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Background A large proportion of proton pump inhibitor (PPI) prescriptions, including those for stress ulcer prophylaxis (SUP), are inappropriate. Our study purpose was to systematically review the effectiveness of de-implementation strategies aimed at reducing inappropriate PPI use for SUP in hospitalized, non-intensive care unit (non-ICU) patients. Methods We searched MEDLINE and Embase databases (from inception to January 2020). Two authors independently screened references, performed data extraction, and critical appraisal. Randomized trials and comparative observational studies were eligible for inclusion. Criteria developed by the Cochrane Effective Practice and Organisation of Care (EPOC) group were used for critical appraisal. Besides the primary outcome (inappropriate PPI prescription or use), secondary outcomes included (adverse) pharmaceutical effects and healthcare use. Results We included ten studies in this review. Most de-implementation strategies contained an educational component (meetings and/or materials), combined with either clinical guideline implementation (n = 5), audit feedback (n = 3), organizational culture (n = 4), or reminders (n = 1). One study evaluating the de-implementation strategy effectiveness showed a significant reduction (RR 0.14; 95% CI 0.03–0.55) of new inappropriate PPI prescriptions. Out of five studies evaluating the effectiveness of de-implementing inappropriate PPI use, four found a significant reduction (RR 0.21; 95% CI 0.18–0.26 to RR 0.76; 95% CI 0.68–0.86). No significant differences in the occurrence of pharmaceutical effects (n = 1) and in length of stay (n = 3) were observed. Adverse pharmaceutical effects were reported in two studies and five studies reported on PPI or total drug costs. No pooled effect estimates were calculated because of large statistical heterogeneity between studies. Discussion All identified studies reported mainly educational interventions in combination with one or multiple other intervention strategies and all interventions were targeted at providers. Most studies found a small to moderate reduction of (inappropriate) PPI prescriptions or use.

To the Editors—I read with great interest the article on “Trends in the Ambulatory Management of Headache”1 reporting a decline in clinician counseling for headache. While the paper references three clinical guidelines2–4 suggesting lifestyle modification counseling during headache visits, a review of those guidelines shows no evidence to support lifestyle counseling as having efficacy in reducing migraine or headarche frequency. Review of the headache literature also fails to show scientific evidence that lifestyle modification—changes in diet, sleep, or exercise—have ever been proven to reduce headache frequency. Lifestyle modification counseling may provide value in specific situations. There is evidence that simple advice can be effective as a withdrawal strategy in medication overuse headache.5 Obesity and smoking have been associated with increased severity of headaches, in addition to other myriad medical problems, and should be discouraged. Physicians have limited time with headache patients to take a detailed history, perform an appropriate physical examination, review the diagnosis and treatment options, and explore patient preferences for therapy. Using that limited time for lifestyle modification counseling that provides no clinical benefit offers no value. As a headache specialist for over 30 years, I find that I spend increasing amounts of patient time debunking myths about the value of lifestyle modification. While increased stress, dehydration, lack of sleep, sedentary lifestyle, and poor diet all may contribute to poor health, they have not been scientifically linked to increased migraine frequency. Emphasis on lifestyle modification may detract from non-pharmacologic therapies that have evidence to support their use in headache, such as biofeedback, relaxation therapy, and cognitive-behavioral therapy.2 While I find it discouraging that the use of advanced imaging and referrals have increased for headache patients, I do not believe that the decline in lifestyle modification counseling reflects a lost opportunity to improve the value of healthcare.