Beyond the procedure: a game-theoretic analysis of multilevel determinants shaping doctor-patient engagement after angioplasty

Cardiovascular diseases (CVDs) are a leading global health burden, with coronary artery disease (CAD) often requiring percutaneous coronary intervention (PCI). While PCI improves survival, long-term outcomes hinge on post-procedural patient engagement, a multifaceted process influenced by individual, interpersonal, and systemic factors. Despite its importance, limited research explores the multilevel determinants of doctor-patient engagement in post-angioplasty contexts, particularly in resource-constrained settings like Iran. This study addresses this gap by exploring multilevel determinants shaping doctor-patient engagement in post-angioplasty contexts, distinguishing itself from prior qualitative studies (e.g., those focusing solely on lived experiences or cardiac rehabilitation perceptions in high-income countries) by integrating a game theory lens and examining socioeconomic disparities in an LMIC setting. A qualitative study was conducted in Mashhad, Iran, involving 24 post-angioplasty patients (mean age 50.17 years) purposively sampled from public and private hospitals. Semi-structured interviews explored treatment decision-making, follow-up challenges, and healthcare system interactions. Data were analyzed using thematic content analysis in MAXQDA 20, with intercoder reliability (κ = 0.92) and rigorous validation strategies like member checking and expert review. Four key determinants emerged: (1) Facility-related factors, where digital systems (e.g., online scheduling) enhanced engagement, but disparities between public and private hospitals created inequities; (2) Trust and satisfaction, built on physician accessibility, empathy, and professionalism; (3) Educational interactions, where multi-modal resources (e.g., videos, culturally tailored analogies) improved understanding, though health literacy gaps persisted; and (4) Financial barriers, including high out-of-pocket costs and insurance complexities, disproportionately affected marginalized groups. A game theory lens revealed cooperative interactions fostered adherence, while misaligned incentives led to disengagement. Doctor-patient engagement in post-angioplasty care is a dynamic interplay of structural, relational, and economic factors. Interventions must address these multilevel determinants holistically, such as investing in digital infrastructure, training providers in patient-centered communication, and implementing policy reforms to reduce financial barriers. The study underscores the need for culturally tailored, equity-focused strategies to optimize long-term outcomes. Future research should evaluate targeted interventions in diverse settings.