Physicians’ perspectives on the impact of echocardiographic feedback: a qualitative interview study

Echocardiography is a widely used non-invasive imaging modality central to diagnosing and monitoring heart failure, valvular disease, congenital heart disease, and cardiomyopathy. However, inappropriate requests, variability in reporting quality, and limited follow-up of diagnostic performance remain concerns, particularly in low- and middle-income countries. Audit and feedback is an established strategy for improving professional practice, but its application in echocardiography remains underdeveloped. This study aimed to explore physicians’ perspectives on how the impact of echocardiographic feedback on clinicians can be assessed in Iran. A qualitative study was conducted using semi-structured interviews with an inductive approach and reflexive thematic analysis, following Braun and Clarke’s six-phase framework. From August 2022 to September 2023, 30 semi-structured interviews were conducted with purposively sampled participants, including cardiologists, university faculty in statistics, biostatistics, and health sciences, health insurance experts, and physicians working in health insurance organizations and research centers. The average interview duration was 49 min. Data saturation was reached after interview 27. Transcripts were coded by two independent researchers using MAXQDA 20 software. Trustworthiness was ensured using Lincoln and Guba’s criteria. The analysis generated five main themes and twelve subthemes: (1) indications for performing echocardiography; (2) diagnosing a patient’s need for echocardiography; (3) components of a complete echocardiography report; (4) sample selection and control group; and (5) data recording and analysis method. Participants emphasized the importance of guideline-based indications, standardized reporting, a before-and-after design with a control group, and the Difference-in-Differences (DID) technique for evaluating feedback. A cross-cutting finding regarding the role of body habitus and thoracic morphology in echocardiographic interpretation was integrated into the framework. The findings provide a comprehensive qualitative basis for a proposed framework for future quantitative evaluation of echocardiographic feedback. Future studies should operationalize these domains into valid and reliable indicators and prospectively evaluate whether feedback can improve the appropriateness, quality, and consistency of echocardiographic practice.