Letter to the Editor
Barriers for the development of home haemodialysis in Spain. Spanish nephrologists survey
Barreras para el desarrollo de la hemodiálisis domiciliaria en España. Encuesta a nefrólogos españoles
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Spanish nephrologists survey" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "665" "paginaFinal" => "668" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Alejandro Pérez Alba, Fernanda Slon Roblero, Sandra Castellano Gasch, M. Auxiliadora Bajo Rubio" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Alejandro" "apellidos" => "Pérez Alba" "email" => array:1 [ 0 => "aperezalba@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Fernanda" "apellidos" => "Slon Roblero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Sandra" "apellidos" => "Castellano Gasch" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "M. Auxiliadora" "apellidos" => "Bajo Rubio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Hospital General Universitario de Castellón, Castellón, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital de Navarra, Pamplona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "FMC Madrid Dialcentro, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Barreras para el desarrollo de la hemodiálisis domiciliaria en España. Encuesta a nefrólogos españoles" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2428 "Ancho" => 3483 "Tamanyo" => 354173 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Barriers to implementing home haemodialysis programmes.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Last decade, the number of patients treated with home haemodialysis (HHD) worldwide has increased considerably<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a>; this is in part due to the clinical benefits of more intensive haemodialysis (HD) regimens in HHD.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2–5</span></a> In Spain, however, despite a growing interest and modern systems that simplify HHD, the number of patients using HHD has not increased substantially.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> We administered a survey to Spanish nephrologists, sent mainly by e-mail through the Spanish Society of Nephrology, to learn more about the barriers for implementing HHD in Spain.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Between February and November of 2015, we received 142 surveys from 76 different HD units, 60 of them hospital-based and 16 out-of-hospital (mean age of surveyed: 44.69<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>10.55 years). HHD programmes were available in 32 of these centres (42.1%); 15 (19.73%) offered the option even though they did not have their own HHD unit, and in 29 (38.15%) the patients were not offered this possibility. All the HHD units were hospital-based, with no HHD programmes dependent on peripheral HD centres, in which it was only offered in 18.7% of cases (compared with 73.3% of HHD offerings performed in hospitals). 47% of HHD programmes were started after 2011; 23% between 2006 and 2010; 13% between 2001 and 2005; and 17% before 2000. In all, 60.5% of the nephrology units stated that they would be capable of offering their own HHD programmes within one year's period.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The median number of patients per HHD unit was 2 (range: 0–17); 59.4% of the centres had 2 patients or fewer; and only 12.5% had 6 patients or more. The nephrologist in charge of the HHD programme in 42% of the cases was also responsible for HD; in 32% for peritoneal dialysis (PD); and in 26% for both methods. In 46% of the cases the patients came from HD at the centre; 22% from PD; 25% from outpatient clinics; and 7% from renal transplantation.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We asked the nephrologists for their opinions about any clinical benefits of HHD. We obtained the highest percentage of affirmative responses in regard to quality of life (95.8%), and the lowest in regard to mortality (67.6%). As for anaemia, high blood phosphate levels, blood pressure, nutrition and morbidity, opinion was in favour of HHD in 80.3%, 84.5%, 87.3%, 88% and 76%, respectively. In addition, 85.9% of the surveyed said that HHD could produce economic benefits to the health service. In total, 45.8% of the nephrologists said that living far from the referral centre was a factor favouring implementing of HHD and, did not compete with PD, according to 52.8% of the responses.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We asked about possible barriers for the development of HHD by dividing them into patient-related factors (lack of information, technical complexity, need for carers, fear of acute adverse effects of the method and difficulty with vascular access); medical staff-related factors (lack of properly trained medical personnel, lack of personnel motivated to perform home methods, consideration of excessive patient morbidity, lack of scientific evidence in favour of HHD); and resource-related factors (lack of equipment to work with HHD, lack of a physical space to conduct training) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Next, we divided the barriers according to the size of the HHD unit (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), to see whether they varied depending on whether the nephrologist had more experience with the home method.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">This survey showed that there is a growing interest in HHD on the part of Spanish nephrologists. The data must be analysed by considering that all surveys are answered mainly by those who are the most interested in the subject being investigated, and therefore we are aware that this real interest in the method may be overvalued and the possible barriers greater than what has been expressed. In any case, it seems that as HHD programmes develop, the initial barriers, which stem from a lack of practical knowledge of the method, are disappearing<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a> and only resource-related barriers remain<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a> (lack of information, training and personnel dedicated exclusively to HHD).</p><p id="par0040" class="elsevierStylePara elsevierViewall">From the HHD Support and Promotion Group in Spain, we must focus our efforts on showing the results obtained in regard to generating HHD programmes, trusting that in the coming years the barriers stated in this survey – and which in many cases prevent this method of treatment from being offered to all patients as one more option to improve their quality of life – may be problems that will be overcome.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pérez Alba A, Slon Roblero F, Castellano Gasch S, Bajo Rubio MA. Barreras para el desarrollo de la hemodiálisis domiciliaria en España. Encuesta a nefrólogos españoles. Nefrologia. 2017;37:665–668.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2428 "Ancho" => 3483 "Tamanyo" => 354173 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Barriers to implementing home haemodialysis programmes.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Sig: statistical significance between types of centre <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="8" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Type of centre per patient</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">3 or more</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2–1</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">None</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Yes % \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Yes % \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Yes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Yes % \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lack of information \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Technical complexity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sig. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Carers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sig. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Adverse effects \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sig. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sig. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vascular access \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Training \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">76.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sig. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Motivation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Morbidity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Evidence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Personnel \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sig. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Space \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sig. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sig. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1609202.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patient-, medical staff- and resource-related barriers by size of centre.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "US renal data system annual data report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 3 | 5 |
| 2024 October | 43 | 48 | 91 |
| 2024 September | 47 | 24 | 71 |
| 2024 August | 73 | 79 | 152 |
| 2024 July | 45 | 28 | 73 |
| 2024 June | 59 | 31 | 90 |
| 2024 May | 57 | 32 | 89 |
| 2024 April | 71 | 29 | 100 |
| 2024 March | 57 | 26 | 83 |
| 2024 February | 69 | 45 | 114 |
| 2024 January | 31 | 58 | 89 |
| 2023 December | 33 | 30 | 63 |
| 2023 November | 53 | 39 | 92 |
| 2023 October | 23 | 32 | 55 |
| 2023 September | 33 | 35 | 68 |
| 2023 August | 54 | 28 | 82 |
| 2023 July | 37 | 28 | 65 |
| 2023 June | 37 | 24 | 61 |
| 2023 May | 49 | 28 | 77 |
| 2023 April | 24 | 15 | 39 |
| 2023 March | 52 | 19 | 71 |
| 2023 February | 44 | 18 | 62 |
| 2023 January | 50 | 31 | 81 |
| 2022 December | 61 | 25 | 86 |
| 2022 November | 54 | 38 | 92 |
| 2022 October | 50 | 54 | 104 |
| 2022 September | 48 | 33 | 81 |
| 2022 August | 58 | 43 | 101 |
| 2022 July | 39 | 42 | 81 |
| 2022 June | 40 | 47 | 87 |
| 2022 May | 44 | 29 | 73 |
| 2022 April | 39 | 59 | 98 |
| 2022 March | 54 | 57 | 111 |
| 2022 February | 31 | 47 | 78 |
| 2022 January | 46 | 24 | 70 |
| 2021 December | 40 | 45 | 85 |
| 2021 November | 37 | 28 | 65 |
| 2021 October | 50 | 33 | 83 |
| 2021 September | 44 | 43 | 87 |
| 2021 August | 36 | 38 | 74 |
| 2021 July | 35 | 31 | 66 |
| 2021 June | 29 | 27 | 56 |
| 2021 May | 51 | 43 | 94 |
| 2021 April | 84 | 53 | 137 |
| 2021 March | 41 | 28 | 69 |
| 2021 February | 50 | 37 | 87 |
| 2021 January | 43 | 19 | 62 |
| 2020 December | 42 | 16 | 58 |
| 2020 November | 36 | 13 | 49 |
| 2020 October | 13 | 11 | 24 |
| 2020 September | 33 | 14 | 47 |
| 2020 August | 59 | 10 | 69 |
| 2020 July | 39 | 13 | 52 |
| 2020 June | 24 | 21 | 45 |
| 2020 May | 38 | 15 | 53 |
| 2020 April | 34 | 14 | 48 |
| 2020 March | 33 | 14 | 47 |
| 2020 February | 51 | 27 | 78 |
| 2020 January | 54 | 20 | 74 |
| 2019 December | 53 | 20 | 73 |
| 2019 November | 48 | 19 | 67 |
| 2019 October | 19 | 12 | 31 |
| 2019 September | 31 | 13 | 44 |
| 2019 August | 17 | 11 | 28 |
| 2019 July | 28 | 19 | 47 |
| 2019 June | 33 | 25 | 58 |
| 2019 May | 26 | 29 | 55 |
| 2019 April | 38 | 32 | 70 |
| 2019 March | 42 | 22 | 64 |
| 2019 February | 30 | 14 | 44 |
| 2019 January | 26 | 25 | 51 |
| 2018 December | 85 | 32 | 117 |
| 2018 November | 153 | 24 | 177 |
| 2018 October | 89 | 11 | 100 |
| 2018 September | 88 | 22 | 110 |
| 2018 August | 55 | 15 | 70 |
| 2018 July | 53 | 15 | 68 |
| 2018 June | 48 | 16 | 64 |
| 2018 May | 67 | 8 | 75 |
| 2018 April | 67 | 14 | 81 |
| 2018 March | 41 | 10 | 51 |
| 2018 February | 27 | 3 | 30 |
| 2018 January | 44 | 10 | 54 |
| 2017 December | 39 | 11 | 50 |
| 2017 November | 53 | 9 | 62 |
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