P2D197: Improving the Recognition, Identification and Documentation of Pubertal Development and Sexual Maturity Rating in the Outpatient Clinic Setting

Purpose/Objectives: Normal pubertal onset ranges between 8-13 years of age in females and 9-14 years of age in males. There can be confounding variables, such as race, obesity, and premature thelarche/adrenarche that may alter assessment of pubertal status. However, there are many conditions that would require further assessment and possible intervention from a subspecialist. Therefore, it is essential that general pediatricians regularly and accurately assess pubertal status. Accurate documentation of pubertal development, identification of abnormalities, and proper subspecialist referrals, are all essential to optimal patient care. Our quality improvement project aims to assess and improve resident physician completion and documentation of pubertal status during well visits.

Design/Methods: A knowledge assessment and current practices survey was first administered to assess baseline understanding of Sexual Maturity Rating (SMR) and pubertal development was administered to residents. The first PDSA cycle included an educational session on SMR staging and proper documentation. The second PDSA cycle introduced a standardized EMR template to be inserted into physical exam documentation. Data sets of 90 well visit patient charts, aged 3-17 years, were collected prior to intervention, and after PDSA cycles one and two. We evaluated if physicians had both appropriately documented SMR staging and if the plan acknowledged any concerns for aberrant development, when appropriate.

Results: Prior to intervention, 77% (n= 69) of well visits had documented SMR exams. However, out of 42 visits for female patients, only 7 (17%) had 2 SMR values documented (breast and pubic hair). This correlated with our pre-intervention survey, which demonstrated that only 50% of resident physicians palpated for the presence of breast tissue. No male charts had 2 SMR values documented (pubic hair and testes volume). After our first PDSA cycle, 74% (n=67) of well visits had documented SMR exams, and 20% had 2 separate SMR values documented. After our second PDSA cycle, 81% (n=73) of well visits had documented SMR exams, and 57% had 2 separate SMR values documented.

Conclusion/Discussion: Our data demonstrated that over the course of two PDSA cycles, there was significant improvement in the recognition of pubertal development and proper documentation of SMR staging. While this study was limited by the fact that we were unable to confirm the accuracy of the physical exam findings, this project demonstrates that resident education and the introduction of standardized physical exam models within the EMR can create clinical change in the outpatient clinic setting. This project also helped to elucidate further barriers to the performance of pubertal staging and there is potential for further work to address those barriers.