1. 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

2. 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

3. Aim
Improve adherence to PCOS guidelines using a curriculum based intervention

4. 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

5. 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

10. 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

11. 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

12. Intervention Step 1. Develop PCOS protocol and flowchart
Made accessible via 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

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

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

17. 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?

18. 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?

19. 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

20. 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

21. 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

22. Results

23. 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%)

24. 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

25. *p<0.001

26. *p<0.001

28. *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

30. 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

31. 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

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

33. 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

34. 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

35. 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

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

37. 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