Decision fatigue in low-value prostate cancer screening

Abstract

Background: Low-value prostate-specific antigen (PSA) testing is common yet contributes substantial waste and downstream patient harm. Decision fatigue may represent an actionable target to reduce low-value urologic care. The objective of this study was to determine whether low-value PSA testing patterns by outpatient clinicians are consistent with decision fatigue.

Methods: Outpatient appointments for adult men without prostate cancer were identified at a large academic health system from 2011 through 2018. The authors assessed the association of appointment time with the likelihood of PSA testing, stratified by patient age and appropriateness of testing based on clinical guidelines. Appointments included those scheduled between 8:00 am and 4:59 pm, with noon omitted. Urologists were examined separately from other clinicians.

Results: In 1,581,826 outpatient appointments identified, the median patient age was 54 years (interquartile range, 37-66 years), 1,256,152 participants (79.4%) were White, and 133,693 (8.5%) had family history of prostate cancer. PSA testing would have been appropriate in 36.8% of appointments. Clinicians ordered testing in 3.6% of appropriate appointments and in 1.8% of low-value appointments. Appropriate testing was most likely at 8:00 am (reference group). PSA testing declined through 11:00 am (odds ratio [OR], 0.57; 95% CI, 0.50-0.64) and remained depressed through 4:00 pm (P < .001). Low-value testing was overall less likely (P < .001) and followed a similar trend, declining steadily from 8:00 am (OR, 0.48; 95% CI, 0.42-0.56) through 4:00 pm (P < .001; OR, 0.23; 95% CI, 0.18-0.30). Testing patterns in urologists were noticeably different.

Conclusions: Among most clinicians, outpatient PSA testing behaviors appear to be consistent with decision fatigue. These findings establish decision fatigue as a promising, actionable target for reducing wasteful and low-value practices in routine urologic care.

Lay summary: Decision fatigue causes poorer choices to be made with repetitive decision making. This study used medical records to investigate whether decision fatigue influenced clinicians' likelihood of ordering a low-value screening test (prostate-specific antigen [PSA]) for prostate cancer. In more than 1.5 million outpatient appointments by adult men without prostate cancer, the chances of both appropriate and low-value PSA testing declined as the clinic day progressed, with a larger decline for appropriate testing. Testing patterns in urologists were different from those reported by other clinicians. The authors conclude that outpatient PSA testing behaviors appear to be consistent with decision fatigue among most clinicians, and interventions may reduce wasteful testing and downstream patient harms.

Keywords: clinical decision making; early detection of cancer; health care costs; health services research; physicians; prostate-specific antigen; prostatic neoplasms.

Figure 1.. Distribution of Outpatient Appointments Resulting in a PSA Test Order

Heatmap shows the absolute number of PSA tests ordered during outpatient appointments from July 2011-June 2018, stratified by day and hour of appointment. Appointment times are grouped to the start of the hour (e.g., those scheduled at 8:00 AM, 8:15 AM, and 8:30 AM, etc. were grouped to 8:00 AM).

Figure 2.. Clinicians’ Trends in PSA Testing Likelihood by Appropriateness

Graphs show the adjusted odds of a PSA test being ordered by appropriateness and hour of outpatient appointment (A), stratified by patient age as ≤55 (B) and >55 (C) years. Clinicians includes physicians from family medicine, general surgery, internal medicine, medicine subspecialties, surgical subspecialties, and other specialties, as well as advanced practice clinicians. Urologists are presented separately in Figure 3. Appointment times are grouped to the start of the hour. Appropriateness of PSA testing was determined for each appointment based on patient characteristics and clinical guidelines. Models were adjusted for clinician sex, medical school rank, medical school graduation year, specialty, and appointment type, scheduled duration, and day of week. Odds ratios and confidence intervals were found through spline effects.

Figure 3.. Urologists’ Trends in PSA Testing Likelihood by Appropriateness

Graphs show the adjusted odds of a PSA test being ordered by appropriateness and hour of outpatient appointment with a urologist (A), stratified by patient age as ≤55 (B) and >55 (C) years. Appointment times are grouped to the start of the hour. Appropriateness of PSA testing was determined for each appointment based on patient characteristics and clinical guidelines. Models were adjusted for clinician sex, medical school rank, medical school graduation year, specialty, and appointment type, scheduled duration, and day of week. Odds ratios and confidence intervals were found through spline effects.