INFORMING the CONSTRUCTION of a FALL PREVENTION CLINICAL PRACTICE GUIDELINE for PODIATRY PATIENTS 65 YEARS of AGE and OLDER a Di

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INFORMING THE CONSTRUCTION OF A FALL PREVENTION CLINICAL PRACTICE GUIDELINE FOR PODIATRY PATIENTS 65 YEARS OF AGE AND OLDER

A dissertation submitted to Kent State University in partial fulfillment of the requirements for the degree of Doctor of Philosophy.

Matthew Nichols

August, 2018

Dissertation written by Matthew David Nichols MPH, Kent State University, USA, 2014 BS, Kent State University, USA, 2011

Approved by

Sonia Alemagno, PhD, Chair, Doctoral Dissertation Committee

Jonathan VanGeest, PhD, Doctoral Dissertation Committee

Ken Zakariasen, PhD, Doctoral Dissertation Committee

Vincent J. Hetherington, DPM, Doctoral Dissertation Committee

Accepted by

Eric Jefferies, PhD, Graduate Faculty Representative

Sonia Alemagno, PhD, Dean, College of Public Health

TABLE OF CONTENTS

LIST OF FIGURES…………………………………………...…………………………………vii

LIST OF TABLES…………………………………………………………………………...…viii

LIST OF ABBREVIATIONS…………………………………………………………………….xi

ACKNOWLEDGEMENTS…………………………………………………………………..…xiii

CHAPTER 1 INTRODUCTION………………………………………………………………….1

CHAPTER 2 REVIEW OF LITERATURE……………………………………………………....4

2.1 Age of fallers………………………………………………………………………………..…4

2.2 Fall risk factors……………………………………………………………………………..…4

2.3 The cycle of falls……………………………………………………………………………....5

2.4 Fall frequency and the economic impact…………………………………………………...…7

2.5 Fall interventions……………………………………………………………………………...8

2.6 Prevention and practice: clinical practice guidelines………………………………………...10

2.7 Primary care and fall prevention…………………………………………………………..…15

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2.8 Podiatry and fall prevention………………………………………………………………….16

CHAPTER 3 METHODS………………………………………………………………………..19

3.1 Survey content………………………………………………………………………….……19

3.2 Survey population…………………………………………………………………………....20

3.3 Survey data collection……………………………………………………………..…………20

3.4 Survey burden……………………………………………………………………………..…23

3.5 Survey incentive……………………………………………………………………………...23

3.6 Data analysis…………………………………………………………………………………23

3.7 Focus group…………………………………………………………………………………..24

CHAPTER 4 FINDINGS………………………………………………………………………...25

4.1 Survey distribution…………………………………………………………………………...25

4.1.1 The American Podiatric Medical Association……………….…………………….25

4.1.2 Kent State College of Podiatric Medicine………………………….……………...25

4.2 Survey respondent demographics……………………………………………………………26

4.3 Research question 1………………………………………………………………………….26

4.4 Research question 2………………………………………………………………………….28

4.5 Research question 3………………………………………………………………………….30

4.6 Research question 4………………………………………………………………………….32

4.7 Research question 5……………………………………………………………………….…34

4.8 Research question 6………………………………………………………………………….37

4.9 Research question 7……………………………………………………………………….…41

4.10 Research question 8……………………………………………………………………...…42

CHAPTER 5 DISCUSSION, LIMITATIONS, AND IMPLICATIONS…………………….…45

5.1 Fall knowledge and providing a fall intervention……………………………………………45

5.2 The addition of fall-related content to the current podiatry curriculum…………………..…50

5.3 Increased fall-related continuing education………………………………………………….52

5.4 Fall referrals, fall screening tools, and continuity of care……………………………………53

5.5 Recommendations for a clinical practice guideline………………………………………….55

5.6 Limitations………………………………………………………………………………...…55

5.7 Implications………………………………………………………………………………..…57

APPENDIX A IRB APPROVAL LETTER………………………………………………..……59

APPENDIX B IRB APPLICATION SUMMARY………………………………………...……61

APPENDIX C INFORMED CONSENT………………………………………………………...65

APPENDIX D AMERICAN PODIATRIC MEDICAL ASSOCATION EMAIL………………69

APPENDIX E KENT STATE COLLEGE OF PODIATRIC MEDICINE EMAIL……………77

APPENDIX F SURVEY INSTRUMENT……………………………………………………….79

APPENDIX G FOCUS GROUP DISCUSSION GUIDE…………………………………….…85

APPENDIX H FOCUS GROUP TRANSCRIPT………………………………………………..90

REFERENCES…………………………………………………………………………………109

LIST OF FIGURES

Fig. 5.1 The impact of fall knowledge…………………………………………………………...46

Fig. 5.2 The fall knowledge continuum…………………………………………………….……48

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LIST OF TABLES

Table 2.1: Fall publication matrix………………………………………………………………..13

Table 4.1: Fall knowledge………………………………………………………………………..27

Table 4.2: Fall knowledge (recoded) ……………………………………………………………27

Table 4.3: Fall knowledge and sex………………………………………………………………27

Table 4.4: Fall knowledge and podiatry specialty……………………………………………….28

Table 4.5: Asking about falls…………………………………………………………………….28

Table 4.6: Asking about falls and sex……………………………………………………………29

Table 4.7: Asking about falls and podiatry specialty………………………………………….…29

Table 4.8: Asking about falls and fall knowledge……………………………………………….30

Table 4.9: Identifying risk factors for falls………………………………………………………30

Table 4.10: Identifying risk factors for falls and fall knowledge………………………………..31

Table 4.11: Identifying risk factors for falls and podiatry specialty……………………………..31

Table 4.12: Identifying risk factors for falls and asking about falls……………………………..32

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Table 4.13: Documenting fall risk factors……………………………………………………….32

Table 4.14: Documenting fall risk factors and fall knowledge…………………………………..33

Table 4.15: Documenting fall risk factors and asking about falls……………………………….33

Table 4.16: Documenting fall risk factors and podiatry specialty……………………………….34

Table 4.17: Documenting fall risk factors and identifying fall risk factors……………………...34

Table 4.18: Providing a fall referral…………………………………………………………...…34

Table 4.19: Fall referral and fall knowledge……………………………………………………..35

Table 4.20: Fall referral and asking about falls………………………………………………….35

Table 4.21: Fall referral and podiatry specialty………………………………………………….36

Table 4.22: Fall referral and identifying fall risk factors………………………………………...36

Table 4.23: Fall referral and documenting fall risk factors………………………………...……37

Table 4.24: Providing a fall intervention…………………………………………………...……37

Table 4.25: Providing a fall intervention and fall knowledge……………………………...……38

Table 4.26: Providing a fall intervention and asking about falls………………………………...38

Table 4.27: Providing a fall intervention and identifying fall risk factors……………………….39

Table 4.28: Providing a fall intervention and documenting fall risk factors…………………….39

Table 4.29: Providing a fall intervention and providing a fall referral…………………………..40

Table 4.30: Providing a fall intervention and hours each week in direct patient care…………...40

Table 4.31: Providing a fall intervention and podiatry specialty………………………………...41

Table 4.32: Fall prevention barriers……………………………………………………………...42

LIST OF ABBREVIATIONS

AFO: Ankle Foot Orthosis

APMA: American Podiatric Medical Association

DVT: Deep Vein Thrombosis

CME: Continuing Medical Education

CPM: College of Podiatric Medicine

GDP: Gross Domestic Product

IRB: Institutional Review Board

LS: Life Satisfaction

MIPS: Merit-based Incentive Payment System

NICE: National Institute for Health and Care Excellence

OSI: Allied OSI Labs

OT: Occupational Therapy

PT: Physical Therapy

TBI: Traumatic Brain Injury

U.S.: United States

USPSTF: United States Preventative Services Task Force

VA: Veterans Affairs

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ACKNOWLEDGEMENTS

This document is composed of roughly 29,000 words, and none of them could aptly describe the appreciation and respect I have for my dissertation committee; thank you for facilitating this academic journey, and for your continued professional support. Moreover, I would like to thank Elizabeth Shaffer-King for her data analysis support, and Dr. Peter Leahy for his mentorship and collective wisdom. I am infinitely grateful for the support and patience of my wife, Krysten Nichols, my parents, David and Patricia Nichols, my brother, Ryan Nichols, and for all the friends and family that, while not listed, have been equally impactful.

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CHAPTER 1

Introduction

Unintentional falls amongst those 65 years of age and older remains a pervasive public health problem, both domestically and abroad. A fall can be defined as “…an unexpected event during which” …an… “individual comes to rest on the ground, floor, or lower level, typically during the performance of basic daily activities” (Finlayson and Peterson 2010). The risk of falling advances linearly with age (Peel 2011). Roughly one-third of those 65 years of age, and roughly half of those 80 years of age, experience a fall annually (Inouye et al. 2009, Ambrose et al. 2013), 5.8 million of which have fallen in the last three months (Stevens et al. 2008,

Finlayson and Peterson 2010). Multivariate in nature, said falls account for 40 percent of all injury-related deaths (Stevens et al. 2008, Peel 2011) and more than 80 percent of all injury- related hospital admissions amongst those 65 years of age and older (Peel 2011). Thirty percent of falls result in an injury and require medical attention, while fractures occur in roughly 10 percent (Berry and Miller 2008). These figures likely fail to capture the entire epidemiological scope of falls, as under-reporting is commonplace (Noble and Pronovost 2010) and less than half of those who sustain a fall tell a healthcare professional (Shumway-Cook et al. 2009), likely due to fears of institutionalization or loss of independence.

Fall rates are higher among those living in an institutional setting, as opposed to their community-living counterparts, and have been documented with rates two (Damian et al. 2013) to six times higher, on average (Tinetti and Kumar 2010, Peel 2011). The likelihood of

1 sustaining a fall is also affected by the presence of comorbidity and/or chronic disease (Finlayson and Peterson 2010), the combination and severity of which vary from individual to individual.

Overall, direct and indirect costs of falls amongst those 65 years of age and older are expected to exceed $54.2 billion by 2020 in the U.S alone (Finlayson and Peterson 2010), and these totals do not include more elusive measures, such as health-related quality of life (HRQOL) and life satisfaction (LS) (Stenhagen et al. 2014).

Given the fiscal and health-related burden connected to falls, and despite the implementation of fall-derived clinical practices and subsequent fall prevention programs, podiatric medicine, the medical specialty responsible for addressing the structure, function, and management of primarily the foot and ankle (Vernon et al. 2011), has not yet developed an integrated, fall prevention protocol for those patients 65 years of age and older. As such, the following aims to inform the development of a clinical practice guideline for the prevention of falls among those 65 years of age and older, under the auspices, and specifically tailored to, the unique needs of podiatric medicine. In order to do so, the following research questions will be addressed:

1) What are podiatrists’ current knowledge of falls and fall prevention?

2) What are the characteristics of podiatrists that ask about falls amongst those podiatric

patients 65 years of age and older?

3) What are the characteristics of podiatrists that identify fall risk factors amongst those

podiatric patients 65 years of age and older?

4) What are the characteristics of podiatrists that document fall risk factors amongst those podiatric patients 65 years of age and older?

5) What are the characteristics of podiatrists that refer podiatry patients 65 years of age and older to fall professionals?

6) What are the characteristics of podiatrists that provide a fall prevention intervention to those podiatric patients 65 years of age and older?

7) What barriers do podiatrists foresee pertaining to the prevention of falls among those podiatric patients 65 years of age and older?

8) What are podiatrists’ recommendations for the prevention of falls among those podiatric patients 65 years of age and older?

CHAPTER 2

Review of literature

2.1 Age of fallers

The occurrence of falls is not confined to aging populations, as falls are also the most frequent source of injury for children between the ages of 0 and 14 (McKinlay et al. 2008).

Rather, a high incidence, coupled with increasing susceptibility to injury, prolonged recovery time, the presence of comorbidities (which may include one or more chronic diseases), and both physiological and psychological changes make falls particularly dangerous among those 65 years of age and older (Rubenstein 2006). Due to this relatively large time span, elderly fallers are often categorized as young-old (64 to 74), old-old (75 to 84), and oldest-old (85 and older) (Peel

2011). As age increases, as does the risk for sustaining a fall (Karlsson et al. 2013); 30% of those 65 years of age and older, and upwards of 50% of those 80 years of age and older, will fall annually (Frick et al. 2010).

2.2 Fall risk factors

Falls are associated with a wide range of risk factors. These risk factors can most readily be categorized as intrinsic or extrinsic (Finlayson and Peterson 2010, Peel 2011). With respect to intrinsic risk factors, falls are often associated with, but not limited to: age (Yoshida 2007,

Peel 2011, Ambrose et al. 2013), ethnicity (Peel 2011),

4 female gender (Finlayson and Peterson 2010, Peel 2011), a history of falls (Ambrose et al. 2013), fear of falling and falls self-efficacy (Finlayson and Peterson 2010), comorbidity, such as postural hypotension, or neurological and cardiovascular disorder (Moylan and Binder 2007), chronic disease (Moylan and Binder 2007, Berry and Miller 2008, Ambrose et al. 2013), strength and gait imbalance (Rubenstein 2006, Finlayson and Peterson 2010, Damian et al. 2013,

Ambrose et al. 2013), mental health status (Tzeng and Yin 2008), visual impairment (Rubenstein

2006, Finlayson and Peterson 2010, Damian et al. 2013, Ambrose et al. 2013), hearing impairment (Moylan and Binder 2007, Grue et al. 2009, Lopez et al. 2011), urinary incontinence

(Chiarelli et al. 2009, Damian et al. 2013), and psychological decline (Rubenstein 2006, Wang et al. 2012, Ambrose et al. 2013).

Extrinsic risk factors, such as medication and polypharmacy, especially psychotropic and anti-depressant use (Hartikainen et al. 2007, Berry and Miller 2008, Woolcott et al. 2009,

Finlayson and Peterson 2010, Damian et al. 2013, Ambrose et al. 2013), maladaptive footwear

(Tzeng and Yin 2008), and both physical environment and home-based hazards (Lord et al.

2007, Finlayson and Peterson 2010, Ambrose et al. 2013) have also been linked to falls. While these risk factors apply to both community-based and institutionalized elderly, emphasis on comorbidity, chronic disease, urinary incontinence, antidepressant use, arrhythmia, and polypharmacy are especially relevant among the institutionalized (Damian et al. 2013).

2.3 The cycle of falls

Beyond the intrinsic and extrinsic risk factors associated with falls amongst those 65 years of age and older, a well-documented chain of events is important to note regarding the psychology of falls. Oftentimes an individual that sustains a fall, in a natural effort to recover

5 from said fall, will downregulate his/her daily activities (Rubenstein 2006), and fear of falling will develop, the latter of which is characterized by the fear of losing independence (Lee et al.

2008, Finlayson and Peterson 2010), injury, being unable to get up after a fall, being removed from his/her home, or having to use a wheelchair in lieu of walking (Finlayson and Peterson

2010).

While this may seem natural to most, physical downregulation and fear of falling frequently spiral into chronic restricted activity (Zijlstra et al. 2007), leading to prolonged physical inactivity and social isolation (Finlayson and Peterson 2010).

Subsequently, this lack of physical activity and social participation leads to further physical deconditioning and general weakness (Deshpande et al. 2008), abnormal gait patterns

(Salzman 2010), and a general fear of falling (Alcalde 2009), all of which are risk factors for sustaining another fall (Rubenstein 2006). Multiple falls advances the chances for more significant injury and in turn, one fall can induce negatively adopted behaviors that further increase the risk of fall and loss of independence. Such a cycle is imperative to outline to both fallers and non-fallers, as 30% of non-fallers (Alcalde 2009) and 54% of community-based falling and non-falling elderly (Zijlstra et al. 2007) present a fear of falling, and these projections vary considerably (Zijlstra et al. 2007).

Additionally, and as outlined by Rubenstein (2006), “optimal approaches…” to fall prevention “…involve interdisciplinary collaboration in assessment and interventions, particularly exercise, attention to co-existing medical conditions, and environmental inspection and hazard abatement”. In doing so, the dangerous cycle of physical deconditioning, fear of

6 falling, and social isolation associated with a fall can be avoided, empowering the individual and potentially thwarting future fall events.

2.4 Fall frequency and the economic impact

Falls are the leading cause of fatal and non-fatal injury among those 65 years of age and older (Peel 2011). From 2001 to 2008, the rate of fall-related hospitalizations among those 65 years of age and older increased from 1,046 to 1,368 per 100,000 (Hartholt et al. 2011). While most falls occur inside a residential location (82%), falls also occur outdoors (12%), in healthcare facilities (4.8%), and at public transportation sites (1%) (Gelbard et al. 2014). Injuries sustained from a fall can vary considerably, but prevalent injuries include: soft-tissue damage, abrasion, laceration, sprain, joint dislocation, or fracture, centralized around the hip, wrist, arm, shoulder, lower vertebrae, ribs, nose, leg, ankle, and/or foot (Findorff et al. 2007). While fractures are only responsible for 35% of injury, they compel 61% of total fall-related costs

(Stevens et al. 2006). In 2007 alone, Medicare payments allotted for radial fractures amounted to

$170 million (Shauver et al. 2011).

Traumatic brain injury (TBI) amongst fallers 65 years of age and older is also prevalent, with 950,132 TBI hospitalizations and 107,666 TBI-related deaths occurring between 2000 and

2010 (Haring et al. 2015). While cost incurred as the result of TBI amongst those 65 years of age and older is not well defined in the current literature (Farrer and Stuart 2016), there is some evidence to suggest that elderly TBI accounts for 10% of the $86 billion spent annually on TBI- related treatment (Gooch et al. 2017).

With respect to mean cost per victim, per fall, and per hospitalization, totals range from

$2,044 to $25,955, $1,059 to $10,913, and $5,654 to $42,840, respectively (Heinrich et al. 2010).

Of non-fatal fall-related injuries, 63% of the cost has been attributed to the hospitalization itself, with another 21% accounting for emergency room visits (Davis et al. 2010). Average length of hospital stay per fall event has been documented between 5 days (Siracuse et al. 2012) to 9 days

(Large et al. 2006) depending upon the injury type and severity, and the majority of individuals are discharged to rehabilitation facilities for further treatment (Siracuse et al. 2012).

In a 2010 international cost comparison, the United States spent $23.3 billion on falls,

14.6 times more than the United Kingdom’s fall-related $1.6 billion U.S. currency equivalent

(Davis et al. 2010). Overall, systematic review place fall-related costs in the United States at

1.5% of total healthcare costs and 0.2% of the total Gross Domestic Product (GDP), equating to

$36 billion in 2015 (Heinrich et al. 2010).

2.5 Fall interventions

Falls are multivariate in nature and associated with a variety of risk factors. As such, a number of intervention strategies have been documented and utilized, and these include single- factor (Campbell and Robertson 2007), multi-factorial (Kenny et al. 2011), and multi-component

(Kenny et al. 2011) frameworks, respectively. While single-factor interventions focus solely on the remediation of one fall risk factor presented by an individual (Campbell and Robertson

2007), multi-factorial interventions address multiple fall risk factors that an individual may display (Kenny et al. 2011). Comparatively, multi-component interventions are standardized, non-individualized fall prevention programs that address a number of fall risk factors, and are intended for broad dissemination (Kenny et al. 2011).

Fall intervention components “…can be described under the broad headings of exercise and physical activity, medical assessment and management, medication adjustment,

8 environmental modification, and education”, and may include the following: medication management, customized exercise programs, vision correction, the management of postural hypotension and cardiovascular disorders, vitamin D supplementation, foot and footwear consultation, home environment modification, and fall prevention education (Kenny et al. 2011).

Additionally, meta-analyses of randomized control trials (RCTs) reveal that effective fall prevention interventions are often categorized into seven distinct groups, and include some combination of medication management of psychotropic medication, tai chi, muscle and balance exercise, vitamin D supplementation, multi-factorial elderly fall programs, multi-factorial high- risk elderly programs, and home modification (Frick et al. 2010).

Albeit general consensus and wide utilization, it is interesting to note that, while multifactorial interventions are effective in reducing fall risk (Karlsson et al. 2013), they have not been conclusively deemed more effective than single-factor interventions, despite the added intervention breadth (Campbell and Robertson 2007). One potential explanation is multiple interventions may be confusing to the individual at risk for fall, or lead to too many changes at once that the individual is not willing to adhere to, leading to the rejection of one or more parts of the intervention entirely (Campbell and Robertson 2007). As multi-factor interventions are also more involved, and subsequently more costly than single-factor interventions, single-factor interventions may also provide considerable cost savings. Such a statement is highlighted in the case of polypharmacy. According to Frick and colleagues (2010), medical management of psychotropic medication was the least expensive and most effective fall risk intervention, as compared to six other avenues of standard care, followed by vitamin D supplementation, home modification, multi-factorial elderly fall programs, muscle and balance exercise, and multifactorial high-risk elderly programs.

Not surprisingly, previously published literature has linked the use of sedatives and hypnotics, anti-depressants, and benzodiazepines with significantly increased risk for fall among those 65 years of age and older (Woolcott et al. 2009), discontinuation from which has been effective in reducing falls (Kenny et al. 2011). These findings are especially relevant for those institutionalized individuals 65 years of age and older, as both polypharmacy and fall rates in the aforementioned population are higher than their community-based counterparts, leading to severe injury and poor survival rates (Damian et al. 2013).

2.6 Prevention and practice: clinical practice guidelines

Clinical practice guidelines are integrated, evidence-based recommendations, intended to direct healthcare professionals across a variety of situations and conditions (Weisz et al. 2007).

More specifically, they are “…statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options” (Steinberg et al. 2011). Based upon the wide array of fall risk factors, as well as the inherent crossover between healthcare disciplines, a number of clinical practice guidelines have been created specifically for, or have thus integrated, the prevention of falls in the elderly.

The Agency for Healthcare Research and Quality, the federal entity responsible for the quality and safety of the U.S. healthcare system, houses the National Guideline Clearinghouse, which serves as an archive for clinical practice guidelines (Agency for Healthcare Research and

Quality 2014). A National Guideline Clearinghouse database search with the key term “fall” produced 230 clinical practice guidelines across 48 clinical specialties. Said clinical practice guidelines include, but are not limited to, primary care (Moncada 2011, Beauchet et al. 2011,

Stevens and Phelan 2012, Moyer 2012) and osteopathic medicine (Papaioannou et al. 2010), and specialties such as endocrinology (Holick et al. 2011, Watts et al. 2012), orthopedics (Kanis et al.

2011), geriatrics (Kenny et al. 2011), otolaryngology (Bhattacharyya et al. 2008), and pharmacy

(Gallagher and Mahoney 2008, Bulat et al. 2008a, Bulat et al. 2008b, Bulat et al. 2008c).

Moreover, the treatment of certain chronic diseases, such as Parkinson’s, are also supplemented with clinical practice guidelines pertaining to fall prevention (van der Marck et al. 2014). While three podiatry clinical practice guidelines were produced, their content was not fall-related, but focused rather on footwear-based prevention of foot ulcers amongst those with diabetes (Bus et al. 2016), stroke rehabilitation (National 2013), and the management of type II diabetes (Redmon et al. 2014).

The key term “elderly fall” produced 46 clinical practice guidelines across 38 clinical specialties, and while a single podiatry clinical practice guideline was identified, the clinical focus was the management of type II diabetes (Redmon et al. 2014). The key term “fall prevention” produced 166 clinical practice guidelines across 48 clinical specialties, and while three podiatry clinical practice guidelines were identified, their content of focus was not fall prevention amongst podiatry patients 65 years of age and older, but once again the footwear- based prevention of foot ulcers amongst those with diabetes (Bus et al. 2016), stroke rehabilitation (National 2013), and the management of type II diabetes (Redmon et al. 2014).

When applying the clinical practice guideline search criteria “Aged (65 to 79 years)” to the key term “fall prevention”, 115 clinical practice guidelines are identified, two of which pertain to podiatry and have been mentioned previously (National 2013, Redmon et al. 2014); of these 115 clinical practice guidelines, five deal directly with falls (Kluger 2007, HCANJ 2012,

Moyer 2012, Longton et al. 2013, Crandall et al. 2016), should be considered the most relevant to the purposes of this study, and are outlined below (Table 2.1).

Table 2.1 Fall Publication Matrix Publicat Title Developin Recommendation Summary Citation ion Year g Agency 2003 Fall Health Key Elements to a Fall Health Care (revised Manageme Care Management Program should Association of New 2012) nt Associatio include facility leadership Jersey (HCANJ). Guideline. n of New approval and participation, (2012). Fall Jersey assessment-based dynamic management treatment plan, the appropriate guideline. Hamilton and necessary use of devices, (NJ): Health Care re-assessments, Association of New implementation, and Jersey (HCANJ). 34 evaluation of treatment plan, p. and fall education/awareness. 2003 Fall Hartford Assess and document all older Kluger, M. (revised Prevention. Institute adult patients for intrinsic risk (2007). Evidence- 2012) Evidence- for factors to fall, and routinely based geriatric based Geriatric for extrinsic risk factors to nursing protocols for Geriatric Nursing fall. Institute corrective action best practice. E. Nursing and perform a post-fall Capezuti, D. Protocols assessment following a fall to Zwicker, M. Mezey, for Best identify possible causes. If T. T. Fulmer, & D. Practice. possible, begin the Gray-Miceli (Eds.). identification of possible Springer Publishing causes within 24 hours of a Company. fall. Due to known incidences of delayed complication of falls, observe all patients for about 48 hours after an observed or suspected fall. 2004 Falls: National Use of case/risk identification, Longton, H. A. D., (revised Assessment Institute multifactorial falls risk Arkut, S., Brown, E. 2013) and for Health assessment, multifactorial C., Gordijn, H., Prevention and Care interventions, strength and Healey, F., of Falls in Excellence balance training, exercise in Jankowski, R., & Older (NICE) extended care settings, home Sahota, O. (2013). People. hazard and safety intervention, Falls: assessment and psychotropic medication prevention of falls in management, cardiac pacing, older and fall education are people. National recommended. Institute for Health and Care Excellence.

Table 2.1 Fall Publication Matrix (continued) Publicat Title Developin Recommendation Summary Citation ion Year g Agency 2012 Prevention U.S. The USPSTF recommends Moyer, V. A. (2012). of Falls in Preventive exercise or physical therapy, Prevention of falls in Community Services and vitamin D community-dwelling -dwelling Task Force supplementation to prevent older adults: US Older falls in community-dwelling Preventive Services Adults: adults aged 65 years or older Task Force U.S. who are at increased risk for recommendation Preventive falls. statement. Annals of Services No single recommended tool internal Task Force or brief approach can reliably medicine, 157(3), Recommen identify older adults at 197-204. dation increased risk for falls, but Statement. several reasonable approaches are available. The USPSTF does not recommend automatically performing an in-depth multifactorial risk assessment in conjunction with comprehensive management. 2016 Prevention Eastern Conditionally Crandall, M., of Fall- Associatio recommends vitamin D and Duncan, T., Mallat, related n for the calcium supplementation, hip A., Greene, W., Injuries in Surgery of protectors, evidence-based Violano, P., the Elderly. Trauma exercise programs, physical Christmas, A. B., & environment modification, and Barraco, R. (2016). frailty screening, and strongly Prevention of fall- recommends risk stratification related injuries in the with targeted, comprehensive elderly: An Eastern risk-reduction strategies. Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery, 81(1), 196-206.

Based upon a number of recommendations, including standards published by the Institute of Medicine (IOM) (Steinberg et al. 2011), clinical practice guidelines involve a best practice approach to construction, which includes a thorough and systematic review of current literature- based evidence, followed by a multidisciplinary guideline construction panel to which the aforementioned evidence has been presented (Hollon et al. 2014). The quality of this process can then be evaluated by six quality domains, which include: (1) scope and purpose, (2) stakeholder involvement, (3) rigor of development, (4) clarity and presentation, (5) applicability, and (6) editorial independence (Brouwers et al. 2010). When constructed appropriately and thereafter utilized, clinical practice guidelines can facilitate consistent decision making (Hollon et al. 2014), evidence-based practice (Stallings et al. 2008), and patient-centered outcomes (Barr et al. 2013).

2.7 Primary care and fall prevention

Primary care, widely considered the foundation of an efficacious healthcare system

(Schoen et al. 2009, Bodenheimer et al. 2014), includes “…family physicians, general internists, geriatricians, general pediatricians, nurse practitioners, and physician assistants”, in addition to

“Nurses, pharmacists, health educators…” and “…medical assistants…” (Bodenheimer and

Pham 2010). Primary care physicians, often treated as a patient’s “gatekeeper” (Gambert 2013), are increasingly required to fulfill a variety of roles and responsibilities centered around first- contact care, continuity of care, comprehensive care, and care coordination (Starfield 1992,

Bodenheimer et al. 2014), and are often tasked with addressing falls and fall-related injury.

Despite the aforementioned practice frequency, as well as the availability of primary care fall interventions, primary care physicians tend to possess poor fall awareness, a lack of fall knowledge, and struggle to assess fall risk (Michael et al. 2010). These trends persist amid a

15 growing body of fall-related clinical practice guidelines (American Geriatrics Society and British

Geriatrics Society 2011, Goodwin et al. 2011), highlighting a disconnect between the growing literature base and clinical practice (Goodwin et al. 2011). And yet, when a fall prevention intervention is integrated into clinical care, primary care physicians provide less than half of the recommended care (Wenger et al. 2009). Barriers to fall prevention strategies have been well documented, and include limited treatment time, a lack of fall knowledge, health status complexity, poor care coordination, and financial constraints (Tinetti et al. 2006, Goodwin et al.

2011). In contrast, those primary care physicians that have successfully implemented fall prevention interventions demonstrate strong leadership and collaborative efforts, promote simplified interventions, present fall prevention program benefits, and gravitate towards an adaptable programmatic approach (Ganz et al. 2008, Goodwin et al. 2011).

2.8 Podiatry and fall prevention

Podiatry, the medical specialty responsible for foot pathology treatment (Farndon et al.

2009), is comprised of podiatrists, or podiatric physicians or surgeons (American Podiatric

Medical Association n.d.) “…with expertise and treatment of pathologies of the structures related to the foot and ankle” (Kim et al. 2012), in addition to structures related to the leg (American

Podiatric Medical Association n.d.). Podiatrists have the opportunity to specialize, and said specializations include sports medicine, surgery, diabetic care, wound care, and pediatrics

(American Podiatric Medical Association n.d.).

A large proportion of the general population will experience foot problems in their lifetime (Farndon et al. 2009), and such conditions can vary considerably. While normally addressing nail, corn, callus, and soft tissue conditions, as well as footwear and overall foot

16 health (Farndon et al. 2009), routine podiatric treatment may include corn and/or nail debridement, or the treatment of plantar fasciitis, tendonitis, sprain, and fracture (Bennett 2012).

With the rising prevalence of diabetes in the United States, podiatrists are increasingly tasked with caring for diabetic foot lesions (Bakker et al. 2012), accounting for more than one-third of the $116 billion spent on direct diabetes care in 2007 (Driver et al. 2010), a figure more recently projected at $176 billion (American Diabetes Association 2013). For many diabetics, foot lesions are characterized by repetitive tissue damage and constant infection (Benotmane et al.

2008).

Peripheral neuropathy, a long-term complication commonly associated with diabetes

(Abbott et al. 2011) that often precipitates diabetic foot lesions (Bakker et al. 2012), is especially concerning for podiatrists, as neuropathy’s nerve fiber dysfunction leads to unnatural gait patterns, or antalgic gait (Lalli et al. 2013), foot ulceration (Elliott et al. 2009), bone deformity

(Fernando et al. 2013), and risk of amputation (Monteiro‐Soares et al. 2012). The chronic insensitivity and foot deformity associated with peripheral neuropathy, coupled with antalgic gait and the resulting ulceration, creates a cycle of subcutaneous hemorrhaging and impaired healing

(Bakker et al. 2012). While the development of peripheral neuropathy is not limited to those with diabetes (Sadowsky et al. 2008), up to 50% of those with diabetes develop peripheral neuropathy, and the various foot-based morbidities associated with peripheral neuropathy lend to an increased risk of fall (Lalli et al. 2013). In fact, diabetic individuals who have developed peripheral neuropathy are twice as likely to fall than those diabetics devoid of peripheral neuropathy (Agrawal et al. 2010).

Despite previous fall prevention protocols (Cockayne et al. 2014, Cockayne et al. 2017), interventions (Spink et al. 2008, Spink et al. 2011, Najafi et al. 2013), and general fall prevention efforts within podiatry (Menz and Hill 2007, Helfand 2007, Ritchie 2014), as well as the inherent fall risk associated with diabetic neuropathy, there are currently no clinical practice guidelines that address fall prevention amongst those 65 years of age and older in a podiatry setting. The aforementioned foot-based risk pathologies, coupled with age-related fall risk factors, present a sizeable public health concern and need to be addressed.

CHAPTER 3

Methods

3.1 Survey content

Survey literature regarding podiatry and podiatry-based fall prevention practices is not well-documented. As such, current survey literature addressing fall knowledge (Peel et al. 2008) and current fall prevention practices among physical therapists (Peel et al. 2008), respectively, as well as fall prevention barriers among physicians (Jones et al. 2011), were adapted to produce a

14-item, 6-construct questionnaire. Developed in Qualtrics, a web-based survey platform, the questionnaire’s 6 constructs consisted of (1) fall prevention knowledge, (2) current fall prevention practices, (3) fall risk factors, (4) fall prevention interventions, (5) fall prevention barriers, and (6) demographic information (Appendix A).

Items were adapted from two previously validated instruments (Peel et al. 2008, Jones et al. 2011) in order to specifically address podiatrists. Additionally, a previously-validated fall knowledge question was amended to address experience (Peel et al. 2008), and a previously- validated question addressing how often patients were asked about fall history was modified to posit patient injuries related to a fall (Peel et al. 2008). Two current fall practices response categories were modified from “Almost never or never” to “Never” and “Almost always or always” to “Always”, and a fall risk factor ranking question was omitted (Peel et al. 2008). A follow-up podiatrist-estimated patient fall frequency question, an open-ended question

19 regarding opportunities associated with a fall prevention intervention, and a demographic question concerning age, were also created and included. The question, “On average, how many hours each week do you spend treating adults 65 years of age and older?”, was modified to “On average, what percentage of your practice is spent treating adults 65 years of age and older?”. In light of previous findings regarding response quality and open-ended questions (Symth et al.

2009), all open-ended questions were provided with large answer boxes and the following motivational que: “You are not limited in the length of your response by the size of the box”.

3.2 Survey population

As the aim of this study is to inform a clinical practice guideline for podiatry-based fall prevention practices, the survey population consisted of currently practicing podiatrist members of the American Podiatric Medical Association, a leading resource for foot and ankle health, as well as alumni from Kent State University’s College of Podiatric Medicine, one of nine accredited podiatry schools in the United States. Collectively, the two podiatry organizations presented a potential survey audience of more than 21,000 currently practicing podiatrists.

Given the point estimate sufficiency of 30 representative participants for the purposes of a pilot study addressing preliminary survey development (Johanson and Brooks 2010), it was reasonable to assume that the sample size would be adequately powered.

3.3 Survey data collection

Based upon the documented efficacy of mixed-mode survey collection (Scott et al. 2011), as compared to traditional mail surveys (Greenlaw and Brown-Welty 2009) and online survey collection (Cho et al. 2013), as well as the inherent cost savings associated with online survey collection (Scott et al. 2011), a mixed-mode survey methodology was employed. Following IRB

20 approval from Kent State University, a convenience sample list-based solicitation approach was utilized, consisting of an introductory email, endorsed by Kent State University’s College of

Podiatric Medicine, Kent State University’s College of Public Health, and the American

Podiatric Medical Association. The survey was distributed to currently practicing podiatrist members of the American Podiatric Medical Association, and currently practicing podiatrist alumni from Kent State University’s College of Podiatric Medicine. Each distribution was separate, and introductory email content was amended to fit the unique context of the American

Podiatric Medical Association and Kent State University’s College of Podiatric Medicine, respectively.

Following a study introduction, a request to complete the questionnaire, and a questionnaire expiration date, an embedded link to the electronic version of the questionnaire was included in the email. Additionally, detailed instructions for those who would prefer a mailed questionnaire were provided. This mixed-mode methodology represents a concurrent mixed-mode approach, as both modes, or survey distribution options, were offered simultaneously (De Leeuw and Dillman 2008). Concurrent mixed-mode survey methodologies have been documented preferably amongst physicians, given the assumption that their ability to choose a preferred response mode is important (McMahon et al. 2003, Vangeest et al. 2007,

Scott et al. 2011).

The subsequent methodology has been previously documented to “…increase response rates and sample representativeness, decrease nonresponse bias, increase coverage of the target population or subgroups, reduce measurement error, and reduce costs” (De Leeuw 2005, Beebe et al. 2007, Dykema et al. 2013). Alternatively, conflicting literature reports the enhanced potential for measurement error, as the characteristics and response patterns of those

21 administered an online survey may differ from those administered a mailed paper survey, and thus act as a confounder (De Leeuw and Dillman 2008); the following dichotomy was noted as a potential limitation prior to survey distribution. As such, a dataset variable was included to indicate whether survey responses were produced by either a mail or online survey, such that differences between respondent types could be analyzed. While the use of an electronic/mail survey design was employed here to reduce costs, mail/electronic survey designs are associated with higher response rates (Beebe et al. 2007, Converse et al. 2008, Stevenson et al. 2011,

Dykema et al. 2013), and this design selection was also noted as a potential limitation.

The electronic questionnaires remained active for 30 days, and mailed questionnaires with return postmarks dated within 30 days of the initial email introduction were accepted and included in the data analysis. The aforementioned data collection period was based upon a similar, previously documented mixed-method physician survey approach (Beebe et al. 2007).

In order to increase response rate, a total of two electronic reminders (Cho et al. 2013) to complete the questionnaire were proposed to both the American Podiatric Medical Association and Kent State University’s College of Podiatric Medicine, to be distributed in two, two-week

(14 day) intervals, based upon the initial distribution date.

Identifiable information was not actively collected; mailed questionnaires were to be separated from their addressed envelopes, and the latter shredded and discarded. All electronic questionnaire responses were de-identified, and any Qualtrics-based IP linking addresses were removed. Electronic responses were stored on a password-protected, Kent State University server, in a password-protected file folder, and accessed only by a password-protected, university-owned computer. Mailed responses, once separated from their corresponding addressed envelopes, were to be stored in a locked filing cabinet, located in an on-campus office.

3.4 Survey burden

The Qualtrics-estimated response time for completion of the 14-item questionnaire was six minutes.

3.5 Survey incentive

While completion of the questionnaire was voluntary, a monetary incentive, in the form of a lottery for four $250 gift cards, was linked to the completion of each questionnaire, as the association between monetary incentive and increased survey response rate has been well- documented (Göritz 2006, VanGeest et al. 2007, Cho et al. 2013, Sauermann and Roach 2013).

In order to provide this incentive, a total of $1,000 was secured from the College of Public

Health. Mailed incentives were not linked, in any way, to questionnaire responses.

3.6 Data analysis

Seven separate analyses were performed for research questions #1 through #7, and research question #8, “What are podiatrists’ recommendations for the prevention of falls among those podiatric patients 65 years of age and older?”, was addressed by way of a post-survey focus group, which is outlined later. All tests were two-tailed, and data was analyzed in SPSS v.22. Statistical significance was assigned a priori, with an alpha level of α = 0.05. Quantitative statistical analysis consisted primarily of chi-square and descriptive statistics techniques, and qualitative data analysis methods were based upon a previously documented methodology of theme identification (Yang et al. 2015).

3.7 Focus group

A focus group of currently practicing podiatrists was facilitated by the Kent State

University College of Podiatric Medicine. Following an introduction of the moderator, the voluntary nature of the focus group was explained, and those who wished to participate were asked to sign an informed consent form. Thereafter, an oral and PowerPoint presentation of the survey results was utilized to prompt focus group discussion regarding the fall knowledge of currently practicing podiatrists, current fall prevention practices, and the characteristics associated with podiatrists that provided a fall prevention intervention. A discussion guide built upon the respective study’s research questions was utilized to facilitate discussion (Appendix B), and probing questions were employed when discussion was halted, or responses proved incomplete or unclear.

The focus group was recorded for transcription purposes only, and no personal identifiers were collected or maintained. Following the audio transcription, recurrent themes were identified (Yang et al. 2015), vetted according to the context of the statement (Bazeley 2009), organized according to both theme and respondent frequency (Schilling 2009), and accompanied by exemplary theme quotations (Anderson 2010).

CHAPTER 4

Findings

4.1 Survey distribution

4.1.1 The American Podiatric Medical Association

The mixed-mode survey design was administered by the American Podiatric Medical

Association, and was distributed to 12,371 members on July 20, 2017; the survey remained active until August 19, 2017, for a total of 30 days. Despite requests for the American Podiatric

Medical Association to distribute survey reminders on both August 3 and August 17, 2017, respectively, one reminder to complete the survey was distributed to the aforementioned recipients on July 25, 2017, and both the initial and reminder distributions, respectively, were embedded in an American Podiatric Medical Association newsletter. During the survey distribution period, a total of 92 Qualtrics-based responses were recorded. While one potential participant requested a paper questionnaire, it was not completed and returned. Given the potential sample size, a response rate of 0.7% was observed.

4.1.2 Kent State College of Podiatric Medicine

A second survey distribution was administered by Kent State University’s College of

Podiatric Medicine, and was distributed to 3,057 College of Podiatric Medicine alumni

25 on September 20, 2017. The subsequent distribution was active until October 20, 2017, for a total of 30 days, and was distributed via a College of Podiatric Medicine-endorsed email outlining the study. During the survey distribution period, a total of 201 Qualtrics-based responses were recorded. Paper questionnaires were not requested during this time, and despite requests for the distribution of two survey reminders, no survey reminders were distributed by the College of Podiatric Medicine. Given the potential sample size, a response rate of 6.6% was observed.

4.2 Survey respondent demographics

Respondents were primarily male (74.3%) and 53.5 years of age, had 24.3 years of experience as a practicing podiatrist, and spent 30.7 hours per week in direct patient care. On average, respondents indicated that 51.6% of their practice was spent treating adults 65 years of age and older. Respondents characterized their podiatry specialty as general care (42.3%), specialty care (25.7%), surgery (23.4%), and sports medicine/biomechanics (8.6%).

4.3 Research question 1

What are podiatrists’ current knowledge of falls and fall prevention?

Of those whom responded, 46.8% indicated they were “Very knowledgeable” regarding specific risk factors for falls in adults 65 years of age and older, while another 46.8% indicated they had “Some knowledge” of falls, collectively representing the majority (93.6%) of respondents (Table 4.1). Conversely, 5.4% of respondents indicated they had “Little knowledge”, and 1.1% indicated “No knowledge” of fall risk factors, respectively (Table 4.1).

Table 4.1 Fall Knowledge

Knowledge Level N (%) “Very knowledgeable” 130 46.8 “Some knowledge” 130 46.8 “Little knowledge” 15 5.4 “No knowledge” 3 1.1

Upon recoding “Very knowledgeable” into “High knowledge”, and “Some knowledge”,

“Little knowledge” and “No knowledge” into “Less knowledge”, 46.8% of respondents indicated

“High knowledge”, while 53.2% of respondents indicated “Less knowledge” (Table 4.2).

Table 4.2. Fall Knowledge (recoded)

Knowledge Level N (%) High knowledge 130 46.8 Less knowledge 148 53.2

With reference to podiatrist gender, 46.8% of male respondents and 44.2% of female respondents indicated a high knowledge of falls (Table 4.3).

Table 4.3 Fall Knowledge and Sex

N Male (%) Female (%) Chi-square df p High 106 46.8 44.1 .130 1 .718 Knowledge Less 124 53.2 55.9 Knowledge

Fall knowledge was significantly associated with podiatry specialty (p = 0.004); as such, both surgery (61.5%) and specialty care (56.1%) indicated high fall knowledge, while sports medicine/biomechanics (73.7%) and general (62.8%) indicated less fall knowledge (Table 4.4).

Table 4.4 Fall Knowledge and Podiatry Specialty

Podiatry Specialty (%)

Fall N General Surgery Sports Medicine/ Specialty Chi- df p Knowledge Biomechanics Care square High 104 37.2 61.5 26.3 56.1 13.189 3 .004 Knowledge Less 118 62.8 38.5 73.7 43.9 Knowledge

Fall knowledge was also significantly associated with asking about falls (p < 0.001;

Table 4.8). Of those respondents that asked about falls, 73.6% indicated a high knowledge of falls, while 55.4% reported less fall knowledge, and did not ask about falls (Table 4.8).

4.4 Research question 2

What are the characteristics of podiatrists that ask about falls amongst those podiatric patients 65 years of age and older?

More than half of respondents (58.6%) indicated that they asked podiatry patients 65 years of age and older about falls (Table 4.5).

Table 4.5 Asking about falls

Asked about Falls N (%) Yes 147 58.6 No 104 41.1

A statistically significant relationship between podiatrist gender and asking podiatry patients about falls was identified (p < 0.001), as 81.4% of female and 51.5% of male respondents, respectively, indicated that they asked their patients about falls (Table 4.6).

Table 4.6 Asking about Falls and Sex

Asked N Male (%) Female (%) Chi-square df p about Falls Yes 136 51.5 81.4 16.221 1 <.001 No 94 48.5 18.6

While no significant differences were identified between podiatrist age, hours spent in direct patient care, and percentage of practice spent treating podiatry patients 65 years of age and older, podiatry specialty (p = 0.026; Table 4.7) and fall knowledge (p < 0.001; Table 4.8) largely affected whether a respondent asked about falls.

Specialty care (73.7%), sports medicine/biomechanics (63.2%), and surgery (61.5%) specialties asked about falls most often, while general care podiatrists (48.9%) asked about falls just short of half the time (Table 4.7).

Table 4.7 Asking about Falls and Podiatry Specialty

Podiatry Specialty (%)

Asked N General Surgery Sports Medicine/ Specialty Chi- df p about Falls Biomechanics Care square

Yes 132 48.9 61.5 63.2 73.7 9.304 3 .026 No 90 51.1 38.5 36.8 26.3

Those podiatrists that asked about falls reported a significantly higher knowledge of falls

(p < 0.001) than those that reported less knowledge; 73.6% of respondents that indicated high fall knowledge asked about falls, while 55.4% of those reporting less knowledge did not ask about falls (Table 4.8).

Table 4.8 Asking about Falls and Fall Knowledge

Fall Knowledge (%)

Asked about N High Less Chi-square df p Falls Yes 147 73.6 44.6 21.627 1 <.001 No 104 26.4 55.4

4.5 Research question 3

What are the characteristics of podiatrists that identify fall risk factors amongst those podiatric patients 65 years of age and older?

In total, more than half of respondents (55.2%) indicated identifying fall risk factors

(Table 4.9). Fall knowledge (p < 0.001; Table 4.10), podiatry specialty (p = 0.001; Table 4.11), and asking about falls (p < 0.001; Table 4.11) were significantly associated with identifying fall risk factors.

Table 4.9 Identifying Risk Factors for Falls

Identified Risk N (%) Factors for Falls

Yes 137 55.2 No 111 44.8

Of those respondents that identified fall risk factors, 74.2% reported a high fall knowledge; inversely, more than half of respondents that did not identify fall risk factors reported less fall knowledge (62.5%; Table 4.10).

Table 4.10 Identifying Risk Factors for Falls and Fall Knowledge

Fall Knowledge (%)

Identified N High Less Chi-square df p Risk Factors for Falls Yes 137 74.2 37.5 33.678 1 <.001 No 111 25.8 62.5

The relationship between identifying fall risk factors and podiatry specialty was also statistically significant (p = 0.001), and specialty care (71.9%), surgery (64.0%), and sports medicine/biomechanics (57.9%) reported identifying fall risk factors most often; general podiatrists identified fall risk factors less than half of the time (39.4%; Table 4.11).

Table 4.11 Identifying Risk Factors for Falls and Podiatry Specialty

Podiatry Specialty (%)

Identified N General Surgery Sports Medicine/ Specialty Chi- df p Risk Biomechanics Care square Factors for Falls Yes 121 39.4 64.0 57.9 71.9 17.590 3 .001 No 99 60.6 36.0 42.1 28.1

Concurrently, identifying fall risk factors and asking about falls were significantly related

(p < 0.001), as 73.8% of those respondents that asked about falls also identified fall risk factors

(Table 4.12). Similarly, 70.9% of those respondents that did not ask about falls did not identify fall risk factors (Table 4.12).

Table 4.12 Identifying Risk Factors for Falls and Asking about Falls

Asked about Falls (%)

Identified N Yes No Chi-square df p Risk Factors for Falls Yes 137 73.8 29.1 48.594 1 <.001 No 111 26.2 70.9

4.6 Research question 4

What are the characteristics of podiatrists that document fall risk factors amongst those podiatric patients 65 years of age and older?

Less than half (47.8%) of respondents indicated that they documented fall risk factors

(Table 4.13). Fall knowledge (p < 0.001; Table 4.14), asking about falls (p < 0.001; Table 4.15), podiatry specialty (p = 0.012; Table 4.16), and identifying fall risk factors (p < 0.001) were significantly associated with documenting fall risk factors amongst podiatric patients 65 years of age and older.

Table 4.13 Documenting Fall Risk Factors

Documented Fall Risk N (%) Factors

Yes 118 47.8 No 129 52.2

Roughly two-thirds (65.5%) of those respondents that reported high fall knowledge documented fall risk factors, while 68.7% of those respondents that reported less fall knowledge did not document fall risk factors (Table 4.14).

Table 4.14 Documenting Fall Risk Factors and Fall Knowledge

Fall Knowledge (%)

Documenting N High Less Chi-square df p Fall Risk Factors Yes 118 65.5 31.3 29.072 1 <.001 No 129 34.5 68.7

More than two-thirds of respondents (68.3%) that asked about falls also documented fall risk factors, while 81.4% of those respondents that did not ask about falls did not document fall risk factors (Table 4.15).

Table 4.15 Documenting Fall Risk Factors and Asking about Falls

Asked about Falls (%)

Documenting N Yes No Chi-square df p Fall Risk Factors Yes 118 68.3 18.6 59.157 1 <.001 No 129 31.7 81.4

Respondents that documented fall risk factors predominately reported podiatry specialties in surgery (60.0%) and specialty care (57.9%), while sports medicine/biomechanics (36.8%) and general specialties (36.6), respectively, documented fall risk factors less than half of the time

(Table 4.16).

Table 4.16 Documenting Fall Risk Factors and Podiatry Specialty

Podiatry Specialty (%)

Documenting N General Surgery Sports Medicine/ Specialty Chi- df p Fall Risk Biomechanics Care square Factors Yes 104 36.6 60.0 36.8 57.9 10.932 3 .012 No 115 63.4 40.0 63.2 42.1

Table 4.17 Documenting Fall Risk Factors and Identifying Fall Risk Factors

Identifying Fall Risk Factors (%)

Documenting N Yes No Chi- df p Fall Risk square Factors Yes 118 71.3 19.1 66.475 1 <.001 No 129 28.7 80.9

4.7 Research question 5

What are the characteristics of podiatrists that refer podiatry patients 65 years of age and older to fall professionals?

41.8% of respondents provided a fall referral, while the remaining 58.2% did not (Table 4.18).

Table 4.18 Providing a Fall Referral

Providing a Fall N (%) Referral

Yes 104 41.8 No 145 58.2

Respondents that referred podiatry patients 65 years of age and older to fall professionals displayed high fall knowledge (p < 0.001; Table 4.19), asked about falls (p < 0.001; Table 4.20), identified a podiatry specialty (p = 0.048; Table 4.21), identified fall risk factors (p < 0.001;

Table 4.22), and documented fall risk factors (p < 0.001; Table 4.23).

About half (54.2%) of those respondents indicating high fall knowledge provided a fall referral, while 69.8% of respondents reporting less fall knowledge did not provide a fall referral

(Table 4.19).

Table 4.19 Fall Referral and Fall Knowledge

Fall Knowledge (%)

Fall N High Less Chi-square df p Referral Yes 104 54.2 30.2 14.642 1 <.001 No 145 45.8 69.8

Respondents that performed a fall referral asked about falls 57.5% of the time, while

80.6% of those respondents that did not provide a fall referral did not ask about falls (Table

4.20).

Table 4.20 Fall Referral and Asking about Falls

Asked about Falls (%)

Fall Referral N Yes No Chi-square df p Yes 104 57.5 19.4 36.076 1 <.001 No 145 42.5 80.6

Respondents that indicated a podiatry specialty of specialty care referred patients 50.9% of the time, while surgery (49%) and sports medicine/biomechanics (47.4%) provided fall

35 referrals less than half of the time (Table 4.21). General podiatrists provided fall referrals roughly one-third of the time (30.9%; Table 4.21).

Table 4.21 Fall Referral and Podiatry Specialty

Podiatry Specialty (%)

Fall N General Surgery Sports Medicine/ Specialty Chi- df p Referral Biomechanics Care square Yes 92 30.9 49.0 47.4 50.9 7.904 3 .048 No 129 69.1 51.0 52.6 49.1

Respondents that identified fall risk factors provided fall referrals less than half the time

(40.9%) of the time, while those that did not identify fall risk factors did not provide fall referrals

80.2% of the time (Table 4.22).

Table 4.22 Fall Referral and Identifying Fall Risk Factors

Identified Fall Risk Factors (%)

Fall Referral N Yes No Chi- df p square Yes 137 40.9 19.8 39.009 1 <.001 No 111 59.1 80.2

More than half (66.1%) of respondents that documented fall risk factors also provided a fall referral, while those respondents that did not document fall risk factors provided a fall referral less than a quarter of the time (20.2; Table 4.23).

Table 4.23 Fall Referral and Documenting Fall Risk Factors

Documented Fall Risk Factors (%)

Fall Referral N Yes No Chi- df p square Yes 118 66.1 20.2 53.371 1 <.001 No 129 33.9 79.8 4.8 Research question 6

What are the characteristics of podiatrists that provide a fall prevention intervention to those podiatric patients 65 years of age and older?

Roughly one-third (31.8%) of respondents indicated providing a fall intervention, while the remaining 68.2% did not (Table 4.24).

Table 4.24 Providing a Fall Intervention

Providing a Fall N (%) Intervention

Yes 74 31.8 No 159 68.2

Respondents that provided a fall intervention reported high fall knowledge (p < 0.001;

Table 4.25), asked about falls (p < 0.001; Table 4.26), identified fall risk factors (p < 0.001;

Table 4.27), documented fall risk factors (p < 0.001; Table 4.28), provided a fall referral (p <

0.001; Table 4.29), spent hours in direct patient care (p = 0.019; Table 4.30), and indicated a specific podiatry specialty (p = 0.033; Table 4.31).

Roughly half (45.5%) of respondents indicating high fall knowledge provided a fall intervention, while the remaining 54.5% of respondents indicating high fall knowledge did not;

81.0% of respondents indicating less fall knowledge did not provide a fall intervention (Table

4.25).

Table 4.25 Providing a Fall Intervention and Fall Knowledge

Fall Knowledge (%)

Providing a N High Less Chi-square df p Fall Intervention Yes 74 45.5 19.0 18.885 1 <.001 No 159 54.5 81.0

Less than half (47.1%) of respondents that asked about falls provided a fall intervention, while the remaining 52.9% did not; 91.4% of respondents that did not ask about falls did not provide a fall intervention (Table 4.26).

Table 4.26 Providing a Fall Intervention and Asking about Falls

Asked about Falls (%)

Providing a N Yes No Chi-square df p Fall Intervention Yes 74 47.1 8.6 38.298 1 <.001 No 159 52.9 91.4

Of those respondents that identified fall risk factors, 50.0% provided a fall intervention, while the remaining 50.0% did not; 93.0% of those respondents that did not identify fall risk factors did not provide a fall intervention (Table 4.27).

Table 4.27 Providing a Fall Intervention and Identifying Fall Risk Factors

Identified Fall Risk Factors (%)

Providing a N Yes No Chi- df p Fall square Intervention Yes 73 50.0 7.0 48.784 1 <.001 No 159 50.0 93.0

Just more than half (54.9%) of respondents that documented fall risk factors also provided a fall intervention, while 89.8% of those respondents that did not document fall risk factors did not provide a fall intervention (Table 4.28).

Table 4.28 Providing a Fall Intervention and Documenting Fall Risk Factors

Documented Fall Risk Factors (%)

Providing a N Yes No Chi- df p Fall square Intervention Yes 74 54.9 10.2 52.968 1 <.001 No 157 45.1 89.8

More than half (64.3%) of respondents that provided a fall referral also provided a fall intervention, while 91.9% of those respondents that did not provide a fall referral did not provide a fall intervention (Table 4.29).

Table 4.29 Providing a Fall Intervention and Providing a Fall Referral

Providing a Fall Referral (%)

Providing a N Yes No Chi- df p Fall square Intervention Yes 74 64.3 8.1 82.565 1 <.001 No 159 35.7 91.9

Of those respondents that indicated spending 51 to 75 hours and 76 to 100 hours each week in direct patient care, 62.5% and 100.0%, respectively, reported providing a fall intervention, and this trend declined with decreasing weekly hours in direct patient care, as those spending 26 to 50 hours provided a fall intervention 31.7% of the time, and respondents spending 1 to 25 hours provided a fall intervention 24.5% of the time (Table 4.30).

Table 4.30 Providing a Fall Intervention and Hours Each Week in Direct Patient Care

Hours Each Week in Direct Patient Care (%)

Providing a N 1-25 26-50 51-75 76-100 Chi- df p Fall Hours Hours Hours Hours square Intervention Yes 65 24.5 31.7 62.5 100.0 11.159 3 .011 No 138 75.5 68.3 37.5 0

Respondents that indicated a podiatry specialty in specialty care and surgery provided a fall intervention 45.3% and 40.0% of the time, respectively, while sports medicine/biomechanics

(25.0%) and general podiatrists (23.6%) provided a fall intervention less than one-third of the time (Table 4.31).

Table 4.31 Providing a Fall Intervention and Podiatry Specialty

Podiatry Specialty (%)

Providing a N General Surgery Sports Medicine/ Specialty Chi- df p Fall Biomechanics Care square Intervention Yes 69 23.6 40.0 25.0 45.3 8.722 3 .033 No 139 76.4 60.0 75.0 54.7

4.9 Research question 7

What barriers do podiatrists foresee pertaining to the prevention of falls among those podiatric patients 65 years of age and older?

Respondents were presented with a number of fall prevention barriers, and asked: “Do you experience any of the following barriers when providing a fall prevention intervention”.

These items were coded dichotomously (yes/no), and a frequency analysis identified an agreement high of 48.9% (“Patients do not feel they are at risk for a fall”), and a low of 18.6%

(“Too complex to address in one office visit”) (Table 33). “Patients have more pressing issues”

(32.0%), “I do not have enough time” (27.3%), and “Lack of podiatry training” (26.4%) were similarly grouped (Table 33). Chi-square was utilized to compare each barrier to whether a fall prevention intervention was delivered (yes/no), and no statistically significant relationships were identified.

Table 4.32 Fall Prevention Barriers Barrier N (%) “Patients do not feel they 113 48.9 are at risk for a fall” “Lack of educational 95 41.1 materials” “Patients have more 74 32.0 pressing issues” “I do not have enough time” 63 27.3 “Lack of podiatry training” 61 26.4 “Lack of podiatry referral 57 24.7 resources” “Too complex to address in 43 18.6 one office visit”

4.10 Research question 8

What are podiatrists’ recommendations for the prevention of falls among those podiatric patients

65 years of age and older?

On November 17, 2017, a focus group of currently practicing podiatrists was held at the

Kent State College of Podiatric Medicine. A total of nine podiatrists, collectively representing academic, inpatient, and outpatient-based podiatry subsets, respectively, participated in the focus group, and discussion lasted roughly 40 minutes. Survey results were presented to the focus group participants, and particular focus was given to the linear relationship between (1) knowledgeable podiatrists that (2) ask about falls, (3) identify and (4) document fall risk factors,

(5) refer to other healthcare professionals, and those that (6) provide a fall prevention intervention; this relationship, within the context of the study’s eight research questions, was used to drive the focus group discussion. Of the nine focus group participants, one individual

(Respondent 9; Appendix I) opted not to actively contribute to the discussion. The focus group

42 dialogue was audio recorded and transcribed; the resulting themes were identified, organized according to frequency, and included:

1. Collation of fall-related symptoms, or “triggers”:

a. “…I think that a lot of us in podiatry are probably comfortable because we talk

about things like gait, and then I think there’s a trigger, so there is something that

we always need to ask patients about, and there is maybe some of that knowledge

part of where do we go from here” (Appendix I; Page 98).

2. Creation of a structured fall referral process:

a. “The question then becomes what is the referral process? Is it self-referral,

because you can prevent falls with an AFO, is it referral to an urologist, is it

referral to podiatry, is it physical therapy?” (Appendix I; Page 95).

3. The addition of fall-related content to the current podiatry curriculum.

a. “Look at the residency documents; there is nothing in there that relates to that

(falls), and as a requirement, and then the question that I would ask here is in our

curriculum, do we have an identifiable segment on the importance of falls?”

(Appendix I; Page 93).

4. Opposition to a podiatry-specific fall checklist.

a. “I think that most podiatrists now would be a little bit irritated with the idea of

following a checklist” (Appendix I; Page 100).

5. Creation of a financial incentive for podiatrists to ask patients about falls.

a. “…if there was some level of compensation for that extra added time that it does

take to do that, that might be enough (of a) motivating factor right there to balance

that number out” (Appendix I; Page 102).

6. Creation of a podiatry-specific fall risk decision tree.

a. “I don’t know if you need a checklist, but it sounds like a decision tree or

something, sort of what you are saying, and so I think that might be helpful, at

least when people are in the student population, and (for) new residents…”

(Appendix I; Page 100).

7. Custom orthotics.

a. “One is custom orthotics, but probably more depending on the exact cause of the

imbalance; it’s just that custom orthotics work pretty darn well…” (Appendix I;

Page 105).

CHAPTER 5

Discussion, limitations, and implications

5.1 The fall knowledge continuum and providing a fall intervention

The linear, stepwise relationship between (1) podiatrists with fall-related knowledge pertaining to those 65 years of age and older, that (2) ask about falls, (3) identify and (4) document fall risk factors, (5) refer to other healthcare professionals, and ultimately (6) provide a fall prevention intervention, is arguably the seminal finding of the two respective podiatry surveys. Regardless of sex, years of experience as a podiatrist, percentage of practice treating adults 65 years of age and older, and reported fall intervention barriers, those podiatrists that indicated high knowledge of falls ultimately took the necessary action steps to provide a fall intervention (Figure 5.1), a process that, as stated previously, began by asking their respective patient(s) about falls.

Figure 5.1 The Impact of Fall Knowledge

With these considerations in mind, only 46.8% of survey respondents indicated that they had a high knowledge of falls. Of this 46.8%, those podiatrists with specialized training, such as surgery and specialty care, indicated higher fall knowledge than their general and sports medicine/biomechanics peers, despite 62.2% of general specialties indicating that a large percentage of their practice (51% to 100%) was spent treating podiatry patients 65 years of age and older, which was greater than both surgery (40.8%) and sports medicine/biomechanics

(42.1%), but less than specialty care (69.7%; p = 0.005). Moreover, 51.6% of general specialty respondents indicated considerable podiatry practice experience (28 to 55 years), which was just less than surgery (51.9%), but notably greater than both sports medicine/biomechanics (42.1%) and specialty care (28.1%; p = 0.037).

Approximately three-quarters (73.6%) of the 46.8% of respondents reporting high fall knowledge asked about falls (p < 0.001), ultimately resulting in the pathway illustrated in Figure

2. Of the 73.6% of respondents who asked about falls, 73.8% identified fall risk factors (p <

0.001), and 71.3% of those that identified fall risk factors (74.2%) also documented fall risk factors (p < 0.001; Figure 2). Concurrently, 66.1% of respondents that documented fall risk factors (65.5%) provided a fall referral, and 64.3% of those that provided a fall referral (54.2%) provided a fall intervention (p < 0.001; Figure 5.2).

Figure 5.2 The Fall Knowledge Continuum

These relationships reaffirm the hierarchical importance of fall knowledge, and suggest that specialized podiatry training, and not years of experience or clinical activity, drive improved fall-related outcomes, as evidenced by higher fall knowledge and greater propensity to ask about falls, and thus provide a fall intervention, amongst surgical and specialty care specializations. In parallel to the fall-related efforts outlined in Section 2.7, primary care physicians are often perceived as the foundation of a quality healthcare system (Schoen et al. 2009, Bodenheimer et al. 2014), have access to a growing body of clinical practice guidelines (American Geriatrics

Society and British Geriatrics Society 2011, Goodwin et al. 2011), and often integrate fall prevention strategies into regular clinical care. Despite these clinical supports, a lack of fall knowledge persists (Tinetti et al. 2006, Goodwin et al. 2011), resulting in less than half of the recommended care (Wenger et al. 2009). This distinction points to the dangers of directing clinical practice ahead of the respective provider knowledge base, as the mere availability of fall- related tools and recommendations does not ensure their use.

Furthermore, this finding could potentially suggest a level of curriculum or scope of practice indoctrination amongst long-practicing general podiatrists, a concept of which has been previously documented in the context of medical curriculum (Cartwright et al. 1992), or an otherwise medical avoidance of “the elephant in the room” (Souba et al. 2011). In either case, expanded dialogue regarding the significance of falls amongst podiatry patients 65 years of age and older, in tandem with a shift in fall-related podiatry education, may facilitate increased fall awareness, thus reinforcing fall-related clinical behavior and environment (Prochaska 2013).

Given the variety of fall-related pathologies podiatrists are tasked with treating (Spink et al. 2011), coupled with the fall risk factors associated with those 65 years of age and older (Peel

2011), and the consistent clinical behavior compelled by a clinical practice guideline, these

49 results warrant an increased focus on podiatrist fall knowledge, and prompt the following curriculum and continuing education recommendations.

5.2 The Addition of fall-related content to the current podiatry curriculum

The lack of geriatric-specific competencies has been previously documented in U.S. medical training (Rowe 2008, Leipzig et al. 2009; Oakley et al. 2014), and a number of these competencies pertain to the identification, and subsequent treatment of, fall risk factors identified in this study. As a result, fall assessments performed by medical students are often subpar (Sutin et al. 2011) and incomplete (Rolita et al. 2009). Similar undertones were also expressed during the podiatry focus group, as evident from the following excerpts:

 “The typical neurological exam outside of practice is ‘do you feel this?’, ‘yes’; you’re not

going to pick up much with that. I know that because when students come back in, I’m

saying ‘you didn’t do it all’; you need a couple more things here. And it could even be

more extensive than that, but I think if I look at a physical examination alone, that is

probably the place where people seem to skip things, and that could pick up more people

who are at risk for falls” (Appendix I; Page 105).

 “Generally, I don’t think that we screen, maybe in geriatrics but not internal medicine,

you know, for falls, unless somebody presents with a fall, then we ask…tell me about

what’s at home…” (Appendix I; Page 107).

In order to combat the aforesaid practice gaps, a number of medical programs have integrated geriatric and fall-related content into their curriculum, and with positive result (Nanda et al. 2013, Yanamadala et al. 2016). While a number of effective medical curriculum types have been identified, the efficacies of competency-based (Lobst et al. 2010), evidence-based

(West and McDonald 2008), and simulation-based (McGaghie et al. 2011) curriculums in increasing medical student knowledge have been well documented and advocated for (Frank et al. 2010, Englander et al. 2013).

It has been clearly documented that said shifts in the medical curriculum can directly affect clinical focus and practice, and validation of this relationship can be exemplified by the substantial growth in palliative care over the past two decades. In 2002, considerable shortcomings regarding palliative care knowledge and curriculum, respectively, were identified

(Block 2002). Following the enhancement of educational resources, faculty development, clinical programs, textbook modification, and fellowship training opportunities, palliative care has since transformed into a robust clinical specialty (Block 2002), characterized by new care- delivery models, payment mechanisms, and both clinical and nonclinical awareness (Kelley and

Morrison 2015).

As such, it is advisable that evidence-based, competency-based, and/or simulation-based fall curriculum, pertaining to falls amongst those 65 years of age and older, be integrated into the current podiatry curriculum, mirroring the aforesaid palliative care example with the enhancement of educational resources, faculty development, clinical programs, textbook modification, and fellowship training opportunities (Block 2002). Additionally, this integration should be facilitated by national podiatry organizations, such as the American Podiatric Medical

Association, the Council on Podiatric Medical Education, the American College of Foot

Orthopedics and Medicine, and the American Association of Colleges of Podiatric Medicine.

The dissemination of developed curriculums should then be directed to accredited podiatry schools for further review and input, including, but not limited to: the Barry University School of

Podiatric Medicine, the California School of Podiatric Medicine at Samuel Merritt University,

Des Moines University College of Podiatric Medicine and Surgery, Kent State University

College of Podiatric Medicine, Midwestern University Arizona School of Podiatric Medicine,

New York College of Podiatric Medicine, Dr. William M. Scholl College of Podiatric Medicine,

Temple University School of Podiatric Medicine, and Western University of Health Sciences

College of Podiatric Medicine. This top-down approach to fall-related podiatry curriculum enhancement may help to promote consistent national adoption, program buy-in, and likewise prevent regional, state, and/or local educational silos.

5.3 Increased fall-related continuing education

While the addition of fall-related curriculum is beneficial to current podiatry students, it does little to impact the fall knowledge, and subsequent fall practices, of currently practicing podiatrists. In order to bridge this gap, continuing education that expands upon the intersection of podiatry and the fall-related pathologies associated with podiatry patients 65 years of age and older is recommended. Support for continuing education was also expressed during the podiatry focus group, and is evident from the following excerpt:

 “…we did a couple posters at Kent, and one of them was, uh, it was at one of the

aging seminars and they just asked people to recognize, you know what a bunion

(is), a hammer toe, do you recognize this, and you’d be surprised how many

people had no clue, and these are the people that are working with the aging all

the time…” (Appendix I; Page 104).

The efficacy of continuing medical education has been widely recognized (Cervero and

Gaines 2014), and is particularly useful in combatting the natural decline in clinical performance over time (Glasziou et al. 2008), positively impacting both physician and patient outcomes

(Cervero and Gaines 2014). In the wake of an ever-increasing medical research publication rate of roughly 86 peer-reviewed manuscripts per day (Bastian et al. 2010), continuing education also provides an opportunity to introduce, or regularly update, clinicians on new medical findings, publications, and methodologies.

In order to effectively position the initiation and construction of said podiatry-focused continuing education pertaining to falls amongst those 65 years of age and older, the sponsorship of interactive, educational meetings, such as courses, conferences, lectures, workshops, seminars, or symposiums (Forsetlund et al. 2008), sponsored by national podiatry organizations such as the

American Podiatric Medical Association, the Council on Podiatric Medical Education, the

American College of Foot Orthopedics and Medicine, and the American Association of Colleges of Podiatric Medicine (in continuum with Section 5.1.1), are recommended.

5.4 Fall referrals, fall screening tools, and continuity of care

The complexities and challenges associated with connecting primary and specialized medical care, respectively, have been well documented (Pham et al. 2009, O’Malley and

Reschovsky 2011, Tuot et al. 2015). Characterized by a fragmented healthcare system (Pham et al. 2009) and nonexistent and/or inconsistent referral mechanisms (Aragam et al. 2015), “there are breakdowns and inefficiencies in all components of the specialty-referral process” (Mehrotra et al. 2011), and the aforementioned shortfalls make patient referrals to the appropriate provider increasingly challenging (Bodenheimer 2009). Adding another layer of complexity to the referral process is the lack of reliable fall screening mechanisms to “trigger” a referral, as the efficacy of commonly used fall screening tools for those 65 years of age and older, such as the

Tinetti Gait and Balance Instrument, the Timed Get Up and Go, and the Mobility Interaction Fall

Chart lack sufficient evidence in their ability to determine fall risk (Gates et al. 2008).

Moreover, fall referral to healthcare providers or existing community programs, as opposed to the direct management of a given fall risk factor, may have little impact (Tinetti 2008).

The aforementioned challenges, however, are not unique to podiatry. Few fall-related screening rates, practices, and protocols in acute care settings have been documented, and the majority of documented fall interventions are characterized by non-validated instruments and measures (Hempel et al. 2013). Moreover, the “…reporting of outcomes, implementation, adherence, intervention components, and comparison group information…” has been historically omitted from acute care fall prevention efforts (Hempel et al. 2013). As a result, fall prevention protocols in this setting warrant considerable revision (Anderson et al. 2016), and are not unlike the inconsistent podiatry-based fall prevention practices identified by this study.

With respect to fall referral, the practicing podiatrist is immediately presented with two viable options: (1) the construction of a robust, practice-specific fall referral network, and/or (2) the identification, or subsequent development of, an accurate and reliable fall screening assessment, from which to substantiate podiatry-based intervention. Simplicity associated with the latter is recommended, and may do well to mirror primary care efforts surrounding smoking cessation. The addition of “Current smoker?” and “Plan to quit?” to a primary care physician’s treatment routine has been associated with an 18% increase in smoker identification, a 100% increase in the assessment of a plan to quit, and a 26% increase in cessation counseling

(McCullough et al. 2009). Similarly, the integration of asking about falls during the delivery of core podiatry services may serve as the “trigger” to increase the identification and assessment of current and potential fallers, as evidenced by the fall knowledge continuum outlined in Figure

5.2.

Success in either of the aforementioned arenas could conceivably position podiatry as a medical authority with respect to fall-related efforts, and potentially expound upon the traditional podiatry scope of practice.

5.5 Recommendations for a clinical practice guideline

As evidenced from both the podiatry survey results and subsequent podiatry focus group, there is no clear consensus for the construction of a clinical practice guideline for podiatry patients 65 years of age and older, as high fall knowledge is the key driver to fall-related practices (Figure 5.1). While participating podiatrists recognized the importance of falls in podiatry patients 65 years of age and older, unpredictable clinical behavior, a wide fall knowledge gap, and a clear lack of focus group consensus regarding how best to mediate these inconsistencies lends the construction of a clinical practice guideline inappropriate at this time.

Concurrently, unfamiliar practice content and the need for specific fall resources prove to be considerable barriers (Francke et al. 2008). As such, the addition of fall-related podiatry curriculum to current podiatry programs, fall-specific continuing education, structured fall referral mechanisms, and the utilization of reliable fall risk assessments are recommended at this time.

5.6 Limitations

This study has several limitations. Firstly, the low response rates associated with both convenience sample survey distributions carry the potential risk for nonresponse bias (Davern

2013). Given a documented mixed-mode clinician survey response rate of 49%, and 60% associated with surveys employing monetary incentives (Cho et al. 2013), the 0.7% response rate associated with the American Podiatric Medical Association distribution, and the 6.6% response

55 rate associated with the Kent State College of Podiatric Medicine distribution are overwhelmingly low in comparison. The degree of nonresponse bias, however, is unclear, as it has been suggested that response rates are an imperfect predictor of data quality (Halbesleben and Whitman 2013), and that lower response rates do not always equate to greater nonresponse bias (Peytchev 2013). Some evidence suggests that nonresponse amongst physician-based surveys carry little to no response bias (Kellerman and Herold 2001), and Sudman (1985) has suggested that “…that for some variables there are no biases caused by respondents who do not cooperate”.

Concurrently, nonresponse bias is largely affected by the nature of the nonresponse. The difference between active nonrespondents, or those who choose not to participate, and passive nonrespondents, or those who may have forgotten to participate or were otherwise encumbered by their respective workload has been documented, and passive respondents displaying similar attitudes as respondents (Rogelberg et al. 2003, Halbesleben and Whitman 2013). According to

Rogelberg and colleagues (2013), the attitudes associated with active nonrespondents were statistically different from respondents, though their occurrence is less common than passive nonrespondents (Glicksman et al. 1992, Kaner et al. 1998, Halbesleben and Whitman 2013).

With the association between passive nonresponse and elevated workload in mind, 25.6% of respondents reported weekly obligations of 25 hours or less per direct patient care, and 68.4% of respondents reported weekly obligations of 26 to 50 hours per direct patient; only 6.1% of respondents indicating more than 50 hours of direct patient care (4.2% spent 51-75 hours per week, and 1.9% spent 76-100 hours per week, respectively). Given the proportion of respondents spending 50 hours or less in direct patient care per week (94%), and the

56 underrepresentation of those working extended weekly hours, the introduction of passive nonresponse due to workload is plausible.

Population-level comparison, or the comparison of respondents to the national population, represents another viable test for nonresponse bias (Beebe et al. 2011). Based upon national podiatry demographic data, 70.3% of the podiatry workforce in the United States is male with a mean age of 52.8 years, while females comprise 29.7% of the workforce with a mean age of 42.1 years (Data USA 2016). Ironically, these demographics are strikingly similar to those collected by this study, and varied only 4% with respect to sex (74.3% male and 25.7% female),

3.4 years of age for male podiatrists (56.2), and 3.7 years of age for female podiatrists (45.8). As such, these similarities question the traditional association between low response rate and a lack of generalizability, and suggest that respondents, at a minimum, may have been representative of the larger profession. Given these uncertainties, however, a cautious interpretation of the results is recommended.

5.7 Implications

Fall knowledge, regardless of demographics or professional podiatry experience, was the driving force behind a step-wise relationship resulting in a fall referral and/or fall intervention for podiatry patients 65 years of age and older. However, less than half of surveyed podiatrists reported a high knowledge of falls, less than half provided a fall referral, and only one-third provided a fall intervention. With these figures in mind, future research would do well to better operationalize fall knowledge, such that an explicit delineation of content areas pertaining to fall knowledge could be compared against current fall-related practices, and likewise addressed.

Per the construction of a clinical practice guideline, the addition of fall-related podiatry curriculum to current podiatry programs, fall-specific continuing education, structured fall referral mechanisms, and the utilization of reliable fall risk assessments should precede, and serve to inform, the construction of a fall prevention clinical practice guideline for podiatry patients 65 years of age and older at this time.

APPENDIX A

IRB approval letter

RE: Protocol #17-511 - entitled “Informing the Construction of a Fall Prevention Clinical

Practice Guideline for Podiatry Patients 65 Years of Age and Older Focus Group”

We have assigned your application the following IRB number: 17-511. Please reference this

number when corresponding with our office regarding your application.

The Kent State University Institutional Review Board has reviewed and approved your

Application for Approval to Use Human Research Participants as Level I/Exempt from Annual

review research. This approval is good for 3 years from date of approval. Your research

project involves minimal risk to human subjects and meets the criteria for the following category

of exemption under federal regulations:

 Exemption 2: Educational Tests, Surveys, Interviews, Public Behavior Observation

This application was approved on October 24, 2017.

***Submission of annual review reports is not required for Level 1/Exempt projects. We do NOT

stamp Level I protocol consent documents.

For compliance with:

 DHHS regulations for the protection of human subjects (Title 45 part 46), subparts A, B, C, D

& E

If any modifications are made in research design, methodology, or procedures that increase the risks to subjects or includes activities that do not fall within the approved exemption category, those modifications must be submitted to and approved by the IRB before implementation. Please contact an IRB discipline specific reviewer or the Office of Research

Compliance to discuss the changes and whether a new application must be submitted. Visit our website for modification forms.

Kent State University has a Federal Wide Assurance on file with the Office for Human Research

Protections (OHRP); FWA Number 00001853.

To search for funding opportunities, please sign up for a free Pivot account at http://pivot.cos.com/funding_main

If you have any questions or concerns, please contact us at [email protected] or by phone at 330-672-2704 or 330.672.8058.

Doug Delahanty | IRB Chair |330.672.2395 | [email protected]

Tricia Sloan | Coordinator |330.672.2181 | [email protected]

Kevin McCreary | Assistant Director | 330.672.8058 | [email protected]

Paulette Washko | Director |330.672.2704| [email protected]

APPENDIX B

IRB application summary i) A brief statement of the problem: Unintentional falls amongst those 65 years of age and older remains a pervasive public health problem, both domestically and abroad. Roughly one-third of those 65 years of age, and roughly half of those 80 years of age, experience a fall annually

(Inouye et al. 2009, Ambrose et al. 2013). The risk of falling advances linearly with age (Peel

2011), and the likelihood of sustaining a fall is affected by the presence of comorbidity and/or chronic disease (Finlayson and Peterson 2010). Given the comorbidities often associated with poor podiatric health, podiatry patients 65 years of age and older are often at an increased risk for falling, as compared to their peers devoid of foot-based pathologies or conditions. ii) A statement why this research is important: A large proportion of the general population will experience foot problems in their lifetime (Farndon et al. 2009), and these conditions can vary considerably per individual. Individuals with foot-based pathologies, as well as those with diabetes, peripheral neuropathy, or both, are increasingly at risk for sustaining a fall (Lalli et al.

2013); individuals who have developed peripheral neuropathy are twice as likely to fall than those diabetics devoid of peripheral neuropathy (Agrawal et al. 2010). While individuals 65 years of age and older are at risk for sustaining a fall, individuals with foot-based lesions, foot ulceration, bone deformity, or other podiatric concerns are increasingly at risk for falls,

given the abnormal gait compensation often employed to accommodate these conditions. While podiatrists commonly treat these conditions, fall-specific clinical practice guidelines to address these concerns have not been established. As such, the following study aimed to inform clinical practice recommendations through the evaluation of current podiatrist fall knowledge and practices. iii) Specific summary of the procedure(s) involving human subjects: With respect to survey distribution, a list-based solicitation approach was utilized, consisting of an introductory email outlining the voluntary nature of participation, endorsed by Kent State University’s College of

Podiatric Medicine and College of Public Health, as well as the American Podiatric Medical

Association (APMA), and was distributed to currently practicing podiatrist members of the

APMA, and alumni from the Kent State College of Podiatric Medicine. Following a study introduction, a request to complete the questionnaire, and a questionnaire expiration date, an embedded link to the electronic version of the questionnaire was included in the email.

Additionally, instructions for those who would prefer a mailed questionnaire were provided. For those who choose a mail survey, a paper questionnaire and postage-paid return envelope, as well as a separate incentive drawing card and postage-paid return envelope, was provided by the

College of Public Health.

Following survey distribution, a focus group of currently practicing podiatrists was conducted at Kent State University’s College of Podiatric Medicine. The focus group was roughly one hour in length, preceded with the distribution of an informed consent form, was comprised of 9 participants, and was audio recorded for transcription purposes only; no identifiable participant information was collected, and focus group transcripts were deidentified where necessary. A discussion guide was utilized to guide the focus group.

62 a.) Survey content development: Current survey literature addressing fall knowledge (Peel et al.

2008) and current fall prevention practices among physical therapists (Peel et al. 2008), respectively, as well as fall prevention barriers among physicians (Jones et al. 2011), were adapted to produce a 14-item, 6-construct questionnaire. Developed in Qualtrics, a web-based survey platform, the questionnaire’s 6 constructs consisted of (1) fall prevention knowledge, (2) current fall prevention practices, (3) fall risk factors, (4) fall prevention interventions, (5) fall prevention barriers, and (6) demographic information. b.) Survey testing and burden: The Qualtrics-estimated response time for completion of the 14- item questionnaire was six minutes. c.) Data collection mode and follow-up: The electronic questionnaires were distributed via email, remained active for 30 days, and mailed questionnaires with return postmarks dated within 30 days of the initial email introduction were accepted and included in the data analysis. In order to increase response rate, a total of two electronic reminders (Cho et al. 2013) to complete the questionnaire were proposed to both the American Podiatric Medical Association and Kent State

University’s College of Podiatric Medicine, to be distributed in two, two-week (14 day) intervals, based upon the initial distribution date. The focus group was conducted at Kent State

University’s College of Podiatric Medicine, and is described previously in Section iii. d.) Survey incentive: A monetary incentive, in the form of a lottery for four $250 gift cards, was linked to the completion of each questionnaire. e.) Population surveyed: The respective survey population consisted of currently practicing podiatrist members of the American Podiatric Medical Association, a leading resource for foot

63 and ankle health, as well as alumni from Kent State University’s College of Podiatric Medicine, one of nine accredited podiatry schools in the United States. f.) Anonymity control: Identifiable information was not actively collected; mailed questionnaires were to be separated from their addressed envelopes, and the latter shredded and discarded. All electronic questionnaire responses were de-identified, and any Qualtrics-based IP linking addresses were removed. Electronic responses were stored on a password-protected, Kent State

University server, in a password-protected file folder, and accessed only by a password- protected, university-owned computer. Mailed responses, once separated from their corresponding addressed envelopes, were to be stored in a locked filing cabinet, located in an on- campus office.

APPENDIX C

Informed consent i) Survey

Greetings!

The Kent State College of Public Health and Kent State College of Podiatric Medicine are currently facilitating a Doctoral dissertation, entitled "Informing the Construction of a Fall

Prevention Clinical Practice Guideline for Podiatry Patients 65 Years of Age and Older", which aims to inform a set of clinical practice guidelines for the prevention of falls amongst podiatry patients 65 years of age and older.

The professional insight of practicing podiatrists is essential to inform the construction of such guidelines, in addition to ensuring both their relevance and applicability in current practice. A brief online survey has been prepared, and your responses would be greatly appreciated.

The survey will only require roughly 5 to 10 minutes to complete. Your answers will be anonymous, and only aggregate information from all respondents will be reported. While participation is voluntary, those who complete the survey will be entered in a drawing for four

$250 gift cards. Upon survey completion, you will be redirected to a page to enter in this drawing.

Thank you in advance for agreeing to participate in this survey.

If you have any questions about this survey, please contact Ph.D. Candidate Matthew Nichols at [email protected] or 330-672-6500. If you have any questions about your rights as a survey participant, please contact the KSU Institutional Review Board at 330-672-2704. ii) Focus group

Kent State University Institutional Review Board

Informed Consent to Participate in a Research Study

Study Title: “Informing the Construction of a Fall Prevention Clinical Practice Guideline for Podiatry Patients 65 Years of Age and Older” Focus Group

Principal Investigator: Sonia Alemagno, PhD

Program Manager: Matthew Nichols, MPH

You are being invited to participate in a research study. This consent form will provide you with information on the research project, what you will need to do, and the associated risks and benefits of the research. Your participation is voluntary. Please read this form carefully. It is important that you ask questions and fully understand the research in order to make an informed decision. You will receive a copy of this document to take with you.

Purpose: The purpose of this proposed research is to discuss the results of a survey concerning fall knowledge and current fall prevention practices among podiatrists, in order to produce recommendations to inform the production of a clinical practice guideline for the prevention of falls amongst podiatry patients 65 years of age and older.

Procedures:

 Eligible participants will be recruited with assistance from Kent State University’s College of

Podiatric Medicine.

 For those who express interest, Inform Consent documents will be completed before the

focus group is conducted.

 A focus group discussion will take place, requiring roughly one hour, and participants will

share ideas/opinions based on their own experiences.

 The discussions during the focus group will be audio recorded and transcribed before the data

analysis.

Audio and Video Recording and Photography:

Participants will be de-identified from the focus group audio tapes. The short survey after the focus group will be de-identified as well. Focus group audio will be utilized for transcription purposes only.

Benefits:

Although there is no direct benefit of participating in the study, potential benefits from this study may include the informing of a clinical practice guideline for podiatry patients 65 years of age and older, the utilization of which stands to enhance the delivery of podiatry services with respect to falls, and subsequently produce better health outcomes amongst the aforementioned population.

Risks and Discomforts:

The only foreseeable potential risk might be the disclosure of focus group information and opinions by participants outside of the focus group itself (such as sharing information with family and/or friends about the focus group after the commencement of such).

Privacy and Confidentiality

No identifying information will be collected. Your signed consent form will be kept separate from your study data, and responses will not be linked to you. Additionally, participants will be de-identified from the focus group audio tapes. The short survey after the focus group will be de-identified as well.

Voluntary Participation

Taking part in this research study is entirely up to you. You may choose not to participate or you may discontinue your participation at any time without penalty or loss of benefits to which you are otherwise entitled. You will be informed of any new, relevant information that may affect your health, welfare, or willingness to continue your study participation.

Contact Information

If you have any questions or concerns about this research, you may contact Sonia Alemagno at

330-672-6500, or [email protected], or Matthew Nichols at 330-715-7236, or [email protected]; this project has been approved by the Kent State University Institutional

Review Board. If you have any questions about your rights as a research participant or complaints about the research, you may call the IRB at 330-672-2704.

Consent Statement and Signature

I have read this consent form and have had the opportunity to have my questions answered to my satisfaction. I voluntarily agree to participate in this study. I understand that a copy of this consent will be provided to me for future reference.

______

Participant Signature Date

APPENDIX D

American Podiatric Medical Association email i) July 20, 2017

74 ii) July 25, 2017

APPENDIX E

Kent State College of Podiatric Medicine email

Greetings Alumni,

The College of Podiatric Medicine is asking your help in completing a brief, online survey. In conjunction with the College of Public Health and the American Podiatric Medical Association, we are currently facilitating a Doctoral dissertation, entitled "Informing the Construction of a

Fall Prevention Clinical Practice Guideline for Podiatry Patients 65 Years of Age and Older", which aims to inform a set of clinical practice guidelines for the prevention of falls amongst podiatry patients 65 years of age and older.

The professional insight of practicing podiatrists is essential to inform the construction of such guidelines, in addition to ensuring both their relevance and applicability in current practice. Your responses to this brief, online survey would be greatly appreciated.

If you agree to take our survey, please click here!

The survey will only require roughly 5 to 10 minutes to complete. Your answers will be anonymous, and only aggregate information from all respondents will be reported. While participation is voluntary, a drawing for four $250 Visa gift cards will be offered to those who complete the survey. Upon survey completion, you will be redirected to a page from which to enter the drawing.

If you have any questions about this survey, or would like to complete a paper version of this survey, please contact Ph.D. Candidate Matthew Nichols at [email protected] or 330-672-

6500. If you have any questions about your rights as a survey participant, please contact the KSU

Institutional Review Board at 330-672-2704.

Thank you in advance for agreeing to participate in this survey.

Vincent J. Hetherington, DPM

Senior Associate Dean

Kent State University College of Podiatric

APPENDIX F

Survey instrument

Greetings!

The Kent State College of Public Health and Kent State College of Podiatric Medicine are currently facilitating a Doctoral dissertation, entitled "Informing the Construction of a Fall

$250 gift cards. Upon survey completion, you will be redirected to a page to enter in this drawing.

Thank you in advance for agreeing to participate in this survey.

______

Q1 How would you rate your level of knowledge about specific risk factors for falls in adults 65 years of age and older?

Very knowledgeable (1)

Some knowledge (2)

Little knowledge (3)

No knowledge (4)

Q3 The following questions relate to your current fall prevention practices as a podiatrist. For the purposes of this question, the term "older adults" refers to individuals 65 years of age and older.

Never Sometimes Often Always

(1) (2) (3) (4)

In your initial assessment of patients, how often do you ask older adults if they have a history of falls?

(1)

In your initial assessment of patients, how often do

older adults present a fall-related injury? (2)

For those older adults who present a fall-related

injury, how would you characterize their fall

frequency? (3)

In your assessment of older adult patients, how

often do you identify risk factors for falling? (4)

In your assessment of older adult patients, how often do you document risk factors for falling? (5)

Based on your assessment of older adult patients,

how often do you provide a fall prevention

intervention? (6)

In your treatment planning how often do you refer

older adult patients to other health care professionals to address fall risk factors (MD, OT,

PT, Optometrist, Pharmacist, etc) (7)

Q4 Please list as many preventable risk factors for falls as you can think of. (You are not limited in the length of your response by the size of the box)

1 (1)

2 (2)

3 (3)

4 (4)

5 (5)

6 (6)

7 (7)

8 (8)

Q5 While realizing that all fall risk factors are important, what would you consider the top three fall risk factors from those identified in the previous question?(You are not limited in the length of your response by the size of the box)

1 (1)

2 (2)

3 (3)

Q6 Please list as many activities or treatments that might help prevent falls in your patients 65 years of age and older. (You are not limited in the length of your response by the size of the box)

1 (1)

2 (2)

3 (3)

4 (4)

5 (5)

6 (6)

7 (7)

8 (8)

Q7 Do you experience any of the following barriers when providing a fall prevention intervention?

Patients have more pressing issues (1)

I do not have enough time (2)

Lack of educational materials (3)

Patients do not feel they are at risk (4)

Lack of training (5)

Lack of referral resources (6)

Too complex to address in one office visit (7)

Patient's insurance does not cover referrals (8)

Reimbursement is too low (9)

Patients do not want to discuss it (10)

I do not provide fall prevention interventions (11)

Other (12) ______

Q8 What opportunities are associated with providing a fall prevention intervention? (You are not limited in the length of your response by the size of the box)

Q9 What is your sex?

Male (1)

Female (2)

Q10 What is your age (in years)?

Q12 How many years of experience do you have as a podiatrist?

Q14 On average, how many hours each week do you spend in direct patient care?

Q15 On average, what percentage of your practice is spent treating adults 65 years of age and older?

Q16 What do you consider to be your specialty area(s) in Podiatry?

APPENDIX G

Focus group discussion guide

Informing the Construction of a Fall Prevention Clinical Practice Guideline for Podiatry Patients 65 Years of Age and Older

* Statements will not be made verbatim but are guidelines for what will be said.

Introduction

Opening:

Greeting and brief overview

Introduce moderator self/assistant moderator/participants

“Thank you for coming today; let me first introduce myself, I am (moderator name).

Introduce assistant moderator if applicable.

Now let us start by everyone in the group telling us your first name. You can use an alias if you wish”.

Ask if any of participants have participated in a “focus group” before

“If so, great; if not, no problem”.

Briefly explain what a “focus group” is “A discussion group where participants share ideas/opinions about the specific topic (in this case, the construction of a fall prevention clinical practice guideline for podiatry patients 65 years of age and older) based on their own experiences”.

“No right or wrong answers; your thoughts and opinions are what matter”.

“All answers and information will be kept confidential”.

Purpose and Procedure

Briefly describe what will be discussed

“The purpose of this focus group is to learn about your thoughts and opinions regarding findings from a survey of current podiatrists on several aspects of falls and fall prevention amongst podiatry patients 65 years of age and older. In particular, we would like to hear your thoughts regarding how these findings might be addressed with a clinical practice guideline”.

“While your thoughts and opinions are what matter here, you do not have to participate in the discussion for all the questions”.

“Our discussion will last approximately one hour. In the interest of time, we may have to move on to the next question before the discussion for a question is finished. We do not want to cut anyone off and there will be a chance to return to anything that you would like to say before we end”.

“It is OK to disagree with each other; we are not looking for everyone to agree”.

Statement of confidentiality and respect among participants

“We would like everyone to feel comfortable sharing their thoughts during the discussion, so we ask that all of you be respectful of the opinions of others and to avoid discussion of any details of things that are said with people outside of this group”.

Explanation of the purpose of audiotape

“With your permission, this session will be recorded to make sure that we collect all of your comments. Your responses are anonymous and you will not be identified by name on the recording. We will not use your name in our reports; all information will be kept confidential”.

“To make sure that we understand your thoughts and ideas, please speak loud and clear and one at a time. Also, you may request that the tape recording be stopped at any time, either for you to make a comment or answer a question you do not want recorded, or to stop the recording completely”.

Ask participants if they have any questions

***Start to record and let participants know.

“We will start to record now”.

Key Questions

“Throughout this process, I will preface each question with survey findings related to the question’s scope. We will begin with a discussion regarding the current knowledge of falls and fall prevention amongst surveyed podiatrists”.

* Summarize current knowledge of falls and fall prevention findings

Let’s have each of you tell me what your thoughts are on the findings regarding podiatrist current knowledge of falls and fall prevention.

Probing Questions as applicable/needed

1) Do you agree or disagree with these findings?

2) In your opinion, how might we best way to address these findings?

“Thank you for your responses; they were a great start to this discussion. At this point, I would like to move on to the next question concerning current fall prevention practices”.

* Summarize findings regarding current fall prevention practices

What is your reaction to current podiatry-based fall prevention practices?

Probing Questions as applicable/needed

1) Do you agree or disagree with these findings?

2) Are current practices sufficient to address the fall prevention needs of podiatry patients

65 years of age and older?

3) What types of strategies might be effective in addressing the (lack of/continued promotion) of current fall prevention practices?

“These are all wonderful points; moving on to the next question, I will again summarize some relevant findings to facilitate discussion”.

* Summarize findings regarding the characteristics of podiatrists who provide fall interventions

What do you think, in general, are characteristics associated with a podiatrist who provides a fall intervention to a podiatry patient 65 years of age and older at risk for fall?

Probing Questions as applicable/needed

1) Are there characteristics that you feel were missing from the survey findings?

2) Might there be any characteristics that stand out to you as increasingly important?

3) What, in your opinion, might comprise the most important characteristics when providing a fall intervention?

“Thank you very much. At this point, I would like to move on to the last question of this discussion, which calls on the collective expertise of this room to inform specific guideline content”.

Ending Question

Overall, do you have any specific recommendations for the development of a fall prevention clinical practice guideline for podiatry patients 65 years of age and older?

Probing Questions as applicable/needed

1) Feel free to expound upon the findings of this survey, as well as any additional content that we have not touched upon.

“Thank you very much for your time and your participation. Your experience and insight will be of great value to our project. The information you have provided will be summarized and incorporated with podiatrist survey results to inform the development of a fall prevention clinical practice guideline for podiatry patients 65 years of age and older”.

APPENDIX H

Focus group transcript

College of Podiatric Medicine Focus Group

Friday, November 17, 2017

Nine participants

Respondent 1: So you said that approximately 96 percent, or 94 percent of podiatrists, had at least some knowledge of fall prevention, right?

Moderator: Correct.

Respondent 1: So, do you think that it’s a lack of knowledge that prevents them from taking that further step, or do you think that its, they just don’t take it for the reasons that you listed; you said that there were multiple reasons; I’m sure that the biggest reason is time, in practice.

Moderator: So that's actually one of the things I was expecting to come out. Time was on the survey; time actually didn't come out.

Respondent 1: Really?

Moderator: Yeah.

Respondent 1: So what came out as the primary reasons people didn’t talk about fall prevention?

Moderator: So those…those three; a lack of podiatry training, patients don't want to discuss falls, and the gender. So granted, this is from this sample and I will say that the response rates…

Respondent 1: Small sample size.

Moderator: Well, big potential sample size but very small response rates. And so to some degree this information has a response bias; not to some degree, it does. Obviously the people that responded, their characteristics were different than the people that did not respond. So, with this, I can only use the data that I have. And so that's why the supplementary nature of the focus group is very important. So I'm not sure if I danced around your question or answered it.

Respondent 2: So on your surveys; give me an example of when you say fall knowledge, I guess to have a little clarification, how was that queried out here? Do you have any idea of what a fall is, or how was that asked?

Moderator: It was rate your level of fall knowledge; some knowledge…I’d have to look at the exact question, I don’t think I actually have…

Respondent 2: Was it risk for falls?

Moderator: Well it wasn't risk for falls, it was actually knowledge of falls.

Respondent 1: Yeah, it was pretty generic; I actually took the survey.

Moderator: All the questions were adapted from a previous instrument that was used for physical therapy, so the items had been validated previously, as opposed to kind of just throwing out new items with no…

Respondent 2: One of the things that occurs to me is that, you know, part of this process is the podiatrists, what they know about it is just a very broad question, but one of things you could do, one other direction you could take is, you know, an area for curriculum involvement potentially, if it’s not in there already, is which patients are at risk for falls, identifying those patients would be one way that, so that podiatrists, if those same podiatrists that express their very knowledgeable about falls, so they say that this neurological exam demonstrates that this patient

91 has balance problems, or this patient demonstrates postural hypotension, at least identifying that patient as a fall risk. I mean, were they actually included in the people that had no knowledge, or very little knowledge of falls, perhaps…see what I’m saying, it was the way that it was asked, so

I don’t know what to do with that; can I assume that these people would not have made the right steps if I identify a clear-cut neurological deficit or something like that or another exam that suggest these people have equilibrium, or are a great fall risk. It wasn’t asked that way, so…

Respondent 3: I could assume that when I ask you what your knowledge is that you would say,

Oh, with regards to falls it could be neurological, it could be several things…

Respondent 2: So the assumption is in there that they would be able to identify a patient for a fall?

Respondent 1: Yes, I think that that would be true, from what I say from the survey anyway.

The assumption was that either you had the knowledge of what causes falls, or you didn’t have the knowledge.

Respondent 2: So it would make sense that a (indiscernible) focus since the numbers were underwhelming.

Respondent 1: They weren’t really underwhelming.

Respondent 2: Well 50, what did you say, a little bit better than half…

Moderator: As far as?

Respondent 2: Fall knowledge…

Respondent 1: 47, 47, and…

Moderator: Very knowledgeable and some knowledge makes about 94 percent. And so I don't want to take all the time obviously to go through every item on the survey but following the fall knowledge question, participants were asked to basically identify the top three risk factors for

92 falls, and so all of those were very much on par with for those that did respond. Now some people didn't respond to those, they just skipped over them, but for those that did respond they were very much on par with obviously fall risk factors you mentioned; postural hypertension was one, things like antalgic gait, peripheral neuropathy was big, you know, muscle weakness, things like that. So there was a variety of those and there was quite a bit of consensus as well. So the folks that did answer did, they obviously displayed their level of fall knowledge as far as knowing what the risk factors are and they all kind of aligned there, you know; there was consensus with their answers.

Respondent 2: So in other words, the knowledge part is not a major concern, is what you’re saying.

Moderator: Well I guess that would be up to…

Respondent 4: I think that’s what he is asking us.

Moderator: Right. Do you…do you feel that if 94 percent of podiatrists indicate that they have a knowledge of falls, but yet only 32 percent provide a fall intervention, or 59 percent of podiatrists asked about falls, is that good enough? I mean that that is a question.

Respondent 3: You know, I think part of the first question is, you know, you have 97 percent and there was people that said they had knowledge, and others say some knowledge, which I’m not sure there equivalent to each other. So, 97 percent admitted to having some knowledge; what

I’m looking at is, my own observation is, you know, for example, do you ever see anything at the

APMA meetings about falls? They did one lecture but it was for geriatric patients, it wasn’t on falls. I don’t see a lot of that in the CME programs. Look at the residency documents; there is nothing in there that relates to that, and as a requirement, and then the question that I would ask here is in our curriculum, do we have an identifiable segment on the importance of falls? This is,

I think, becoming on a national basis; APMA is willing to put together a group to do a big study because this has become so important. At the (indiscernible) meeting, there were a couple people there that said this is an important issue that’s not getting any attention. So, I guess when

I’m looking at this and saying are we doing a good job, or could we do a better job, and how would we do that?

Respondent 5: I think that a couple years ago we added a part to part of the podiatric medicine courses on geriatrics specifically, where we didn’t have anything before; (to respondent 6), I know that there is some mention of falls in there, but do you want to elaborate on the level of that?

Respondent 6: Yeah, it wasn’t that extensive I thought. The talk that I gave was at the VA and that was a couple years ago. I don’t think that we routinely ask in clinic, as opposed to going to your primary care physician or specialist. I think that universally now, everyone asks if you’ve had a fall in the past year or so and so I think that its standard protocol for them, but it’s not really standard protocol for us.

Respondent 1: Yeah, that is exactly true at the Cleveland Clinic too, so I think large institutions are looking at this right now, and that’s part of like DVT prophylaxis in the hospital; fall prevention is another one of those major things, but in private practices, I’m not sure that’s something that comes into play. Whether that’s normally in their intake information that they get; I think…do we get that information here in our intake?

Respondent 7: In the clinic for about 6 months, a couple of us, we were doing the John Hopkins risk assessment, and we would actually get one on every patient that we saw, so we did that for about 6 months. I think that the real trip-up there is referral. Once you get to that point, is it the podiatrist, because there is (name omitted), you guys know, he speaks out on CME, he speaks a

94 lot about fall prevention and he has an AFO, his wife's a physical therapist, but the literature is a little sketchy on whether the AFO actually does prevent a fall or not, and there is some financial incentive for him because he developed this brace; that’s on the outside.

(Indiscernible interruptions)

Respondent 3: But there is also, just keeping in mind, it’s an OSI that’s one of the companies? I got a call after the survey went out from somebody on their board saying that they want to be involved in this, and I said I don’t think that we can have you involved because you talking about building a…their talking about building an AFO that they are saying is going to prevent falls, and so obviously there is some commercial benefit to this, but the question is, and I’m not saying that we should support their commercial venture; I’m just saying if there is enough commercial interest, then there is a market, which means there is a definite interest.

Respondent 7: The question then becomes what is the referral process? Is it self-referral, because you can prevent falls with an AFO, is it a referral to an urologist, is it a referral to podiatry, is it physical therapy?

Respondent 2: There is no one referral because one part of fall prevention is that someone goes out and looks at the patient’s environment at home and assesses that.

Respondent 4: (Respondent 8) had her hand up for a while, so you go first (respondent 8).

Respondent 8: One quick question (to the moderator); was this stratified across physicians that do both inpatient and outpatient, or was this just given to physicians who solely treat patients on an outpatient basis?

Moderator: This was across both.

Respondent 4: Because in inpatient, one of the things is that fall risk is assessed automatically, and referral will be much easier because you’ll have physical therapy come in and evaluate them,

95 along with occupational (therapy), and they’ll evaluate them, as well as devices that can help, as well as other things as well, such as rugs in the house, those are things, so the inpatient part

(indiscernible), there is going to be a bias there. As for outpatient knowledge, I think that a lot of us are knowledgeable, but I think it depends on the patient complaint, and it also depends on what you get to see. So if I get to watch my patient walk in, as opposed to being in another room, then I can watch their gait pattern a little bit more easily. Let’s say they are there for another complaint and I see that, then I can bring that up. If their chief complaint is that they have a concern with muscle weakness or some type of neuropathy complaint, or a fall, and they get injured in that fall, than that fall assessment will be much more prominent, so it may not be pending the complaint that the patient comes in with, sometimes. And also, I think for me, as a patient and I know them and I can see that they used to walk in easily and now I see that their using a device, and their muscle strength is going down, so I think fall knowledge is probably the most important part, and then the next part is something to trigger us to ask about it. So most primary cares within a health system have a whole list: are you safe in your house, do you have these (indiscernible) things, do you have a risk of falls or have you fallen recently, and so most of us don’t have that trigger, so if we had the trigger, and you have the knowledge, then that might come up in the topic of discussion, and the next thing is referrals, so it depends on what the problem is as to whether we might do something with a brace or send them out for a physical therapy gait and strengthening evaluation, which can lead to home too, so, they can go in and evaluate the house; I think that it depends, sort of, on the concern as to where we will send them.

Respondent 7: There is a home health agency that is doing that in our clinic that we can refer them to, but I’m just saying that overall, of all the people that you probably had sent a survey that is probably an obstacle. At that point, you’ve identified…

Respondent 4: And I think that that might be a knowledge part, that maybe knowledge after identifying is a problem…where…what’s the (indiscernible).

Respondent 7: And I totally agree with the trigger part because, that, I mean, it’s just a part of their EMR.

Respondent 1: It’s a lot like smoking cessation, you know.

Moderator: This actually is exactly, looking through this, and to piggy-back off that comment, it’s almost exactly, as far as clinical behavior goes.

Respondent 1: So, you know, once they say that they smoke, then I can refer them for a smoking cessation program, but without that mechanism it does make it more difficult. Looking back on this, it probably would have been interesting to see how many of the people that answered the survey were practicing in a hospital setting that have (a) trigger point, and how many were in private practice using a generic EMR, had that trigger.

Respondent 2: (Indiscernible) The survey is done, so that doesn’t help you, right?

Moderator: There’s always another project.

Respondent 1: Yeah, there you go.

Respondent 3: I find, you know, when you’re talking about the hospital kind of interesting because a couple of months ago I was in the hospital and they asked me “Do you feel like you’re at a risk for fall”? No. “Do you feel safe at home”? I said yeah. And then everybody, I looked around had an orange wristband that said ‘fall risk’.

Respondent 1: Because as soon as you hit a certain age, you’re automatically a fall risk.

Respondent 3: Yeah, that is what I was getting at.

Respondent 4: Where you on certain medication?

Respondent 3: Yeah. Well it seemed to me to be more age-related.

Respondent 1: But you are right, it’s medication-related too…

Respondent 2: Yes, but there are triggers.

Respondent 4: But they have a checklist, you know, a checklist the nurse details out, I mean I did that back when I was (indiscernible).

Respondent 7: Checklists can be bad in a sense too because when somebody gets used to a checklist, it’s almost like your hoping that they’re going to say, you know, so you can just go through your checklist.

Respondent 2: Well if you ask about dizziness, does it mean you’re going to follow it up?

Recent history, or changes, but these checklists, if somebody’s not part of a HPI kind of thing, you’re not going to work it off on stuff like that (indiscernible).

Respondent 4: And I think it just needs to be simple; its knowledge ahead of time of falls, so that we are all comfortable, and I think that a lot of us in podiatry are probably comfortable because we talk about things like gait, and then I think there’s a trigger, so there is something that we always need to ask patients about, and there is maybe some of that knowledge part of where we go from there.

Respondent 2: What would trigger your movement toward an intervention?

Respondent 1: That trigger, also though, I think you mentioned it, it’s that there is a patient reluctance to admit to…

Moderator: Sure, fear of loss of independence…

Respondent 1: Absolutely, and it sets them down a whole path; it’s like if you ask somebody if they feel safe in their home. If they answer that ‘no’, boy that sets off a serious…

Respondent 2: Or a nurse comes out and says you’re not safe in this environment, and I have to report you to social services, or something like that, because you shouldn’t be living alone; those are patient fears that are out there that are real.

Respondent 5: Several years ago, well not several years ago, in recent years we had to meet with our (respondent 7 knows about this), certain metrics, so if you’re doing a diabetic foot exam, and there was some financial incentive for doing it, so I would think that putting a financial incentive on asking patients their fall risk…

Respondent 4: I think that’s why, I don’t think they care if you’re safe in your home or you’re a fall risk; I think that’s Medicare’s…

Respondent 5: It is, but that’s for hospitals, but I’m saying for private offices, if they put that incentive onto a podiatrist, tack it on and say hey, if you guys ask these patients if they are a fall risk, or determine that they’re a fall risk, and you do enough of them, then you’ll have a financial bonus in your…

Respondent 7: I just pulled it up, it’s a MIPS, measured on 154, falls risk assessment, specialty measure sets for internal medicine and general practice for family medicine, so it doesn’t mention podiatry, which is interesting because this is MIPS and governmental, and where not even mentioned as someone who should be using that particular measurement.

Respondent 3: You know, one other thing, and I understand what you’re saying and I agree with you completely; have you ever heard some of the lectures by outside people on this, I don’t really want to mention names.

Respondent 5: On the MIPS?

Respondent 3: No, on falls.

Respondent 5: The only thing I ever heard was on (name omitted).

Respondent 3: But their pretty much, they’ve been in the realm of practice management lectures, and they do a survey, and they do this, and they can bill for this, and you can bill for an orthotic, and then you can bill for this, and you can bill for this, and I mean if you look at, I’ve sat through his lectures twice, and I’ve seen some of the stuff that has been published, like in

Podiatry Management, and, uh, I mean, he’s got good stuff there, but at the same time, it’s how to improve your practice and generate more revenue, and I’m not saying that is a good or a bad thing, I’m just saying when you read it that way it’s sort of like…

(Laughs and generally indiscernible dialogue)

Moderator: I will say looking through the, I can back pedal a little bit; initially getting into the literature review for this, it was very surprising to me, in my opinion, podiatry, with what you deal with on a daily basis, almost everything is a fall risk, and so I expected there to be some sort of literature base around that, and there isn’t, except for (name omitted), who wants to sell a brace, and all that, we all understand that, but with that, I mean, and this is more of a question to pose to you, kind of consolidating some of your comments with the referral checklist, you know, would it be helpful to have, if you have a patient that comes in and obviously they have peripheral neuropathy, and they have antalgic gait, a checklist, refer to; well that would be something that you would treat I imagine, but medication management, refer to their primary care physician; home hazards, refer to PT or OT, or some other outpatient service.

Respondent 4: I don’t know if you need a checklist, but it sounds like a decision tree or something, sort of what you are saying, and so I think that might be helpful, at least when people are in the student population, and (for) new residents to have a decision tree, to sort of, what are their options for those kinds of things. I think that most podiatrists now would be a little bit irritated with the idea of following a checklist. Well I know what I need to do and what works

100 and not, but a decision tree helps, maybe newer practitioners and some of us that have been in practice a while, to start thinking about other ideas, and that might be a good option.

Moderator: Well, and to that extent too, not everyone would refer to the same, if it was PT or

OT for home hazards, not everyone is going to refer to the same PT or OT, so that is a good point.

Respondent 5: That, but referring to primary care, referring to neurology, how do you, there is a wide range that you have to consider, and then it brings in to the fact, the scope and picture, maybe one of the reasons why we’re not in that MIPS thing is (that it’s) outside of our scope of practice assessing some of these things and determining, is this a neurologic issue or, obviously, if its orthopedic and the foot and ankle its within our scope.

Respondent 4: Yeah, but we can still be like a primary care doctor, and they are sometimes the gatekeeper; they get people where they need to go, and so I think that is part of our job…

Respondent 5: But we’re not viewed as that in the medical community, as a primary care physician…

Respondent 4: I think we should be…

Respondent 5: (Indiscernible talk between respondent 5 and respondent 4)…limited scope

Respondent 4: Yes, but I think we should be viewed as maybe the gatekeeper…

Respondent 5: Well, then that would be something…

Respondent 3: You know, what (respondent 5) was saying before about, you know, well if we could get compensated for it like we did for other things, and like (respondent 7) said, well they don’t include us in this, maybe if we had developed a…and it takes time I understand that, within the education of the profession, that we do this and we have mechanisms to do this, I mean, I think looking at it from a public health perspective is what we really want to look at here, is that,

101 you know, making it a judgement that yeah, we probably could improve the educational process, we could develop maybe a research project or something like that; what (respondent 4) mentioned a variety of, a decision tree or that type of thing. I mean, we see patients all the time outside our scope of practice, that, you know, we make referrals for, but why did we make a referral? Well, because it’s something that we picked up. So, what I’m getting at is maybe if we are going to be involved in doing the screening and that type of thing, then we need to build an infrastructure that says yes, we teach this and do this, we have a recommendation about it.

Respondent 5: Well, I think if you look at the numbers up there, there’s 94-95 percent of people

(that) say they feel they know enough about it, knowledge-wise, but it’s been implementing an action based off of that knowledge, and so that’s where, when I first said something, you know, it comes down to time probably, and then, you know, it’s the time factor that it takes you to do that stuff, and if there was some level of compensation for that extra added time that it does take to do that, that might be enough (of a) motivating factor right there to balance that number out.

Respondent 3: And you might get reimbursed if you can show that the training and the experience…

Respondent 5: Well yeah…

Respondent 3: And that’s where I’m going with this…

Respondent 5: Yeah…

Respondent 3: I mean to me, you know, when people say that they have some knowledge…

Respondent 1: That means they heard about it once…

Respondent 3: They heard about falls, so to me I’m not overwhelmed with adding the two numbers together, and to be fair to (the moderator), you know, we couldn’t get into the details,

102 otherwise you it’s like with any survey based thing, the more questions you have, the less response and the less valuable responses you have.

Moderator: Not to change course a little bit but to come to a point that you (respondent 3) had made, and I saw it in the literature, and actually the very definition that I used initially

(respondent 3) had pointed out, (respondent 3) said we do a lot more than that; you (respondent

5) had mentioned that podiatrists are viewed from the ankle down, basically. Do you think something systematic, and this is for anyone in the room, something systematic like this, that, you know, takes your level of expertise when you refer out, whether it’s refer or treat, or what not, do you think that would push that paradigm back a bit?

Respondent 5: Yeah…you mean…make it worse?

Moderator: As far as…better…as far as being viewed very much kind of in a tunnel vision…

Respondent 5: Sure, no I think there are different hits from doing things like this multiple times and multiple ways, would advance that part of our profession.

Respondent 2: Once again, I’m not familiar with what exactly is in the syllabi or curriculum, but it sounds like the err for emphasis is, you know, what are the trigger points for following up on this and, you know, for doing that so to make sure that the trigger points are there so people say, this is what’s triggered, so I don’t send the patient home, you know, with, you know, I did their toenail, their hot toenail, and ignored the fact that they’re at risk for falls. Let the triggers be emphasized.

Respondent 1: I don’t think this is any different than, you know, having a patient who has a complaint, or you find out their hyperglycemic, and they don’t know they’re diabetic, right…

Respondent 2: Right, it’s a trigger point for us…

Respondent 1: It’s a trigger point for us.

103

(Indiscernible between a number of respondents)

Respondent 2: So the examinations are being done, your knowledgeable in the examinations to identify patient fall risk, but you know, once again, apparently there’s a problem, there’s a disconnect between what time you trigger, are you going to lead them to an outcome?

Respondent 1: One big part of this, pointing out the importance of the disability, morbidity that falls lead to, uh, we all know, everybody knows that if a patient’s diabetic, that you have an extremely poor outcome if it’s not treated, but I’m not sure that people do understand how frequently people fall, and how those falls point to the subsequent morbidity, or mortality, and if that was emphasized, that may be something that would increase referral.

Respondent 4: Well if you suffer a hip fracture, it’s a 5 year survival rate, so… (Indiscernible)

Respondent 3: And, you know, I was working with students, actually they’re residents, on a paper that we’re finishing up that dealt with falls, and uh, two things that really came out of this was that, uh, we did a couple posters at Kent, and one of them was, uh, it was at one of the aging seminars and they just asked people to recognize, you know what a Bunion (is), a hammer toe, do you recognize this, and you’d be surprised how many people had no clue, and these are the people that are working with the aging all the time, and the second part of it was, when you just focus on falls and foot deformity, there is a correlation between individuals with Hallux Valgus and hammer toes, and other deformities, having an increased number of falls versus…

(Indiscernible between respondent 2 and respondent 3)

Respondent 6: I think there’s the issue of time; to piggy-back on what (respondent 3) was saying, its biomechanical, again, your hammer toe, your bunions, whatever, that seems more in our arena so, but even then your bringing the patient back for an evaluation, and how you bill for it, how much time was taken, and so that might be it, and I’ve also get x number of patients to

104 see, I dealt with the pertinent complaint; that other one I didn’t get time to really, so that might be an issue. You have to contrast that with, like, um you know, someone who says they’ve got an occupational therapist, a physical therapist, and other people as a part of this large office than your likely to refer directly in your practice, and you’re going to talk about that being a barrier, so that, um, you then have to identify those people and create a system of referrals. I think that time is definitely an issue and the reality is people are trying to make a living.

Respondent 5: With what (respondent 3) was just saying, I’ve seen these studies out there before talking about bunions and hammer toes and leading, contributing to, uh, falls, and there, there may be interventions that we could use to improve balance, custom orthotics, but…

Respondent 8: One is custom orthotics, but probably more depending on the exact cause of the imbalance; it’s just (indiscernible) that custom orthotics work pretty darn well; if it’s even a little higher than that than your looking at some type of AFO, and my first choice for just about anything is not something like the Moore Balance Brace.

Respondent 5: Well what I was saying is that in the population, which is 65 years of age and older, custom orthotics aren’t usually a covered benefit from the insurance, and so that may be a reason why some of that gets skipped over in that age group of people because how do we know if they have the insurance benefit for it, and most people, when you try to explain that it’s not covered they don’t want to pay for it anyway.

Respondent 7: You know, the thing is, at any point of the physical examination, outside of here, is the neurological exam; we at least, for each patient test proprioception, uh, so at least we know if that’s intact or not. The typical neurological exam outside of practice is ‘do you feel this?’,

‘yes’; you’re not going to pick up much with that. I know that because when students come back in, I’m saying ‘you didn’t do it all’; you need a couple more things there. And it could even be

105 more extensive than that, but I think if I look at a physical examination alone that is probably the place where people seem to skip things, and that could pick up more people who are at risk for falls.

Respondent 3: Does anybody look at (name omitted) website? Well I do because I was in and I scanned it and I don’t know, maybe you might remember (name omitted), she was one of our graduates, she’s, she got her Master’s in Public Health I believe before she came here, and he has been so (indiscernible) with this paper she just published, so I was able to actually, (name omitted) helped me track down the paper and it’s a very…it came out of the VA hospital she’s in in Florida, and, but, not with, she did a literature review and they came back, all with documentation of, federal documentation available for falls and stuff and diabetes, and, I mean, it’s a really great, well-done study, it’s not like, he’s only referring to this, it’s not like

(indiscernible) in Podiatry Management that write an article, and…their correlation was a tremendous amount of…that falls and peripheral neuropathy are directly related. You have peripheral neuropathy and you’re going to fall, and I think, so going back to, you know, what your saying was, I mean, I hate to identify everybody that has peripheral neuropathy as a fall risk, uh, but maybe it’s something that we need to start thinking about and, you know, when you were saying, well what can we do to get, you know, recognized for doing it, and so I think that there’s so any things that affect the foot, that maybe there is a need for us to be more involved in this, and establishing, pretty much, what we think is important to the assessment of these patients.

Moderator: I'm not sure if it even comes before peripheral neuropathy because whether they are diagnosed or not with diabetes, 50 percent of those with diabetes will develop peripheral neuropathy in their lifetime and, to the point of peripheral neuropathy, you're twice as likely to

106 fall as somebody that doesn't have, that has diabetes but doesn't have peripheral neuropathy, and so it kind of snowballs from there.

Respondent 3: (To the moderator), do you have any specific questions that you want to throw out?

Moderator: Well so, I think you answered my question, you know, kind of on the spectrum of whether it needs to be, you know, a fall knowledge piece, something along some type of protocol about asking for falls, from the conversation here it kind of seems to fall between asking about falls and the fall intervention, having some sort of very quick straightforward easy, not so much a checklist, but some type of referral system. Correct me if I'm wrong…if that's not what…it's kind of being said here; maybe less of a referral system, but a decision tree.

Respondent 3: (Respondent 5), I’m just asking you because, or anyone else, is there anything about falls in the CPM curriculum guide?

Respondent 5: There is a section on geriatrics that (indiscernible); that’s where it would be; it’s not in any of the other (indiscernible)…that’s a newer section; the geriatric section is a newer section that was added to the curriculum guide more recently than the original versions so it’s not in the other sections.

Respondent 3: (To the moderator) any other questions, or things you want to go through?

Moderator: I don’t have anything else.

Respondent 3: Anybody else have any comments? (To respondent 9), you’ve been very awfully quiet in the corner there.

Respondent 9: Um, no, I just thought that this would be something different than it was, and I think that probably as an internist, the only time I ask about falls is if I have a patient who presents with a fall or the result to; an injury, or something as a result of a fall. Generally, I don’t

107 think that we screen, maybe in geriatrics but not internal medicine, you know, for falls, unless somebody presents with a fall, then we ask…tell me about what’s at home, how did you fall, that kind of stuff. But just seeing a patient that has a particular thing, you know, like diabetes or even peripheral neuropathy…

Respondent 6: (To respondent 3) this is, so in geriatrics, one of the things, questions or topics is create a management plan for falls, balance disorders, and gait disorders for the geriatric patient.

So this was, I think, two years ago when things were re-written, so this is a new thing that has been put out, so yes, falls is now a part of the curriculum.

Respondent 3: It is?

Respondent 6: Yeah.

(Indiscernible)

Respondent 3: I think that if students learn about it, they value it more later on, as opposed to...

Moderator: Well thank you, I appreciate your time.

(Moderator collects informed consent forms and shares unrelated dialogue with respondent 3)

108

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