Does Appointment Time Impact Decision to Order Cancer Screening?

Patients with primary care physician (PCP) appointments scheduled later in the day are less likely to receive ordered screenings for breast cancer and colorectal cancer (CRC), according to a study published in JAMA.

PCPs are recommended by the U.S. Preventive Services Task Force guidelines to prescribe breast cancer and CRC screening to all eligible patients. However, as the day wares on, PCPs become susceptible to decision fatigue, which is defined in the study as “the depletion of self-control and active initiative that results from the cumulative burden of decision-making.”

As such, researchers sought to examine the correlation between PCP appointment time and ordering and patient completion of breast cancer and CRC screening.

In this retrospective, quality-improvement study, researchers evaluated 19,254 patients eligible for breast cancer screening (100% female; mean age = 60 years; 60.7% white) and 33,468 patients eligible for CRC screening (55.8% female; mean age = 59.6 years; 66.2% white) from 33 primary care practices in Pennsylvania and New Jersey between September 2014 and August 2016.

To assess the outcomes by clinical appointment time, the researchers grouped appointment times from 8:00 a.m. to 5:59 p.m. by the hour. Data analysis was conducted from April 24, 2018, through November 8, 2018.

Screenings Decrease as the Day Progresses

Among patients eligible for breast cancer screening, test order rates were highest at 8 a.m. at 63.7% and diminished throughout the morning to 48.7% by 11 a.m. before again increasing to 56.2% at 12 p.m., and then subsiding to 47.8% at 5 p.m. (adjusted odds ratio [OR] for overall trend = 0.94; 95% CI, 0.93-0.96; P<0.001). Also, the results indicate that trends in screening test completion rates were similar beginning at 33.2% at 8 a.m. and decreasing to 17.8% at 5 p.m. (adjusted OR = 0.95; 95% CI, 0.94-0.97; P<0.001).

Moreover, among the total number of patients eligible for CRC screening, test order rates were 36.5% at 8 a.m. before decreasing to 31.3% by 11 a.m. and rising at 12 p.m. to 34.4% before dropping to 23.4% at 5 p.m. (adjusted OR = 0.94; 95% CI, 0.93-0.95; P<0.001). Trends in screening test completion rates also showed similar results beginning at 28.0% at 8 a.m. and decreasing to 17.8% at 5 p.m. (adjusted OR = 0.97; 95% CI, 0.96-0.98; P<0.001).

“These findings expand our understanding of how time of day may influence medical decision-making for cancer screening in several ways,” the study authors wrote. “Future work could be conducted to further understand the existing behaviors identified in this study such as evaluating the relative contributions of clinician versus patient factors on variations in ordering of cancer screening tests, as well as other factors associated with patient completion of screening tests. Future work could also be focused on ways to improve these behaviors patterns.”