Electronic Strategies for Tailored Exercise to Prevent Falls (eSTEPS): Evaluating Implementation in Primary Care

Background: Falls are the leading cause of injury and injury-related death among older adults. Clinical decision support (CDS) may improve clinician referral and patient access to fall prevention exercise. Objectives: We evaluated implementation of a CDS intervention linking high-risk older adults to gait and balance exercises and identified patient and clinician factors associated with success. Methods: Using the RE-AIM framework, we evaluated implementation year one after a three-month wash-in period at clinics in an academic health system. Community-dwelling adults aged ≥65 seen in person by a physician or advanced practice provider were eligible. We implemented standardized fall risk screening, a CDS alert for positive screens, linked electronic order sets for gait and balance exercise, and pre-configured documentation text. We assessed reach, adoption, implementation, and maintenance; the primary outcome was connection to exercise via order sets or confirmed ongoing gait and balance exercise. Hierarchical logistic regression evaluated associations between patient and clinician characteristics and odds of this outcome. Results: The CDS alert reached 5,458 of 5,891 eligible patients (92.6%); 1,664 (30.5%) were connected to exercise. Male patient sex (OR 0.82; 95% CI 0.70–0.95) was associated with lower odds of connection, while multiple recent falls or a fall with injury increased odds (OR 1.24; 95% CI 1.02–1.49) compared to self-reported fear of falling. Variation in adoption by clinician was substantial (intraclass correlation coefficient ≈ 30%). No significant differences were found by patient age, race/ethnicity, or insurance, nor for clinician department or qualification. Conclusions: CDS can identify older adults at high fall risk and prompt referral to gait and balance exercise. However, adoption was modest and varied by clinician, with patient sex and recent fall history influencing uptake. Targeted strategies to improve clinician adoption and address patient biases may enhance implementation.