Physicians More Likely to Order Cancer Screening in the Morning

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Patients with primary care appointments in the morning were more likely to have orders for and receive recommended breast and colorectal cancer screenings.

The time of your primary care appointment may influence whether you are ordered for cancer screening, according to a new study, which found that physicians are more likely to order cancer screening in the morning.

Underuse of cancer screening tests is common, with the CDC estimating that among patients who meet guideline recommendations, approximately 37% of adults have not been screened for colorectal cancer and 28% of women have not been screened for breast cancer. As a result, identifying target areas to improve screening is crucial.

Examining screening test order rates from 33 primary care practices in Pennsylvania and New Jersey between September 1, 2014, and August 31, 2016, the researchers found that rates were highest early in the morning and dipped toward the end of morning and afternoon shifts.

Among more than 19,000 patients eligible for breast cancer screening, test order rates were 63.7% at 8:00 am, 48.7% at 11:00 am, 56.2% at noon, and 47.8% at 5:00 pm. Similarly, for the nearly 33,500 patients eligible for colorectal cancer screening, test order rates dropped from 36.5% at 8:00 am to 23.8% at 11:00 am and increased to 26.3% at noon before dropping again to 23.4% at 5:00 pm.


The time of day might influence this decision making in several ways, according to the researchers. For example, as each shift progresses, clinicians may fall behind schedule, leading to shorter interactions with the patient at the end of the morning and afternoon shifts and causing cancer screening discussions to be pushed to a future visit.

“As the overall clinic day progresses, clinicians may face decision fatigue, defined as the depletion of self-control and active initiative that results from the cumulative burden of decision making,” added the researchers.

One year of follow-up revealed that patient completion rates of screening tests followed a pattern similar to that seen with screening test order rates. Among patients with orders for breast cancer screening, completion rates were 33.2% for those who were ordered during an 8:00 am appointment, 23.8% at 11:00 am, 26.3% at noon, and 17.8% at 5:00 pm.

Among patients ordered for colorectal cancer screening, completion rates were 28% at 8:00 am, 23.6% at 11:00 am, 25.6% at noon, and 17.8% at 5:00 pm.

“This indicates that decisions made during a single primary care provider visit may have a lasting effect on patient behaviors,” wrote the researchers. “Clinicians may decide to defer discussion of cancer screening or other guideline-recommended care to future visits, and these findings indicate that this could potentially result in suboptimal care.”

They did note that screening tests must be completed outside of the primary care provider, suggesting that improving completion rates may require interventions outside of the primary care visit.


Hsiang E, Mehta S, Small D, et al. Association of primary care clinic appointment time with clinician ordering and patient completion of breast and colorectal cancer screening [published online May 10, 2019]. JAMA Netw Open. doi: 10.1001/jamanetworkopen.2019.3403.