Compliance with clinical guidelines: the role of incentives and competition between practitioners

Area of Science:

• Health Economics
• Clinical Practice Management
• Public Health Policy

Background:

• Chronic kidney disease (CKD) management programs aim to improve patient care and slow disease progression.
• Understanding clinician behavior within these programs is crucial for optimizing healthcare delivery.
• A dual-agency model, considering patient and payer demands, can explain physician decision-making.

Purpose of the Study:

• To analyze general practitioner (GP) and specialist (nephrologist, cardiologist) adherence to CKD management program guidelines.
• To investigate clinician behavior using a dual-agency framework, considering financial incentives and effort reduction.
• To assess the impact of facility role and reputation on specialist referral practices within the program.

Main Methods:

• Utilized a unit record, panel dataset of 44,686 CKD patients in Italy over 8 years.
• Employed multiple-treatment differences-in-differences (DIDm) and panel fixed-effects linear probability models.
• Analyzed data on specialist visits, GP concentration, and disease severity.

Main Results:

• Evidence suggests GPs engage in income-maximizing and effort-reducing strategies.
• Specialists exhibit strategic behavior, with some adhering more closely to guidelines.
• Specialists in leading CDMP facilities showed referral practices more aligned with guidelines, potentially due to reputational concerns.

Conclusions:

• Clinician behavior within CKD management programs can be influenced by dual agency, including financial and reputational factors.
• GPs may prioritize income and minimize effort, while specialists' adherence varies.
• Hub facilities play a role in promoting guideline adherence among specialists.