Five Things Physicians and Patients Should Question

Released October 29, 2014


Don’t perform population based screening for 25-OH-Vitamin D deficiency.

Vitamin D deficiency is common in many populations, particularly in patients at higher latitudes, during winter months and in those with limited sun exposure. Over the counter Vitamin D supplements and increased summer sun exposure are sufficient for most otherwise healthy patients. Laboratory testing is appropriate in higher risk patients when results will be used to institute more aggressive therapy (e.g., osteoporosis, chronic kidney disease, malabsorption, some infections).


Don’t screen women with Pap smears if under 21 years of age or over 69 years of age.

Follow provincial guidelines for cervical cancer screening. Screening before the recommended age of initiation (age 21 in most provinces), screening women over the age of 69, or annual screening is not recommended.


Avoid routine preoperative laboratory testing for low risk surgeries without a clinical indication.

Most preoperative laboratory tests (typically a complete blood count, prothrombin time and partial thromboplastin time, basic metabolic panel and urinalysis) performed on elective surgical patients are normal. Findings influence management in under 3% of patients tested. In almost all cases, no adverse outcomes are observed when clinically stable patients undergo elective surgery, irrespective of whether an abnormal test is identified. Preoperative laboratory testing is appropriate in symptomatic patients and those with risks factors for which diagnostic testing can provide clarification of patient surgical risk.


Avoid standing orders for repeat complete blood count (CBC) on inpatients who are clinically/laboratorily stable.

Standing orders for inpatients for CBC testing should be avoided as this can lead to over-testing in relatively stable patients. Particularly in patients with longer term hospital stays, there is some evidence that repeated blood testing can have a negative effect on patients including some increase in anemia. Trauma patients often have blood draws repeated frequently even in the absence of indications of hematologic instability on admission.


Don’t send urine specimens for culture on asymptomatic patients including the elderly, diabetics, or as a follow up to confirm effective treatment.

There is no evidence that antibiotic treatment is indicated in any of these patients. Thus sending urine specimens in asymptomatic patients will only result in inappropriate antibiotic use and increased risk of resistance. The only exceptions are screening of pregnant women early in pregnancy for whom there are clear guidelines for screening/management; and screening for asymptomatic bacteriuria before urologic procedures for which mucosal bleeding is anticipated.

How the list was created

The Canadian Association of Pathologists (CAP-ACP) list of recommendations was developed in conjunction with the Canadian Leadership Council on Laboratory Medicine Laboratory (CLCLM) Utilization Subcommittee, under the joint leadership of the President of CAP-ACP and the President of the Canadian Society of Clinical Chemists (CSCC). The joint committee reviewed the recommendations made by the American Society for Clinical Pathology (ASCP) to the Choosing Wisely US campaign and modified two of those to reflect Canadian practice. Additional recommendations, dealing with cervical cancer screening, standing orders for hematology testing and urine cultures on asymptomatic patients, were added to make up the set of recommendations. The joint committee solicited review and input on these recommendations from the various subspecialty groups in laboratory medicine. Recommendations 1 and 3 were adopted with permission from the Five Things Physicians and Patients Should Question. © 2013 American Society for Clinical Pathology.



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