Establishing and controlling chronic renal failure treatment costs. A pressing need
Conocer y controlar los costes del tratamiento de la insuficiencia renal crónica. Una necesidad inaplazable
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A pressing need" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "256" "paginaFinal" => "259" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "R. Martín Hernández" "autores" => array:1 [ 0 => array:4 [ "Iniciales" => "R." "apellidos" => "Martín Hernández" "email" => array:1 [ 0 => "rmartinh@senefro.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Clínico San Carlos, Madrid, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Conocer y controlar los costes del tratamiento de la insuficiencia renal crónica. Una necesidad inaplazable" ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">Chronic renal failure (CRF) is currently one of the main problems of public heath in Western countries due to its high prevalence and high social and economic costs. From the data published in the last report of the <span class="elsevierStyleItalic">Registro Español de Enfermos Renales </span>(Spanish Registry of Renal Patients) for 2009,<span class="elsevierStyleSup">1</span> we can see that around 48 600 CRF patients (0.1%) are currently alive in Spain thanks to different methods of renal replacement therapy. This represents a prevalence of 1039 cases per million population (pmp), with a growth of 1.6% in the last year. Around 6000 patients start renal replacement therapy every year, with an incidence of 129 new patients pmp. Both of these figures are at the middle-upper end of the countries surrounding Spain. In Spain, incidence has remained stable for the last five years and prevalence has increased by 1.6% in the last year and a little higher in previous years; however, there are significant differences between the different Autonomous Communities of Spain. The Registry shows that 47% of CRF patients (23 000 patients) are undergoing haemodialysis (HD), 6% (2350) peritoneal dialysis (PD) and 47% (23 000) have a functioning kidney transplant (KT). There are also large differences in these figures between the different Autonomous Communities.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">END-STAGE RENAL FAILURE TREATMENT COSTS IN SPAIN</span></p><p class="elsevierStylePara">Although the actual cost of CRF replacement therapy is unknown in Spain (there are large differences in the articles published),<span class="elsevierStyleSup">2,3</span> it is estimated that it makes up between 1.6% and 2.5% of total healthcare costs. Villa estimated the total cost to be 1400 million Euros in a recent publication in <span class="elsevierStyleItalic">Nephrol Dial Traspant</span>:<span class="elsevierStyleItalic"> </span>73% of this cost was for HD, 6% for PD and 31% for KT.<span class="elsevierStyleSup">4</span> The annual increase in costs is also unknown, although the introduction of highly expensive new drugs in dialysis and transplantation, new solutions in PD, new HD and PD techniques and the tendency in recent years to increase the frequency of dialysis sessions in certain patients or to implement HD sessions daily, must have led to a large increase recently.</p><p class="elsevierStylePara">Public or reference hospitals (PH) provide approximately 40% of HD services in Spain and private hospitals that provide services for patients referred from the Spanish National Health System (PCNHS) provide 60% of HD. The hospitals also take on the care costs of all patient complications, hospitalisation, the execution and maintenance of the vascular access, and the administration of erythropoietin (EPO) and other drugs for all the patients being treated.</p><p class="elsevierStylePara">Some articles have been published in Spain with interesting data and conclusions with regard to CRF treatment costs, although not with the frequency that one would expect for such a costly issue. These articles are becoming more frequent at the present time: a period of crisis and cuts in the healthcare system. In this way, 16 articles on costs have been published in <span class="elsevierStyleItalic">Nefrología</span> since 1994, three of them in the last few months.<span class="elsevierStyleSup">5-13</span></p><p class="elsevierStylePara">However, it does not seem as if this analysis has sparked much interest amongst nephrologists, as the subject of CRF treatment costs is notable for its absence in the Masters programmes, postgraduate certificate courses, general or monographic congresses or conferences, or in training for the speciality itself. Also, as Rodríguez Carmona already stated in 2007, it has hardly had any impact on our clinical practice.<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">Healthcare planners, managers and administrators do not seem to prioritise improving efficiency in CRF treatment when planning and providing resources for treating CRF. We have two examples of this in the Autonomous Community of Madrid, where they chose to increase hospital haemodialysis (HHD), which is the least efficient method, creating macro-units in new hospitals. Another example is the differences in the rates for the same service in the agreements with private hospitals in the different Autonomous Communities. These differences can exceed 45% between some communities.</p><p class="elsevierStylePara">Analysis carried out on cost articles published and reports prepared by the Evaluation Agencies in Spain<span class="elsevierStyleSup">14,15</span> highlights how difficult it is to draw conclusions from studies based on theoretical models with different cost allocation regimes and methodologies. Furthermore, many of them are estimates, and/or studies that base their data and calculations on those provided in previous publications, some of which are old and/or are based on consultancy databases or the rates of the Autonomous Communities, which are not actual costs.</p><p class="elsevierStylePara">Meanwhile, although these are not actual costs, the studies comparing different techniques, especially in PD and HD outsourced to private hospitals, which have known rates justifying a large part of their costs, do seem to be more valuable. HHD is the hardest method to analyse given that each department and unit is managed separately, the number and type of techniques used and the different structural costs.</p><p class="elsevierStylePara">Considering the above mentioned limitations, the following deductions can be made from analysing articles and reports published in Spain, especially in the last few years, and the data of some publications from other countries<span class="elsevierStyleSup">16,17</span>:</p><p class="elsevierStylePara">KT is the most efficient therapeutic option and the cheapest from the second year. Furthermore, it offers the patients a higher quality of life. It is necessary to update the costs of some very old studies in Spain<span class="elsevierStyleSup">18-20 </span>due to the use of new immunosuppressive drugs with very high costs, the results with the current type of donations and the need to use other drugs in many patients, such as EPO and antiviral drugs. It is crucial that the actual costs of KT are known in the country where the transplants are performed so that the results and efficiency of the different transplant teams can be compared and resources optimised, among other reasons.</p><p class="elsevierStylePara">PD, in any of its forms, is a more economical therapeutic option than HHD.<span class="elsevierStyleSup">3,4</span> PD costs less than HD outsourced to a private hospital, according to current rates; however, it may have a higher cost in automatic peritoneal dialysis (APD) and when special, more expensive liquids are used for the exchanges. Moreover, these regimes are becoming increasingly more wide-spread in daily medical practice.</p><p class="elsevierStylePara">With regard to the costs of HD, HHD is the most expensive treatment method. It costs between 25% and 48% more than the rate for HD outsourced to private centres, according to different studies.<span class="elsevierStyleSup">2-4</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">COMPARING AND ANALYSING THE COSTS OF HAEMODIALYSIS</span></p><p class="elsevierStylePara">The publication of the study by Parra Moncasi and other members of the Quality Management Group of the Spanish Society of Nephrology (S.E.N.) in this issue of the Journal,<span class="elsevierStyleSup">21</span> which is the reason for this Editorial comment, provides new interesting data on the costs of HD. It is a pioneering, prospective and descriptive study that was financed by public funds. It analysed for the first time in Spain the actual costs allocated using analytical accounting in six hospitals (two PH and four PCNHS).</p><p class="elsevierStylePara">The article shows, in contrast to what had been previously thought in other publications,<span class="elsevierStyleSup">5 </span>that there were no significant differences in age, time on dialysis, Charlson comorbidity index or dialysis techniques between the PH and the PCNHS. Clinical results and quality indicators were not analysed, which according to the authors will be looked at in a later study, although we can assume that they will be analysed in a similar way. It is worth remembering that a lot more PCNHS have external quality accreditation than PH do in Spain.</p><p class="elsevierStylePara">With the limitations that the authors themselves recognise, the study reported that the cost per session in PH was 30% higher than in PCNHS (€257 compared to €198). As the authors state, these differences are due to the higher staffing (67%) and consumables (83%) costs in PH. There are smaller differences in other items, such as drug consumption, maintenance management, etc., and others which are difficult to explain, such as the higher costs of outpatient pharmacy and transport in two of the PCNHS.</p><p class="elsevierStylePara">With regard to staffing costs, the differences are not due to higher wages in PH as shown in Table 4 of the article, which are equal or lower in overall wages as well as price per hour compared to PCNHS. They, therefore, must be explained by a less efficient organisation of the PH units and lower staff productivity rate (no. of patients seen to or sessions by each member of staff during their working day).</p><p class="elsevierStylePara">The productivity rate highlighted in the article using number of sessions/12 hours was 46% lower for doctors, 46% for nurses and 49% for nursing auxiliaries in PH. If we calculate the staff/session cost, productivity would also be lower in PH: 34% for doctors, 100% for nurses and 99% for nurse assistants.</p><p class="elsevierStylePara">These differences in productivity can be explained by the differences in the ratios of staff per patient or station between PH and PCNHS. The S.E.N., in the Guidelines for dialysis centres,<span class="elsevierStyleSup">22</span> recommends ratios of 40-50 patients per nephrologist, 4-5 stations in operation per nurse and 8-10 per nurse assistant. Some Autonomous Communities, such as the Autonomous Community of Madrid,<span class="elsevierStyleSup">23</span> have established 4 stations per nurse or 8 per nurse assistant under their legislation. This means that, in the best case scenario, we can achieve an actual ratio of 3-3.5 sessions per nurse and 6-7 sessions per nurse assistant, and 4-4.5 actual sessions per nurse and 8-9 per nurse assistant if 5 and 10 sessions are scheduled for the nurse and nurse assistant. It is impossible to improve these ratios, especially in small units, as a result of deaths, transplants, admissions and the fact that patients start on dialysis when they need it and not when there is a station free.</p><p class="elsevierStylePara">The other factor that, in our opinion, has an effect on the difference in staffing costs between the two types of hospitals is the organisation of the unit. In general, PCNHS schedule three HD sessions in a 14-15 hour day, while many PH schedule one HD session of 5 hours for a 7-hour day. Therefore, 28% of nursing staff’s day is unproductive.</p><p class="elsevierStylePara">Furthermore, with regard to staff management, the greater working flexibility in PCNHS to adapt staffing to the healthcare needs at each moment in time is, without doubt, another factor that contributed to reducing these costs in PCNHS.</p><p class="elsevierStylePara">Improving the patient or session ratios per doctor, nurse and nurse assistant, adapting the organisation of staff working hours to the needs of the unit and scheduling higher activity with short, daily or other types of dialysis between work shifts are all essential measures to improve the units’ productivity.</p><p class="elsevierStylePara">The second piece of information that is highlighted in the article is the 83% difference in the costs of consumables between the PH and PCNHS, when, as the authors stated, better prices would be expected according to the use of economies of scale. We think that this difference is even greater between the prices awarded in public tenders and the prices that can be achieved in direct negotiations. These differences may be explained by the delay in payments in Government bodies and the need to finance monitors, ultrasound scanners or other equipment for the units, which results in high financing costs and makes it impossible to manage future purchases better as a commitment has been made for a set length of time, and the introduction of new products in several protocols. Also, as De Francisco<span class="elsevierStyleSup">24</span> stated in 2004, the financing of continuous training of nephrologists by the pharmaceutical and dialysis industry must be another factor that increases the costs of consumables for PH. This financing, without a doubt, must have grown over the last few years with the rise in congresses, conferences, general, local and monographic courses of all types. The PCNHS do this on a much lower scale.</p><p class="elsevierStylePara">Lastly, the study also highlights that other costs such as equipment maintenance, management, food, waste products, etc., which make up between 12% and 14% of the total, are also 19% lower in PCNHS. This may be due to the fact that it is easier to manage simpler units and that PCNHS are more concerned with costs and controlling any type of cost.</p><p class="elsevierStylePara">We agree with Arrieta and with the authors of this study when they reported that the understanding of the costs must be used to allocate resources. However, we cannot agree with them that making savings is not the objective of cost studies. When the sustainability of CRF treatment as we know it may be compromised, establishing, controlling and reducing costs becomes a priority.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">KEY CONCEPTS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">1.</span><span class="elsevierStyleBold">            </span>Awareness of costs should always be present in the nephrologist’s clinical decisions.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">2.</span><span class="elsevierStyleBold">            </span>Establishing costs and their economic impact should be an essential aspect when making planning decisions and allocating resources.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">3.</span><span class="elsevierStyleBold">            </span>Establishing and limiting costs in all CRF treatment methods in Spain (HD, PD and KT) is a pressing need in order to maintain the healthcare model.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">4.</span><span class="elsevierStyleBold">            </span>The increase in staff productivity in public hospitals and an improved economic management of purchases are essential to be able to improve the costs of these units.</p>" "pdfFichero" => "P1-E521-S2951-A10959-EN.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Registro Español de Enfermos Renales. Informe de Diálisis y Trasplante, 2009. Página Web de la Sociedad Española de Nefrología. www.senefro.org." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "2.\u{A0}Lorenzo V,\u{A0}Perestelo I,\u{A0}Barroso M,\u{A0}Torres A, Nazco J. Evaluación económica de la hemodiálisis. Análisis de los componentes del coste basado en datos individuales. Nefrologia 2010;30(4):403-12. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20651881" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "3.\u{A0}Arrieta J. Evaluación económica del tratamiento sustitutivo renal(hemodiálisis, diálisis peritoneal y trasplante) en España. Nefrologia 2010;1(Supl Ext 1):37-47." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "4.\u{A0}Villa G,\u{A0}Rodríguez Carmona A, Fernández Ortiz L,\u{A0}Cuervo J,\u{A0}Rebollo P,\u{A0}Otero A, et al.\u{A0}Cost analysis of the Spanish renal replacement therapy programme. Nephrol Dial Tansplant 2011;0:1-6." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "5.\u{A0}Rodríguez Carmona A,\u{A0}Pérez Fontan M. Estudio de costes en diálisis. Un instrumento esencial para optimizar recursos. Nefrologia 2007;27(3):237-40. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17725443" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "6.\u{A0}Rodríguez Carmona A,\u{A0}Pérez Fontan M,\u{A0}Valdés Cañedo F. Estudio comparativo de costes de las diferente modalidades de diálisis. Nefrologia 1996;16(6):539-48." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "7.\u{A0}Hernández-Jaras H, García A, Bernat V.\u{A0}Aproximación al análisis de costes de diferentes tipos de hemodiálisis mediante unidades relativas de valor (URV). Nefrologia 2000;20(3):284-90. <a href="http://www.ncbi.nlm.nih.gov/pubmed/10917006" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "8.\u{A0}Rodríguez Carmona A,\u{A0}Castro A, Pérez Fontan M.\u{A0}Estudio económico de diálisis por el método de costes por procedimiento ajustado a protocolo clínico. Nefrologia 2007;27(3):359-69. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17725456" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Lamas J, Alonso M, Saavedra J, García-Trío G, Rionda M, Ameijeiras M. Costes de la diálisis en un hospital público: mitos y realidades. Nefrologia 2001;21(3):283-94. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11471309" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "10.\u{A0}Martín Hernández M. Análisis de los costes en nefrología. Situación actual y futuro. Nefrologia 1998;18(Supl 6):40-51." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "11.\u{A0}Conde J. Aspectos económicos y organizativos del tratamiento de la insuficiencia renal crónica. Nefrologia 1994;14(Supl 1):3-9." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "12.\u{A0}Temes JL. Coste y calidad en el tratamiento de la insuficiencia renal crónica. Nefrologia 1994;14(Supl 1):9-13." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:1 [ "itemHostRev" => array:3 [ "pii" => "S0140673602093273" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "13.\u{A0}Burgos R,\u{A0}Martín Martín J,\u{A0}Pérez del Amo MP, Arellano J,\u{A0}Pérez Romero C,\u{A0}Pozo F. Importancia del método de estimación de costes en diálisis y trasplante renal. Nefrologia 2001;21(4):86-90. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11642187" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "14.\u{A0}Estrada MD. Diálisis peritoneal en comparación con hemodiálisis en centros de diálisis: beneficios riesgo, coste y preferencia. Barcelona: Agencia de Información, Evaluación y Calidad en Salud, Servicio Catalán de la Salud; 2010." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:1 [ "itemHostRev" => array:3 [ "pii" => "S0140673604165136" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "15.\u{A0}Varela Lema L, Ruano Raviña A. Efectividad y seguridad de las diferentes variantes de hemodiálisis y hemodiafiltración. Santiago de Compostela: Servicio Galego de Saude. Axencia de Evaliacion de Tecnoloxias Sanitarias de Galicia, INF 2005/03." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "16.\u{A0}Haller M,\u{A0}Gutjahr G,\u{A0}Kramar R, Harnoncourt F,\u{A0}Oberbauer R. Cost-effectiveness analysis of renal replacement therapy in Austria. Nephrol Dial Tansplant 2011;0:1-8." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Benain JP,\u{A0} Faller B, Jaquelinet C, Barmi M, Dubois JP, Rieu P, et al.\u{A0}Cost of dialysis in France. Nephrol Ther 2007;3:96-106. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17540311" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "18.\u{A0}Aranzábal J,\u{A0}Perdigo L.\u{A0}Renal transplantation costs: an economic analysis and comparison with dialysis costs. Transplant Proc 1991;23:2574.. <a href="http://www.ncbi.nlm.nih.gov/pubmed/1926487" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 18 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "19.\u{A0}Felipe C,\u{A0}Naya M,\u{A0}Rivilla R,\u{A0}Matesanz R. Impacto económico de la incorporación de nuevos avances biotecnologicos en el tratamiento de la insuficiencia renal crónica en España (1992). Nefrologia 1994;14(Supl 1):111-7." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 19 => array:3 [ "identificador" => "bib20" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "20.\u{A0}Ortega Montoliu T,\u{A0}Ortega Suárez F. Diversos aspectos del análisis de costes en el trasplante renal. Nefrologia 2005;25(3):213-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16053001" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 20 => array:3 [ "identificador" => "bib21" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "21.\u{A0}Parra E,\u{A0}Arenas MD,\u{A0}Alonso M,\u{A0}Martínez MF,\u{A0}Gámen A,\u{A0}Rebollo P, et al., Grupo de Gestión de la calidad de la Sociedad Española de Nefrología. Nefrología 2011;31(3):299-307. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21629336" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 21 => array:3 [ "identificador" => "bib22" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "22.\u{A0}Alcalde G,\u{A0}Martín de Francisco AL,\u{A0}Fernández A,\u{A0}Conde JL. Dotación de personal para centros de hemodiálisis ambulatoria. Guías de Centros de Hemodiálisis. Nefrologia 2006;26(Supl 8):11-4. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17802665" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 22 => array:3 [ "identificador" => "bib23" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "23.\u{A0}Orden 101/2008 del 14 de febrero de la Consejería de Sanidad de la CAM. B.C.O.M n.º 50:13-28." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 23 => array:3 [ "identificador" => "bib24" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Martín de Francisco AL. El futuro del tratamiento de la enfermedad renal crónica. Nefrologia 2010;30(1):1-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20098467" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003100000003/v0_201502091638/X2013251411052044/v0_201502091638/en/main.assets" "Apartado" => array:4 [ "identificador" => "35428" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorial Comments" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003100000003/v0_201502091638/X2013251411052044/v0_201502091638/en/P1-E521-S2951-A10959-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251411052044?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 13 | 17 |
| 2024 October | 40 | 37 | 77 |
| 2024 September | 49 | 36 | 85 |
| 2024 August | 67 | 59 | 126 |
| 2024 July | 39 | 39 | 78 |
| 2024 June | 56 | 40 | 96 |
| 2024 May | 55 | 48 | 103 |
| 2024 April | 49 | 36 | 85 |
| 2024 March | 37 | 30 | 67 |
| 2024 February | 29 | 25 | 54 |
| 2024 January | 42 | 23 | 65 |
| 2023 December | 25 | 23 | 48 |
| 2023 November | 35 | 28 | 63 |
| 2023 October | 58 | 35 | 93 |
| 2023 September | 65 | 30 | 95 |
| 2023 August | 56 | 21 | 77 |
| 2023 July | 58 | 39 | 97 |
| 2023 June | 38 | 18 | 56 |
| 2023 May | 34 | 29 | 63 |
| 2023 April | 20 | 12 | 32 |
| 2023 March | 18 | 20 | 38 |
| 2023 February | 28 | 15 | 43 |
| 2023 January | 29 | 27 | 56 |
| 2022 December | 38 | 35 | 73 |
| 2022 November | 35 | 39 | 74 |
| 2022 October | 34 | 39 | 73 |
| 2022 September | 36 | 29 | 65 |
| 2022 August | 37 | 41 | 78 |
| 2022 July | 32 | 42 | 74 |
| 2022 June | 33 | 32 | 65 |
| 2022 May | 26 | 33 | 59 |
| 2022 April | 28 | 48 | 76 |
| 2022 March | 50 | 47 | 97 |
| 2022 February | 34 | 42 | 76 |
| 2022 January | 30 | 29 | 59 |
| 2021 December | 34 | 46 | 80 |
| 2021 November | 23 | 35 | 58 |
| 2021 October | 35 | 45 | 80 |
| 2021 September | 29 | 39 | 68 |
| 2021 August | 27 | 40 | 67 |
| 2021 July | 43 | 33 | 76 |
| 2021 June | 26 | 24 | 50 |
| 2021 May | 26 | 31 | 57 |
| 2021 April | 46 | 84 | 130 |
| 2021 March | 50 | 37 | 87 |
| 2021 February | 16 | 10 | 26 |
| 2021 January | 20 | 18 | 38 |
| 2020 December | 13 | 12 | 25 |
| 2020 November | 23 | 17 | 40 |
| 2020 October | 11 | 20 | 31 |
| 2020 September | 22 | 11 | 33 |
| 2020 August | 39 | 10 | 49 |
| 2020 July | 28 | 7 | 35 |
| 2020 June | 13 | 27 | 40 |
| 2020 May | 34 | 12 | 46 |
| 2020 April | 22 | 19 | 41 |
| 2020 March | 28 | 11 | 39 |
| 2020 February | 25 | 24 | 49 |
| 2020 January | 29 | 21 | 50 |
| 2019 December | 26 | 23 | 49 |
| 2019 November | 28 | 14 | 42 |
| 2019 October | 11 | 11 | 22 |
| 2019 September | 16 | 13 | 29 |
| 2019 August | 11 | 12 | 23 |
| 2019 July | 19 | 32 | 51 |
| 2019 June | 10 | 7 | 17 |
| 2019 May | 12 | 14 | 26 |
| 2019 April | 29 | 35 | 64 |
| 2019 March | 16 | 22 | 38 |
| 2019 February | 23 | 11 | 34 |
| 2019 January | 24 | 18 | 42 |
| 2018 December | 58 | 38 | 96 |
| 2018 November | 72 | 17 | 89 |
| 2018 October | 40 | 11 | 51 |
| 2018 September | 49 | 17 | 66 |
| 2018 August | 29 | 18 | 47 |
| 2018 July | 32 | 21 | 53 |
| 2018 June | 25 | 10 | 35 |
| 2018 May | 29 | 16 | 45 |
| 2018 April | 30 | 9 | 39 |
| 2018 March | 21 | 8 | 29 |
| 2018 February | 30 | 7 | 37 |
| 2018 January | 32 | 9 | 41 |
| 2017 December | 39 | 14 | 53 |
| 2017 November | 33 | 9 | 42 |
| 2017 October | 34 | 10 | 44 |
| 2017 September | 33 | 12 | 45 |
| 2017 August | 30 | 14 | 44 |
| 2017 July | 23 | 8 | 31 |
| 2017 June | 29 | 14 | 43 |
| 2017 May | 23 | 12 | 35 |
| 2017 April | 24 | 17 | 41 |
| 2017 March | 26 | 26 | 52 |
| 2017 February | 13 | 7 | 20 |
| 2017 January | 16 | 5 | 21 |
| 2016 December | 41 | 7 | 48 |
| 2016 November | 52 | 10 | 62 |
| 2016 October | 72 | 3 | 75 |
| 2016 September | 76 | 4 | 80 |
| 2016 August | 170 | 6 | 176 |
| 2016 July | 115 | 6 | 121 |
| 2016 June | 117 | 0 | 117 |
| 2016 May | 104 | 0 | 104 |
| 2016 April | 88 | 0 | 88 |
| 2016 March | 92 | 0 | 92 |
| 2016 February | 112 | 0 | 112 |
| 2016 January | 107 | 0 | 107 |
| 2015 December | 93 | 0 | 93 |
| 2015 November | 82 | 0 | 82 |
| 2015 October | 81 | 0 | 81 |
| 2015 September | 51 | 0 | 51 |
| 2015 August | 67 | 0 | 67 |
| 2015 July | 62 | 0 | 62 |
| 2015 June | 31 | 0 | 31 |
| 2015 May | 63 | 0 | 63 |
| 2015 April | 5 | 0 | 5 |
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