Changes in physical therapy providers' use of fall prevention strategies following a multicomponent behavioral change intervention.

One third of community-dwelling adults over age 65 years fall each year. (1) People who experience a fall are at increased risk for subsequent falls. (2) Major injuries, including fractures, head trauma, and soft tissue injuries, occur in about 10% of individual falls. (1) Falls have been associated with decreased physical and social functioning as well as a 3- to 6-fold increased risk for nursing home placement. (3)

Observational studies (2,4,5) have shown falls in community-dwelling older people to be associated with several risk factors, including muscle weakness, gait and balance deficits, polypharmacy, and postural hypotension. Falling appears to result from the accumulated effect of these and other multiple risk factors. (2,6) In several randomized controlled trials (RCTs), (1,5,7-11) both single and multifactorial intervention strategies have proven effective in both decreasing these risk factors and reducing falls. In particular, physical therapy interventions, including gait training, progressive balance exercises, and home evaluation for environmental hazards, have proven effective, both as a single intervention and as part of a multifactorial intervention strategy. (12) Although a wealth of evidence suggests that interventions targeting fall risk factors are effective, it remains unknown whether, or to what extent, this body of evidence has affected the clinical practice of outpatient physical therapy providers.

The Connecticut Collaboration for Fall Prevention (CCFP) program is an ongoing, community-wide effort in the north-central Connecticut area to translate RCT evidence into clinical practice. The objective is to embed multifactorial fall risk factor assessment and management throughout the health care system. The focus of the CCFP effort is on health care providers caring for ambulatory, community-living older adults, the group for which evidence of effectiveness of fall prevention efforts is the strongest. Physicians, nurses, discharge planners, and physical therapists and occupational therapists working in home health care, ambulatory settings, and hospitals are involved in the CCFP effort. Outpatient physical therapy providers, the focus of the current study, represent one arm of the ongoing CCFP effort.

In a sample of outpatient physical therapy providers exposed to efforts to increase knowledge and promote relevant risk factor assessment and management, the aims of this study were: (1) to describe the physical therapy providers' knowledge of, and attitudes toward, fall risk factors and fall reduction strategies; (2) to assess their self-reported behaviors and practices related to use of fall reduction strategies for their patients; and (3) to identify factors associated with an increase in use of fall reduction strategies for patients in their practices.

Method

Setting and Participants

North-central Connecticut was the designated intervention area and includes all of Hartford and surrounding suburbs and rural areas. Of the more than 871,000 people residing in the north-central Connecticut area, 11% are 70 years of age or older. (13) All hospital-based and freestanding outpatient physical therapy practices in this area that see patients 70 years of age or older were identified via 2 methods. First, a physical therapy provider familiar with the practices in the area compiled a list, and second, telephone book listings were accessed through several Web sites via the Internet. Practices were contacted by letter to inform them of the CCFP effort and were then individually contacted by telephone and an outreach visit was scheduled. A total of 129 outpatient rehabilitation practices were identified, including both freestanding and hospital-based practices. Of those, 8 practices refused to participate and 2 practices did not provide data on their physical therapy providers. The sample of physical therapy providers, therefore, was derived from 119 practices. Three hundred physical therapy providers were employed in these practices. Potential participants for the present study included all outpatient physical therapy providers, including physical therapists and physical therapist assistants, who had been exposed to CCFP efforts, defined as having received one outreach visit by April 1, 2003. One hundred forty-two physical therapy providers met this criterion. Ninety-four providers eventually participated in the study. Figure 1 presents the flow of potential participants and the number of individual physical therapy providers affiliated with the targeted 119 outpatient rehabilitation practices.

[FIGURE 1 OMITTED]

The number of physical therapy providers interviewed from each practice ranged from 1 to 5. Individual participants were excluded only if they relocated prior to completion of a questionnaire or if an interview could not be scheduled.

Baseline characteristics of the cohort are shown in Table 1. Overall, the group was predominantly female (69%), and the majority were physical therapists (91%). Direct patient care accounted for the majority of their work hours (mean hours per week=31.0, SD=9.6), with older patients (70 years of age and older) accounting for one third of those hours.

Intervention

Based on the available literature that suggests that multiple approaches are most effective when professional and organizational behavioral change is the objective, (14) the CCFP program uses a multifaceted approach to encourage the adoption of fall risk factor assessment and management in the care of older patients. The professional and organizational behavioral change strategies used include outreach visits; procuring support for the CCFP effort by facility administrators and supervisors; training manuals with instructions for implementing components of fall risk assessment and management; patient and physical therapy provider risk factor checklists and patient handouts; a Web site from which all materials could be downloaded; working groups of local physical therapy providers who adapted the fall prevention protocols for practical implementation and who worked with investigators in encouraging other physical therapy providers to implement fall prevention practices; "opinion leaders," defined as providers whose opinion was valued by the rest of the group; encouragement of early adopters, or those providers who are first to adopt new ideas and put into practice new behaviors; newsletter reminders to the physical therapy providers about various aspects of the CCFP program; and media attention to heighten community awareness of falls as an important clinical problem. (14-21) All of these strategies were in place in the north-central Connecticut area during the study. The CCFP efforts focus on 6 risk factors based on RCT evidence that interventions targeting these risk factors are effective at reducing fall rates. (1,5,7-11) These risk factors are: gait or balance impairments, multiple medications, postural hypotension, sensory and perceptual deficits, foot and footwear problems, (22,23) and environmental hazards.

The outreach visits were the primary strategy and included a presentation, in the physical therapy providers' offices, of the 6 risk factors along with the recommended management and specific strategies for incorporating the assessment and management into their clinical practice. A team that included a physician, a nurse, and a physical therapist made the outreach visits, and all physical therapy providers included in the study were exposed to a visit at least once during the study period. Sessions usually occurred before or after work or during lunch and lasted for approximately 1 hour. Strategies for fall-related assessment included examination of gait and balance; examination of the feet for calluses, bunions, and nail problems; review of the medications for number and types; and examination of blood pressure in the supine and standing positions. Fall-related interventions suggested for incorporation into physical therapist management included progressive balance exercises, gait training, referral to a podiatrist if foot and footwear problems were noted or to the primary care provider if the patient was noted to have orthostatic hypotension or to be taking multiple medications. The physical therapy intervention was essentially the same as that described for the Yale FICSIT trial. (24)

Potential incentives and barriers also were addressed during these visits, and easy-to-use materials were provided in the form of a training manual. The training manual included the strategies for assessing and managing each of the risk factors and patient handouts. A one-page evaluation and management form also was developed for use in the patient charts. Because the physical therapy providers practiced in the area where the CCFP effort was occurring, they were exposed to the additional behavioral change strategies described earlier. During the outreach visit, names, addresses, and telephone numbers of physical therapy providers were obtained for the purpose of constructing a database. The participants were informed that they would be contacted at a later date to provide feedback about the CCFP program.

Interview

Participants were contacted, by telephone or electronic mail, at least 6 weeks after the outreach visit, with a range of 6 to 24 weeks, and invited to complete an in-depth telephone interview at their convenience. One of the authors (CJB) or a trained research nurse administered a telephone questionnaire to all consenting physical therapy providers according to procedures approved by the Institutional Review Board of Yale University School of Medicine. The questionnaire was a mixture of open and closed-ended questions designed to obtain qualitative and quantitative information that focused on knowledge, attitudes, and self-reported practice behaviors concerning fall risk assessment and management. Closed-ended questions were scored using a Likert-type scale, with responses ranging from 1 to 4. For example, attitude questions asked how important the physical therapy providers thought the risk factor was for managing patients in their clinical practice, and responses for these questions were scored as: 1="not very important," 2="somewhat important," 3="moderately important," and 4="very important." Responses varied depending on the question asked, but all closed-ended questions had 4 possible answers, with 1 being the lowest rating and 4 being the highest rating. Demographic data and practice-related information also were obtained. The time required to complete the telephone questionnaire ranged from 25 to 40 minutes.

To assess interrater reliability, the 2 interviewers each administered the questionnaire to the same 8 physical therapy providers within a 48-hour period. Interviewers were masked to each other's questionnaire results. Test-retest reliability data were assessed in 9 participants by repeating the interview 7 days after the initial interview without knowledge of the original responses. For both interrater and test-retest reliability data, weighted kappa statistics were calculated for the 17 four-level data questions (ie, all questions that asked participants to rate on a Likert scale from 1 to 4). Weighted summary kappas of .65 and .64 were obtained for interrater and test-retest reliability, respectively, suggesting good reliability. (25) Answers that were either 2 points more or less than the previous score on the ordinal scale were considered to be outliers, an event that occurred in less than 4% of the responses.

Outcome Measures

The primary outcome measures were the physical therapy providers' post-CCFP self-report of use of fall prevention strategies with their patients and a change in use of fall prevention strategies from before to after exposure to CCFP outreach efforts. Participants were asked to compare their fall prevention practice behaviors a year ago (pre-CCFP) with their current behaviors (post-CCFP). Specifically, they were asked to respond to the following 2 questions: "Thinking back a year ago, how often did you consider fall prevention in your routine care of older adults?" and "In your clinical practice now, how often do you consider fall prevention in your routine care of older adults?" A change in behavior was defined as changing one or more levels on the 4-level ordinal scale, which ranged from "almost never or never" to "almost always or always." If changes had been made, they were asked to give specific examples of the behaviors that had changed. To examine the open-ended questions about change in practice, the interviewers recorded all answers. One of the authors (CJB) and 2 other researchers independently coded the practice behaviors into broad categories. The coders discussed the categories and reached a consensus about the categories to be used in the coding. Categories chosen by the coders included an increase in assessment, education, referral, or awareness; increased use of exercises or training; and no change noted by the physical therapy provider. The individual physical therapy provider's answers and the category in which the answers had been placed were compared among the 3 coders. Any differences in coding were discussed and resolved by the coders.

The secondary outcomes were knowledge of, and attitudes toward, fall risk factor assessment and management strategies. To assess knowledge, providers were asked to list risk factors and available interventions that had been presented during the outreach visit. The number of risk factors and interventions listed were summed to create a composite variable for risk factor knowledge and knowledge of available interventions. To assess attitudes, participants were asked to rate, using a Likert-type scale, the importance of the 6 risk factors for falls in patients in their clinical practice and their confidence in the effectiveness of the strategies presented by the CCFP program, as previously described.

Data Analysis

Appropriate descriptive statistics, including frequencies, proportions, means, standard deviations, and medians, were developed for the characteristics of the study group and for each of the questions addressing knowledge, attitudes, and self-assessed behaviors. To investigate the relationship among demographics, knowledge, attitudes, and the self-reported change in fall prevention behaviors, bivariate analyses using Kendall rank correlation coefficients (26) were conducted. The Bowker test of symmetry was used to test the equality of the self-rated behaviors before and after exposure to the CCFP program. (27) Subsequently, the independent contributions of demographics (ie, age, sex, type of certification), knowledge, and attitudes to change in practice behaviors were explored using 2 logistic regression models. The first model used a change score for self-rated behaviors from before exposure to after exposure to the CCFP program. Due to a skewed frequency distribution and small numbers in some categories, change scores were trichotomized into those with a decrease or no change, an increase of 1 point, or an increase of 2 or more points on the ordinal scale. The second model examined only the post-CCFP practice behavior score. In models with post-CCFP behaviors as the outcome measure, serf-reported pre-CCFP exposure practice behaviors was included as an independent variable. Models were fit using the backward elimination method. Analyses were carried out using SAS statistical software, version 8.01. * A probability value of less than .05 was considered statistically significant.

Results

Table 2 presents the risk factors and available interventions named by the physical therapy providers when asked, in an open-ended fashion, to list any factors or interventions they could. The most frequently named risk factors were environmental hazards and gait or balance impairments. Multiple medications was named as a risk factor by 77% of the participants, a close third in frequency of responses to gait or balance impairments. Postural hypotension was named as a risk factor by 30% of the physical therapy providers.

The participants rated the importance of each of the 6 risk factors emphasized during the CCFP outreach visits and in the training materials to the patients in their clinical practice. Impaired gait or balance was considered very important by 76 physical therapy providers (81%). Multiple medications and environmental hazards were both rated as "very important" by 48 participants (51%). Postural hypotension was rated as "very important" by 43 participants (46%). The risk factor receiving the lowest percentage of "very important" ratings, by 36 participants (38%), was sensory and perceptual deficits.

Figure 2 presents a comparison of the frequency of use of fall prevention practice behaviors by examining the physical therapy providers' self-reported behaviors from a year ago and their self-reported behaviors after exposure to the CCFP behavioral change effort. Specifically, participants were asked how often they considered fall prevention in their clinical practice at the present time and a year ago. The Bowker test of symmetry comparing self-reported behaviors before and after exposure to the CCFP program showed the difference between the scores was significant (P<.0001) and is evidence that this difference was not due to chance alone. Figure 3 presents the distribution of change in physical therapy providers' self-reported fall prevention behaviors from before to after exposure to the CCFP program.

Table 3 presents the practice behaviors noted by the physical therapy providers to have changed from a year ago. We also analyzed the data excluding the data for the physical therapist assistants and found the same results, so data for the entire sample are presented in the table. The area of multiple medications was noted most frequently, with 77 participants (82%) noting a behavior change related to medication use. Forty-one participants reported referring patients to their primary care provider or pharmacist to review medications; 31 participants were now listing and reviewing patients' medication lists at intake; and 32 participants were doing some education, either verbally or with written handouts, about medications and fall risk. The areas of foot and footwear problems and sensory and perceptual deficits had the smallest amount of practice behavior change, with 50 and 58 providers noting no change in their practice behavior, respectively.

Using multivariate logistic regression, we examined the independent contribution of demographics (age, sex, type of certification), post-CCFP knowledge, and attitudes to the primary outcome of an increase in self-reported fall prevention practice behaviors. In the multivariate model, using the change score from before exposure to after exposure to the CCFP effort as the outcome measure, only post-CCFP knowledge of the risk factors for falls was associated with an increase in self-reported fall prevention behaviors, with an odds ratio (OR) of 1.5 (95% confidence interval [CI]=1.1-2.2). When post-CCFP behavior scores, which ranged from 1 ("almost never or never") to 4 ("almost always or always"), were used in the model as the outcome measure, similar results were demonstrated. Pre-CCFP behaviors had an OR of 2.4 (95% CI = 1.6-3.8), indicating that those who were frequently using the fall reduction strategies before the CCFP program were 2.4 times more likely to be using them after the program. Risk factor knowledge had an OR of 1.4 (95% CI = 1.0-2.1), indicating that those who had greater knowledge of fall risk factors were 1.4 times as likely to be using the strategies. None of the other factors were associated with post-CCFP practice behaviors in either model.

Discussion and Conclusion

The participants reported an increase in use of fall reduction strategies with patients in response to the multicomponent behavioral change strategy. As expected, knowledge of and attitudes toward the fall risk associated with gait or balance impairments and environmental hazards were high. However, multiple medications, not under the usual purview of physical therapy providers, also was recognized as a risk factor by 78% of the participants, and 51% believed multiple medication use to be a very important risk factor in their clinical practice. Only 30% of the participants mentioned postural hypotension as a risk factor. After exposure to the CCFP effort, however, 22 participants noted that they routinely checked postural blood pressures in their older patients.

More than two thirds of the physical therapy providers reported increased frequency of use of fall reduction strategies in their older patients. Results of the Bowker test of symmetry provide evidence that the changes from before exposure to the CCFP program to after exposure to the CCFP program are not due to chance alone. More importantly, the majority of the physical therapy providers had adopted strategies for reduction of fall risk factors that they had not used in the past. These strategies included an increase in the use of referrals to other health care providers, increased use of exercises, and increased education of patients about their fall risk factors.

In multivariate models, only post-CCFP knowledge of the risk factors for falls and fall-related practices prior to exposure to the CCFP effort were significantly and independently associated with an increase in self-reported use of fall prevention strategies with patients. Our findings are in agreement with those of previous studies that suggest that knowledge alone does not result in professional behavioral change. (18,28,29)

Strengths of this study include the high level of participation by those physical therapy providers who had been reached during this study. Only 15 (13%) of those physical therapy providers who were contacted refused to participate either in the CCFP program or in this study. This high participation rate lessens the likelihood of selection bias. The telephone questionnaire itself is an intervention that may further enhance the use of fall reduction behaviors by physical therapy providers. Frequently, after completion of the questionnaire, the participants acknowledged they had not been assessing risk factors and using management strategies as often as they would have liked, and they verbalized a plan to increase their use of the behaviors.

Several important caveats warrant comment. First, concern may be raised that, by choosing to use retrospective preintervention self-assessment, physical therapy providers may have overestimated their current fall reduction behavior compared with previous behavior. However, it has been theorized that there could be a change, due to the intervention itself, in the standards used to judge the preintervention and postintervention self-assessments. (29) For example, physical therapy providers may believe that they are well versed in fall reduction strategies and would rate themselves highly on a pretest. Yet, once they receive an educational intervention, they may realize they know less than they previously believed they knew. In a posttest, they may rate themselves on a similar level as they did before the intervention, but now their assessment is based on what they learned. If, at the same time, they did a retrospective pretest (ie, what did you know before?), they have a better sense of what they knew, compared with what they know now. This may be particularly important when evaluating an educational intervention, because participants may have an increased understanding of or insight into the subject they are rating. The change in the standards used to rate the intervention can reduce the validity of the self-ratings. Retrospective ratings have been well validated in this type of research, as they afford consistent criteria for the preintervention and postintervention self-assessments. (30,31) Similarly, the self-reported behaviors may have overestimated the actual behaviors. The validity of self-report will need to be addressed to determine how well self-report reflects true behavior. The addition of the open-ended questions about what behaviors had changed adds strength to the physical therapy providers' self-assessment. The open-ended questions were used to encourage accountability for their answers because participants were expected to justify the answers they gave. In this study, the physical therapy providers noted an increase in their use of fall prevention strategies with patients and were able to give numerous examples of the strategies they were consistently using in their clinical practice.

In addition, the participants may have wanted to please the interviewers. We attempted to minimize this by having the interview occur by telephone, which theoretically lessens the pressure of answering in a socially desirable manner, as the interviewee never meets the interviewer. (32)

Of greatest importance in predicting who would adopt the fall prevention strategies was the knowledge of the risk factors for falls and, not surprisingly, pre-CCFP practice behaviors. The education and materials presented during the outreach visit were tailored for immediate use by the physical therapy providers, which may have facilitated successful adoption of fall assessment and management. Materials included the training manuals with instructions for implementing components of the fall risk assessment and management, patient and physical therapy provider risk factor checklists, and a variety of patient-centered handouts. The outreach effort used a "hands-on" approach that addressed barriers to change, allowed for problem solving, and permitted ease of integration of the fall prevention strategies into the physical therapy provider's usual routine. The results of this study suggest that the use of a multicomponent change strategy can be successful in promoting behavioral change, even in an area as complex and multifactorial as fall risk factor assessment and management.

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* SAS Institute Inc, PO Box 8000, Cary, NC 27511.

Cynthia J Brown, Margaret Gottschalk, Peter H Van Ness, Richard H Fortinsky, Mary E Tinetti

CJ Brown, MD, is Investigator, Birmingham/Atlanta VA Geriatric Research, Education, and Clinical Center, and Assistant Professor, Department of Medicine, University of Alabama at Birmingham. Address all correspondence to Dr Brown at University of Alabama at Birmingham, VAMC GRECC 11-G Room 8225, 1530 3rd Ave S, Birmingham, AL 35294-0001 (USA) ([e-mail]).

M Gottschalk, PT, MS, is Staff Physical Therapist, Department of Rehabilitation Services, Yale-New Haven Hospital, New Haven, Conn.

PH Van Ness, PhD, MPH, is Lecturer, Department of Epidemiology and Public Health, and Associate Research Scientist/Senior Biostatistician, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn.

RH Fortinsky, PhD, is Professor of Medicine, Center on Aging, University of Connecticut Health Center, Farmington, Conn.

ME Tinetti, MD, is Professor, Department of Epidemiology and Public Health, and Professor, Department of Internal Medicine, Yale University School of Medicine.

Dr Brown, Ms Gottschalk, Dr Fortinsky, and Dr Tinetti provided concept/idea/research design. Dr Brown and Dr Tinetti provided writing and project management. Dr Brown provided data collection, and Dr Brown and Dr Tinetti provided data analysis. Ms Gottschalk provided subjects. Dr Tinetti provided fund procurement and institutional liaisons. Dr Brown, Ms Gottschalk, Dr Van Ness, and Dr Fortinsky provided consultation (including review of manuscript before submission). The authors thank the physical therapy providers who participated in the study; Paula Clark, RN, for assistance in data collection; Bridget Mignosa and Virginia Towle for assistance with data management; and Grace Jeng, MD, and Lisa M Walke, MD, for assistance with coding.

This study was approved by the Institutional Review Board of Yale University School of Medicine.

This project was supported, in part, by a grant from the Donaghue Foundation and by a Yale Pepper Center grant (P60AG10469) from the National Institute on Aging. Dr Brown was supported by a training grant from the National Institute on Aging (T32AG19134) and is a recipient of a John A. Hartford Foundation/American Federation for Aging Research Academic Geriatrics Fellowship Program Award (R04191) and a training support grant from the Hartford Foundation-funded Southeast Center of Excellence in Geriatric Medicine.

An abstract of this research was presented at the Annual Meeting of the American Geriatric Society; May 14-18, 2003; Baltimore, Md.

This article was received December 15, 2003, and was accepted November 4, 2004.

Figure 2

                                           Percentage of Physical
                                             Therapy Providers

Self-reported Frequency of Use of Fall
   Prevention Practice Behaviors by
      Physical Therapy Providers           pre-CCFP     post-CCFP

Almost never or never                         24            3
Sometimes                                     43           23
Often                                         19           36
Almost always or always                       14           38

Self-reported frequency of use of fall prevention strategies with
patients before and after Connecticut Collaboration for Fall Prevention
(CCFP) program (N=94). For each answer, the striped bar corresponds to
the pre-CCFP behavior; the dark bar corresponds to post-CCFP behavior.

Note: Table made from bar graph.

Figure 3

 Change in Self-reported       Percentage of
Fall Prevention Behaviors    Physical Providers

Increased                           68
No change                           25
Decreased                            7

Distribution of change in self-reported use of fall prevention
strategies with patients before and after Connecticut Collaboration for
Fall Prevention (CCFP) program (N = 94)

Note: Table made from bar graph.

Table 1.

Characteristics of Study Sample (N=94)

                                           N (%) or [bar.X] [+ or -] SD
Characteristic                             (Range)

Age (y)                                    37 [+ or -] 9.9 (23-60)
Sex
  Male                                     29 (31)
  Female                                   65 (69)
No. of years since graduation with most     9 (1-38)
  advanced degree, median (range)
Employed
  Full-time                                75 (80)
  Part-time                                19 (20)
Type of provider
  Physical therapist                       86 (91)
  Physical therapist assistant              8 (9)
Hours per week spent in direct patient       31 [+ or -] 9.6 (8-50)
  care
Hours per week spent caring for older      12.2 [+ or -] 8.5 (1-40)
  adults
Physical therapy providers by practice
  type
  Hospital based                           39 (41)
  Freestanding                             55 (59)

Table 2.

Knowledge of Risk Factors and Interventions for Falls (N=94) (a)

                                              Named an
                                   Named      Intervention
                                   Risk       to Address
                                   Factor,    Risk Factor,
Risk Factor                        N (%)      N (%)

Environmental hazards              86 (91)    67 (71)
Gait or balance impairments        73 (78)    90 (96)
Multiple medications               72 (77)    45 (48)
Sensory and perceptual deficits    54 (57)    10 (11)
Foot and footwear problems         44 (47)    35 (37)
Postural hypotension               28 (30)    14 (15)

(a) Open-ended questions posed: "Name as many preventable risk factors
for falls in older adults as you can think of and "Name as many
interventions or treatments that might help prevent falls in your older
patients."

Table 3.

Changes in Fall Reduction Practices Reported by Physical Therapy
Providers (N=94) (a)

                        Fall Risk Factors
Practice Changes
Noted by                Gait or
Physical Therapy        Balance        Multiple          Postural
Providers (b)           Impairments    Medications       Hypotension

No change noted         41             17                50
Increased awareness     19             16                 5
Increased assessment    18              5                22
Increased education/    26             32                17
  recommendations/
  handouts
Increased exercises/    35             Not applicable     4
  training
Increased referral       1             41                10
List and review                        31
  medications

                        Fall Risk Factors
Practice Changes
Noted by                Sensory and    Foot and
Physical Therapy        Perceptual     Footwear    Environmental
Providers (b)           Deficits       Problems    Hazards

No change noted         58             50          40
Increased awareness      4              8           5
Increased assessment    16             21          18
Increased education/    13             29          43
  recommendations/
  handouts
Increased exercises/    15              3          Not applicable
  training
Increased referral       4             10           1
List and review
  medications

(a) or each risk factor, question posed: "Now what do you do
differently, if anything, to address this risk factor?"

(b) Physical therapy providers could give multiple answers to the
question.