Clinical Decision Support for Fall Prevention in Primary Care

Importance Falls are a leading cause of injury among older adults. Although exercise reduces fall risk, implementation in primary care remains limited. Objective To assess whether an electronic health record–integrated clinical decision support intervention, Electronic Strategies for Tailored Exercise to Prevent Falls (eSTEPS), reduces falls among older primary care patients at increased risk. Design, Setting, and Participants This matched-pair cluster randomized clinical trial was conducted from June 9, 2023, to May 8, 2025, with 12 to 23 months of follow-up at primary care practices within an integrated health system in the US. Adults aged 65 years or older with a positive 3-item fall-risk screen at a primary care visit were included. Intervention eSTEPS decision support embedded in the electronic health record with tailored exercise recommendations, optional physical therapy referral, and patient-facing materials (handouts, website, and app). Main Outcomes and Measures The primary outcome was the rate of patients with 1 or more falls identified using electronic health record–derived International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnostic codes. Secondary outcomes were the rate of patients with 1 or more fall-related injuries identified by validated ICD-10 algorithms and mortality. Results Among 11 945 participants (mean [SD] age, 77.05 [7.43] years; 8044 females [67.3%]), of whom 5681 (47.6%) were in the intervention group and 6264 (52.4%) were in the control group, at 22 primary care practices, the rate of 1 or more ICD-10 –coded falls (including falls with injuries) per 100 patient-years over the study period was 19.3 (95% CI, 18.6-20.1) in patients from intervention practices vs 21.2 (95% CI, 20.2-22.1) in patients from control practices (rate ratio [RR], 0.91 [95% CI, 0.88-0.95]; P < .001). The rate of ICD-10 –coded fall-related injuries per 100 patient-years was 15.7 (95% CI, 15.0-16.5) from intervention practices vs 16.7 (95% CI, 16.1-17.4) from control practices over the study period (RR for fall injuries per 100 patient-years, 0.94 [95% CI, 0.90-0.97]; P = .001). No differences were observed in mortality. For intervention patients, eSTEPS exercise prescriptions were issued for 1255 patients (22.1%). Overall, 215 clinicians (77.9%) in intervention practices used the clinical decision support to deliver the exercise program at least once over the study period. Conclusions and Relevance In this cluster randomized clinical trial of an electronic health record–integrated decision support, falls and fall-related injuries were modestly reduced in older adults in primary care. These results suggest support for scalable, workflow-integrated fall prevention. Trial Registration ClinicalTrials.gov Identifier: NCT04993781