A new study suggests that physicians are less likely to schedule cancer screenings for patients during the latter part of the day.

Researchers at the University of Pennsylvania sought to understand how the time of day can influence doctors' behavior when providing cancer screenings.

They examined medical data collected from 33 primary care practices in Pennsylvania and New Jersey between 2014 and 2016. This included eligible screenings for nearly 19,000 breast cancer and 33,000 colorectal cancer patients.

Decision Fatigue

The team found that doctors preferred to order breast cancer screenings at 8 a.m. (64 percent) than at 5 p.m.(48 percent).

As for colon cancer screenings, patients were more often scheduled at 8 a.m. (37 percent) than later in the day (23 percent).

Esther Hsiang, a researcher at Penn Medicine Nudge Unit and one of the investigators of the study, explained that the downward trend may be caused by "decision fatigue." Doctors may be less inclined to provide a new decision after they have been making them all day.

She said the behavior may also stem from overloaded physicians getting behind of their schedules as the day progresses.

Completing Cancer Screenings

Hsiang and her colleagues also looked at the likelihood for patients to complete their cancer screening within a year of their appointment. They also discovered a similar downward trend in patients' behaviors.

One-third (33 percent) of patients who had breast cancer screening at 8 a.m. were able to finish the procedure within a year. However, only 18 percent of those who had 5 p.m. screenings were able to do so.

Meanwhile, less than a third (28 percent) of those who underwent colorectal cancer screenings at 8 a.m. completed their appointments within a year. The figure drops to just 18 percent among those who were scheduled for screenings at 5 p.m. or later.

These results are alarming since they suggest that some doctors may be deferring screening discussions to future appointments, believing that a decision will be made the next time they see their patients.

Breast and colon cancer screenings often require coordination between different departments, as well as multiple visits by patients, to complete. This provides more opportunities for potential lapses in medical screening.

While cancer screening rates tended to drop as the day progressed, the researchers noticed a spike in screening schedules when patients visit their doctors at noon.

An example of this is seen in breast cancer screening orders, which fell to 48.7 percent at 11 a.m. However, rates suddenly increased to 56.2 percent by around 12 p.m. This brief upward trend is also reflected on patients' one-year completion rates.

This may be due to lunch breaks offering physicians a chance to catch up with their schedules and even start fresh.

In 2018, a study was launched to examine a downward trend involving flu vaccination rates. It discussed how time of day played an important role in influencing doctors' behaviors.

To help address the issue, a "nudge" was added to the vaccination system that prompted physicians to either accept or decline influenza vaccine orders. This resulted in a nearly 20 percent increase in vaccinations among doctors who received the nudge.

The Penn Medicine Nudge Unit researchers are exploring the possibility of using similar nudges for cancer screenings.

"Our new study adds to the growing evidence that time of day and decision fatigue impacts patient care," said Mitesh Patel, director of the Penn Medicine Nudge Unit and co-author of the study.

"In past work, we've found that nudges in the electronic health record can be used to address these types of gaps in care, which we suspect will be the case here."

Patel said additional studies can be conducted to find out how nudges can help improve cancer screenings.

The findings of the Penn Medicine Nudge Unit study are featured in the journal JAMA Network Open.

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