Can’t make the live symposium? Register to access the on-demand recordings and still earn 4 CME. Visit acfas.org/firstrayvirtualsymposium for more information and to register today.

Foot and Ankle Surgery

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A retrospective cohort study was conducted to compare minimum five-year functional outcomes of patients who had undergone reoperation following total ankle arthroplasty (TAA) to those who did not require reoperation. The authors allocated 76 ankles (74 patients) who underwent TAA with the Salto Talaris fixed bearing system between 2007 and 2014 into a group of 16 ankles based on presence of reoperation and 60 ankles based on absence of reoperation. There were 11 cases of gutter impingement, which was the most common cause of reoperation, followed by stress fracture of the medial malleolus (two cases), tarsal tunnel syndrome (one case), periprosthetic cyst (one case) and infection (one case). All foot and ankle outcome score subscales other than the Sports and Recreational Activities subscale were significantly lower in the reoperation cohort at final follow-up compared to the non-reoperation group. The reoperation group experienced significantly less improvement in the Pain, Symptoms and Quality of Life subscales at final follow-up, and neither group saw statistical differences in radiographic parameters.


A single-center retrospective study assessed the return-to-sports (RTS) rate and time after arthroscopic surgery to treat chronic lateral ankle instability. Thirty of the 40 included patients resumed their main sport after an average of six months, while 22 did so at the same or a higher level within 12 months after a median follow-up of 29 months. The American Orthopaedic Foot and Ankle Society saw significant improvement from 67 before surgery to 88.5 at last follow-up. The numerical pain score fell from 6 to 1. Multivariate analysis demonstrated that a high level of motivation prior to surgery was the main factor significantly associated with RTS at the same or a higher level within 12 months after surgery. Patients with work-related injuries also had more persistent pain.


Researchers mined the MEDLINE and Embase online databases from Jan, 1, 2011, through Nov. 19, 2021, for randomized controlled trials (RCTs) involving foot and ankle conditions, fragility index (FI) and fragility quotient (FQ) to calculate the difference between the FI and number of subjects lost to follow up. There were 1,262 total studies identified, with 18 included in the final analysis. The median sample size was 65 while the median FI was 2 and the median FQ was 0.026. Ten out of 15 studies with non-zero FI values had FI values less than the number of subjects lost to follow up. A linear association was observed between FI and sample size, leading to the conclusion that RCTs in the field of foot and ankle surgery are highly fragile and bear similarity to other orthopaedic subspecialties.

Practice Management

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Real-time prescription benefit (RTPB) systems that recommend more affordable alternatives can save patients money, a cluster randomized trial found, but this point-of prescribing service is underutilized. The research included medical practices within the NYU Langone Health system and outpatient prescriptions written to adult patients from January 13 to July 31, 2021. At practices assigned to RTPB, prescribers were presented with patient-specific estimates of out-of-pocket costs along with recommendations for a different medication, other durations of the prescription and/or an alternate type of pharmacy as potential money-saving options. Orders were selected at the prescriber's discretion. Based on analysis of 36,419 prescriptions with clinically appropriate alternatives available, the out-of-pocket burden for a 30-day supply was $39.90 for patients at the 97 practices assigned to the intervention vs. $67.80 for patients at the 99 control practices. Investigators calculated that RTPB recommendations lowered patient out-of-pocket expenses by about 11 percent across the board and by nearly 40 percent for high-cost drug classes. The drawback, they reported, is that not even 5 percent of prescriptions ordered during the study period even qualified for RTPB. "Our study data suggest that there is a variation in whether a medication is considered to have alternatives," they concluded, "suggesting that some PBMs make recommendations more conservatively than others. Savings could be broader if more alternatives were recommended."


A Ponemon Institute survey of information technology specialists at 641 healthcare organizations found nearly 90 percent said their organization had suffered at least one cyberattack over the previous year, with the average being 43. Lost productivity was the major financial impact of attacks, averaging $1.1 million, while the average total cost for the most expensive cyberattack on each organization was $4.4 million. Fifty-three percent of respondents said their organization lacked in-house cybersecurity expertise, and 46 percent said they had inadequate staff to defend themselves from cyberattacks. Ponemon also noted that most respondents felt technologies like cloud, mobile big data and the Internet of Things elevate the risks to patient data and safety.

Ransomware attacks were listed as the biggest threat to patient safety and care delivery, as 64 percent of respondents in organizations that experienced such an attack said it led to delays in procedures and tests that exacerbated outcomes for patients. Organizations' main bulwarks against cyberattacks include training and awareness programs and employee monitoring. Sixty-three percent of respondents said their organizations perform training and awareness programs regularly, while 59 percent monitor employee actions.


A recent survey by AMN Healthcare found the average wait time for a physician appointment across five specialties in 15 metropolitan areas was 26 days in 2022, an 8 percent increase from 2017 survey and a 24 percent gain from 2004. The highest average physician appointment wait time across all five specialties is in Oregon, averaging 45.6 days, while New York has the lowest average wait time at 17.4 days. This trend points to an ongoing physician shortage, according to Merritt Hawkins President Tom Florence. "Even though at its height COVID-19 temporarily suppressed demand for physicians, the underlying factors driving the physician shortage never went away," he noted. "These include an aging population, widespread ill-health, an aging physician workforce and a limited supply of newly trained physicians."

Florence also said average physician appointment wait times are even longer in rural areas, while decreases in wait times to see a family medicine physician are associated with change in the healthcare provider market. "More patients are accessing primary care through urgent care centers, retail clinics and telehealth, all venues that often are staffed with a growing number of nurse practitioners and physician assistants," Florence explained. "That makes it less challenging to see a family physician, though it can still be difficult."

Health Policy and Reimbursement

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According to a Kaiser Family Foundation review of 72 insurers' proposals in 13 states, median monthly Affordable Care Act (ACA) premiums will rise 10 percent, but some carriers are proposing increases up to 20 percent. Consumers can begin signing up for ACA plans on November 1. The analysis says rate increases will vary across states and by insurer, as state regulators do not always approve full rate increase requests. Higher medical services prices and growing labor costs are just a couple of the factors leading to premium increases, according to insurance filings. However, the federal government extended enhanced ACA subsidies, which will provide Americans a cushion against the rate increases.


A majority of adults in the United States who say that healthcare is not handled well in the country, according to a new poll from The Associated Press-NORC Center for Public Affairs Research. The poll reveals that public satisfaction with the US healthcare system is remarkably low, with fewer than half of Americans saying it is generally handled well. Just 12 percent say it is handled extremely or very well. Americans have similar views about healthcare for older adults. Overall, the public gives even lower marks for how prescription drug costs, the quality of care at nursing homes and mental healthcare are being handled, with 6 percent or less saying those health services are done very well in the country.


Pediatric cases of type two diabetes have been climbing over the past two decades, prompting the US Preventive Services Task Force (USPSTF) to consider a possible recommendation to screen asymptomatic children and adolescents for the condition. Upon review of the current evidence, however, the panel was met with insufficient data reporting the effect that testing, early detection and treatment of type two diabetes in this population has on outcomes such as cardiovascular death, chronic kidney disease, amputation, visual impairment, neuropathy and death. Moreover, USPSTF acknowledged, the risk-benefit profile could not be determined. While unable to move forward with a screening recommendation for underage individuals without known diabetes, prediabetes or symptoms of either, USPSTF does already have recommendations in place for screening children and teens for obesity — which is a risk factor for type two diabetes. The I statement "is neither a recommendation for nor against screening," task force members conclude. "Clinicians should continue to use their clinical judgment to determine if screening is appropriate for individual patients."

Medicine, Drugs and Devices

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The US Food and Drug Administration (FDA) has released a final rule related to drug companies that agree to supply investigational medicines under the Right to Try Act of 2018, which requires them to submit an annual summary detailing each use to FDA. Manufacturers must include details of the number of doses supplied, the number of patients treated, the use for which the drug was made available and the occurrence of any known serious adverse events. Regarding when manufacturers are required to submit reports, FDA said it "extended the submission date for the first annual summary report from 60 calendar days after the final rule becomes effective as proposed to a specific date of March 31, 2023." FDA noted that "this rule specifies that submissions must be made electronically. Currently, this means attaching a PDF document to an email." The Right to Try Act revised the Food, Drug and Cosmetic Act to establish an option for patients meeting certain criteria to request access to unapproved drugs. In comments about the rule, some stakeholders suggested that reports under the Right to Try Act could be included as an addendum within investigational new drug (IND) annual reports or merged with the comparable Expanded Access program, which requires FDA to determine if a drug is likely to be of benefit. Experimental treatments provided through right to try do not need to be approved by an Institutional Review Board, but this is required for medicines issued under the Expanded Access program. FDA noted, "It would be extremely difficult and resource-intensive for FDA to examine all IND annual reports for the sole purpose of identifying those potentially few reports that have Right to Try information so that we can compile the annual summary required by section 561B(d)(2) of the FD&C Act."


The US Food and Drug Administration's (FDA) "user free" program is under scrutiny as budget negotiations for the regulator move toward a September 30 reauthorization deadline in Congress. The monies pharmaceutical companies pay out have ramped up substantially since the program launched in 1992, making up 75 percent of last year's budget for the agency's drug division and about 50 percent of its funding overall. Pharmaceutical industry groups say company dollars provide the funding for research and development to bring lifesaving medications, but patient advocates and doctors counter that the payments compromise the integrity of an approval process meant to ensure the safety and efficacy of novel interventions. Although the pharmaceutical industry theoretically has no influence over how user fees are utilized, even FDA Commissioner Robert Califf considers the program flawed. "Philosophically," he said this summer, "I wish the taxpayer paid for all the FDA and there were no user fees."


The White House is seeking to allocate more than $2 billion to launch a national biomanufacturing effort to establish new drug manufacturing sites or strengthen existing ones and obtain the raw materials and lab supplies needed to respond to a new pandemic. The funding is part of an executive order US President Joe Biden signed designed to widen the biotech supply chain and make the nation's drug sector less reliant on overseas production. The US Department of Defense pledged to invest $1 billion over the next 5 years to assist public- and private-sector entities broaden their manufacturing capacity. Another $40 million will be used to expand production of antibiotics and the starting materials needed to produce "essential medications and respond to pandemics." There are also plans to invest in regional manufacturing sites in Virginia, New Hampshire, Oregon, North Carolina and Alaska. The US Department of Health and Human Services has been instructed to identify near-, medium- and long-term biomanufacturing priorities, such as which medicines need the most manufacturing assistance, and report back in March 2023, according to a senior administration official.