The U.S. Preventive Services Task Force weighed myriad factors when it published final statements three years ago that parsed the many variables related to whether primary care physicians should recommend screening patients for breast cancer and/or colorectal cancer during clinic visits.
One detail the USPSTF didn't account for? The clock on the wall.
As a retrospective study(jamanetwork.com) published May 10 in JAMA Network Open demonstrated, the time of day a patient is seen in the physician's office can go a long way in determining whether that patient -- if he or she is eligible to be screened for breast or colorectal cancer -- actually receives a referral for screening.
The study, "Association of Primary Care Clinic Appointment Time With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening," found that patients who saw a physician in the morning were significantly more likely to be referred for breast and/or colorectal cancer screening than patients whose appointments were late in the afternoon. The study also showed that patients who saw their physicians later in the day were less likely to follow up on a referral.
- A new study found that the time of day can play a significant role in whether a patient receives screening for breast or colorectal cancer.
- The study found that patients seen early in the morning were more likely to be referred for cancer screenings than patients who saw their primary care physician later in the afternoon.
- The study also found that patients who saw their physician later in the day were less likely to complete screening after receiving a referral.
The study authors evaluated patient visit data at 33 family medicine and internal medicine practices in urban and rural settings in Pennsylvania and New Jersey. Specifically, they evaluated each patient's first new or return visit with a PCP between September 2014 and August 2016, excluding data for acute or sick visits.
From that cohort, they used the practices' EHRs to identify, based on USPSTF guidelines, patients eligible for breast cancer screening (n=19,254), as well as those eligible for colorectal cancer screening (n=33,468).
The researchers measured two outcomes: whether the PCP ordered cancer screening for eligible patients during the visit and whether the patient completed that screening within one year of the visit. To evaluate those outcomes by clinic appointment time, appointment times were grouped by the hour throughout the day (i.e., appointments at 8, 8:15, 8:30 and 8:45 a.m. were grouped to 8 a.m.)
The study team found that unadjusted rates of clinicians ordering breast cancer screening for eligible patients were at their highest (63.7%) when the visit occurred during the 8 a.m. hour. Rates decreased to 48.7% at 11 a.m., rebounded to 56.2% at noon, and then remained steady until declining to less than 48% among patients seen at 4 p.m. or later.
A similar pattern was seen in unadjusted clinician order rates for colorectal cancer screening. Rates topped 36% in eligible patients seen at 8 a.m. and 9 a.m., decreased to slightly higher than 31% at 11 a.m., bounced back to more than 34% at noon, and then dropped to less than 24% among those seen at 5 p.m.
Relative to 8 a.m., adjusted odds ratios of clinician ordering of both breast and colorectal cancer screening were significantly lower for each hour from 10 a.m. to 5 p.m. Similar patterns were seen for patient completion of screening: Relative to 8 a.m., the adjusted odds ratio of completing breast cancer screening was significantly lower for each hour from 10 a.m. to 5 p.m., and the adjusted odds ratio of patient completion of colorectal cancer screening was lower for each hour from 9 a.m. to 5 p.m.
Patients, Clinicians Share Responsibility
The researchers said their findings broaden the current understanding of how time of day may influence the decision-making process. They pointed to specific clinician- and patient-related factors that could affect how the process plays out, including:
- Lack of time. As the day progresses, PCPs may fall behind schedule, leading to shorter interactions with patients. As a result, they may forgo cancer screening discussions during that visit.
- Decision fatigue. Clinicians may be less likely to discuss cancer screening with patients later in the day because they already have had the same discussions -- or made other important decisions -- many times earlier in the day.
- Declining screening. Patients seen earlier in the day who decline cancer screening despite the clinician's recommendation may influence the clinician's likeliness to discuss cancer screening with other patients later that day.
- Being in a rush. Patients who see their clinician later in the afternoon may choose not to discuss cancer screening simply because they want to conclude the appointment quickly and get on with the rest of their day.
In an accompanying commentary,(jamanetwork.com) the authors noted that "in clinic sessions, the amount of work necessary to achieve quality or performance metrics for patients is overwhelming." To improve screening rates, they suggested using non-clinicians to address some types of screening gaps and restructuring clinic time so physicians could better focus on the care patients need at that visit.
Corresponding Author's Perspective
Mitesh Patel, M.D., M.B.A., M.S., an associate professor in the Department of Medicine at the University of Pennsylvania Perelman School of Medicine in Philadelphia and the study's corresponding author, told AAFP News that the results highlighted the physical and mental constraints physicians experience as they deal with a lack of time throughout the day.
"Physicians are increasingly being asked to do more with the same or less amount of time, and this pattern needs to change to address the issues our study found," said Patel.
Physicians also need to recognize decision fatigue and take steps to fight it off, he cautioned.
"Just being aware that (decision fatigue) affects everyone as the day progresses is important," Patel said. He recommended setting aside time for short breaks during the day as a way to address the problem.
Additionally, physicians can help patients who appear fatigued or uninterested in talking about screening.
"It's important that patients know these decisions can have a lasting impact," Patel noted. "Physicians can think about how to prioritize the discussion to focus on the things most important to the patient's health."
Patel viewed the research as offering insight into quality improvement from a slightly different perspective.
"We often think about disparities in care by patient characteristics, but there is an opportunity to address disparities in care by time of day," he said.
For example, Patel recommended that processes involving repetitive decisions be automated or shifted to medical assistants and said that some screening decisions could be addressed before the primary care visit.
Regarding the latter recommendation, he cited a December 2018 study(journals.lww.com) published in The American Journal of Gastroenterology in which patients were randomized to either opt in to or opt out of receiving a mailed fecal immunochemical test to screen for colorectal cancer. Results showed that screening rates were three times higher in the opt-out patients than in those who had to actively opt in to receive the test.
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