Background
Methods
Study design and context
Treatment pathway development
Selection of regions and study participants
Theoretical framework and qualitative guide
Process planning of treatment pathway development
1. Meeting | 2. Meeting | 3. Meeting |
---|---|---|
Explanation of the KARDIO study; introduction of participants; identification of referral pathways; exchange about current diagnostic/therapeutic approach or existing regional standards | Short review of the first meeting; drafting a treatment pathway by developing subcategories; presentation and provision of working materials (national guidelines on CHD and S3 guidelines on chest pain, including decision support material). | Merging the results; further discussion and finalisation of the treatment pathway and facultative patient materials; reflection on current and future standards and potential barriers. |
=>> Development of a regional treatment pathway =>> |
Data collection
Observation
Interviews
Data analysis
Results
Study regions
Region | Description | Urbanity | Geography |
---|---|---|---|
1 | City in a metropolitan region | Metropolitan region | Western Germany |
2 | City with rural periphery | Mixed urban and rural | Southern Germany |
3 | City with rural periphery | Mixed urban and rural | East Germany |
4 | Rural district | Rural | Central Germany |
Physician participants
Demographic data | |
---|---|
Gender n (% of available)* | |
Male | 20 (64.5%) |
Female | 11 (35.5%) |
Age in years mean (range)* | |
Male | 52 (38–65) |
Female | 53 (41–64) |
Specialty n (%) | |
Primary Care | 26 (83.87%) |
Cardiology | 5 (16.13%) |
Interview duration in minutes | |
Range | 6.67––31.70 |
Treatment pathway development
Compliance and commitment
Region | Number of treatment pathway sessions | Cardiologists (n) | General practitioners (n) | Hospital-based cardiologists and emergency physicians (n) | Radiologists or nuclear medicine specialists (n) |
---|---|---|---|---|---|
1 | I | 8 | 7 | 1 | 2 |
II | 5 | 7 | 1 | 2 | |
III | 7 | 5 | 1 | 1 | |
2 | I | 1 | 4 | 3 | 1 |
II | 1 | 4 | 3 | 2 | |
III | 0 | 5 | 2 | 2 | |
3 | I | 0 | 3 | 1 | 3 |
II | 0 | 1 | 2 | 3 | |
III | 1 | 3 | 2 | 0 | |
4 | I | 0 | 4 | 1 | 0 |
II | 1 | 3 | 0 | 0 | |
III | 0 | 1 | 0 | 0 |
Rationale of the treatment pathway
There are areas in Germany where everybody is being taken to the cathlab, irrespective of symptoms or findings. […] We’re not doing that at my current hospital. (Hospital based cardiologist 1 [interview])
[…] In the end it wasn’t about patient welfare, [but] rather hospital finances. (GP 1 [interview])
It’s well known that here in Western Europe we do the most catheter examinations. It may be well that in some cases it is actually exaggerated, because it is also clearly advantageous economically. […] there is a big economic role. (Hospital-based cardiologist 2 [interview])
Characteristics of regional treatment pathways
Content of the developed treatment pathways
Relevance of stress ECG
Well, I think that in the case of symptoms, in symptomatic patients, a stress ECG is an important and correct examination. If the findings are clear, invasive testing would immediately follow. (Cardiologist 2 [interview])
Pretest probability/Marburg heart score
Difficult to practically implement, […] are these scores for estimating CHD probability. […] That– that just takes too long, right? […] And the patient, who has symptoms of some kind, or a possible idea of what diagnosis should look like, is also not satisfied when I explain to him ‘But now you only have a very low CHD probability’, is he? He wants certainty, right? (GP 2 [interview])
Shared decision-making (SDM)
[…] Patient information is still the most helpful thing; in the end the patient makes the decision, and this is how it should be. (GP 2 [interview])
In this treatment pathway the patient’s wishes are just not sufficiently considered. (Cardiologist 3 [interview])
[…] And– yes. […] One aspect which I experience every day, and which was not definitively […] discussed, is that it is mostly up to the patients themselves whether they participate in the diagnostic work-up, right? (GP 3 [interview])
Apart from the fact that many patients don’t necessarily expect or want to participate, they traditionally, especially the older ones, they want me to decide, don’t they? (GP 2 [interview])
Perceived value of CA as a diagnostic test
[…] And then a coronary angiography is done easily; it’s not very invasive. You just give contrast medium and prick the wrist once if everything goes as planned. (Hospital-based cardiologist 3 [interview])
Patients with chronic CHD being put [on the catheterisation table] without demonstrated ischaemia, that happens every day. It [omitting non-invasive demonstration of ischaemia] doesn’t help anybody, does it? That’s why I think that far too many CAs are being performed. (Cardiologist 1 [interview])
This is a relatively good procedure, it is […] easy to use, meanwhile it has very few side effects. I think it’s worse if you miss a case of CHD than if you do one coronary angiogram too many and the result says ‘Yes, everything’s good’. (GP 4 [interview])
[…] And sometimes there are also non-heart patients who need some kind of reassurance… so that the symptoms can simply calm down. […] I have treated patients who did not have CHD in the first place, and [performed CA] three or four times because I simply had to reassure [the patient] or because I had to check it again. (Hospital-based cardiologist 4 [interview])
[…] [CA] shows me the extent of CHD and I obtain guidance for future management. I only get that with coronary angiography. (Hospital-based cardiologist 4 [interview])
Attitudes towards guidelines
I actually found my own way [in treatment]. (GP 4 [interview])
You have to rely on your instincts when seeing a patient, to be honest. (Cardiologist 4 [interview])
[…] that’s definitely good for colleagues who have little experience or are at the beginning of their careers, that they definitely have a recommendation for action that they can rely upon. […] (GP 5 [interview])
[…] For us, this treatment path has no real use because we strictly adhere to the guidelines of the German Society of Cardiology.3 (Cardiologist 2 [interview])
So, we were already working according to this […] or a similar treatment pathway before. So not much has changed now, has it? (Cardiologist 4 [interview])
Well, as I said, we’re basically doing this, or a lot of this, already. We don’t have to change anything. (GP 5 [interview])