1.    Selection of Opportunities for Improvement :
There was an increasing trend in number of patients who were started with proton pump inhibitors (PPIs) at tertiary hospitals and referred to health clinics under PKD Klang for further managements. In 2017, the longest duration of PPI treatment in Klang health clinics was 66 months (5.5 years) which might lead to serious side effects and high expenditure. From an audit, we noticed a high percentage of discharged letters (96.8%) and prescriptions of PPIs (95.7%) received in PKD Klang were incomplete with indications and durations.

2.    Key Measures for Improvement :
The indicator for improvement was the percentage of prescriptions with appropriate use of PPIs in PKD Klang. The standard was set at 66% based on published literature.

3.    Process of Gathering Information :
A quasi-experimental study, which involved a verification study and 2 post interventional cycles, was conducted using universal sampling in all clinics under PKD Klang. All prescriptions of PPIs received during working hours were included in the study except Sistem Pendispensan Ubat Bersepadu (SPUB) prescriptions from other facilities. Validated questionnaires were given to pharmacists, doctors and patients. Pre-test and post-test were carried out for doctors and pharmacists.

4.    Analysis and Interpretation:
Verification study showed only 1.76% of PPI prescriptions was appropriate. The contributing factors included no interventions being done in prescribers and pharmacists (81.67%), no indication of PPI on prescriptions (76.67%), incomplete PPI information on discharge letters (75%), lacking of assessment guideline (41.67%) and followed by demanding from patients (25%).

5.    Strategy for Change :
Pharmacist Review Form (PRF) on PPIs was designed for pharmacists to intervene PPI prescriptions during screening process. Algorithm of PPI deprescribing was adopted for prescribers. PPI Training Module based on National Prescribing Service Limited (NPS) was conducted for prescribers and pharmacists to gain knowledge and awareness. Project findings was shared with the main discharging tertiary hospital to raise the issue of incomplete PPI discharge letters. Counselling checklist and guide were developed for pharmacists. Patient education leaflets were distributed.

6.    Effects of Change:
The numbers of prescriptions with appropriate use of PPIs increased drastically from 1.76% (5/284) to 69.77% (487/698) in cycle 1 and 91.9% (124/135) in cycle 2. Achievable benefit not achieved (ABNA) was improved from 64.24% to -3.77 and further to –25.9. The cost for PPIs reduced 90.01% from RM397,488 (2017) to RM39,420 (2018).

7.    The Next Step:
Empower the sustainability of PPI appropriateness in primary care by ensuring algorithm and guidelines are adhered by all disciplines. Increase public awareness on the appropriate use of PPI enhances quality use of medicine. Publication of this QA project shares the benefits nationwide.