If you want an antibiotic see your doctor later in the day

Clinicians make many patient care decisions each day, and the cumulative demand of these decisions may make inappropriate choices more likely later in the day. In primary care, doctors often prescribe unnecessary antibiotics for acute respiratory infections (ARI). Researchers at Brigham and Women's Hospital (BWH) in Boston found that doctors appeared to "wear down" during their morning and afternoon clinic sessions, and antibiotic prescribing rates increased. These findings are published in JAMA Internal Medicine on October 6, 2014.

"Clinic is very demanding and doctors get worn down over the course of their clinic sessions," explained Jeffrey A. Linder, MD, MPH, a physician and researcher in the Division of General Medicine and Primary Care at BWH and lead author of this study. "In our study we accounted for patients, the diagnosis and even the individual doctor, but still found that doctors were more likely to prescribe antibiotics later in their clinic session."

The researchers merged billing and electronic health record (EHR) data for patient visits to 23 different primary care practices over the course of 17 months. They then identified visit diagnoses using billing codes and, using EHRs, identified visit times, antibiotic prescriptions and chronic illnesses. They analyzed over 21-thousand ARI visits by adults, which occurred during two four-hour sessions, 8a.m. to noon and 1p.m. to 5p.m. The researchers found that antibiotic prescribing increased throughout the morning and afternoon clinic sessions.

"This corresponds to about 5 percent more patients receiving antibiotics at the end of a clinic session compared to the beginning, "explained Linder. "Remedies for this problem might include different schedules, shorter sessions, more breaks or maybe even snacks."

The researchers note that future studies are needed to clarify the sources of the problem and test corresponding solutions.