Decision Fatigue May Lead to Declining Cancer Screening Rates


Study suggests future interventions targeting improvements in cancer screenings may need to focus on the time of day when a patient visits a doctor.

A new study from the Perelman School of Medicine and the Wharton School within the University of Pennsylvania suggests that cancer screening rates decline significantly as the day goes on. The researchers believe that the rates may stem from decision fatigue, which results from both the cumulative burden of screening discussions earlier in the day and physicians’ busy scheduling.

According to the study’s lead author, Esther Hisang, the findings suggest future interventions targeting improvements in cancer screenings may need to focus on the time of day.

“We believe that the downward trend of ordering may be the result of 'decision fatigue,' where people may be less inclined to consider a new decision after they've been making them all day. It may also stem from overloaded clinicians getting behind as the day progresses," Hisang said.

Investigators found that physicians were more likely to order breast cancer screening for eligible patients seen in the 8 am hour (64%) compared with patients whose appointments were at 5 pm (48%). These findings were also similar for patients with colon cancer, wherein tests were ordered more frequently for those seen at 8 am (37%) than those seen later in the day (23%).

After examining data from 2014 to 2016, which included 33 Pennsylvania and New Jersey primary care practices that include approximately 19,000 screenings for breast cancer and 33,000 for colorectal cancer, investigators tracked whether patients completed a screening within a year of their appointment. The data showed that the downward trend associated with the timing of the appointments affected this completion.

Breast cancer screening, including mammograms, remained at a 33% one-year competition rate for the eligible population who had their appointment between 8 am and 9 am. For those who had clinic visits at 5pm or later, only 18% completed screenings. Colorectal cancer screenings, including colonoscopies, sigmoidoscopies, and fecal occult blood tests were completed by 28% of the patients with appointments in the 8am hour, but only 18% for patients whose appointment fell at 5 pm or later.

Researchers warn that these types of cancer screenings require coordination with various departments and additional visits, meaning that there are many opportunities for lapses in screening.

Although order rates did fall as the day progressed, researchers noticed a brief spike in orders for breast and colon cancer screenings for patient visits around 12 pm. Breast cancer screening orders dropped to 48.7% at 11 am but increased to 56.2% around 12 pm, before gradually falling off again. This trend was also evident in one-year completion rates. The study authors estimated that this trend may explain lunch breaks that give clinicians an opportunity to reset after their morning.

This downward trend was also noted in a 2018 study examining the rate of flu vaccination by time of day. In that study, a “nudge” was built into the system that prompted doctors to accept or decline an influenza vaccine order. This add-on assisted in spurring an increase in vaccinations by approximately 20% compared with patients when doctors were not nudged.


Cancer screening rates decline when patients see doctors later in day [news release]. Published May 11, 2019. Accessed May 13, 2019.

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