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    1 Comment for this article
    Does disease severity get higher later in the day?
    Neil Stafford MD | Internal Medicine
    It seems difficult to adjust for disease severity. In outpatient practice, acutely ill patients are fit into the schedule as needed and tend to be seen later in the day. At 3pm, I am only likely to fit in the sickest of patients into the remainder of my afternoon. While diagnosis code should ideally be some marker of disease severity, other factors, such as fever, anorexia, pain, toxic appearance, may all influence use of antibiotics (appropriately or not), but are not explained by provider decision fatigue. Is there disease severity data available in this dataset?
    CONFLICT OF INTEREST: None Reported
    Research Letter
    December 2014

    Time of Day and the Decision to Prescribe Antibiotics

    Author Affiliations
    • 1Division of General Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
    • 2Harvard Medical School, Boston, Massachusetts
    • 3Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
    • 4RAND, Boston, Massachusetts
    • 5Division of General Medicine, Massachusetts General Hospital, Boston
    • 6RAND, Santa Monica, California
    • 7Anderson School of Management, University of California, Los Angeles
    JAMA Intern Med. 2014;174(12):2029-2031. doi:10.1001/jamainternmed.2014.5225

    Clinicians make many patient care decisions each day. The cumulative cognitive demand of these decisions may erode clinicians’ abilities to resist making potentially inappropriate choices. Psychologists, who refer to the erosion of self-control after making repeated decisions as decision fatigue,1,2 have found evidence that it affects nonmedical professionals. For example, as court sessions wear on, judges are more likely to deny parole, the “easier” or “safer” option.3

    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, a desire to do something meaningful for patients, a desire to conclude visits quickly, or an unrealistic fear of complications.4,5 We hypothesized that decision fatigue, if present, would increase clinicians’ likelihood of prescribing antibiotics for patients presenting with ARIs as clinic sessions wore on.

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