Association of Primary Care Clinic Appointment Time With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening

Abstract

Importance: As the clinic day progresses, clinicians may fall behind schedule and experience decision fatigue. However, the association of time of day with cancer screening rates is unknown.

Objective: To evaluate the association of primary care clinic appointment time with clinician ordering and patient completion of breast and colorectal cancer screening.

Design, setting, and participants: Retrospective, quality improvement study of 33 primary care practices in Pennsylvania and New Jersey from September 1, 2014, to August 31, 2016. Participants included adults eligible for breast or colorectal cancer screening. Data analysis was conducted from April 24, 2018, to November 8, 2018.

Exposures: Clinic appointment time during each patient's first primary care physician visit in the study period.

Main outcomes and measures: Primary outcome was clinician ordering of the screening test during the visit. Secondary outcome was patient completion of the tests within 1 year of the visit.

Results: Among the 19 254 patients eligible for breast cancer screening, the mean (SD) age was 60.2 (6.9) years; 19 254 (100%) were female, 11 682 (60.7%) were white, and 5495 (28.5%) were black. Screening test order rates 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 (adjusted odds ratio [OR] for overall trend, 0.94; 95% CI, 0.93-0.96; P < .001). Trends in screening test completion rates were similar beginning at 33.2% at 8 am and decreasing to 17.8% at 5 pm (adjusted OR, 0.95; 95% CI, 0.94-0.97; P < .001). Among the 33 468 patients eligible for colorectal cancer screening, the mean (SD) age was 59.6 (7.4) years; 18 672 (55.8%) were female, 22 157 (66.2%) were white, and 7296 (21.8%) were black. 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 (adjusted OR, 0.94; 95% CI, 0.93-0.95; P < .001). Trends in screening test completion rates were similar beginning at 28.0% at 8 am and decreasing to 17.8% at 5 pm (adjusted OR, 0.97; 95% CI, 0.96-0.98; P < .001).

Conclusions and relevance: 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. Future interventions targeting improvements in cancer screening should consider how time of day may influence these behaviors.

Figure 1.. Breast Cancer Screening Order and Completion Rates by Clinic Appointment Time

Unadjusted data are from September 1, 2014, to August 31, 2016, and based on each patient’s first visit with the primary care physician. Data on order rates represent the day of the primary care visit. Data on completion rates represent a 1-year follow-up from the visit. Clinic appointment times are grouped by the start of each hour (eg, 8:15 am and 8:30 am were grouped to 8 am).

Figure 2.. Colorectal Cancer Screening Order and Completion Rates by Clinic Appointment Time

Unadjusted data are from September 1, 2014, to August 31, 2016, and based on each patient’s first visit with their primary care physician. Data on order rates represent the day of the primary care visit. Data on completion rates represent a 1-year follow-up from the visit. Clinic appointment times are grouped by the start of each hour (eg, 8:15 am and 8:30 am were grouped to 8 am).