Physicians Less Likely to Order Cancer Screening Late in Day

Kerry Dooley Young

May 24, 2019

Physicians are less likely to order routine cancer screening tests at the end of their workdays, new data suggest. The findings 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 May 10 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, fecal immunochemical test, fecal occult blood test, and stool DNA test (Cologuard, Exact Sciences).

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, Illisnois, 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.

In the commentary, Linder suggests that an overhaul of insurers' approach to paying for primary care could aid in combating decision fatigue. Other members of a patient's care team can aid in the effort to increase cancer screenings by reaching out to patients by telephone or email.

The current reimbursement approach is conducive to these kinds of problems regarding office visits, according to Linder.

"Efforts devoted to clinical preventive services should not depend on one's appointment time, nor should they be confined to face-to-face visits," Linder writes. "Payers should recognize that supporting a fee-for-service, face-to-face dominant system encourages overstuffed visits and probably impairs enrollees' quality of care."

Lindsey M. Philpot, PhD, of the Mayo Clinic, Rochester, Minnesota, who also has conducted research on decision fatigue in medicine, said that insurers' approach to payment puts healthcare providers in a continual rush.

"The way that our billing world has structured us in healthcare delivery is that we go from patient to patient to patient to patient," Philpot told Medscape Medical News.

The Mayo Clinic intends to conduct a pilot program that will investigate an approach in which more information about patients is gathered before they arrive, Philpot said. Nurses or other healthcare staff would speak with patients before they arrive at Mayo and perform what Philpot described as triaging for scheduled visits.

"It's not a mechanism that's currently paid for in our current market, but goodness, it would make such a big difference for both our patients and for our providers," Philpot said.

Nudge Unit

There is a broad trend in medicine to examine how to change the workplace demands for physicians to allow them to better care for their patients. Much of this work, including projects from the Center for Medicare & Medicaid Innovation, focuses on how altering the rules for reimbursement could result in improvements.

Another approach is to look at how seemingly small changes in workplace rules may result in larger changes. The research published in JAMA Network Open was conducted through the University of Pennsylvania's Nudge Unit, which describes itself as the world's first behavioral design team embedded in a health system.

Patel told Medscape Medical News that the Nudge Unit uses an approach already in place in many government organizations. Dedicated teams investigate how seemingly small changes in the demands or options presented to employees in a workplace may trigger larger changes. The Nudge Unit, for example, has sought to increase use of generic medicines by changing the default in electronic health records for certain prescriptions.

Another researcher who has studied decision fatigue, Mark Friedberg, MD, MPP, of Rand Corp, said he agreed with the main thesis of Patel's article, but he had an objection to a measurement used in the study.

"The interpretation that later in the day is worse is probably right" with regard to the care that is delivered, Friedberg said, but he noted that the choice of mammography as a measurement was problematic.

"Giving more women mammographies is not necessarily better than giving fewer women mammographies," Friedberg told Medscape Medical News. "Lots of women might decide, in light of the relative ineffectiveness of this cancer screening and the harms associated with it, that they might make a good decision not to have screening."

In his own practice, Friedberg uses an online screening tool developed by HealthDecision, a medical software firm, to help patients make decisions about cancer screening. (Friedberg said he does not have a financial stake in the company.)

In an email to Medscape Medical News, Patel said he agrees with the need for shared decision-making about this test.

"Our findings use electronic health record data to show declining trends in test ordering and completion over the course of the day," Patel said. "While it is not possible to measure shared decision-making through the medical record, we believe our findings indicate that shared decision-making is likely also occurring at declining rates over the course of the day."

The study was supported by the University of Pennsylvania Health System through the Penn Medicine Nudge Unit. Patel is supported by career development awards from the Department of Veterans Affairs Health Services Research and Development Service and the Doris Duke Charitable Foundation. Patel is the founder of Catalyst Health. He has received research funding from Deloitte for unrelated work, personal fees from Catalyst Health, and is an advisory board member for HealthMine Services,, and Holistic Industries outside the submitted work.

JAMA Netw Open. Published online May 10, 2019. Full text, Editorial

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