Improving Polycystic Ovarian Syndrome Diagnostic Practices Among Adolescent Medicine Providers Orquidia Torres, MD Division of Adolescent and Young Adult Medicine Children’s Hospital of Pittsburgh of UPMC

Background Diagnosing PCOS in adolescents is controversial Provider knowledge and lack of consensus affect adherence to existing PCOS guidelines New criteria offer clinical guidance, but not previously used in the division Limited data on practice improvement for PCOS

Aim Improve adherence to PCOS guidelines using a curriculum based intervention

CHALLENGES WITH ADHERING TO GUIDELINES RECOGNITION EVALUATION Different labs to rule out metabolic risk PCOS symptoms common during adolescence Testosterone levels most likely abnormal Obesity and metabolic risks associated with PCOS Cost of labs; limit labs to most essential Existing guidelines based on adults VARIATION IN PCOS DIAGNOSIS Pediatric vs adult normal androgen cutoff levels Reliable vs unreliable androgen assays Lack of well-defined normal values INTERPRETATION

CHALLENGES WITH ADHERING TO GUIDELINES DIAGNOSTIC DECISION MANAGEMENT Treating multiple symptoms Provider knowledge and comfort level Adherence to medication and/or lifestyle changes Interpretation of lab and clinical findings VARIATION IN PCOS DIAGNOSIS Repeating labs Length of treatment Patient follow-up; shared decision making NEXT STEPS

Methods Retrospective chart review (n=200) Adolescent females evaluated for irregular menses, abnormal uterine bleeding, oligomenorrhea, acne, hirsutism, obesity, or PCOS Data abstraction of presenting symptoms, physical exam findings, laboratory evaluation, and assessment statements Cpt codes jan-dec 2013

Method of Evaluation Post chart review (n=65) Outcomes: 1. Diagnosis of PCOS using clinical and laboratory evidence of hyperandrogenism 2. Laboratory evaluation for PCOS involving a full androgen panel 3. Laboratory evaluation for metabolic comorbidities using OGTT and lipid panel Feb-oct 2016

Intervention Step 1. Develop PCOS protocol and flowchart Made accessible via email and division drive Revisions incorporated provider feedback Step 2. Provider education Consensus guidelines for adolescent PCOS discussed in detail Addressed provider questions regarding PCOS diagnostic features, evaluation of other disorders in the setting of possible PCOS, and metabolic risk evaluation Step 3. Case based learning Reinforced PCOS knowledge through application with 8 real life cases

Intervention Three one hour sessions during scheduled division meetings in February, April, and July 2016 15 Adolescent medicine faculty, advanced practice practitioners, and fellows

Intervention Protocol and flowchart based on published guidelines (Witchel et al, 2015). Emailed to division members Made accessible on division network drive and google drive Provider feedback encouraged for revision

Questions Addressed in Protocol Information Sheet What is menstrual irregularity in adolescent PCOS? What is recalcitrant acne? What is moderate-severe hirsutism? When to evaluate for PCOS? What labs are abnormal in PCOS? What to do if other androgen labs are abnormal? What other labs can be ordered for menstrual irregularities? How metabolic comorbidities relate to PCOS? What is the utility of OGTT in PCOS?

Questions Addressed in Protocol Information Sheet Is ultrasound needed to identify polycystic ovarian morphology in adolescents? Is diagnosis more important than symptom management? What to do with “at risk for PCOS” patients? How do you counsel patients on long term cardiovascular and fertility outcomes of PCOS? Why is it important to test and treat metabolic comorbidities of PCOS? Can obesity and metabolic comorbidities be used to make the diagnosis of PCOS?

Intervention First session (February 2016) Discussion of baseline chart findings Provider concerns with diagnosing PCOS PCOS protocol and flowchart Second session (April 2016) Revision of protocol and flowchart Discussion of new guidelines Address system practice issues with diagnosing PCOS

Intervention Third session (July 2016) Providers worked in teams to discuss cases that could be evaluated for PCOS Eight case examples used PCOS, hypothyroidism, von Willebrand’s disease, late onset CAH, hyperprolactinemia

Case example 14 year old female presenting for follow-up of irregular periods AUB and severe acne resolved on COCPs Maternal history of PCOS Parent concerned that the patient will have fertility issues in the future

Results

Demographics Pre-intervention (total N=200) N (%) Post-intervention (total N=65) N (%) Age 12-13yo 14-16yo 17-18yo ≥19yo 33 (16.5%) 118 (59%) 43 (21.5%) 6 (3%) 7 (10.8%) 27 (41.5%) 20 (30.8%) 11 (16.9%) Presenting symptom Oligomenorrhea Heavy periods Irregular periods Amenorrhea 18 (9%) 48 (24%) 91 (45.4%) 22 (11%) 1 (1.5%) 19 (29.2%) 32 (49.2%) Physical exam findings Obesity (BMI >95%) Obesity with PCOS* Acanthosis nigricans Acanthosis with PCOS* Hirsutism Acne 77 (38.5%) 62/103 (60.2%) 56 (28%) 44/103 (42.7%) 60 (30%) 96 (48%) 24 (36.9%) 15/23 (65.2%) 9 (13.8%) 7/23 (30.4%)

Reason for Diagnosing PCOS Number of Charts with Documented Reason (%) Justification for PCOS Diagnosis in Patients with Irregular Menses as Documented by Providers Reason for Diagnosing PCOS Number of Charts with Documented Reason (%) Pre-intervention Post-intervention Clinical signs of hyperandrogenism* 17 (16.5%) 1 (4.3%) Elevated androgens++ 40 (38.8%) 13 (56.5%) Elevated androgens and clinical signs of hyperandrogenism 26 (25.2%) 4 (17.4%) Acanthosis nigricans** 10 (9.7%) 0 (0%) Reason not specified 5 (21.7%) *Clinical hyperandrogenism of acne and hirsutism not clearly defined **Patients diagnosed using acanthosis nigricans as the sole exam finding in addition to irregular menses. These patients did not have clinical or laboratory evidence of hyperandrogenism ++Variability in normal cutoff values; included patients diagnosed at levels considered normal for adults

*p<0.001

*p<0.001

*p<0.001 Metabolic labs included both lipid and ogtt---significant because included OGTT Pcos orders included all: 17ohp, full and total testosterone, androstenedione, DHEAS

Intervention Challenges Using new guidelines Defining clinical symptoms Specific laboratory orders Diagnosis versus symptom management Practice based learning and improvement Cost of PCOS labs EMR (Cerner) Laboratory testing centers Systems based practice Stigma Followup Adherence Patient care

Discussion This project validates the importance of provider education for implementing evidence based practices Despite most providers questioning the utility of OGTT, there was a significant increase in the proportion of OGTT ordered Proportion of androgen labs (17OHP, DHEAS) also increased

Discussion Providers participating in discussion likely contributed to a change in behavior Understanding the evidence Self-reflection of practices Encouraging use of the protocol

Discussion Accurate PCOS diagnosis did not improve We want to ensure that providers are performing essential lab testing Gonadotropins were ordered in post review HbA1C, fasting glucose, and fasting insulin ordered Accurate PCOS diagnosis did not improve Thought process may be correct, but documentation is key

Limitations Access to charts One clinical site Chart review Missing data Interpretation of written documentation Selection bias Access to charts Time frame of post review Lack of patient follow-up and obtaining labs

Limitations Overall proportion of patients diagnosed with PCOS in the post review was less than the baseline Change in providers during course of project Not accounted for in the post review Partial intervention Some providers missed case based learning and received separate sessions

Conclusion Provider education is only one component related to adhering to guidelines Future work to assess provider attitudes about changing behaviors

Next steps Create a PCOS note template Include macros for correct documentation Revise the PCOS powerplan in Cerner Include a systems check before providers sign lab orders