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Qualitative studies exploring the factors behind a doctor's decisions to order clinical laboratory blood testing are lacking. A better understanding of these factors can help in formulating interventions that could improve the quality of health care and limit costs. The purpose of this qualitative case series study was to identify factors that influence a doctor's decision to order routine clinical laboratory blood tests. Fifteen doctors from Western New York, working in different hospital settings, were interviewed. There were 5 doctors in each case type: major, community, and private hospitals. When analyzed by case, there was a difference between the three groups in the ordering of tests based on fear of malpractice. The majority of the doctors from the community hospitals group (4 of 5) and private practice group (3 of 5) said that they had ordered tests based on the fear of malpractice. However, in the major hospital group, only 1 doctor followed this pattern. Although, the majority of the doctors (13 of 15) held favorable views of the guidelines for administering the blood tests, most (8 of 13) thought that they were impractical for use in their practice, and hence needed major modifications. To increase effectiveness for guideline adherence, a multifaceted local team approach is recommended that includes a review of guidelines by a committee comprised of respected local doctors in consultation with the area doctors. In addition, the development of continuing education could have a positive effect on guideline adherence and the reduction of unnecessary testing. This reduction could result in increased quality of care and reduced cost burden to the health care system.