Motivations, experiences and perspectives of physicians in Germany regarding monitoring routines in coronary heart disease and post-stroke patients: A qualitative interview study.

Chronic conditions, like coronary heart disease and post stroke status require lifelong care which negatively impacts upon patients' quality of life and increases burden on the healthcare system. Monitoring routines in chronic conditions, including echocardiography and carotid ultrasound, should have evidence of benefit for the patient, detect deterioration and guide treatment adaptations. However, monitoring routines often lack evidence for intervals, specific tests or apparative diagnostic tools. The aim of this qualitative interview study was to identify the motivations, typical procedures and consequences of monitoring including echocardiography or carotid ultrasound in patients with coronary heart disease or stroke. We conducted semi-structured interviews with 22 physicians from three different specialties (general practitioners, cardiologists and neurologists) in two German states. Transcripts were analysed with thematic analysis. Physicians considered monitoring generally as beneficial for the patient and the health system, as it helps to detect and in consequence prevent disease progression through adaptation of therapy. Physicians discussed the risks of monitoring like overdiagnosis, overuse and overtreatment when examinations are done too frequently. Reasons and motivations given for echocardiography on coronary heart disease patients and carotid ultrasound monitoring on stroke patients were diverse and ranged from individual feelings and values, like personal assurance and safety concerns for patients, to external factors like financial incentives. Ultrasound examinations as routine monitoring procedures were considered as controversial. Physicians reported insufficient medical benefit for the patient and rarely saw therapeutic consequences. These regularly performed ultrasound examinations strain resources in daily practice and limit availability for acute care. In order to achieve a more efficient and balanced use of monitoring examinations, systematic changes are required at a political level. Further research is needed to evaluate monitoring routines and incorporate evidence-based recommendations into guidelines that optimize patient care and resource use.