Causes of Inappropriate Laboratory Test Ordering from the Perspective of Medical Laboratory Technical Professionals: Implications for Research and Education.

OBJECTIVE: Inappropriate laboratory test ordering is a significant and persistent problem. Many causes have been identified and studied. Medical laboratory professionals (MLPs) are technical staff within clinical laboratories who are uniquely positioned to comment on why inappropriate ordering occurs. We aimed to characterize existing MLP perceptions in this domain to reveal new or underemphasized interventional targets. METHODS: We developed and disseminated a self-administered survey to MLPs in Canada, including open-ended responses to questions about the causes of inappropriate laboratory test ordering. RESULTS: Four primary themes were identified from qualitative analysis: ordering-provider factors, communication factors, existing test-ordering processes, and patient factors. Although these factors can largely be found in previous literature, some are under-studied. CONCLUSION: MLP insights into nonphysician triage ordering and poor result communication provide targets for further investigation. A heavy focus on individual clinician factors suggests that current understandings and interprofessional skills in the MLP population can be improved.

Engaging Laboratory Staff in Stewardship: Barriers Experienced by Medical Laboratory Technologists in Canada.

BACKGROUND: Laboratory stewardship programs aim to improve the use of laboratory resources, including reducing inappropriate testing. These programs should engage all healthcare stakeholder groups, including all levels of laboratory staff. Medical laboratory technologists (MLTs) are highly skilled professionals and are well positioned to play a supportive role in stewardship but may be overlooked. The aim of this study is to identify the barriers to MLT participation in stewardship activities. METHODS: We developed and disseminated a self-administered survey to MLTs in Canada to assess their knowledge and attitudes toward inappropriate laboratory utilizatioz and explore perceived barriers to taking on an active role in stewardship initiatives. Themes were identified in open-ended responses and mapped to the Theoretical Domains Framework (TDF). RESULTS: MLTs feel accountable for helping ensure appropriate resource use and recognize that it is an important issue to address. However, they experience significant barriers and have low intention to act. The self-reported barrier most frequently described was lack of time arising from excessive workloads, but other constraints exist. Themes mapped to the TDF most strongly in the domain of environmental context and resources, supporting evidence that workplace structure and culture play key roles in impacting this group. CONCLUSIONS: To meaningfully engage MLTs in stewardship activities, these barriers should be addressed. Highlighting MLT expertise and creating communication structures and opportunities for their unique contributions may be fruitful.

A New List for Choosing Wisely Canada From the "Hidden Profession" of Medical Laboratory Science.

OBJECTIVES: Choosing Wisely Canada (CWC) publishes practices that may contribute to medical overuse and patient harm. Many practices concern laboratory testing, but the recommendations are often written for the test-ordering professionals. Our objective was to develop a list for CWC reflecting the scope of practice of nonpathologist medical laboratory professionals (MLPs). METHODS: We used a national survey, a convention session, and a panel of MLPs from across Canada to generate content for the CWC list. We used a modified Delphi process to identify the most important items and scoping reviews to gather evidence supporting each item. RESULTS: We identified 95 potential CWC list items. After 2 Delphi rounds, there was little movement in the top items. Scoping reviews revealed varying degrees of evidentiary support, which influenced the composition of the final list of 7 CWC items submitted. Three of the final recommendations address ways MLPs preserve the status quo with respect to overutilization of laboratory tests by other health care professionals. The remaining recommendations prompt MLPs to exert clinical judgment in specific scenarios, particularly where they can impact blood collection volumes. CONCLUSIONS: This work brings a more nuanced and comprehensive understanding of the relationships among MLPs, patient safety, and resource waste.

Evaluation of thyroid test utilization through analysis of population-level data.

BACKGROUND: Inappropriate laboratory test utilization can result in unnecessary patient testing and increased healthcare costs. While several thyroid function tests are available, thyroid-stimulating hormone (TSH) is recommended as the first-line test for investigating and monitoring thyroid dysfunction. We evaluate thyroid test utilization in Northern Alberta in terms of testing patterns, frequencies, and reflex cutpoints. METHODS: This retrospective study analyzed thyroid test requests from January to December 2014. Each request was designated as appropriate or potentially inappropriate as per clinical practice guidelines and Choosing Wisely recommendations, and the frequencies of each testing pattern were calculated. Sub-analysis was performed to categorize testing patterns based on physician specialty. The number of test requests per patient was determined to assess the appropriateness of testing frequency. Receiver operating characteristic (ROC) curves were generated to define optimal TSH cutpoints for automatic reflex to FT4 testing. RESULTS: Of 752,217 test requests, approximately 10% were potentially inappropriate in terms of testing patterns. Free thyroxine (FT4) and free triiodothyronine (FT3) requested with TSH accounted for 59% of all potentially inappropriate test requests, and 49% of requests from endocrinologists (ENDO) were potentially inappropriate, occurring most frequently among those with less experience. Excessive testing frequencies were observed in 869 patients, accounting for 9382 test requests. Adjustment of our TSH reflex cutpoint would significantly increase specificity for identifying a low FT4 without compromising sensitivity. CONCLUSIONS: This study suggests that questionable testing patterns, excessive testing frequencies, and suboptimal reflexive testing cutpoints contribute to inappropriate thyroid test utilization.