Selection of opportunities for improvement (Outline for problem)
Concerns have been raised with regards to the overutilization of AST as SUP where studies have emerged with reports claiming that AST usage without proper indication is common. Inappropriate AST such as ranitidine and Proton Pump (esomeprazole, pantoprazole and omeprazole) inhibitor usage were observe among hospitalized patients in general wards Hospital Kulim and upon discharged. The overutilization of AST accounts for a significant increase in cost expenditure.

Key Measures for improvement
The rate of inappropriate AST indication among hospitalized patients is 28.6% while rate of inappropriate continuation of AST at discharge is 35%. The standard was chosen after an agreement achieved between Department of Pharmacy and Department of Medical, Hospital Kulim in departmental meeting.

Process of gathering information
A cross-sectional study was conducted and all patients prescribed AST in wards were assessed in a month period. A total of 159 patients were assess retrospectively in pre intervention and post intervention evaluation data were collected prospectively with total number of patients are 114(2016),135 (2017) and 89 in 2018. The patients’ medical records were accessed to evaluate the appropriateness based on ASHP Guidelines on (SUP), and ESC Recommendations. Costs of AST used are obtained from Store Pharmacy Unit. All information were recorded in a standard data collection form.

Analysis and Interpretation
From the verification study, 55.9% of patients were prescribed AST inappropriately during admission and 56.1% were discharged home with AST unnecessarily. Identified areas for improvement are selection of standard guideline, optimization for guideline utilization, and AST usage surveillance
Strategy for Change Intervention strategies include the development of Android Apps and websites on AST for SUP, distribution of handouts, and CMEs to educate clinicians and ward pharmacists.

Effects of change
Rate of inappropriate AST as SUP among hospitalized patients reduced from 55.9% to 28.1%(2016), to 19.5% (2017) and sustain in 2018 (20.3%). The ABNA successfully reduced from 27.3% to -0.5% in 2016, and to -9.1% in 2017 and sustain in 2018(-8.3%).Rate of inappropriate continuation of AST upon discharge patients successfully reduced from 56.1% to 40% in 2016, to 40.9%in and sustain in 2018 (33.3%).The ABNA successfully reduced from 21.15 to 5% in 2016 to 5.9% in 2017 and -1.7% in 2018. Cost saving is RM200 to RM300 per month and projected cost saving in a year are RM2000 to Rm3500.

The next step
The strategies had been expand to Nephrology Ward. Establishment of hospital policy, expansion to Out Patient Clinic and others ward on AST use will be the next strategies.