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

## TL;DR

This study explores how incentives and competition influence doctors' adherence to guidelines for managing chronic kidney disease in Italy.

## Contribution

The paper introduces a dual-agency framework to analyze clinician behavior under a chronic disease management program using panel data.

## Key findings

- GPs appear to follow income-maximizing and effort-reducing strategies when complying with guidelines.
- Specialists in hub facilities align more closely with guidelines, possibly for reputational reasons.
- Strategic behavior is observed among specialists, suggesting non-uniform compliance with CDMP guidelines.

## Abstract

In this study we use a unit record, panel dataset, to examine the behaviour of clinicians under a chronic disease management program (CDMP) that is designed to improve care and slow the progression of chronic kidney disease (CKD). Using 8 years of quarterly data on the population of CKD patients (n = 44,686) in the Emilia-Romagna region of northern Italy, we analyse a setting where medical practitioners are agents who respond to the demands of two principals: their patient and the third-party payer. Exploiting detailed information on specialist visits and the concentration of general practitioners (GP) in local areas, as well as disease severity, we study how GPs on one side, and specialist nephrologists and cardiologists on the other comply with the CDMP guidelines, as may be predicted on the basis of a dual-agency approach. Our application of both multiple-treatment differences-in-differences (DIDM) and panel fixed-effects linear probability models produces evidence coherent with income-maximizing and, to a lower extent, effort-reducing strategies on the part of the GPs, as well as with strategic behaviour by some specialists. We also produce evidence that specialists who practice in hub facilities with a leading role in CDMP implementation, also for reputational reasons, exhibit referral practices that are more closely related to the CDMP guidelines.

The online version contains supplementary material available at 10.1007/s10198-025-01784-5.