Clinical Decision Support for Fall Prevention in Primary Care: The eSTEPS Cluster Randomized Clinical Trial.

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.