Dear Dr. Heisig,

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PLOS ONE

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The authors would like to thank all physicians for participation in this interview study. The authors would also like to thank all researchers from the Institutes who participated in the analysis sessions. We acknowledge financial support by “Deutsche Forschungsgemeinschaft (DFG)” and University of Marburg within the funding programme “Open Access Publication Funding”.

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The research presented in this article was part of the project ChroMo (Monitoring routines for people with chronic diseases: Assessment and roadmap for the future) and was funded by the German Innovation Fund of the Federal Joint Committee (G-BA) [grant number 01VSF22046]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: N/A

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: General comments: interesting manuscript well written but elements missing about the design which decreases the rigor of the presentation. The data analysis analysis is appropriate.

Line 27: the authors should add more information about the design which will be used not only the method of data collection

Line 49: add information why you put cancer (reference, some are in remission and the monitoring is different based on the type of cancer, etc.)

Great details about the German health care system (lines 56-68)

Lines 79-86: provide the rationale to chose these 2 conditions; is it related to their incidence in your country or....

Line 93: requirement to add information about the type of design leading to the semi-structured interview; more details required about the qualitative design

Line 112: sample size? any details about your target number, references to support whatever you are coming up with

Line 114: what did you use to develop your interview guide? frameworks, theory or only experiences?

Line 134: did you use data saturation principle or clinical saturation; important to guide it with evidence

Line 158: did you ask the participants to review their transcripts? if not why?

Line 171: how many subthemes and why so many?

Line 227 and other: when you start a new subtheme can you indicate in your summary which type (s) of physicians your are focusing on because sometimes the quotes are from the GPs, cardiologists or neurologists, randomly

and your summary always start with physicians

some misleading information for the reader as each physician provides a different perspective; so make sure to link the quotes with the description

Line 275 and the figure can you highlight the link with the DMP and the figure because of the arrows

Line 301: can you explain what you mean by assurance in more details as you did for safety after

GREAT summary at the end and I like the way the authors compare with existing literature

Line 438 can you expand of what you mean about the following: "independent on their specialty"

Reviewer #2: Thank you for the opportunity to read your paper. It’s a really interesting piece of work and it is well written and structured, and for the most part, is presented clearly. I believe this fits well with Plos One, addresses the Criteria for Publication and would make interesting reading for the Plos One readership and more broadly, those interested in this field.

I've suggested the minor revisions below (including comments / questions), structured under the headings of each section of your paper. All are offered with the intention to enhance and provide additional clarity on the work you have done. The main area where further content / greater clarity on your work is needed is the methods and results.

Title & Abstract

Title

Perhaps add ‘influences’ into the title given the focus in the paper on external influences (policy, funding / reimbursement) on physicians motivations, actions etc.

Abstract

22,23 – to support clarity and flow change to “which negatively impacts upon patients quality of life and increases burden on healthcare systems” or something similar.

25 – remove ‘and ‘ so sentence reads “…benefit for the patient, detect deterioration and guide treatment adaptations”

31 – add how the interview data was analysed, add reference to following COREQ and Stenfors (2020) reference.

29 – change viewed controversially to “considered as controversial”

43, 44 – I think it’s unclear what reimbursement structures means in the abstract, while its explained in the main body of the text, for the abstract I think this could be reworded or briefly explained for clarity.

44 – not sure what “complex” means here, is it that this is about technically complex monitoring routines and / or is it the context and individual interpretations / applications that are complex?

Introduction

General point – consistency between use of this study, this interview study etc. perhaps for clarity refer to this paper and its focus. For example, “this paper focuses on interviews with physicians, we have published a separate paper from the ChroMO study which presents patients views etc…”

49, 50 – perhaps reword to “…place a burden on both patients’ well-being and quality of life as well as the healthcare system” or as suggested above.

76 – is there a reference that could be added here to support your point?

77, 78 – provide full name of the study before abbreviation, perhaps add some further information on what specifically ChroMO involves, other methods etc. or include link to website / study page / other publications will support the reader to gain a more detailed understanding of the wider work or add reference which provides this information.

83, 84 – add reference regarding your point on there being no clear benefit and negative impact on patients.

85, 86 – add reference to your other work regarding patients perspectives.

77, 86 – rewording is needed here to clarify the different projects and what they specifically focus on, It’s important to make it as clear as possible that the patient focused work is the focus of your other paper.

87, 91 – was there only one RQ? Were there any secondary Q’s? Could this one question be broken so that it aligns with the structure of the topic guide?

For example:

1. What are physicians motivations for monitoring of patients with CHD/after stroke?

2. How do physicians collaborate with other physicians and with patients?

3. What are consequences of monitoring (including benefits and risks)?

Methods

Study Design

94 – change wording to “we conducted semi structured interviews with GPs”

96-97 – to better align with Plos Ones criteria for publication regarding clarity of methods and reproducibility more is needed here regarding how Stenfors (2020) position on qualitative research has informed your work as well as its compatibility with Braun and Clarke’s TA, see Toward good practice in thematic analysis: Avoiding common problems and be(com)ing a knowing researcher, Braun and Clarke 2022.

Study Sample

General – how were physicians identified / chosen by the study centres, how were physician emails accessed? How many physicians were invited in total? How many declined, didn’t respond, accept but then not able to take part?

104 – change wording to ‘ The recruitment period for this study was…’

105 – change wording to “invitations were sent out via email through the research practice network….”

Data Collection

General – check tense through, focus on works that has already been complete.

116, 117 – clarify who the interview guide pretested with.

120 – add a brief explanation of which physicians completed which fictional patient case(s).

119, 122 – perhaps additional RQs can be derived here

123, 124 – clarify what video call software was used and reference if applicable.

132-134 – reference data saturation here although there are wider questions regarding whether data saturation (more of a positivist stance) aligns with Braun and Clarkes reflexive TA.

135 – who completed the transcription?

137 – include demographic survey as supplementary material.

142 – Braun and Clarke’s work from 2006 has since been updated, was this consulted?

144 – add reference to B&Cs work again.

147 – clarify who these institutes were.

150 – reword to ensure consistency with Braun and Clarke’s approach, rather than themes emerged, state that authors / researchers created themes.

156, 157 – transparency and trustworthiness, this perhaps does not related to Braun and Clarke’s approach instead reflecting a more positivist paradigm perhaps reword to support the interpretation of data via multiple viewpoints or something along these lines.

Results

General points

� Clear thematic structure throughout, quotes primarily support points made in the main body of the text (a couple noted below, could be removed / changed).

� Any way to draw out any difference in views between different physicians within / between groups?

167 – any reason for no small practices? Important to acknowledge and explain, briefly.

171 – Reword ‘emerged’ to created or designated etc. by the research team.

173 – reword emerged to created by the research team.

191-193 – repetition of point on cooperation across systems – perhaps reference guideline.

196, 197– edit sentence to support flow, as follows: “Depending on the physicians' specialty, this framework was either readily accepted, met with critical reflection or even rejection”

201, 210 – to support clarity for the reader my preference would be to separate out quotes and align with points in main point of text i.e. one quote per piece of text but I know Plos One do not follow this.

203 – add more nuance here RE quote, the out of touch point seems really important to emphasise.

211-212 – not sure what “…considered themselves firm in details” means, I think rewording to clarify your point here would be helpful for the reader.

220 – instead of “the medical community” say “physicians in this study”. The medical community implies a much larger population than included in this work.

250 – add additional point here about reduced burden on the healthcare system as a whole, was there anything here about workload burden on physicians too and the potential positive impact of monitoring in reducing it?

254-262 – can a point be added here which is the opposite of the point above, namely that too frequent monitoring creates additional system, staff burden etc.?

265-268 – change “…some told…” to “some reported that there were…” . Also, I’m not clear on how the quote reflects the point made before it, is there another quote that could be used to illustrate this point more clearly?

270-272 – reword for clarity here i.e. “Physicians reported that frequencies of ultrasound monitoring were determined by structural requirements (guidelines or quartile billing system) as well as their own assessment and experience on the course of the disease or the patient's wishes.”

279 – not sure that quote C-13 is adding much here, perhaps use other that outlines the variation in monitoring frequency.

282 – add additional words to the second sentence to aid flow and clarity i.e. “The factors primarily mentioned were progress control…” this is a really interesting point and would add analytical value if explored more, were their differences between / within physicians?

301 – remove contraction ‘don’t’ change to do not

312-320 – repeating the same point made in lines 292-299, could be integrated above and therefore cut down.

321 – I wonder whether a bit more explanation could be added to the sub-theme financial incentives, for example, ‘ Financial incentives driving clinical practice’

352 – perhaps sub-theme could be reworded to emphasise the wide impact across the health system for example “burden on the healthcare system”

372-73 – This quote from (N-18) does not deny the point made therefore I think this quote should be separated from the other two and further text added highlighting that not all physicians denied it.

Discussion

Summary

General point– review tense throughout to ensure consistency.

382 – clarify what you mean by “critical approach” as I do not think it is clear at the moment.

377-379 – slight rewording would help clarity here regarding difference between GPs and Cardiologists and Neurologists, for example: “GPs treated their patients along DMPs if they were available, however, they primarily treated patient based on their individual experience. In contrast, cardiologists and neurologists oriented their care procedures mostly based on guidelines supported by their clinical experience”

379-380 – slight rewording here for clarity would be helpful for the reader: “GPs were seen as the managers and gatekeepers in health care with patients being referred to other specialties by their GP.”

383-385 - slight rewording here for clarity would be helpful for the reader: “Monitoring was generally seen as beneficial for the patient and the health system. It was viewed as facilitating the early detection of deterioration, delaying disease progression through adaptation of therapy and leading to less hospitalizations.”

Comparison with existing literature

General point– any useful points to make regarding difference views between professions and alignment or difference with wider literature?

Rink et al (2025) reference to be updated if possible following outcome of review.

394-397- is this reported in the wider literature?

408 – A really important point RE increased workload, I think this should be highlighted further with additional quote(s) in the Results.

411-414 – Another important point regarding the impact of declining patients request, could any quotes / content be added to the results?

417-425 – I think its really important to bring in one of your important findings here regarding physicians openness about conducting an ultrasound because of the financial incentives. For example, this implies that the education of students and practitioners / physicians isn’t the issue as they are aware of its risks / lack of need at times. While this is a systemic issue, there’s also a behavioural / individual level challenge here.

429 – in-text reference should read (9, 32)

430 - “time needed to treat” is this a quote from an interview / paper? If so should be referenced / an ID provided.

432 – in-text reference should read (30, 31)

449-450- explain ‘lack of peer mentality’ briefly, was this observed / felt by interviewees?

451 – to clarify your point, change “some” to “further” as you’ve already mentioned a potential limitation in line 450.

455 – to clarify your point, change “provided further points of view” to “offered alternative or differing points of view.”.

456-457 – Qualitative work isn’t about representativeness of all studied populations so I don’t think this limitation is necessary. I think you should finish on a positive / strength, i.e. contribution to the literature / field and where it could go in the future.

460 – expand upon point RE financial incentives, reiterate that this is a fault in the current policy / medical system.

References

517-521 - reference 9. Is in German rather than English

522-524 - reference 10. Is in German rather than English

531-532 – reference 15. Is in German rather than English

550-551 – add DOI - Buss L F, Spitzer D, Watson J C. Can I have blood tests to check everything is alright? BMJ 2023; 382 :e075728 doi:10.1136/bmj-2023-075728

560-561 – add doi

564-567 - reference 29. Is in German rather than English

Supplementary Information

COREQ Checklist

13. Clarify why this information hasn’t been included?

Thanks again and hope this is helpful!

**********

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Reviewer #1: No

Reviewer #2: Yes:  Jordan Van Godwin

**********

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Dear Dr. Heisig,

Please submit your revised manuscript by Mar 13 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

• A letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
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• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Ahmed Qasim Mohammed Alhatemi, Mbchb

Academic Editor

PLOS One

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: Yes

**********

Reviewer #2: Thank you for the opportunity to read your paper again. The revisions have enhanced the clarity and contribution of your work.

A couple of small further change suggested,

Abstract Line 32-33 - add appropriate reference to Braun and Clarke reference "Transcripts were analysed with thematic analysis according to Braun and Clarke (REFERENCE HERE)".

Methods Line 174 - 174 – to ensure consistency with how Braun and Clarke describe their form analysis change "reflexible thematic analysis" to "reflexive thematic analysis".

All the best,

Jordan

**********

what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review?  For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #2: Yes:  Jordan Van Godwin

**********

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Dear Dr. Heisig,

Please submit your revised manuscript by Jun 19 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

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Emma Campbell, Ph.D

Staff Editor

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If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #3: (No Response)

Reviewer #4: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #3: Yes

Reviewer #4: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #3: Yes

Reviewer #4: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #3: Yes

Reviewer #4: Yes

**********

Reviewer #3: The manuscript addresses a sensitive and clinically important issue from the perspectives of patients, clinicians, and the healthcare system. The study is methodologically sound: the design is appropriate to the research objectives, and the methods are clearly described and justified. The manuscript is well written and easy to follow, and the inclusion of direct quotations from interviewees enhances transparency and facilitates a deeper understanding of the findings.

The authors provide a thorough comparison of their results with the existing literature and present a balanced discussion of the study’s strengths and limitations. The Conclusions section appropriately highlights key questions emerging from the findings and underscores the need for further research, particularly to evaluate current monitoring practices and to integrate evidence-based recommendations into clinical guidelines aimed at optimizing patient outcomes and resource utilization.

To further strengthen the manuscript, it would be valuable for the authors to articulate more explicitly the novel contribution of this study to the existing body of knowledge. A clearer statement of what specifically advances current understanding would enhance the overall impact and relevance of the work.

Reviewer #4: Monitoring routines for people with chronic conditions: Motivations, experiences and perspectives of physicians from different specialties - a qualitative interview study

By Heisig et. al.

The paper concerns interviews over the relevance and timeliness of monitoring routines for chronic heart disease (CHD) and stroke. My immediate impression is that the paper is relevant, with the survey appropriately carried out, and, to some extent, appropriately summarized. There are however in my opinion a number of things that the authors should address prior to publication. In particular the discussion section appears weak, and would benefit from describing the results and their implications in light of existing literature, rather than the so-called 'comparison with existing literature' that is currently the main section of the discussion. Furthermore it appears to me that some of the conclusions are too strict from the presented evidence. Specific things to attend are listed below.

A. The title. The title indicate general monitoring routines for 'chronic conditions'. But this is not what the authors investigate. 'Chronic diseases' are limited to two diseases, CHD and stroke, which are both diseases from the circulary system, and the authors have not justified nor discussed overlap with general chronic diseases in the monitoring routines. This should be reflected in the title.

B. How have cardiologists and neurologists been selected? The text only describe how they are contacted (email found through web page), but not why the individual cariologists/neurologists were contacted.

C. The structure of the 'Data analysis' section should be tightened. The authors decide to describe 6 steps in a reference to a thematic approach to qualitative analysis. Steps 1-3 and 5 are numbered in the description, but step 4 is referred to as 'the next step' and the contents of step 6 is not specified. Please tighten up this notation.

D. The interviews are grouped to GPs, cardiologists and neurologists. However, when going over the results, it appears that in particular neurologists are not mentioned. For example, in the 'Subtheme: DMPs and guidelines as framework', the GP attitude and cardiologist attitudes are scrutinized, but neurologists are not mentioned. Despite what seems to be a quote from a neurologist (N-19). Attitudes should be described either as a general trend with specification of deviations among the groups, or be mentioning all three groups. Otherwise the results are partial.

E. In light of the results in Theme 4, I will question whether the authors have evidence for writing that the regular use of EKG/ultrasound was considered unnecessary. Theme 4 lists benefits from monitoring with EKC/ultrasound, and while other themes may indicate attitudes that support that such monitoring is unnecessary, this may be voiced at other interviews than those that lists benefits in Theme 4, essentially dividing the sample population into two heterogeneous groups, where one group voice benefits and the other that it is unnecessary. The authors should argue from their thematic approach that this is not the case, if the evaluation of the EKG/ultrasound as unnecessary is maintained.

F. The use of past tense in the section 'comparison with existing literature'. Here it is difficult to distinguish when the authors refer to results from the literature, and when it is aspects of their own results that is discussed. In terms of what the comparison means prospectively, it is odd that past tense is used. For example lines 464-467, where it is (was) essential with continuous medical education and evaluation of diagnostic technologies.

G. I am curious as to why patients perception of intervention benefits is discussed in lines 445-448 as it is. There are no patients in this study, only the thoughts from the physicians about such, which may be a very different thing. The discussion should refflect that.

H. I believe that the authors in a number of passages are overstating the evidence from the survey. In line 449, they mention 'overtesting'; but do their data data support that overtesting takes place, whether overtesting is the rule? And what do the authors consider as 'overtesting'? Needless to say, more testing than needed, but when is the benefit sufficiently small to rate a test procedure as 'overtesting'?

I. In the S&L section, the authors claim that the work captures 'perspectives that extend beyond the viewpoint of any single speciality'. Considering that the authors only look into 2 specialities, which are even for the same group of diseases, I think that such a claim is stretching it a bit, cf. my view on the title of the paper. The authors should argue for that the information gathered can be formulated in such a broad way. It is worth noting that the authors inline 499 state that 'physicians from other specialities also could have additional perspectives'. Yes indeed.

J. In the conclusion I believe that the authors overstate the evidence from the survey. For example, they write that 'The medical benefits of ultrasound are limited for CHD and stroke patients'. The authors cannot know that. The evidence is at the most that the benefit APPEARS limited from the survey, but to draw a conclusion beyond the material, and indeed over all interviewees, as as I see it unfounded.

K. In the abstract, the authors state that 'transcripts were analysed with thematic analysis according to Braun and Clarke'. 'Braun and Clarke' is here the authors of a publication that the authors refer to wrt. thematic analysis. However, in the abstract, these names should not appear, thematic analysis in itself should be enough, as the reference may be found in the main text. Laypersons may be mislead to think that 'Braun and Clarke' is a principle rather than a reference, which there by the way is two of (two papers of Braun and Clarke).

L. Grammar: Line 47, line 130.

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Reviewer #3: Yes:  Marine Gambaryan, MD, MPH, D.M.Sc, Associate Professor

Reviewer #4: Yes:  Anders Stockmarr

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

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