Editorial

Timing matters — so do breaks

As oncologists, making our services as convenient and accessible as possible for our patients is a major goal and an ongoing challenge.

Providing services for extended hours during the week and additional services on weekends is frequently proposed as a potential solution. Many of our infusion centers and radiation oncology centers already are open from early morning to mid-evening.

Although such hours are now an accepted norm for these services, the concept of more widespread “stretching” of the day hasn’t gained as much traction in other domains. Many providers are happy to embrace the notion of early starts or late finishes, but the requirements for support staff and services have proved to be a logistical and financial barrier for many centers.

John Sweetenham, MD, FRCP, FACP
John Sweetenham

Additionally, and importantly, this is one more thing that threatens the life-work balance of the oncology workforce.

Impact on outcomes

A key issue in provision of services outside of ‘conventional’ hours is whether we can maintain the same quality, patient experience and, perhaps most importantly, the same outcomes.

Published data raise concerns that outcomes are not as good for some patients treated during the weekend compared with those treated on weekdays. Studies of patients with acute leukemia admitted on weekends have shown that certain interventions — such as bone marrow biopsies or line placement — may be delayed due to unavailability of the appropriate staff. In the big picture, these delays may not ultimately influence outcomes, but a recent report by Parikh and colleagues suggested that mortality is higher among patients admitted over the weekend. The report did not identify specific causes for the worse outcomes — although patients admitted during the weekend tended to be slightly older with more comorbidities, these factors did not predict for outcome in a multivariate analysis.

Reports for patients with solid tumors have shown similar findings, both for those requiring emergent surgical intervention on the weekend, and those undergoing systemic therapy.

These data suggest that if we can ensure adequate specialist and ancillary services outside conventional hours, these differences in outcomes could be eliminated. If so, provision of similar services during extended weekday hours would hopefully predict for the same high quality we aim for during current “office hours.”

Cancer screening

An interesting study by Lapointe-Shaw and colleagues suggests there may be more subtle influences on the quality of cancer care that will need to be addressed as the pressure for extended-hours clinics mounts.

This report explored the association between the time of a clinic appointment in primary care practices and the likelihood that physicians will order, and patients will complete, colorectal and breast cancer screening. The retrospective study investigated almost 20,000 patients eligible for breast cancer screening and almost 34,000 eligible for colon cancer screening. In both situations, the likelihood that the primary care physician would order screening was highest at 8 a.m., declined throughout the morning, had a second, minor peak at noon, then tended to diminish during the afternoon.

Concerningly, the rate at which patients completed their recommended screening showed a remarkably parallel trend — not only were physicians most likely to recommend screening earlier in the day, but it appeared that they were also more persuasive early on and less effective as the day progressed.

The causes for this pattern are likely to be multifactorial — many of us can relate to the fact that as clinic progresses during the day, the potential for backups increases and we may feel constrained to defer discussion of less urgent issues to a subsequent visit.

Similarly, patients who are late to appointments may wish to curtail a visit due to their own time constraints. Previous experience in other contexts in primary care have shown, for example, that the rate of recommendations for flu vaccines also declines during the day.

Decision fatigue

These are just a couple examples of changes in physician clinical behavior related to time of day.

A more concerning question for us is whether decision fatigue plays a role in our practice.

A famous study published in 2011 showed a panel of Israeli judges were much more likely to grant parole to prisoners after a break or a meal. As each session progressed, the likelihood of granting parole declined in a fashion completely unrelated to characteristics of the crime or the inmate under consideration. The group became decision-averse as the session progressed, and more positive in their decision-making after a break.

If the observations in these studies are confirmed, they have implications for the way we design our clinical care models, particularly in the “extended-hours” world.

These data suggest that we might perform better with more, shorter clinics — moving away from the traditional morning and afternoon clinic sessions to, say, three shorter sessions in a day might be more efficient and reduce the potential for decision fatigue as the day progresses. This decision fatigue, often associated with provider burnout, could also become an issue as weekend practice becomes more commonplace.

Extended hours for clinics and routine hospital functions may be in our future. To maximize quality care and outcomes for our patients and acceptable practice patterns for providers, we will need some movement away from the present status. We should probably formulate these plans early in the morning or right after lunch!

References:

Danzinger S, et al. Proc Natl Acad Sci U S A. 2011;doi:10.1073/pnas.1018033108.

Hsiang EY, et al. JAMA Netw Open. 2019;doi:10.1001/jamanetworkopen.2019.3403.

Huijts DD, et al. J Natl Compr Canc Netw. 2018;doi:10.6004/jnccn.2018.7016.

Lapointe-Shaw L, et al. J Natl Compr Canc Netw. 2016;14:867-874.

Parikh K, et al. Clin Lymphoma Myeloma Leuk. 2017;doi:10.1016/j.clml.2017.07.256.

For more information:

John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is associate director for clinical affairs at Harold C. Simmons Comprehensive Cancer Center at UT Southwestern Medical Center. He can be reached at john.sweetenham@utsouthwestern.edu.

Disclosure: Sweetenham reports no relevant financial disclosures.

As oncologists, making our services as convenient and accessible as possible for our patients is a major goal and an ongoing challenge.

Providing services for extended hours during the week and additional services on weekends is frequently proposed as a potential solution. Many of our infusion centers and radiation oncology centers already are open from early morning to mid-evening.

Although such hours are now an accepted norm for these services, the concept of more widespread “stretching” of the day hasn’t gained as much traction in other domains. Many providers are happy to embrace the notion of early starts or late finishes, but the requirements for support staff and services have proved to be a logistical and financial barrier for many centers.

John Sweetenham, MD, FRCP, FACP
John Sweetenham

Additionally, and importantly, this is one more thing that threatens the life-work balance of the oncology workforce.

Impact on outcomes

A key issue in provision of services outside of ‘conventional’ hours is whether we can maintain the same quality, patient experience and, perhaps most importantly, the same outcomes.

Published data raise concerns that outcomes are not as good for some patients treated during the weekend compared with those treated on weekdays. Studies of patients with acute leukemia admitted on weekends have shown that certain interventions — such as bone marrow biopsies or line placement — may be delayed due to unavailability of the appropriate staff. In the big picture, these delays may not ultimately influence outcomes, but a recent report by Parikh and colleagues suggested that mortality is higher among patients admitted over the weekend. The report did not identify specific causes for the worse outcomes — although patients admitted during the weekend tended to be slightly older with more comorbidities, these factors did not predict for outcome in a multivariate analysis.

Reports for patients with solid tumors have shown similar findings, both for those requiring emergent surgical intervention on the weekend, and those undergoing systemic therapy.

These data suggest that if we can ensure adequate specialist and ancillary services outside conventional hours, these differences in outcomes could be eliminated. If so, provision of similar services during extended weekday hours would hopefully predict for the same high quality we aim for during current “office hours.”

Cancer screening

An interesting study by Lapointe-Shaw and colleagues suggests there may be more subtle influences on the quality of cancer care that will need to be addressed as the pressure for extended-hours clinics mounts.

This report explored the association between the time of a clinic appointment in primary care practices and the likelihood that physicians will order, and patients will complete, colorectal and breast cancer screening. The retrospective study investigated almost 20,000 patients eligible for breast cancer screening and almost 34,000 eligible for colon cancer screening. In both situations, the likelihood that the primary care physician would order screening was highest at 8 a.m., declined throughout the morning, had a second, minor peak at noon, then tended to diminish during the afternoon.

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Concerningly, the rate at which patients completed their recommended screening showed a remarkably parallel trend — not only were physicians most likely to recommend screening earlier in the day, but it appeared that they were also more persuasive early on and less effective as the day progressed.

The causes for this pattern are likely to be multifactorial — many of us can relate to the fact that as clinic progresses during the day, the potential for backups increases and we may feel constrained to defer discussion of less urgent issues to a subsequent visit.

Similarly, patients who are late to appointments may wish to curtail a visit due to their own time constraints. Previous experience in other contexts in primary care have shown, for example, that the rate of recommendations for flu vaccines also declines during the day.

Decision fatigue

These are just a couple examples of changes in physician clinical behavior related to time of day.

A more concerning question for us is whether decision fatigue plays a role in our practice.

A famous study published in 2011 showed a panel of Israeli judges were much more likely to grant parole to prisoners after a break or a meal. As each session progressed, the likelihood of granting parole declined in a fashion completely unrelated to characteristics of the crime or the inmate under consideration. The group became decision-averse as the session progressed, and more positive in their decision-making after a break.

If the observations in these studies are confirmed, they have implications for the way we design our clinical care models, particularly in the “extended-hours” world.

These data suggest that we might perform better with more, shorter clinics — moving away from the traditional morning and afternoon clinic sessions to, say, three shorter sessions in a day might be more efficient and reduce the potential for decision fatigue as the day progresses. This decision fatigue, often associated with provider burnout, could also become an issue as weekend practice becomes more commonplace.

Extended hours for clinics and routine hospital functions may be in our future. To maximize quality care and outcomes for our patients and acceptable practice patterns for providers, we will need some movement away from the present status. We should probably formulate these plans early in the morning or right after lunch!

References:

Danzinger S, et al. Proc Natl Acad Sci U S A. 2011;doi:10.1073/pnas.1018033108.

Hsiang EY, et al. JAMA Netw Open. 2019;doi:10.1001/jamanetworkopen.2019.3403.

Huijts DD, et al. J Natl Compr Canc Netw. 2018;doi:10.6004/jnccn.2018.7016.

Lapointe-Shaw L, et al. J Natl Compr Canc Netw. 2016;14:867-874.

Parikh K, et al. Clin Lymphoma Myeloma Leuk. 2017;doi:10.1016/j.clml.2017.07.256.

For more information:

John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is associate director for clinical affairs at Harold C. Simmons Comprehensive Cancer Center at UT Southwestern Medical Center. He can be reached at john.sweetenham@utsouthwestern.edu.

Disclosure: Sweetenham reports no relevant financial disclosures.