Leader: Luke Connelly (UNIBO); Other collaborator(s):
Task 3 will also rely on the availability of the integrated platform developed in Task1 to analyse the specific problems arising in the management of chronic care programs for multimorbid patients where different specialists may be given the leadership and/or where more than one program is simultaneously implemented. The main aim of the Task is to provide guidance to the policy maker on how to regulate the interaction between specialist practitioners and between them and the general practitioners to avoid discontinuities of care and under/over provision of care. Special attention will be devoted to the specific role of the new organizational settings in primary and intermediate care to better align the incentives of professionals.
Brief description of the activities and of the intermediate results
During the period November ‘23 to March ’24 the group involved in task 3 has been working on a panel dataset to examine the behaviour of clinicians involved in a chronic disease management program designed to improve the quality of care and to slow down the progression of chronic kidney disease. The panel dataset made use of eight years of quarterly data on the population of chronic kidney disease patients in the EmiliaRomagna region. The empirical analysis was driven by a theoretical model in which medical practitioners are conceived of as “double agents” who respond to the demands of two principals: their patient and the third-party payer (in this case the regional authority). Exploiting detailed information on specialist visits and the concentration of general practitioners (GPs), as well as disease severity, we investigated how various specialists and especially nephrologists and cardiologists comply with the guidelines of the chronic disease management program, as may be predicted by the dual-agency model. We made use of both multipletreatment (staggered in time) differences-in-differences and panel fixed-effects linear probability models. The preliminary evidence shows that there might be evidence of strategic behavior by some specialists, as well as by some GPs. We also produce some evidence that specialists who practice in facilities that are closely controlled by the Local Health Authorities (LHAs) exhibit referral practices that are more closely related to the guidelines for chronic disease management program as issued by the regional authorities.
Main policy, industrial and scientific implications
Chronic disease management programs are based on guidelines that are implemented by physicians who interact between themselves—and with the patients—in a closely linked network of relationships. This includes not only primary care professionals such as GPs, but also specialists from various disciplines, because most patients who are enrolled in such chronic disease management programs are multimorbid. These practitioners act in an agent-multiple principal setting with conflicting incentives to comply with the guidelines on how patients should be treated at different stages. Our preliminary results show that the effectiveness of a chronic disease management program, which depends critically on targeting the right patients at the right time, may be influenced by the professional competition between the various specialists involved. In other words, the effective implementation of such programs may crucially depends on the incentive compatibility of its main operational rules (guidelines or clinical pathways) with respect to the objective functions of the physicians involved. The planners should consider how to overcome the problems due to conflicting incentives between the crucial players.
Brief description of the activities and of the intermediate results
- Meetings to define dataset key linkage and data format.
- Setup of a secure UNIBO cloud environment for data sharing among UNIBO researchers.
- Development of a model to investigate the competitive and collaborative interactions between GPs, nephrologists, and cardiologists in the management of chronic kidney disease patients.
- Development of an Instrumental variable strategy to evaluate the effects of complying with primary prevention policies (screenings) on healthcare use and health status using data from Share.
Brief description of the activities and of the intermediate results
- Definition of an empirical strategy to estimate the incentives for GPs and for nephrologists and cardiologists in competition between them, to comply with clinical guidelines in the management of chronic kidney disease patients.
- Development of an Instrumental variable strategy to evaluate the differential effects of compliance with primary prevention policies (screenings) between genders on healthcare use and health status using data from Share.
- Development of a quasi-experimental approach that leverages the discontinuities in the supply of prevention services during the peak of the Covid period, to estimate the effects of complying with screening policies on healthcare use using data from Share.
Brief description of the activities and of the intermediate results
- Meetings with Romagna LHA to discuss and update ongoing projects.
- Preparatory work to create a unified dataset for heart failure patients from 2017 to 2023, including comprehensive information on health services consumption (such as hospitalization and access to ED rooms), diagnoses, and organizational healthcare settings.
- Preparatory work to collect comprehensive information about GPs, including the patients registered on their lists and the respective periods, the organizational forms adopted, their primary unit of affiliation, the incentives provided, and their adherence to integrated care programs.
Brief description of the activities and of the intermediate results
- Meetings with LHA of Romagna officers and statisticians to discuss data integration issues aimed at improving the datasets to be used in the empirical analysis.
- Drafting of the paper “Preventive Behaviours and Healthcare Use: Is there a gender gap?”
- Drafting of the paper “Exogenous Disruptions and Changes in the Pattern of Healthcare Services Use”
- Completion of a comprehensive dataset on CHF patients collecting information on primary care physicians, including the patients registered on their lists and the corresponding time periods, the organizational forms adopted, their primary unit of affiliation, the incentives provided, and their participation in integrated care programs.
- WP meeting to discuss the policy brief deliverable, followed by the preparation of a joint abstract.
Brief description of the activities and of the intermediate results
- Meetings with LHA of Romagna officers and statisticians to discuss the data integration issues aimed at improving the datasets to be used in the empirical analysis.
- Drafting of the paper “The Causal Effects of Outpatient Nursing Clinic on Congestive Heart Failure Outcomes: An Event Study Approach”.
- Drafting of the paper “Community-Based Nursing Programs, Health and Healthcare Use” based on the dataset with chronic CHF patients.
Brief description of the activities and of the intermediate results
- Response to reviewers and final acceptance of the paper "Tough versus soft regulations to promote generic medications in Italy" at the European Journal of Health Economics.
- Organization of the Workshop “Age-itiamoci. Invecchiare bene in una società che invecchia”, Partenariato Age-It, Bologna, Settembre 2025.
- Organization of the Meetings with LHA of Romagna officers and statisticians to discuss the data integration issues aimed at improving the datasets to be used in the empirical analysis.
- Contribution to the story-telling exercise of Spoke 10, Partenariato Age-It, “Agenda per strategie integrate di invecchiamento sano e attivo” by the identification and discussion of three main indicators to monitor the healthy aging of the population related to effective management of health policies, September 2025.
- Finalisation of the paper “The Causal Effects of Outpatient Nursing Clinic on Congestive Heart Failure Outcomes: An Event Study Approach”.
- Finalisation of the paper “Integrated Care, Engaging Patients and Financial Incentives: The Impact of Primary Care Nursing Programs”
- Co-editing for the WP4 of policy brief deliverable into a publication in a special issue of Quaderni di Epidemiologia e Prevenzione, which will include all policy briefs from Spoke 10.
- Paper published "Compliance with Clinical Guidelines: The Role of Incentives and Competition Between Practitioners" The European Journal of Health Economics, 2025
- Paper published: "Tough versus Soft Regulations to Promote Generic Medications among Italian Physicians", The European Journal of Health Economics, 2025
- Submission of "Community-Based Nursing Programs, Health and Healthcare Use"
- Submission of “The Impact of Nurse-Led Chronic Care on Health Behaviors and Acute Care Use After Hospitalization”
- Presentation of ongoing work at Age-it Unibo meeting held in Bologna on 30 of May 2025
- Presentation of “Tough versus Soft Regulations to Promote Generic Medications among Italian Physicians” at the Universitat Autonoma de Madrid Workshop on the Economics of Health and Human Capital, June 20th, 2025.
- Presentation “Politiche per migliorare la conformità alle linee guida organizzative e cliniche nei programmi di promozione della salute degli anziani”, Workshop “Politiche per migliorare la conformità alle linee guida organizzative e cliniche nei programmi di promozione della salute degli anziani” Partenariato Age-It, Spoke 10, Università la Sapienza, Roma, 16-17 Settembre 2025.
- Organization of the Workshop “Age-itiamoci. Invecchiare bene in una società che invecchia”, Partenariato Age-It, Bologna, Settembre 2025.