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Feasibility of a pharmacy-led intervention to de-implement non-guideline-concordant proton pump inhibitor use



Proton pump inhibitors (PPIs) are among the most prescribed medications and are often used unnecessarily. PPIs are used for the treatment of heartburn and acid-related disorders. Emerging evidence indicates that PPIs are associated with serious adverse events, such as increased risk of Clostridioides difficile infection. In this study, we designed and piloted a PPI de-implementation intervention among hospitalized non-intensive care unit patients.


Using the Systems Engineering Initiative for Patient Safety (SEIPS) model as the framework, we developed an intervention with input from providers and patients. On a bi-weekly basis, a trainee pharmacist reviewed a random sample of eligible patients’ charts to assess if PPI prescriptions were guideline-concordant; a recommendation to de-implement non-guideline-concordant PPI therapy was sent when applicable. We used convergent parallel mixed-methods design to evaluate the feasibility and outcomes of the intervention.


During the study period (September 2019 to August 2020), 2171 patients with an active PPI prescription were admitted. We randomly selected 155 patient charts for review. The mean age of patients was 70.9 ± 9 years, 97.4% were male, and 35% were on PPIs for ≥5 years. The average time (minutes) needed to complete the intervention was as follows: 5 to assess if the PPI was guideline-concordant, 5 to provide patient education, and 7 to follow-up with patients post-discharge. After intervention initiation, the week-to-week mean number of PPI prescriptions decreased by 0.5 (S<0.0001). Barriers and facilitators spanned the 5 elements of the SEIPS model and included factors such as providers’ perception that PPIs are low priority medications and patients’ willingness to make changes to their PPI therapy if needed, respectively. Ready access to pharmacists was another frequently reported facilitator to guideline-concordant PPI. Providers recommended a PPI de-implementation intervention that is specific and tells them exactly what they need to do with a PPI treatment.


In a busy inpatient setting, we developed a feasible way to assess PPI therapy, de-implement non-guideline-concordant PPI use, and provide follow-up to assess any unintended consequences. We documented barriers, facilitators, and provider recommendations that should be considered before implementing such an intervention on a large scale.

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Proton pump inhibitors (PPIs) are a class of medication used for the treatment of heartburn and acid-related disorders. PPIs are among the most prescribed medications in both inpatient and outpatient settings [1]. Over 61% of prescribed PPIs among patients in non-intensive care unit (ICU) settings are not guideline-concordant [2, 3]. Unnecessary and especially long-term PPI use are associated with severe adverse outcomes, such as increased incidence of Clostridioides difficile infection (CDI) [4,5,6,7,8,9]. In addition, overuse of PPIs is costly, with over $11 billion spent on PPIs annually in the USA [10, 11].

Unlike PPI use for stress ulcer prophylaxis (SUP) in critically ill patients, which improves clinical outcomes [12], using PPIs for SUP among non-ICU patients is not recommended [13].

De-implementation—“reducing or stopping the use or delivery of services or practices that are ineffective, unproven, harmful, overused, or inappropriate” [14, 15]—of non-guideline-concordant PPIs remains a major gap. De-implementation encounters unique challenges, as there may be more incentives to adopt a new proven innovation than to abandon a long-established practice, even when it is low value or associated with severe adverse events [15,16,17]. Norton and Chambers highlighted more challenges to de-implementation, including (1) loosely characterizing an intervention as evidence-based or non-evidence-based without providing details, such as effect size; (2) patient factors, such as inaccurate perceptions about the intervention; and (3) healthcare providers’ past experience of negative events and fear of medical malpractice [16].

Previous interventions to reduce unnecessary PPI use have largely been conducted in ambulatory care settings and focused on patient education about PPIs. Involvement of the full spectrum of provider stakeholders is lacking [18], and PPI overuse persists despite these previous efforts [19,20,21]. To address the continued need for effective interventions to promote guideline-concordant PPI use, we designed and pilot-tested a PPI de-implementation intervention and assessed its feasibility in an inpatient non-ICU setting.


Study design

We used a convergent parallel mixed-methods design to evaluate the intervention. Quantitative and qualitative data were collected in parallel. Quantitative methods were used to evaluate both the feasibility and outcomes of the de-implementation intervention. Qualitative methods were used to assess barriers and facilitators. We analyzed both forms of data independent of each other, but integration occurred during data interpretation [22]. We report the findings following the Template for Intervention Description and Replication (TIDieR) [23] (see Additional file 1). This study was approved by the University of Wisconsin Health Sciences Institutional Review Board.

Participants and setting

The study was conducted from September 2019 to August 2020 at a 129-bed facility that serves ~130,000 Veterans. Adult non-ICU patients with an active PPI prescription admitted to a medical or surgical unit were included. Patients on the psychiatric, residential rehabilitation, extended stay, and hospice units were excluded because of differences in management and follow-up of these patients.

Intervention development and content

Our intervention strategy involved developing stakeholder relationships, using evaluative and iterative strategies to define the intervention blueprint, supporting clinicians through pharmacy recommendations for PPI therapy changes, training and educating stakeholders, and engaging consumers (i.e., involving patients in the decision about their PPI therapy). This approach was based on the findings of the Expert Recommendations for Implementing Change (ERIC) study [24].

Intervention development involved input from pharmacists, physicians, and nurse practitioners (Fig. 1). Patients were not directly involved in developing the intervention. We started by assembling planning meetings with the antibiotic stewardship (AS) team. In our study, we wanted to leverage the existing AS program that was already performing prospective audit and feedback on antibiotic use, with the rationale that PPI de-implementation shares a common goal with AS with regard to prevention of CDI. In these meetings, we presented a prototype intervention to be refined or revamped following feedback from stakeholders, particularly inpatient pharmacist and physician workgroups. The feedback obtained guided selection of process measures, refinement of outcomes, and development of materials for the intervention. This process of intervention mapping also involved presentations to provide education and awareness about PPI effects and usage to our hospital. Two inpatient pharmacists interested in the study became its champions and supported the intervention within the facility during the implementation period. This approach of intentional collaborative efforts with stakeholders has been described as likely to improve the success of an intervention [25].

Fig. 1
figure 1

Overview of the intervention development

We used the Systems Engineering Initiative for Patient Safety (SEIPS) framework to design and identify barriers and facilitators to the intervention [26]. The SEIPS model describes 5 elements of a work system that can affect processes and outcomes: people, tasks, tools and technologies, organization, and environment, allowing for complete assessment of context [27]. We used the SEIPS model to consider all elements of the system that could influence non-guideline-concordant PPI prescriptions: (1) people—physicians, nurse practitioners, pharmacists, and patients; (2) tasks—evaluation of guideline-concordance; (3) tools and technologies—electronic medical record (EMR) and institutional guidelines; (4) organization—multidisciplinary research and operations team; and (5) environment—hospital units with intervention. We reasoned the SEIPS model would help us better understand how various aspects of the hospital’s system may interact to ultimately affect non-guideline-concordant PPI prescriptions, especially as factors affecting de-implementation are multi-level and cut across all elements of the work system [16].

The final pharmacy-led intervention developed over 3 months involved pharmacist review of patients’ PPI use to assess guideline-concordance [28], patient education about PPIs plus therapeutic options for their condition, and pharmacist recommendation to either stop, reduce dose, or change to a different medication class. The hospital’s Pharmacy and Therapeutics Committee approved the intervention.

Intervention deployment

On a bi-weekly basis, a list of eligible patients was generated. A trainee pharmacist reviewed a random sample of eligible patients’ charts (using patients’ unique identification numbers) to assess if the PPI prescription was guideline-concordant. (A pharmacy resident tested this process first.) A tool to decide PPI guideline-concordance was collaboratively developed through literature review and input from inpatient pharmacists, a gastroenterology physician, and the research team (see Additional file 2). If a prescription was deemed non-guideline-concordant based on indication, dose, or duration, the trainee pharmacist would provide patient education regarding the risks associated with chronic PPI use. PPI education was provided to patients individually. Patients could either accept the recommendation and provide verbal consent or could reject it without any effect on their care. If the patient consented, the trainee pharmacist would recommend de-escalation of therapy to the medical team according to a PPI de-implementation guideline developed by Farrell et al. [28]: (1) step-down PPI, (2) alternate non-PPI therapy, or (3) on-demand PPI usage by the patient. Following hospital discharge, an outpatient gastrointestinal specialty pharmacist followed up with the patient via telephone to assess tolerance and continue the taper if applicable (Fig. 2).

Fig. 2
figure 2

Flow chart of the intervention


Outcomes included acceptability and feasibility of the intervention and PPI usage (number of PPI prescriptions) before and after intervention initiation. We assessed acceptability directly from pharmacists and physicians during participatory planning meetings and through qualitative interviews. To assess the feasibility of the intervention, time to complete the intervention was recorded. This was categorized as the time to determine if the PPI prescription was guideline-concordant, time to provide patient education, and time needed to perform post-discharge follow-up.

Quantitative data collection

We abstracted patient demographics and details related to PPI use from the EMR and entered it into a standardized form in REDCap 8.1.1® [29]. We obtained weekly PPI data for the institution for the period 8 months before and 9 months after intervention initiation.

Qualitative data collection

In descriptive qualitative work, we documented barriers and facilitators to the intervention through qualitative interviews conducted at the end of the 6-month intervention period, and by documenting participatory planning and ongoing meetings with pharmacists and physician workgroups. We conducted phone interviews using an interview guide (see Additional file 3) with pharmacists, nurse practitioners, and physicians. Participants were identified from workgroup listservs, and we sent email invitations to participate in the interviews. Further, we used a snowball approach, where we asked the initial set of interviewees to suggest additional interviewees. The interviews were audio-recorded and transcribed. All participants provided verbal consent.

Statistical analysis

Descriptive statistics were used for demographics, time needed to complete the intervention, and PPI usage. PPI use before and after intervention initiation was calculated using segmented regression analysis of interrupted time-series (ITS) analysis [30]. We analyzed the weekly trend of PPI prescriptions over the study period. The Huber–White sandwich estimator was used to obtain robust standard errors. We performed statistical analyses using Stata software, version 16.0 (Stata Corp. College Station, TX).

Qualitative analysis

Content analysis was used to code the qualitative data. Two authors (JSM, MJK) independently open-coded 2 interview transcripts inductively and deductively according to the 5 elements of the SEIPS model. The authors convened, compared coding, and discussed discrepancies until they reached agreement. Once a final coding scheme was developed, one author (JSM) used it to code the remaining 8 transcripts, consulting with the other author (MJK) as necessary. Emerging themes were classified as barriers, facilitators, or recommendations for guideline-concordant PPI use. The themes were also assigned a SEIPS model element accordingly. Findings are reported according to the Standards for Reporting Qualitative Research guidelines [31].


Patient characteristics

During the study period, 2171 patients were admitted with an active PPI prescription. We reviewed 155 randomly selected patient charts. Mean age of patients was 70.9 ± 9 years, 97.4% were male, and 35% were on PPIs for ≥ 5years; primary care providers initiated PPI therapy most frequently (Table 1). Thirty-one (20%) patients were determined to have non-guideline-concordant PPIs. The most common finding was inappropriate dose (20/31). The following recommendations were made: PPI stopped in 5 patients, PPI dose reduced in 19 patients, and PPI changed to an H2 blocker in 5 patients. All patients were educated about their condition and PPI therapy. Two recommendations were made to de-escalate PPI therapy but were declined by the inpatient pharmacist due to insight that the medical team initiated the PPIs for an alternative indication. None of the patients followed up post-discharge (n=16) reported unintended consequences, such as GI bleeding. The average time taken to complete the intervention was as follows: 5 min to assess if the PPI was guideline-concordant, 5 min to provide patient education prior to making changes to their PPI therapy, and 7 min to follow up with patients post-discharge.

Table 1 Patient characteristics and PPI usage details

Interrupted time series analysis

Figure 3 shows the weekly number of patients on PPI prescriptions. Using regression analysis, we found a baseline mean of 53 PPI prescriptions per week in the general wards. Immediately after the intervention was implemented, the mean number of PPI prescriptions per week (or level) decreased by 2.58, but this was not statistically significant (P=0.411). However, after the intervention, the week-to-week (or trend) mean number of PPI prescriptions decreased by 0.5 (P<0.0001). The week-to-week (or trend) change in the mean number of PPI prescriptions before the intervention was 0.11 (P=0.273). No parameters changed significantly in non-intervention units (Table 2).

Fig. 3
figure 3

Line plot showing the number of patients on PPIs over time

Table 2 Parameter estimates, standard errors, and P-values of segmented regression models predicting weekly numbers of PPI prescriptions over time

Qualitative analysis

We conducted 10 interviews total (20 min on average) with 6 physicians, 2 nurse practitioners, and 2 inpatient pharmacists. Barriers and facilitators spanned the 5 elements of SEIPS and included factors, such as providers’ perception that PPIs are low priority medications and ready access to pharmacists, respectively (Table 3). Below, we describe several salient barriers and facilitators to guideline-concordant PPI use arising from this analysis. We also identified providers’ recommendations for promoting guideline-concordant PPI use.

Table 3 Barriers and facilitators to guideline-concordant PPI use organized by the corresponding SEIPS element

Barrier—PPIs are low priority medications (tools and technology)

Even though side effects of PPIs are acknowledged, providers stated that PPIs are still considered low-priority medications compared to, for example, antibiotics whose non-guideline-concordant use has more far-reaching consequences (Q1).

Barrier—the GERD assumption (organization)

For patients whose PPI is initiated in the outpatient setting, there was a general perception that these patients have a GERD diagnosis and should be on a PPI. For such patients, providers were reluctant to assess the appropriateness of their PPI during admission. This may result in patients taking PPIs unchecked for a long duration (Q3).

Facilitator—ready availability of pharmacists (organization)

Providers noted that ready availability of pharmacists at the facility and a close working relationship with them facilitated guideline-concordant PPI prescriptions. Providers would easily consult pharmacists for help with medication reconciliation (Q12).

Facilitator—patients’ willingness to change to their PPI (person)

We noted that patients were willing to have their PPI therapy changed if necessary. We encountered only 2 patients who insisted that their PPI therapy could only be changed by the outpatient provider who had initiated it (Q13).


We designed an intervention to de-implement non-guideline-concordant PPI use in the inpatient setting that was feasible and decreased the week-to-week mean number of PPI prescriptions. We found that providers’ perception that PPIs are low priority medications was a major barrier, while ready access to pharmacists was a major facilitator to guideline-concordant PPI use.

Our study builds on previous work to address the problem of non-guideline-concordant PPI use. Some prior studies were conducted in the outpatient setting and may not address factors unique to the inpatient setting, the focus of our study [32, 33]. However, a study by Michal et al. in adult non-ICU hospitalized patients found pharmacists’ review of PPIs and recommendation to physicians led to a 25% decrease in PPI prescriptions [34]. Unlike our study in which the intervention lasted for 9 months, the intervention period in Michal et al. was only 1 month. Sustainability of interventions is more likely with a long intervention period [35]. In addition, Gleason et al. found that pharmacists take on average 21.2 min to conduct a complete medicine reconciliation intervention [36]. Our intervention took a total of 10 min, a comparatively short time.

Our pilot intervention was feasible and reduced week-to-week PPI prescriptions following the intervention, without reported unintended adverse effects of PPI de-implementation. The latter, rather than an immediate decline in PPI use, is consistent with the evidence that successful de-implementation efforts require regular messaging after the initial rollout of the intervention [15]. Other than the ongoing medicine reconciliation efforts at our facility, there were no other new medication-related interventions during the intervention period. Moreover, no changes in PPI prescriptions were observed in the non-intervention units (ICU and mental health unit). Although there was a downtrend in PPI prescriptions prior to the intervention (Fig. 3), this trend was not statistically significant, unlike the significant week-to-week decline in PPI prescriptions observed after the intervention. Given that this was a single-site study, it is difficult to ascertain the clinical significance of this week-to-week decline. Larger multisite studies are needed to further assess the effect of such a PPI de-implementation intervention on the number of PPI prescriptions and patient outcomes.

We noted barriers to guideline-concordant PPI use that spanned all elements of the SEIPS model. First, providers perceived PPIs as low priority medications. This may be due in part because most PPI adverse events take a long time to manifest [37, 38]. Hence, there is a need for more education and provision of evidence of serious adverse events of PPIs to providers. Evidence is one of the major driving forces of change in the process of de-implementation [17]. A second barrier was the “GERD assumption,” an organizational barrier where inpatient providers have a general perception that patients who are hospitalized while on a PPI therapy have a diagnosis of GERD. For such patients, inpatient providers were reluctant to intervene in PPI therapy. Mitigating this barrier may require targeted provider education.

Similarly, the facilitators spanned all 5 SEIPS model elements. Prescribing providers noted that ready access to a pharmacist was paramount in ensuring guideline-concordant PPI use. Notably, patients were willing to make changes to their PPI treatment if needed. This is important because providers can be assured of patient engagement in the process, which improves adherence to the proposed medication changes [39].

Providers consistently recommended that they would like a specific intervention that directs them on what to do for the patient. This is important for saving time, one of the barriers stated by providers. In addition, providers recommended a pharmacy-driven intervention. This would fit well in the medication reconciliation role that pharmacists are already performing, albeit with special emphasis on PPIs. Medication reconciliation, the “process of comparing a patient's medication orders to all of the medications that the patient has been taking,” is done to prevent errors, such as duplication, dosing errors, and duration errors, which can potentially lead to patient harm. One strategy used is pharmacy-led review of medications at transition points, such as from ICU to ward or at discharge. Instituting PPI review at such times may be a plausible approach to reducing non-guideline-concordant PPI use [40,41,42].

Strengths of our study include the involvement of patients through education prior to changes in their PPI therapy. Patient involvement is associated with adherence to interventions [39]. Another strength was that the development of our PPI de-implementation intervention was informed by provider input, where we started by assembling planning meetings with an already existing AS team. However, any organized inpatient team, such as pharmacy and therapeutics committees, can be a starting point. Limitations included the single-site nature of the study. However, the use of the SEIPS model, which captures contextual, system-wide factors, increases the applicability of our results.


We developed an approach to assess PPI therapy, de-implement non-guideline-concordant PPI use, and provide follow-up to assess unintended consequences of PPI modification in an inpatient setting. Providers’ perceptions that PPIs are low priority medications was a frequently reported barrier, while ready access to pharmacists was a frequently reported facilitator to guideline-concordant PPI use. Future studies should consider provider recommendations, including using a provider-friendly intervention, forced EMR functions, and pharmacy-driven interventions.

Availability of data and materials

The data on which conclusions are based is available from authors upon request.



Proton pump inhibitors


Electronic medical records


Intensive care unit


Systems Engineering Initiative for Patient Safety


Clostridioides difficile infection


Gastroesophageal reflux disease


  1. Nehra AK, Alexander JA, Loftus CG, Nehra V. In Reply-A relationship between proton pump inhibitors and hypomagnesemia? Mayo Clin Proc. 2018;93(10):1530–1.

    Article  PubMed  Google Scholar 

  2. Haroon M, Yasin F, Gardezi SK, Adeeb F, Walker F. Inappropriate use of proton pump inhibitors among medical inpatients: a questionnaire-based observational study. JRSM Short Rep. 2013;4(8):2042533313497183.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Eid SM, Boueiz A, Paranji S, Mativo C, Landis R, Abougergi MS. Patterns and predictors of proton pump inhibitor overuse among academic and non-academic hospitalists. Intern Med. 2010;49(23):2561–8.

    Article  PubMed  Google Scholar 

  4. Kwok CS, Arthur AK, Anibueze CI, Singh S, Cavallazzi R, Loke YK. Risk of Clostridium difficile infection with acid suppressing drugs and antibiotics: meta-analysis. Am J Gastroenterol. 2012;107(7):1011–9.

    Article  CAS  PubMed  Google Scholar 

  5. Eom CS, Jeon CY, Lim JW, Cho EG, Park SM, Lee KS. Use of acid-suppressive drugs and risk of pneumonia: a systematic review and meta-analysis. CMAJ. 2011;183(3):310–9.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Filion KB, Chateau D, Targownik LE, Gershon A, Durand M, Tamim H, et al. Proton pump inhibitors and the risk of hospitalisation for community-acquired pneumonia: replicated cohort studies with meta-analysis. Gut. 2014;63(4):552–8.

    Article  CAS  PubMed  Google Scholar 

  7. Lazarus B, Chen Y, Wilson FP, Sang Y, Chang AR, Coresh J, et al. Proton Pump Inhibitor Use and the Risk of Chronic Kidney Disease. JAMA Intern Med. 2016;176(2):238–46.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Zhou B, Huang Y, Li H, Sun W, Liu J. Proton-pump inhibitors and risk of fractures: an update meta-analysis. Osteoporos Int. 2016;27(1):339–47.

    Article  CAS  PubMed  Google Scholar 

  9. Cheungpasitporn W, Thongprayoon C, Kittanamongkolchai W, Srivali N, Edmonds PJ, Ungprasert P, et al. Proton pump inhibitors linked to hypomagnesemia: a systematic review and meta-analysis of observational studies. Ren Fail. 2015;37(7):1237–41.

    Article  CAS  PubMed  Google Scholar 

  10. Heidelbaugh JJ, Goldberg KL, Inadomi JM. Overutilization of proton pump inhibitors: a review of cost-effectiveness and risk in PPI. Am J Gastroenterol . 2009;104:S27–32.

    CAS  PubMed  Google Scholar 

  11. Heidelbaugh JJ, Kim AH, Chang R, Walker PC. Overutilization of proton-pump inhibitors: what the clinician needs to know. Therap Adv Gastroenterol. 2012;5(4):219–32.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Alshamsi F, Belley-Cote E, Cook D, Almenawer SA, Alqahtani Z, Perri D, et al. Efficacy and safety of proton pump inhibitors for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis of randomized trials. Crit Care. 2016;20(1):120.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Qadeer MA, Richter JE, Brotman DJ. Hospital-acquired gastrointestinal bleeding outside the critical care unit: risk factors, role of acid suppression, and endoscopy findings. J Hosp Med. 2006;1(1):13–20.

    Article  PubMed  Google Scholar 

  14. Norton WE, Kennedy AE, Chambers DA. Studying de-implementation in health: an analysis of funded research grants. Implement Sci. 2017;12(1):144.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Prusaczyk B, Swindle T, Curran G. Defining and conceptualizing outcomes for de-implementation: key distinctions from implementation outcomes. Implement Sci Commun. 2020;1(1):43.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Norton WE, Chambers DA. Unpacking the complexities of de-implementing inappropriate health interventions. Implementation Sci. 2020;15(1):2.

    Article  Google Scholar 

  17. Powers BW, Jain SH, Shrank WH. De-adopting low-value care: evidence, eminence, and economics. JAMA. 2020;324(16):1603–4.

    Article  PubMed  Google Scholar 

  18. Haastrup P, Paulsen MS, Begtrup LM, Hansen JM, Jarbøl DE. Strategies for discontinuation of proton pump inhibitors: a systematic review. Fam Pract. 2014;31(6):625–30.

    Article  PubMed  Google Scholar 

  19. Wahking RA, Steele RL, Hanners RE, Lockwood SM, Davis KW. Outcomes from a pharmacist-led proton pump inhibitor stewardship program at a single institution. Hosp Pharm. 2018;53(1):59–67.

    Article  PubMed  Google Scholar 

  20. Reeve E, Andrews JM, Wiese MD, Hendrix I, Roberts MS, Shakib S. Feasibility of a patient-centered deprescribing process to reduce inappropriate use of proton pump inhibitors. Ann Pharmacother. 2015;49(1):29–38.

    Article  PubMed  Google Scholar 

  21. Jaynes M, Kumar AB. The risks of long-term use of proton pump inhibitors: a critical review. Ther Adv Drug Saf. 2019;10:2042098618809927.

    Article  Google Scholar 

  22. Fetters MD, Curry LA, Creswell JW. Achieving integration in mixed methods designs-principles and practices. Health Serv Res. 2013;48(6 Pt 2):2134–56.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348(mar07 3):g1687.

    Article  PubMed  Google Scholar 

  24. Waltz TJ, Powell BJ, Matthieu MM, Damschroder LJ, Chinman MJ, Smith JL, et al. Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: results from the Expert Recommendations for Implementing Change (ERIC) study. Implement Sci. 2015;10(1):109.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Huynh TM. Innovators and early adopters of population health in healthcare: real and present opportunities for healthcare-public health collaboration. Healthc Pap. 2013;13(3):53–7; discussion 85-9.

    Article  PubMed  Google Scholar 

  26. Holden RJ, Carayon P, Gurses AP, Hoonakker P, Hundt AS, Ozok AA, et al. SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics. 2013;56(11):1669–86.

    Article  PubMed  Google Scholar 

  27. Shekelle PG, Pronovost PJ, Wachter RM, Taylor SL, Dy SM, Foy R, et al. Advancing the science of patient safety. Ann Intern Med. 154(10):693–6.

  28. Farrell B, Pottie K, Thompson W, Boghossian T, Pizzola L, Rashid FJ, et al. Deprescribing proton pump inhibitors: evidence-based clinical practice guideline. Can Fam Physician. 2017;63(5):354–64.

    PubMed  PubMed Central  Google Scholar 

  29. Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O'Neal L, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019;95:103208.

    Article  Google Scholar 

  30. Wagner AK, Soumerai SB, Zhang F, Ross-Degnan D. Segmented regression analysis of interrupted time series studies in medication use research. J Clin Pharm Ther. 2002;27(4):299–309.

    Article  CAS  PubMed  Google Scholar 

  31. O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51.

    Article  PubMed  Google Scholar 

  32. Inadomi JM, Jamal R, Murata GH, Hoffman RM, Lavezo LA, Vigil JM, et al. Step-down management of gastroesophageal reflux disease. Gastroenterology. 2001;121(5):1095–100.

    Article  CAS  PubMed  Google Scholar 

  33. Zwisler JE, Jarbøl DE, Lassen AT, Kragstrup J, Thorsgaard N, Schaffalitzky de Muckadell OB. Placebo-controlled discontinuation of long-term acid-suppressant therapy: a randomised trial in general practice. Int J Family Med. 2015;2015:175436.

    Article  Google Scholar 

  34. Michal J, Henry T, Street C. Impact of a pharmacist-driven protocol to decrease proton pump inhibitor use in non-intensive care hospitalized adults. Am J Health Syst Pharm. 2016;73(17 Suppl 4):S126–32.

    Article  PubMed  Google Scholar 

  35. Walugembe DR, Sibbald S, Le Ber MJ, Kothari A. Sustainability of public health interventions: where are the gaps? Health Res Policy Syst. 2019;17(1):8.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Gleason KM, McDaniel MR, Feinglass J, Baker DW, Lindquist L, Liss D, et al. Results of the Medications at Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med. 2010;25(5):441–7.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Lyon J. Study questions use of acid suppressors to curb mild infant reflux. JAMA. 2017;318(15):1427–8.

    Article  PubMed  Google Scholar 

  38. Strand DS, Kim D, Peura DA. 25 years of proton pump inhibitors: a comprehensive review. Gut Liver. 2017;11(1):27–37.

    Article  CAS  PubMed  Google Scholar 

  39. Sharma AE, Rivadeneira NA, Barr-Walker J, Stern RJ, Johnson AK, Sarkar U. Patient engagement in health care safety: an overview of mixed-quality evidence. Health Aff (Project Hope). 2018;37(11):1813–20.

    Article  PubMed Central  Google Scholar 

  40. Eggink RN, Lenderink AW, Widdershoven JW, van den Bemt PM. The effect of a clinical pharmacist discharge service on medication discrepancies in patients with heart failure. Pharm World Sci. 2010;32(6):759–66.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Mekonnen AB, McLachlan AJ, Brien JA. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis. BMJ Open. 2016;6(2):e010003.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Almanasreh E, Moles R, Chen TF. The medication reconciliation process and classification of discrepancies: a systematic review. Br J Clin Pharmacol. 2016;82(3):645–58.

    Article  PubMed  PubMed Central  Google Scholar 

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We acknowledge the advice and expertise of the Madison VA Inpatient Pharmacists Work group and the Pharmacy and Therapeutics Committee. We acknowledge Dr. Christopher J. Crnich, the Chief of Medicine, for his support of the project. We acknowledge Erin Patterson, PhD, for proofreading the revised manuscript. We thank all providers who participated in the interviews and the patients who participated in the intervention.

Results were presented in part at the Pharmacy Society of Wisconsin Educational Conference – VIRTUAL, April and August 2020.


This work was supported by Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development pilot [1 I21 HX002618-01]. The views expressed in this article are those of the authors and do not represent those of the Department of Veterans Affairs or the US government.

Author information

Authors and Affiliations



JSM: obtained funding and led the study and manuscript writing. EF: conducted chart reviews and sending PPI recommendations. PL and KW: participated in intervention development and supervised chart reviews and PPI recommendations. MJK: conducted qualitative data analysis. MJH: conducted chart reviews. ARS: participated in intervention development and provided gastroenterology expertise. JST: interview guide development and expertise in chart reviews. KJS: intervention development expertise. NS: intervention development, deployment, and provided implementation science expertise. All authors contributed to manuscript development and read and approved the manuscript.

Corresponding author

Correspondence to Jackson S. Musuuza.

Ethics declarations

Ethics approval and consent to participate

The study was approved by the University of Wisconsin Health Sciences Institutional Review Board. We obtained informed verbal consent from all the participants before any data were collected. The IRB approved the verbal consent procedure.

Consent for publication

Not applicable as the manuscript does not contain any individual person’s data in any form.

Competing interests

Investigators will receive only normal scholarly gains from taking part in this study. The authors declare no competing interests.

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Supplementary Information

Additional file 1.

The TIDieR (Template for Intervention Description and Replication) Checklist

Additional file 2: Table 1.

Proton pump inhibitor indications, doses, and durations of use

Additional file 3.

PPI usage in the VA—interview guide for clinicians

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Musuuza, J.S., Fong, E., Lata, P. et al. Feasibility of a pharmacy-led intervention to de-implement non-guideline-concordant proton pump inhibitor use. Implement Sci Commun 2, 59 (2021).

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