Motivations, experiences and perspectives of physicians in Germany regarding monitoring routines in coronary heart disease and post-stroke patients: A qualitative interview study.
Physicians in Germany considered routine ultrasound monitoring (echocardiography and carotid ultrasound) in coronary heart disease and post-stroke patients as controversial, reporting insufficient medical benefit and rarely seeing therapeutic consequences, while identifying diverse motivations ranging from personal assurance to financial incentives.
Key Findings
Results
Physicians generally considered monitoring beneficial for patients and the health system because it helps detect and prevent disease progression through therapy adaptation.
22 physicians from three specialties (general practitioners, cardiologists, and neurologists) were interviewed
Physicians were recruited from two German states
Semi-structured interviews were conducted and transcripts were analysed with thematic analysis
The perceived benefit was framed around detecting deterioration and guiding treatment adaptations
Results
Physicians identified risks of monitoring including overdiagnosis, overuse, and overtreatment when examinations are performed too frequently.
These risks were explicitly discussed by participating physicians across specialties
Overuse was linked to the frequency of examinations rather than the examinations themselves
Concerns about overtreatment were raised as a consequence of overly frequent monitoring
This finding reflects awareness among physicians of potential harms from excessive monitoring
Results
Motivations for performing echocardiography in coronary heart disease patients and carotid ultrasound in stroke patients were diverse, ranging from individual feelings and values to external factors.
Individual motivations included personal assurance and safety concerns for patients
External motivations included financial incentives
The range of motivations spanned both intrinsic (physician values) and extrinsic (systemic/financial) factors
This diversity of motivations contributed to variability in monitoring practices across physicians
Results
Routine ultrasound examinations (echocardiography and carotid ultrasound) were considered controversial by physicians, who reported insufficient medical benefit and rarely saw therapeutic consequences.
Physicians across specialties questioned the routine use of these ultrasound examinations
Therapeutic consequences following these monitoring examinations were reported as rare
The medical benefit for patients from routine ultrasound monitoring was described as insufficient
This contrasts with the general view that monitoring overall is beneficial, suggesting ambivalence specific to these ultrasound procedures
Results
Routinely performed ultrasound examinations were found to strain resources in daily practice and limit availability for acute care.
Physicians reported that resource strain from routine monitoring affected the healthcare system
Reduced availability for acute care was identified as a practical consequence of routine ultrasound monitoring
This finding points to opportunity costs associated with the current monitoring practices
The concern was raised in the context of calls for more efficient and balanced use of monitoring examinations
Background
Physicians identified that monitoring routines often lack evidence for intervals, specific tests, or apparative diagnostic tools.
The absence of evidence-based recommendations was noted as a gap in current guidelines
Lack of evidence pertained specifically to monitoring intervals and choice of diagnostic tools
Physicians called for further research to evaluate monitoring routines
Evidence-based recommendations were described as needed to optimize patient care and resource use
Results
Systematic changes at a political level were identified by physicians as necessary to achieve more efficient and balanced use of monitoring examinations.
Individual physician-level changes were considered insufficient to address the problem
Political-level intervention was specifically cited as required
The call for systematic change was linked to findings about financial incentives as a driver of monitoring behavior
Incorporation of evidence-based recommendations into guidelines was recommended as part of the solution
What This Means
This research suggests that German physicians have mixed and often conflicting views about routine heart and blood vessel monitoring tests—specifically echocardiography (heart ultrasound) for coronary heart disease patients and carotid ultrasound (neck artery scanning) for stroke patients. While doctors generally believe that monitoring chronic conditions is a good thing because it can catch problems early and guide treatment, many expressed doubt about whether these specific ultrasound tests, when done on a routine schedule, actually lead to meaningful changes in patient care. In practice, physicians said they rarely changed treatment based on these routine scans, raising questions about whether the tests are truly helping patients.
The study also found that doctors' reasons for ordering these tests varied widely. Some doctors ordered them out of a genuine desire to reassure themselves and their patients, while others acknowledged that financial incentives within the German healthcare system played a role. This suggests the decision to perform routine monitoring is not purely based on medical evidence. At the same time, doctors recognized that doing these tests too often carries its own risks, including finding minor abnormalities that lead to unnecessary further testing or treatment (overdiagnosis and overtreatment), as well as using up limited medical resources that could be needed for patients with urgent conditions.
This research suggests that the current approach to routine ultrasound monitoring in these patient groups may not be well-supported by evidence and may place unnecessary burdens on both patients and the healthcare system. The authors argue that clearer, evidence-based guidelines and broader policy changes are needed to help doctors make better decisions about when and how often to use these monitoring tools, ultimately improving care quality while making more efficient use of healthcare resources.