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What’s New in the Patient Safety World

June 2019

More on the Time of Day



Most patients try to schedule their medical appointments and elective procedures around times that are convenient for themselves or their families or friends. But does that always result in the best healthcare?


Our Patient Safety Tip of the Week for May 3, 2011 “It’s All in the Timing” noted disparities in polyp detection rates for colonoscopies done later in the day. Another study (Kim 2018) Influenza vaccination rates significantly declined as the clinic day progressed. The researchers in that study also developed an active choice intervention in the electronic health record that successfully increased influenza vaccination rates that were similar in magnitude throughout the day. And another study analyzed decisions regarding antibiotic prescribing (Linder 2014). Those researchers found that primary care clinicians’ likelihood of prescribing antibiotics increased throughout the morning and afternoon clinic sessions for antibiotics sometimes indicated and antibiotics never indicated acute respiratory infections. This was consistent with the hypothesis that decision fatigue progressively impairs clinicians’ ability to resist ordering inappropriate treatments. And yet another study found that opioid prescribing for low back pain in primary care increased later in the day (Philpot 2018).


Now a new study shows that your chance of receiving cancer screening from your primary care practitioner also depends on what time of day you see him/her. Hsiang et al. (Hsiang 2019) looked at association of primary care clinic appointment time with clinician ordering and patient completion of breast and colorectal cancer screening. They found that clinician ordering of cancer screening tests significantly decreased as the clinic day progressed. Patient completion of cancer screening tests within 1 year of the visit was also lower as the primary care appointment time was later in the day.


Screening test order rates for breast cancer were highest at 8 AM at 63.7%, decreased throughout the morning to 48.7% at 11 AM, increased to 56.2% at noon, and then decreased to 47.8% at 5 PM. Trends in screening test completion rates were similar beginning at 33.2% at 8 AM and decreasing to 17.8% at 5 PM.


For colorectal cancer screening, test order rates were 36.5% at 8 AM, decreased to 31.3% by 11 AM, increased at noon to 34.4%, and then decreased to 23.4% at 5 PM. Trends in screening test completion rates were similar beginning at 28.0% at 8 AM and decreasing to 17.8% at 5 PM.


While fatigue is one obvious explanation for many of these findings, there are other factors that likely contribute. Hsiang et al. noted that, ss each shift progresses, clinicians may fall behind schedule, possibly leading to shorter interactions with the patient at the end of the morning and afternoon shifts. They also note that, if patients earlier in the day decline screening despite the clinician’s recommendation, it could influence how likely the clinician is to bring up the topic later in the day with a different patient. They also note that in this study, and several of the others noted above, behaviors improved slightly after lunch, only to decline again later in the afternoon.


In the accompanying editorial (Liss 2019), Liss and Linder note that “decision fatigue” (progressive erosion of ability, self-control, or will power that occurs as people make choices) occurs in several other industries and social situations. But they also note that other factors, like fatigue among ancillary staff (who often are the ones who arrange for preventive care). And there may well be patient factors that come into play. It may be that end-of-the-day patients were less likely to make immediate arrangements for follow-up or remember that they needed follow-up.


Whatever the cause(s), it’s important that healthcare organizations institute proper systems to identify such missed opportunities. And it is incumbent upon the astute customer of healthcare to recognize that there are vulnerabilities associated with the time of day they receive their healthcare.






Kim RH, Day SC, Small DS, et al.  Variations in influenza vaccination by clinic appointment time and an active choice intervention in the electronic health record to increase influenza vaccination.  JAMA Netw Open 2018; 1(5): e181770



Linder JA, Doctor JN, Friedberg MW, et al. Time of day and the decision to prescribe antibiotics. JAMA Intern Med 2014; 174(12): 2029-2031



Hsiang EY, Mehta SJ, Small DS, et al. Association of Primary Care Clinic Appointment Time With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening. JAMA Netw Open 2019; 2(5): e193403 May 10, 2019



Philpot LM, Khokhar BA, Roellinger DL, et al. Time of day is associated with opioid prescribing for low back pain in primary care. J Gen Intern Med 2018; 33(11): 1828-1830



Liss DT, Linder JA. Decision Fatigue, Running Late, and Population Health Management—Screening Out of Time. JAMA Netw Open 2019; 2(5): e193402 May 10, 2019





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