Patients may miss out on cancer screening referrals by booking afternoon GP appointments

‘Decision fatigue’ may be one of the reasons behind the drop in referrals throughout the day, suggests the lead author of the study

Patients with suspected breast or bowl cancers are less likely to be sent for screenings if they arrive for afternoon appointments than those who had bookings with their GP earlier in the day, new research suggests.

A new US-based study, published in the medical journal JAMA Network Open, found that the chance of getting a cancer referral declined throughout the day, expect for a spike after lunch when doctors were “refreshed”.

The study was conducted by researchers from the University of Pennsylvania School of Medicine who examined medical records across 33 Pennsylvania and New Jersey primary care practices between 2014 to 2016.

The team examined the entire population eligible for screenings at the practices, which accounts for approximately 19,000 for breast cancer and 33,000 for bowl cancer and tracked whether the patients completed a screening within a year of their appointment.

The study found doctors ordered breast cancer screenings – which included mammograms – more often for patients seen at 8am (64 per cent) as compared to those with appointments at 5pm (48 per cent).

As for colon cancer screenings – which includes colonoscopies, sigmoidoscopies, and faecal occult blood tests – tests were also ordered more frequently for 8am patients (37 per cent) compared to those who had appointments later in the day (23 per cent).

Referral ordering rates were found to have far-reaching effects, with records showing the downward trend associated with the timing of the appointments affected how many people underwent a screening the following year.

Breast cancer and colorectal screenings were found to have a 33 per cent and 28 per cent one-year completion rate, respectively, for the entire eligible population who had their appointment first thing at 8am.

However, only 18 per cent of people completed breast cancer and colorectal screenings if they had their original appointments at 5pm or later.

Lead author researcher Esther Hsiang at the University of Pennsylvania School of Medicine explained: "Our findings suggest that future interventions targeting improvements in cancer screening might focus on time of day as an important factor in influencing behaviours.

Hsiang added that the downward trend of ordering referrals later in the day may be the result of “decision fatigue”, which she described as happening when doctors "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,” she added.

The results also showed that there was a brief spike in screening referrals for breast and colon cancers when patients saw their GP around midday.

Breast cancer screening orders dropped to 48.7 per cent at 11am but increased to 56.2 per cent around noon, before gradually dipping again.

The team explained the reason for this spike could be as a result of lunch breaks giving doctors an opportunity to catch up and start afresh in the afternoon.

It’s also worth noting that referring patients for screenings also involves coordinating with hospital department and patients’ schedules which may also increase their risk of missing out on referrals.

In October 2018, an investigation into referral incentive schemes being run by NHS clinical commissioning groups (CCGs) across England found some regions offering GPs as much as 50 per cent of any savings they could make if they didn't send patients to hospital.

At the time, CCGs claimed the schemes are intended to “improve the quality of referrals” and ensure patients are seen at the best service for their needs, rather than trying to reduce numbers overall.

However, GP leaders said it is “insulting” to suggest doctors are sending patients to hospital arbitrarily, and raise significant conflicts of interest.