Association of Primary Care Clinic Appointment Time With Opioid Prescribing

IMPORTANCE Time pressure to provide a quick fix is commonly cited as a reason why opioids are frequently prescribed in the United States, but there is little evidence of an association between appointment timing and clinical decision-making. As the workday progresses and appointments run behind schedule, physicians may be more likely to prescribe opioids. OBJECTIVE To estimate whether characteristics of appointment timing are associated with clinical decision-making about pain treatment. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of physician behavior used data from electronic health record systems in primary care offices in the United States to analyze primary care appointments occurring in 2017 for patients with a new painful condition who had not received an opioid prescription within the past year. MAIN OUTCOMES AND MEASURES The association between treatment decisions and 2 dimensions of appointment timing (order of appointment occurrence and delay relative to scheduled start time) were assessed. The rates of opioid prescribing were measured and compared with rates of nonopioid pain medication (ie, nonsteroidal anti-inflammatory drugs) prescribing and referral to physical therapy. All rates were estimated within the same physician using physician fixed effects, adjusting for patient, appointment, and seasonal characteristics. RESULTS Among 678 319 primary care appointments (642 262 patients; 392 422 [61.1%] women) with 5603 primary care physicians, the likelihood that an appointment resulted in an opioid prescription increased by 33% as the workday progressed (1st to 3rd appointment, 4.0%[95% CI, 3.9%-4.1%] vs 19th to 21st appointment, 5.3%[95% CI. 5.1%-5.6%]; P < .001) and by 17% as appointments ran behind schedule (0-9 minutes late, 4.4%[95% CI, 4.3%-4.6%] vs >= 60 minutes late, 5.2%[95% CI, 5.0%-5.4%]; P < .001). Prescribing of nonsteroidal anti-inflammatory drugs and referral to physical therapy did not display similar patterns. CONCLUSIONS AND RELEVANCE These findings suggest that, even within an individual physician's schedule, clinical decision-making for opioid prescribing varies by the timing and lateness of appointments.