Time of Appointment Could Influence Prescribing Practices for Statin Therapy

Allison Hare

Does the time of an appointment play a factor in a clinician’s decision-making? A new study from Penn Medicine suggests it might when it comes to statin therapy.

The latest study to come from Penn Medicine’s Nudge Unit, results of the analysis, which included data from a network of 28 primary care practices, indicate patients with later appointments were less likely to receive a prescription for statins as prescribing rates appeared to decline progressively by the hour.

"Our findings were concerning but unsurprising. Clinicians are faced with multiple cognitive demands that compete for their attention while providing care, especially later in the day," said lead author Allison Hare, a clinical informatics fellow in the Nudge Unit, in a statement. "Paired with an ever-growing list of evidence-backed treatment guidelines, our findings reveal that care quality can deteriorate as clinicians grapple with the cognitive fatigue and appointment lateness that is more likely to occur at the end of the day."

With an interest in improving patient care and outcomes, Penn Medicine’s Nudge Unit has designed multiple studies examining potential avenues for improvement. In the current study, investigators hoped to identify impact of time on prescribing rates and designed their study to assess rates of statin prescribing at 28 Penn Medicine primary care practices from March 1, 2019-February 29, 2020.

Using data from Clarity, which is an Epic reporting database, investigators assessed all first new or return visits among patients with their primary care practitioner during the aforementioned time period. For the purpose of analysis, appointments from 8:00 AM to 4:59 PM were grouped by hour and used as the exposure in logistic regression analysis adjusted for clinical and demographics factors. Statin eligibility was determined by USPSTF guidelines, presence of clinical ASCVD or familial hypercholesterolemia diagnosis, or presence of low-density lipoprotein cholesterol greater than or equal to 190 mg/dL.

In total, 10,757 patients were identified for inclusion. This patient group had a mean age of 66.0 (SD, 10.5) years, 47.2% were female, and 65.7% were White. Investigators noted patient characteristics did not differ much when comparing those who had appointments early half of the day compared to those who had appointments in the latter half.

Overall, statins were prescribed in 3864 visits. Of these, 2447 (37.5%) occurred during morning visits and 1417 (33.4%) occurred during afternoon visits.

When compared to those who had visits at 8 AM, results indicated odds of statin prescribing were significantly lower at all time points except 9 AM ([10 AM: 0.85; 95% CI, 0.73-0.99; P=.04]; [12 PM: 0.63; 95% CI, 0.49-0.83; P=.001]; [3 PM: 0.69; 95% CI, 0.57-0.82; P <.001]). Compared to their counterparts with morning appointments, which was defined as an appointment occurring before 12:00 PM, those with an afternoon appointment had a 21% lower chance of receiving a statin prescription (aOR, 0.79; 95% CI, 0.73-0.87; P <.001). Additionally, investigators noted the overall time trend for statin prescribing decreased significantly for each additional hour (aOR, 95% CI, 0.94-0.97; P <.001)

"Statin therapy is a foundational part of guideline-directed care in the primary and secondary prevention of cardiovascular disease. It is critical to ensure our clinical choice environment encourages appropriate patients are prescribed this therapy at all times of day," said Srinath Adusumalli, MD, an assistant professor of clinical Medicine and assistant chief medical information officer for Connected Health Strategy and Applications, in the aforementioned statement.

This study, "Assessment of Primary Care Appointment Times and Appropriate Prescribing of Statins for At-Risk Patients,” was published in JAMA Network Open.