Email UpdatesThe purpose of this artifact is to incorporate ASPIRE exercise guidance into the primary care workflow. The United States Preventive Services Taskforce (USPSTF) recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls.
The Advancing Fall ASsessment and PreventIon PatIent-Centered Outcomes REsearch Findings into Diverse Primary Care Practices ( ASPIRE) exercise guidance will be accessed in the EHR in the context of existing primary care workflows. This will facilitate provider and patient review of risk factors, exercise interventions needed, and a platform for prioritizing exercise interventions that the patient agrees to implement. The final exercise care plan is saved as a note in the EHR and provided to the patients as a printout or in the after-visit summary.
Artifact Creation and Usage
- Patricia Dykes
- Robert Lucero
- Nancy Latham
- Pam Neri
- Tien Thai
- Hannah Rice
- Denise Schentrup
- Ragga Bjarnadottir
- Kristen Erika, Shear
This CDS artifact and related data specifications are owned and stewarded by the Brigham and Women's Hospital (BWH), University of Florida Research Foundation, Inc (UF), and Regents of University of California (UC). BWH/UF/UC are not responsible for any use of the CDS artifact. BWH/UF/UC make no representations, warranties, or endorsement about the quality of any organization or physician that uses this CDS artifact.
This is a CQL-based CDS artifact and is executed by one of the components of the CDS Connect project (i.e. CDS-Connect-CQL-Services application). The CDS-Connect-CQL-Services application exposes this CQL_based CDS artifact thru a web-based API so it can be consumed by other applications.
Structured code that is interpretable by a computer (includes data elements, value sets, logic)
Provide CDS for select prioritized recommendations in the USPSTF Fall Prevention Guidelines. The artifact provides CDS for exercise recommendations in the 2018 Final Recommendation Statement, Falls Prevention in Community-Dwelling Older Adults Interventions.
This artifact is designed to be implemented in an EHR during a primary care wellness visit for patients over 65 who have screened positive for fall risk (answered “yes” to one or more fall risk screening questions).
It is designed to offer the clinician guidance for developing exercise prescriptions including home exercise and physical therapy to improve strength, gait and balance in Older adults (age 65+ years) who fail their fall risk screening during a primary care wellness visit.
Not applicable
Sherrington et. al. (2019) found that exercise programs that include balance and functional exercises reduce the rate of falls and the number of people experiencing falls community dwelling older people (high-certainty evidence).
The US Preventive Service Task Force (USPSTF) recommends that older adults at risk of falls be referred to appropriate fall-prevention exercise programs (USPSTF Level B). Direct implementation of the exercise intervention by PCPs conducting the risk assessment, or facilitation of the interventions by qualified healthcare professionals, is strongly recommended for community dwelling older adults (level A evidence).
The American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons (2011) recommends that all multifactorial interventions for community-residing older people should include exercise; specifically include balance, gait, and strength training.
- Sherrington, C., et al., Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev, 2019. 1: p. CD012424.
- U.S. Preventive Services Task Force. Falls Prevention in Community-Dwelling Older Adults: Interventions. 2018; Available from: https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/falls-prevention-in-older-adults-interventions1.
- Guirguis-Blake, J.M., et al., Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA, 2018. 319(16): p. 1705-1716.
- Panel on Prevention of Falls in Older Persons, Panel on Prevention of Falls in Older Persons, American Geriatrics Society, British Geriatrics, Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc, 2011. 59(1): p. 148-57.
- Rice H, Garabedian PM, Shear K, Bjarnadottir RI, Burns Z, Latham NK, Schentrup D, Lucero RJ, Dykes PC. Clinical Decision Support for Fall Prevention: Defining End-User Needs. Appl Clin Inform. 2022 May;13(3):647-655. doi: 10.1055/s-0042-1750360. Epub 2022 Jun 29. PMID: 35768011; PMCID: PMC9242739.
Community dwelling Older adults at risk of falls should be referred to appropriate fall-prevention exercise programs (USPSTF Grade B).
Direct implementation of the exercise intervention by providers conducting the risk assessment, or facilitation of the interventions by qualified healthcare professionals, is strongly recommended for community dwelling older adults (USPSTF Grade A evidence).
Older adults at risk of falls should be referred to appropriate fall-prevention exercise programs (USPSTF Grade B).
Direct implementation of the exercise intervention by providers conducting the risk assessment, or facilitation of the interventions by qualified healthcare professionals, is strongly recommended for community dwelling older adults (USPSTF Grade A evidence).
As noted above, multiple clinical practice guidelines recommend exercise interventions including strength, gait and balance training to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. The evidence for this recommendation is strong, based on clinical trials, meta-analyses.
Based on the evidence this artefact recommends exercise for all patients age 65+ who are at risk for falls. In addition, it recommends physical therapy for patients with evidence of gait disturbance.
The ASPIRE application recommends physical therapy for patients who are homebound. Since this is not captured as structured data in EHR, we capture this information in the ASPIRE user interface when it is invoked in the CDS-enabled workflow.
The content of the CDS can be used to recommend follow-up actions to clinician in a BestPractice Advisory or when the clinician opens an ambulatory wellness visit template.
Primary care patients age 65+ who screen positive for fall risk (answer “yes” to one or more fall risk screening questions).
- Fall prevention exercise recommendations (all)
- Physical therapy referral (homebound and/or patient has a gait disturbance)
We pilot tested this logic in one rural (Florida) and one urban (Boston) primary care practice. We found that providers appreciated access to evidenced based exercise recommendations and that patients are receptive to these recommendations. Upon completion of the clinic visit, the trained research staff member met with the patient in a private setting to ask a small set of open-ended questions and administer a patient-provider communication (Health Care Relationship Trust Scale) and shared decision-making questionnaire (Shared Decision-Making Questionnaire-9). For the HCR Trust Scale, patients from both sites reported a mean score of 58 (median 60, SD 6.1) out of a possible score range of 0-60. For the SDM-Q9 survey, patients from both sites reported a mean score of 92 (median 100, SD 14.9) out of a possible score range of 0-100. Once the 40 observations were completed, a focus group was conducted with clinicians at each site to gather individual perceptions of their experience using ASPIRE. At the end of both focus groups, the Health-ITUES survey was administered to each participating clinician in order to help gauge clinical feasibility and acceptability of the software in the primary care environment.