Time of Day and Decision to Prescribe Antibiotics

Published in: JAMA Internal Medicine, v. 174, no. 12, Dec. 2014, p. 2029-2031

by Jeffrey A. Linder, Jason N. Doctor, Mark W. Friedberg, Harry Reyes Nieva, Caroline Birks, Daniella Meeker, Craig Fox

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Research Question

  1. Are primary care clinicians more likely to prescribe antibiotics for acute respiratory infections at the end of the day?

Clinicians make many patient care decisions each day. The cumulative cognitive demand of these decisions may erode clinicians' abilities to resist making potentially inappropriate decisions. In primary care, prescribing unnecessary antibiotics for acute respiratory infections (ARIs) is a common, inappropriate service. Clinicians may prescribe unnecessary antibiotics—again, the easy, safe option—due to perceived or explicit patient demand, desire to do something meaningful for patients, a desire to conclude visits quickly, or an unrealistic fear of complications. We hypothesized that decision fatigue, if present, would increase clinicians' likelihood of prescribing antibiotics for patients presenting with ARIs as clinic sessions wore on. To test this hypothesis, we analyzed ARI visits by adults which occurred during two 4-hour sessions—8 AM to noon and 1 PM to 5 PM—Monday through Friday. Clinicians worked in 4-hour morning and afternoon sessions; many clinicians worked only 1 session on a given day. We found that primary care clinicians' likelihood of prescribing antibiotics for ARIs increased as clinic sessions wore on, consistent with the hypothesis that decision fatigue progressively impairs clinicians' ability to resist ordering inappropriate treatments. Remedies for decision fatigue might include time-dependent decision support, modified schedules, shorter sessions, mandatory breaks, or snacks. Further studies could clarify the sources of the problem and test solutions.

Key Findings

  • "Decision fatigue"—the cumulative effect of making repeated care decisions—increases the likelihood that primary care clinicians will prescribe unnecessary antibiotics for acute respiratory infections.
  • Clinicians prescribed progressively more antibiotics over the course of their four–hour clinic sessions.

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