421 Improving Proton Pump Inhibitor Prescribing Practices in an Academic Safety Net Primary Care Clinic: Quality Improvement Project

Abstract

INTRODUCTION: Proton Pump Inhibitors (PPI) overuse in both inpatient and outpatient settings have increased drastically over the last 2 decades. Overuse of PPIs continues despite evidence based guidelines and prolonged PPI use carries serious adverse effects. The aim of this quality improvement (QI) is to reduce the percentage of patients inappropriately prescribed PPIs between the ages of 40-75 years from a baseline rate of 80% to < 60% within 1 year at ECMC internal medicine clinic (IMC). METHODS: We used the Plan-Do-Study-Act (PDSA) model and performed a root cause analysis to identify barriers for the reduction of inappropriate use of PPIs. The major barriers included system, provider and patient-based barriers including lack of electronic medical record (EMR) alerts, gaps in knowledge in both the provider and the patient, fear of discontinuation of the PPI. QI team included nursing and ancillary staff, residents, attending physicians, social worker. Outcome measure was to reduce the percentage of patients inappropriately prescribed PPIs from 80% to < 60% in 1 year. Process measures included measuring the percentage of patients who are appropriately referred to GI clinic for an EGD and the percentage of patients on PPI who have their GERD assessed during the clinic including assessment for alarm symptoms. Balancing measures included potential increase in patient wait times in the clinic and esophagogastroduodenoscopy (EGD) wait time. The major interventions included (1) creating a customized EMR template; (2) provider education; (3) tracking continuity of care visits and medication reconciliation; (4) patient education; (5) assessing barriers and response to discontinuation; (6) Pocket guides for physician education. RESULTS/OUTCOME MEASURES: Average rates of PPI discontinuation were 51.1% (n = 92/180), resulting into 30.0% inappropriate chronic PPI use from the baseline rates of 80% within 1 year. Process measures: The total percentage of patients on long term PPI use who had an EGD was recorded as 51.1% which improved from the baseline of < 30%. The EGD completion rates in eligible patients was 43.6% from baseline of < 20%. CONCLUSION: We exceeded the goal, achieved >50% reduction in inappropriate use of chronic PPI use within 1 year. Lack of automated medical decision support tool was identified as the biggest barrier. Optimization of EHR and education to QI team members were crucial for the success of this QI. Future directions include enhancing patient engagement and spread to other clinics.