Doctors are less likely to order routine cancer screening tests at the end of their workdays, new data suggest – findings which add to a growing body of evidence that the time of a patient’s appointment can affect their care.

In a study of 33 primary care practices in the University of Pennsylvania Health System, the rate at which physicians ordered routine screening tests for breast and colon cancer was highest at the beginning of their workdays,

The rate slipped by midmorning, increased around lunch hour, and then dropped to the lowest point at 5 PM, report Esther Y. Hsiang, BA, a student at the Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues in an article published online in JAMA Network Open.

Among 19,254 patients deemed eligible for orders for mammography, order rates were 63.7% at 8 AM, 48.7% at 11 AM, 56.2% at noon, and 47.8% at 5 PM.

Interestingly, the researchers found a similar trend regarding the number of patients who followed through and underwent screening tests within a year. Completion rates were highest, at 33.2%, for the patients seen at 8 AM and fell to 17.8% for those seen at 5 PM.

Similar patterns were found among the 33,468 patients deemed eligible for colorectal cancer screening. At 8 AM, the test order rate was 36.5%; it dropped to 31.3% by 11 AM, rose slightly to 34.4% by noon, and then decreased to 23.4% at 5 PM. Trends in screening test completion rates were similar — the rate was 28.0% at 8 AM and decreased to 17.8% at 5 PM. Methods of screening included colonoscopy, sigmoidoscopy, faecal immunochemical test, faecal occult blood test, and stool DNA test.

Hsiang and colleagues examined data from electronic health records to find patients who were due to undergo either breast or colorectal cancer screening, as determined on the basis of the US Preventive Services Task Force guidelines.

The observed decline in orders for routine cancer screenings over the course of a workday may be attributed to physicians’ struggling to catch up after they fell behind in their appointments, the researchers explain. Another factor could be decision fatigue. Physicians may grow less likely to discuss cancer screenings with patients during the course of day simply because they have already done this a number of times.

Jeffrey A. Linder, MD, of Northwestern University, Evanston, Illinois, and other researchers have for several years been tracking how this weariness can affect care. In an invited commentary on the article by Hsiang and colleagues, Linder observes that many businesses use decision fatigue to boost sales.

“Car dealerships offer more expensive — and probably unnecessary — options toward the end of the purchasing process. Supermarkets offer sugary, unhealthy foods at the checkout counter,” Linder writes. “Within medicine, decision fatigue has been associated with increasing antibiotic prescribing for respiratory infections, increasing opioid prescribing for back pain, decreasing influenza vaccination, and decreasing handwashing.”

Linder says the study by Patel and colleagues stands out from previous research in showing that effects of appointment time carry into the future. The earlier studies focused on more time-sensitive services.


REFERENCE:  Hsiang et al:  Association of Primary Care Clinic Appointment Time With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening;