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    "textoCompleto" => "<p class="elsevierStylePara">Until 1970&#44; Spanish patients with advanced chronic kidney disease died inexorably&#46; Since then&#44; our health system has undergone immense development in renal replacement therapy programmes using dialysis and transplants&#44; and currently&#44; these patients can fortunately be treated with high levels of quality&#46;</p><p class="elsevierStylePara">The progressive increase in the number of patients requiring this type of treatment&#44; as well as the costs it entails&#44; has been the object of several different publications and many special issues in our <span class="elsevierStyleItalic">Nefrolog&#237;a </span>journal&#46; In 1994&#44; we put together a <span class="elsevierStyleItalic">Nefrolog&#237;a </span>supplement based on the conference on economic and organisational aspects of the treatment of chronic renal failure&#44; which took place at the summer Men&#233;ndez-Pelayo University in Santander&#46;<span class="elsevierStyleSup">1</span> Recently&#44; another special supplement was published regarding the sustainability of renal replacement therapy that has served as information for reflection on several of the socioeconomic aspects of this type of treatment&#46;<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">Finding ourselves in the midst of an economic crisis&#44; and looking towards the future&#44; what can we nephrologists do in order to ensure the continuity and equity of renal replacement therapy in Spain&#63; This is the issue that we will debate here&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">THE SUSTAINABILITY OF THE SPANISH HEALTH SYSTEM IS AT RISK</span></p><p class="elsevierStylePara">The life expectancy at birth from 2006 placed Spain as the highest country in the 15 member countries of the European Union&#44; and this came at the lowest health costs as well&#46; With a mean 81&#46;1 years life expectancy&#44; Spain is at the forefront of countries such as France&#44; Italy&#44; Sweden&#44; Austria&#44; etc&#46;&#44; and the health costs &#40;public &#43; private&#41; are only 8&#46;4&#37; of the gross domestic product &#40;GDP&#41;&#44; whereas the mean for the 15 countries of the EU is 9&#46;2&#37;&#44; with extreme values in Luxembourg &#40;7&#46;3&#37;&#41; and France &#40;11&#46;1&#37;&#41; &#40;Sources&#58; Organisation for Economic Cooperation and Development &#91;OECD&#93;&#44; the World Health Organisation &#91;WHO&#93;&#44; and <span class="elsevierStyleItalic">Instituto Nacional de Estad&#237;stica </span>&#40;National Institute of Statistics&#41;<span class="elsevierStyleItalic"> </span>&#91;<span class="elsevierStyleItalic">INE</span>&#93;&#41;&#46; However&#44; this value rose to 9&#37; for Spain in 2008&#46;</p><p class="elsevierStylePara">In the coming 10 years&#44; one in five Spanish citizens will be older than 65 years&#44; and per person health costs will range between 4 and 12 times greater than for those younger than this age&#46; The mean annual cost per capita for the year 2025 is estimated at &#8364;2192 for people younger than 65&#44; &#8364;8570 for those between the ages of 65 and 79&#44; &#8364;14 996 for those between the ages of 80 and 94&#44; and &#8364;28 479 for those older than 95 years &#40;sources&#58; <span class="elsevierStyleItalic">INE</span> &#91;2009&#93;&#44; Statistical Office of the European Communities &#91;EUROSTAT&#93;&#44; OECD&#44; and WHO&#41;&#46; Given the current growth rate&#44; health costs could double in the next 10 years&#46; In other words&#44; in 2020&#44; 50 of every &#8364;100 in public spending in the Spanish Autonomous Communities could be destined to health care&#44; as opposed to the current amount of &#8364;35&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">One of the components in this health cost is renal replacement therapy&#46; Although these patients make up only 0&#46;1&#37; of the population&#44; they consume 2&#46;5&#37; of the National Health Service &#40;NHS&#41; budget&#44; i&#46;e&#46;&#44; in spite of being a small proportion of the total population&#44; they consume a significant amount of resources&#46; This is the problem that must be resolved&#44; or at least given an in-depth analysis&#44; by health authorities and with the help of nephrologists&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RENAL REPLACEMENT THERAPY IN SPAIN</span></p><p class="elsevierStylePara">According to the most recent dialysis and transplant report from 2009&#44; from the Spanish registry of renal patients&#44; developed by the Spanish Society of Nephrology &#40;S&#46;E&#46;N&#46;&#41; and the Spanish National Transplant Organisation&#44;<span class="elsevierStyleSup">4</span> the number of new patients has stabilised since 1999&#44; with an incidence of 129 new patients per million population &#40;pmp&#41; in the year 2009&#44; as opposed to 126 pmp 10 years earlier&#46; In this group&#44; 85&#46;1&#37; of new patients are treated using haemodialysis&#44; 12&#46;1&#37; using peritoneal dialysis&#44; and 2&#46;8&#37; using renal replacement therapy and a kidney transplant before initiating<span class="elsevierStyleBold"> </span>dialysis&#46;</p><p class="elsevierStylePara">This stabilisation in the incidence of the disease has not been mirrored in the prevalence&#46; In 2001&#44; 885 patients pmp were treated using renal replacement therapy&#44; and this value increased to 1039 patients in 2009&#46; Of the patients receiving treatment&#44; 47&#46;67&#37; are on haemodialysis&#44; 47&#46;51&#37; undergo kidney transplants&#44; and 4&#46;82&#37; are on peritoneal dialysis&#46;</p><p class="elsevierStylePara">As we commented on earlier&#44; the general population being treated with dialysis and transplants is aging&#46; In the report from 2009&#44; the incidence was 169 &#40;45-64 years&#41;&#44; 390 &#40;65-74 years&#41;&#44; and 464 &#40;&#62;75 years&#41; pmp&#46;</p><p class="elsevierStylePara">For example&#44; when comparing the years of 2008 and 2009&#44; we observe a 4&#37; increase in the number of patients on peritoneal dialysis&#44; a 3&#37; increase in the number of patients on haemodialysis&#44; and a 2&#37; increase in the number of patients living with a functioning kidney transplant&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DIALYSIS TREATMENT IN SPAIN</span></p><p class="elsevierStylePara">Using public financing&#44; an offer currently exists for both public and private sectors to administer replacement therapy for chronic kidney failure in Spain&#46; According to Largo&#44; who was the assistant director for contracting health services in the Spanish Ministry of Health and Consumer Affairs&#44; it is a sector in which the public-private collaboration within the NHS has contributed efficiently to the resolution of a serious health problem&#46;<span class="elsevierStyleSup">5</span> In Spain in 2009&#44; there were 363 dialysis centres&#44; attending 21 297 patients on haemodialysis &#40;453 pmp&#41;&#46; In 2007&#44; 45&#37; of dialysis centres were owned by companies such as Fresenius&#44; FME&#44; Braun&#44; Diaverum&#44; Baxter&#44; etc&#46; Fifteen percent were managed by private centres&#44; and 40&#37; were located in public facilities&#46; Between 2005 and 2009&#44; the number of dialysis centres managed by companies increased by 3&#37;&#44; the number of private centres decreased by 3&#37;&#44; and the number of public centres increased by 19&#37;&#46;</p><p class="elsevierStylePara">The costs for dialysis in Spain during 2010 can be observed in Table 1 &#40;source&#58; Industry&#41;&#46; These prices only include treatment during the dialysis session&#44; and do not include medications&#44; which must be considered separately&#46; As we can see&#44; the cost of basic peritoneal dialysis is the lowest&#44; although the use of biocompatible supplements&#44; polyglucose&#44; and automation of the process all raise the price even above that of haemodialysis&#46; In 2010&#44; 53&#37; &#40;1237 patients&#41; were on automated peritoneal dialysis&#44; and 47&#37; &#40;1090 patients&#41; on continuous ambulatory peritoneal dialysis &#40;CAPD&#41;&#46;</p><p class="elsevierStylePara">With this in mind&#44; the presentation of peritoneal dialysis as an option must be based primarily on aspects of quality rather than costs&#44; such as the excellent techniques for starting treatment&#44; the preservation of residual kidney function&#44; patient independence&#44; nutritional freedom&#44; reduced need for medication&#44; etc&#46;</p><p class="elsevierStylePara">Even though renal replacement therapy implies costs during the first year that are similar to those of dialysis treatment &#40;including all medical costs&#41;&#44; it is the best cost-effective technique&#44; since the cost in subsequent years is only 20&#37; of this amount&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">HOW CAN THE DECISIONS OF THE NEPHROLOGIST IMPACT THIS INCREASE IN HEALTH COSTS THAT PLACES THE FUTURE OF RENAL REPLACEMENT THERAPY IN DANGER&#63;</span></p><p class="elsevierStylePara">We can list several different possibilities&#58;</p><p class="elsevierStylePara">1&#46; Increase the rate of kidney transplants&#59;</p><p class="elsevierStylePara">2&#46; Increase the percentage of patients on peritoneal dialysis&#59;</p><p class="elsevierStylePara">3&#46; An honest reflection regarding the costs and benefits of prescribing medications&#59;</p><p class="elsevierStylePara">4&#46; Integrated management contract&#59;</p><p class="elsevierStylePara">5&#46; Consider the use of non-universal dialysis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Increasing the rate of kidney transplants</span></p><p class="elsevierStylePara">The actions taken by the Spanish National Transplant Organisation&#44; consolidating the concepts already put into place by the Spanish Society of Nephrology in the development of coordinated kidney transplant programmes&#44; has elevated our country to become the leader in cadaveric kidney transplantation&#46; Currently&#44; based on the transplant and dialysis report from 2009&#44;<span class="elsevierStyleSup">4</span> 47&#37; of the patients living with renal replacement therapy do so through kidney transplants&#46;</p><p class="elsevierStylePara">The use of cadaveric kidneys probably will not surpass the current rates&#46; In 2009&#44; 2328 cadaveric kidneys were transplanted&#44; with 2225 in 2010&#46; It would be difficult to augment this level&#44; although some programmes do exist that could facilitate an increase to some degree&#44; such as implementing kidney transplants from non-heart beating donors&#44; which has produced very positive results in some Spanish health centres&#46;<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">Another possibility for increasing the number of kidney transplants is to promote living-donor transplantations&#44; which are currently on the rise in Spain&#44; although only modestly&#46; In 2001&#44; 26 kidneys were transplanted from living donors&#44; whereas this amount rose to 148 in 2009&#46;<span class="elsevierStyleSup">4</span> The majority of health centres have developed a sufficiently consolidated protocol for us to hope for a significant increase in these numbers&#44; as well as new programmes such as the cross-over kidney transplantation&#46; However&#44; we must keep in mind that only 20&#37; of patients receiving dialysis treatment are also included in waiting lists for kidney transplants&#44; and so global implementation of this type of treatment is impossible&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Increasing the percentage of patients on peritoneal dialysis</span></p><p class="elsevierStylePara">After kidney transplantation&#44; &#40;non-automated&#41; peritoneal dialysis is the most economically viable option for renal replacement therapy after the first year&#46; In spite of this&#44; only 4&#46;8&#37; of patients were receiving this type of treatment in 2009&#46; Some Autonomous Communities have reached rates as high as 25&#37;&#44; but in spite of blatant promotion of this technique &#40;in our nephrology department&#44; all patients that are to be treated with dialysis start out with a consultation for peritoneal dialysis&#41;&#44; we have not been able to increase the overall number&#46; The primary reasons for this failure are that this technique becomes considerably less effective after 2 years&#44; it is given up by tired patients&#44; is interrupted for kidney transplantation and&#44; primarily&#44; the lack of patient dedication to this technique&#46; We must also add to this list the lack of enthusiasm presented by some physicians for this technique&#44; which could increase significantly until all of Spain reaches mean values such as those from Galicia&#44; Cantabria&#44; and Basque Country&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Drug prescriptions</span></p><p class="elsevierStylePara">The concept of cost-effectiveness is still far from being universally adopted by the medical community&#44; and especially so by nephrologists&#46; The problem we deal with is not based on whether or not a drug should be financed&#44; or the financing of drugs that have demonstrated costs and benefits&#44; but rather the financing of drugs that have not demonstrated them&#46;<span class="elsevierStyleSup">7</span> A very clear example is that of phosphate binders&#46;<span class="elsevierStyleSup">8</span> The decision made by a nephrologist can imply a cost that varies between &#8364;61 &#40;calcium carbonate&#41;&#44; 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we spent many millions of Euros in Spain on non-calcium binders in order to control hyperphosphataemia&#44; even when other cheaper and more effective options were available&#46; A recent Cochrane review on phosphate binders also concluded that the most expensive compounds were no better than the cheapest ones&#46;<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara">This is simply one example&#44; and we could also discuss other concepts such as erythropoietic products&#44; vitamin D compounds&#44; etc&#46; The point is that there are many ways to reduce costs&#46; In a study from 2009 with dialysis patients&#44; the greatest economic burden was erythropoietin &#40;&#8364;22&#46;6 per patient per day&#41;&#44; approximately 68&#37; of total drug costs&#46;<span class="elsevierStyleSup">12</span> A more recent estimate from the region of Murcia<span class="elsevierStyleSup">13</span> showed that&#44; from a total cost of &#8364;197 per patient per week&#44; 34&#37; went towards phosphate binders&#44; 25&#37; was for erythropoietin&#44; 16&#37; for calcimimetics&#44; 3&#37; for iron&#44; 5&#37; for vitamin D&#44; and 16&#37; for other drugs&#46; These values have changed somewhat since then&#44; with an increase in calcimimetics and a decrease in erythropoietin&#44; and there is room for the nephrologist to manoeuvre&#44; adjusting and controlling the costs derived from prescribed medications&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Integrated management</span></p><p class="elsevierStylePara">This is a new process with as yet undemonstrated results&#44; but that initially appears to positively influence the costs of renal replacement therapy&#46; The Health Department of the region of Murcia is developing this methodology&#44; which requires tight cooperation between the company in charge of managing dialysis care and the nephrology department from the reference hospital&#46;</p><p class="elsevierStylePara">An integrated management contract would mean state-subsidised treatment with regard to&#58;</p><p class="elsevierStylePara">1&#46; Dialysis treatment of any kind &#40;haemodialysis&#44; on-line haemodiafiltration&#44; peritoneal dialysis&#44; daily haemodialysis&#41;&#44;</p><p class="elsevierStylePara">2&#46; Medications &#40;intra- and extra-dialysis&#41;&#44;</p><p class="elsevierStylePara">3&#46; Laboratory analyses&#44;</p><p class="elsevierStylePara">4&#46; Other diagnostics and tests&#44;</p><p class="elsevierStylePara">5&#46; Vascular and peritoneal access&#44;</p><p class="elsevierStylePara">6&#46; Patient transportation&#46;</p><p class="elsevierStylePara">As we have seen&#44; all types of dialysis are included in this type of integrated contract&#44; which allows the nephrology department in the reference hospital to treat the patient being limited only by the clinical characteristics and condition of the patient&#44; and keeping in mind the objectives set forth regarding quality&#46;</p><p class="elsevierStylePara">Among the benefits provided is the indication of the type of treatment&#44; a greater ease of administering home treatment when indicated&#44; which includes better clinical results and lower overall costs&#44; and an agreement that efficiency is not attained at the cost of lower quality of treatment&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DIALYSIS FOR END-STAGE PATIENTS</span></p><p class="elsevierStylePara">When dialysis programmes were started&#44; the objective was to facilitate the return of relatively healthy patients to work and society&#46; The reality is that many patients older than 75 years with advanced renal failure have three or more comorbidities and very low life expectancy&#46; The ethical issues must be approached with courage and honesty&#58; should dialysis be for everyone&#63;</p><p class="elsevierStylePara">Currently&#44; developed countries have no limitations in the application of renal replacement therapy&#46; This situation frequently implies that the suitability of treatment for each particular patient may not be adequately evaluated&#44; although it is evident that not all patients can receive the same benefits from this treatment&#46; Some studies have retrospectively analysed the survival of patients older than 75 years with stage 5 chronic kidney disease in specialised clinics for this pathology&#44; finding that the advantages provided by dialysis are substantially reduced by comorbidities in these patients&#44; and by ischaemic heart disease in particular&#46;<span class="elsevierStyleSup">14</span> The study performed by Couchoud et al<span class="elsevierStyleSup">15</span> was a truly practical assessment of this subject&#44; and using a simple grading system for comorbidity&#44; they were able to predict the short-term prognosis of patients older than 75 years starting dialysis&#46; In many of these cases&#44; conservative treatment produces equal survival and a better quality of life for the patient and his&#47;her family&#46; This is not simply a question of making renal replacement therapy sustainable&#44; but there is also an ethical issue in protecting a severely incapacitated sick person and the patient&#8217;s family from prolonged agony&#46; End-stage dialysis should be reconsidered against medical treatment without dialysis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">SUSTAINABILITY OF THE SPANISH NATIONAL HEALTH SYSTEM</span></p><p class="elsevierStylePara">All the measures that nephrologists may take to control the costs derived from renal replacement therapy will be very ineffective if not accompanied by a restructuring of our current NHS model&#46; This restructuring cannot logically be discussed in this brief editorial&#44; but the Spanish society&#44; and we especially&#44; the professionals working in the health sector&#44; must express ourselves clearly regarding the current state of affairs&#46; We will comment on just a few of these aspects&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Co-payment</span></p><p class="elsevierStylePara">Current data indicate that the rate of patients seeking medical attention in Spain is 40&#37; greater than the mean for the 15 European Union countries&#46;<span class="elsevierStyleSup">3</span> The logical consequences are a saturation of health services and an increase in expenditure&#46;</p><p class="elsevierStylePara">The <span class="elsevierStyleItalic">Comisi&#243;n de An&#225;lisis y Evaluaci&#243;n del Sistema Nacional de Salud</span> &#40;analysis and evaluation committee of the NHS&#41; &#40;Abril&#8217;s Committee&#41; from 1991 produced an excellent report elaborated by all sectors of Spanish society&#46;<span class="elsevierStyleSup">16</span> This report informed that we must adopt measures that limit the over-prescription of drugs&#46; Acknowledging that these measures would be unpopular&#44; participation in assuming these costs and compensation in other sectors such as pensions and fiscal reimbursements was recommended&#46; The rule of thumb would be participation in assuming costs&#44; except for certain groups when deemed necessary&#46; If&#44; for political reasons&#44; it were not convenient to globally implement cost participation&#44; expenditure could be analised and later reimbursements of 40&#37; could ensue&#46;</p><p class="elsevierStylePara">The majority of European countries use health care co-payment and drug payment plans &#40;Germany&#44; Belgium&#44; France&#44; Italy&#44; Portugal&#44; and Sweden&#41;&#44; although with one exception &#40;United Kingdom&#41;&#46; This idea has always been rejected in Spain with arguments of social protection and elevated management costs&#46; In our opinion&#44; it would be unlikely that a political group would assume this idea due to the impact it would have on elections&#44; but we must abandon the idea of &#8220;political opportunity&#44;&#8221; and instead adopt a concept of &#8220;social opportunity&#46;&#8221;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Government health agreement</span></p><p class="elsevierStylePara">Professor Segovia de Arana&#44; one of the main actors in developing the current excellence provided by the Spanish health system &#40;founder of the internal medicine residency programme&#41;&#44; has worked along with other very important representatives of Spanish medicine in the European Academy of Sciences and Arts to edit a <span class="elsevierStyleItalic">Libro Blanco sobre el Sistema Nacional de Salud </span>&#40;white paper on the Spanish health system&#41;&#46; They predict that if the political parties in Spain do not come to an agreement&#44; the Spanish health system as we know it will be drowned in the sustainability issues that plague it&#46;</p><p class="elsevierStylePara">On September 30<span class="elsevierStyleSup">th</span> 2010&#44; President of the House of Commons&#8217; health committee Gaspar Llamazares concluded that two years of work had been a failure in the attempt to reach a government agreement in order to safeguard the viability of the NHS&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Governmental restructuring</span></p><p class="elsevierStylePara">The debt for health products and medications on 31 December 2010 was 8&#46;739 billion Euros&#44; of which the Communities of Andalusia&#44; Valencia&#44; and Castile and Leon made up more than 35&#37;&#46; Many health care providers have to wait up to 600 days to receive payment&#44; with the greatest delays produced in the Communities of Cantabria &#40;709 days&#41;&#44; Baleares &#40;645 days&#41;&#44; and Murcia &#40;612 days&#41;&#46;<span class="elsevierStyleSup">17</span> Although some of these areas already have a disbursement centre within their territory&#44; it is surprising the frivolousness with which the concept of economies of scale is ignored&#46; Very wide ranges of prices are charged for the same product&#44; causing a rupture in the equity of the system&#46;</p><p class="elsevierStylePara">The existence of different vaccine calendars among Autonomous Communities is a clear expression of the idiocy that permeates our health system&#46; There are also different models for financing certain drugs for particular patient groups&#46; For example&#44; in Castile and Leon&#44; a decreased amount is paid for antifungal and antiviral medications in cancer patients&#59; in Extremadura&#44; the overall cost of drugs is financed when prescribed to large families and patients with chronic diseases that are younger than 14 years of age&#44; and in Valencia&#44; the full cost of treatment for tuberculosis is financed&#46;<span class="elsevierStyleSup">18</span></p><p class="elsevierStylePara">It would be logical to restructure the system in such a way that would concentrate resources&#44; make purchases cheaper&#44; pay for services on time&#44; and ensure equity in the health services provided to any Spanish citizen&#46; Currently&#44; the financing of our health system shows major differences between the Autonomous Communities&#44; with a &#8364;560 difference between the territory with the highest per capita budget &#40;Basque Country&#41; and the lowest &#40;Baleares&#41;&#46;<span class="elsevierStyleSup">18</span></p><p class="elsevierStylePara">Structural changes that involve the concept of concentration&#44; such as attempts at synergy&#44; shared diagnostic platforms &#40;both imaging and laboratory&#41;&#44; restructuring of diagnostic and therapeutic indications&#44; and improved management &#40;human resources&#44; information&#44; equipment&#44; etc&#46;&#41; could be implemented in order to save costs&#46;<span class="elsevierStyleSup">18</span></p><p class="elsevierStylePara">In our opinion&#44; a restructuring of the NHS along with a Government Agreement is necessary for ensuring sustainability&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Need for leadership</span></p><p class="elsevierStylePara">Our NHS has a general lack of leadership&#44; and this is mirrored in all of the institutions that compose it&#46; Nor does it have a governmental entity that must be answered to and that requires proper use of public resources&#44; whether centralised or autonomic&#46; For this&#44; we must have a government that ensures the sustainability of our health system&#44; and therefore&#44; of renal replacement therapy&#46; This government would have to exert political&#44; economic&#44; and knowledgeable authority for the management of national affairs&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusion</span></p><p class="elsevierStylePara">Although the nephrology service provided in Spain is cost-effective and of very high quality&#44; some measures which have been discussed here could be incorporated by nephrologists into our daily practice in order to ensure the sustainability of renal replacement therapy&#46; However&#44; our compliance with our responsibilities as vectors for health costs will be for nothing if it is not accompanied by changes in our NHS&#46; Several of these necessary changes will not come about simply due to the electoral interests of politicians&#46; Perhaps the first step we must take is to demand a global accord to ensure the sustainability of our NHS&#44; both in its social &#40;equity&#41; and economic aspects&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10933&#95;108&#95;17292&#95;en&#95;t110933&#46;jpg" class="elsevierStyleCrossRefs"><img src="10933_108_17292_en_t110933.jpg" alt="Mean dialysis costs in 2010 in Spain &#40;&#191;&#41;"></img></a></p><p class="elsevierStylePara">Table 1&#46; Mean dialysis costs in 2010 in Spain &#40;&#191;&#41;</p>"
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Sustainability and equity of renal replacement therapy in Spain
Sostenibilidad y equidad del tratamiento sustitutivo de la función renal en España
A.L.M. de Franciscoa, Angel LM de Franciscob
a Servicio de Nefrología, Hospital Presidente de la S.E.N. 2002-2008, Hospital Universitario Valdecilla. Santander, Cantabria,
b Servicio de Nefrologia, HU Valdecilla. Presidente SEN 2002-2008, Santander, Cantabria, Spain,
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    "textoCompleto" => "<p class="elsevierStylePara">Until 1970&#44; Spanish patients with advanced chronic kidney disease died inexorably&#46; Since then&#44; our health system has undergone immense development in renal replacement therapy programmes using dialysis and transplants&#44; and currently&#44; these patients can fortunately be treated with high levels of quality&#46;</p><p class="elsevierStylePara">The progressive increase in the number of patients requiring this type of treatment&#44; as well as the costs it entails&#44; has been the object of several different publications and many special issues in our <span class="elsevierStyleItalic">Nefrolog&#237;a </span>journal&#46; In 1994&#44; we put together a <span class="elsevierStyleItalic">Nefrolog&#237;a </span>supplement based on the conference on economic and organisational aspects of the treatment of chronic renal failure&#44; which took place at the summer Men&#233;ndez-Pelayo University in Santander&#46;<span class="elsevierStyleSup">1</span> Recently&#44; another special supplement was published regarding the sustainability of renal replacement therapy that has served as information for reflection on several of the socioeconomic aspects of this type of treatment&#46;<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">Finding ourselves in the midst of an economic crisis&#44; and looking towards the future&#44; what can we nephrologists do in order to ensure the continuity and equity of renal replacement therapy in Spain&#63; This is the issue that we will debate here&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">THE SUSTAINABILITY OF THE SPANISH HEALTH SYSTEM IS AT RISK</span></p><p class="elsevierStylePara">The life expectancy at birth from 2006 placed Spain as the highest country in the 15 member countries of the European Union&#44; and this came at the lowest health costs as well&#46; With a mean 81&#46;1 years life expectancy&#44; Spain is at the forefront of countries such as France&#44; Italy&#44; Sweden&#44; Austria&#44; etc&#46;&#44; and the health costs &#40;public &#43; private&#41; are only 8&#46;4&#37; of the gross domestic product &#40;GDP&#41;&#44; whereas the mean for the 15 countries of the EU is 9&#46;2&#37;&#44; with extreme values in Luxembourg &#40;7&#46;3&#37;&#41; and France &#40;11&#46;1&#37;&#41; &#40;Sources&#58; Organisation for Economic Cooperation and Development &#91;OECD&#93;&#44; the World Health Organisation &#91;WHO&#93;&#44; and <span class="elsevierStyleItalic">Instituto Nacional de Estad&#237;stica </span>&#40;National Institute of Statistics&#41;<span class="elsevierStyleItalic"> </span>&#91;<span class="elsevierStyleItalic">INE</span>&#93;&#41;&#46; However&#44; this value rose to 9&#37; for Spain in 2008&#46;</p><p class="elsevierStylePara">In the coming 10 years&#44; one in five Spanish citizens will be older than 65 years&#44; and per person health costs will range between 4 and 12 times greater than for those younger than this age&#46; The mean annual cost per capita for the year 2025 is estimated at &#8364;2192 for people younger than 65&#44; &#8364;8570 for those between the ages of 65 and 79&#44; &#8364;14 996 for those between the ages of 80 and 94&#44; and &#8364;28 479 for those older than 95 years &#40;sources&#58; <span class="elsevierStyleItalic">INE</span> &#91;2009&#93;&#44; Statistical Office of the European Communities &#91;EUROSTAT&#93;&#44; OECD&#44; and WHO&#41;&#46; Given the current growth rate&#44; health costs could double in the next 10 years&#46; In other words&#44; in 2020&#44; 50 of every &#8364;100 in public spending in the Spanish Autonomous Communities could be destined to health care&#44; as opposed to the current amount of &#8364;35&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">One of the components in this health cost is renal replacement therapy&#46; Although these patients make up only 0&#46;1&#37; of the population&#44; they consume 2&#46;5&#37; of the National Health Service &#40;NHS&#41; budget&#44; i&#46;e&#46;&#44; in spite of being a small proportion of the total population&#44; they consume a significant amount of resources&#46; This is the problem that must be resolved&#44; or at least given an in-depth analysis&#44; by health authorities and with the help of nephrologists&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RENAL REPLACEMENT THERAPY IN SPAIN</span></p><p class="elsevierStylePara">According to the most recent dialysis and transplant report from 2009&#44; from the Spanish registry of renal patients&#44; developed by the Spanish Society of Nephrology &#40;S&#46;E&#46;N&#46;&#41; and the Spanish National Transplant Organisation&#44;<span class="elsevierStyleSup">4</span> the number of new patients has stabilised since 1999&#44; with an incidence of 129 new patients per million population &#40;pmp&#41; in the year 2009&#44; as opposed to 126 pmp 10 years earlier&#46; In this group&#44; 85&#46;1&#37; of new patients are treated using haemodialysis&#44; 12&#46;1&#37; using peritoneal dialysis&#44; and 2&#46;8&#37; using renal replacement therapy and a kidney transplant before initiating<span class="elsevierStyleBold"> </span>dialysis&#46;</p><p class="elsevierStylePara">This stabilisation in the incidence of the disease has not been mirrored in the prevalence&#46; In 2001&#44; 885 patients pmp were treated using renal replacement therapy&#44; and this value increased to 1039 patients in 2009&#46; Of the patients receiving treatment&#44; 47&#46;67&#37; are on haemodialysis&#44; 47&#46;51&#37; undergo kidney transplants&#44; and 4&#46;82&#37; are on peritoneal dialysis&#46;</p><p class="elsevierStylePara">As we commented on earlier&#44; the general population being treated with dialysis and transplants is aging&#46; In the report from 2009&#44; the incidence was 169 &#40;45-64 years&#41;&#44; 390 &#40;65-74 years&#41;&#44; and 464 &#40;&#62;75 years&#41; pmp&#46;</p><p class="elsevierStylePara">For example&#44; when comparing the years of 2008 and 2009&#44; we observe a 4&#37; increase in the number of patients on peritoneal dialysis&#44; a 3&#37; increase in the number of patients on haemodialysis&#44; and a 2&#37; increase in the number of patients living with a functioning kidney transplant&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DIALYSIS TREATMENT IN SPAIN</span></p><p class="elsevierStylePara">Using public financing&#44; an offer currently exists for both public and private sectors to administer replacement therapy for chronic kidney failure in Spain&#46; According to Largo&#44; who was the assistant director for contracting health services in the Spanish Ministry of Health and Consumer Affairs&#44; it is a sector in which the public-private collaboration within the NHS has contributed efficiently to the resolution of a serious health problem&#46;<span class="elsevierStyleSup">5</span> In Spain in 2009&#44; there were 363 dialysis centres&#44; attending 21 297 patients on haemodialysis &#40;453 pmp&#41;&#46; In 2007&#44; 45&#37; of dialysis centres were owned by companies such as Fresenius&#44; FME&#44; Braun&#44; Diaverum&#44; Baxter&#44; etc&#46; Fifteen percent were managed by private centres&#44; and 40&#37; were located in public facilities&#46; Between 2005 and 2009&#44; the number of dialysis centres managed by companies increased by 3&#37;&#44; the number of private centres decreased by 3&#37;&#44; and the number of public centres increased by 19&#37;&#46;</p><p class="elsevierStylePara">The costs for dialysis in Spain during 2010 can be observed in Table 1 &#40;source&#58; Industry&#41;&#46; These prices only include treatment during the dialysis session&#44; and do not include medications&#44; which must be considered separately&#46; As we can see&#44; the cost of basic peritoneal dialysis is the lowest&#44; although the use of biocompatible supplements&#44; polyglucose&#44; and automation of the process all raise the price even above that of haemodialysis&#46; In 2010&#44; 53&#37; &#40;1237 patients&#41; were on automated peritoneal dialysis&#44; and 47&#37; &#40;1090 patients&#41; on continuous ambulatory peritoneal dialysis &#40;CAPD&#41;&#46;</p><p class="elsevierStylePara">With this in mind&#44; the presentation of peritoneal dialysis as an option must be based primarily on aspects of quality rather than costs&#44; such as the excellent techniques for starting treatment&#44; the preservation of residual kidney function&#44; patient independence&#44; nutritional freedom&#44; reduced need for medication&#44; etc&#46;</p><p class="elsevierStylePara">Even though renal replacement therapy implies costs during the first year that are similar to those of dialysis treatment &#40;including all medical costs&#41;&#44; it is the best cost-effective technique&#44; since the cost in subsequent years is only 20&#37; of this amount&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">HOW CAN THE DECISIONS OF THE NEPHROLOGIST IMPACT THIS INCREASE IN HEALTH COSTS THAT PLACES THE FUTURE OF RENAL REPLACEMENT THERAPY IN DANGER&#63;</span></p><p class="elsevierStylePara">We can list several different possibilities&#58;</p><p class="elsevierStylePara">1&#46; Increase the rate of kidney transplants&#59;</p><p class="elsevierStylePara">2&#46; Increase the percentage of patients on peritoneal dialysis&#59;</p><p class="elsevierStylePara">3&#46; An honest reflection regarding the costs and benefits of prescribing medications&#59;</p><p class="elsevierStylePara">4&#46; Integrated management contract&#59;</p><p class="elsevierStylePara">5&#46; Consider the use of non-universal dialysis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Increasing the rate of kidney transplants</span></p><p class="elsevierStylePara">The actions taken by the Spanish National Transplant Organisation&#44; consolidating the concepts already put into place by the Spanish Society of Nephrology in the development of coordinated kidney transplant programmes&#44; has elevated our country to become the leader in cadaveric kidney transplantation&#46; Currently&#44; based on the transplant and dialysis report from 2009&#44;<span class="elsevierStyleSup">4</span> 47&#37; of the patients living with renal replacement therapy do so through kidney transplants&#46;</p><p class="elsevierStylePara">The use of cadaveric kidneys probably will not surpass the current rates&#46; In 2009&#44; 2328 cadaveric kidneys were transplanted&#44; with 2225 in 2010&#46; It would be difficult to augment this level&#44; although some programmes do exist that could facilitate an increase to some degree&#44; such as implementing kidney transplants from non-heart beating donors&#44; which has produced very positive results in some Spanish health centres&#46;<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">Another possibility for increasing the number of kidney transplants is to promote living-donor transplantations&#44; which are currently on the rise in Spain&#44; although only modestly&#46; In 2001&#44; 26 kidneys were transplanted from living donors&#44; whereas this amount rose to 148 in 2009&#46;<span class="elsevierStyleSup">4</span> The majority of health centres have developed a sufficiently consolidated protocol for us to hope for a significant increase in these numbers&#44; as well as new programmes such as the cross-over kidney transplantation&#46; However&#44; we must keep in mind that only 20&#37; of patients receiving dialysis treatment are also included in waiting lists for kidney transplants&#44; and so global implementation of this type of treatment is impossible&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Increasing the percentage of patients on peritoneal dialysis</span></p><p class="elsevierStylePara">After kidney transplantation&#44; &#40;non-automated&#41; peritoneal dialysis is the most economically viable option for renal replacement therapy after the first year&#46; In spite of this&#44; only 4&#46;8&#37; of patients were receiving this type of treatment in 2009&#46; Some Autonomous Communities have reached rates as high as 25&#37;&#44; but in spite of blatant promotion of this technique &#40;in our nephrology department&#44; all patients that are to be treated with dialysis start out with a consultation for peritoneal dialysis&#41;&#44; we have not been able to increase the overall number&#46; The primary reasons for this failure are that this technique becomes considerably less effective after 2 years&#44; it is given up by tired patients&#44; is interrupted for kidney transplantation and&#44; primarily&#44; the lack of patient dedication to this technique&#46; We must also add to this list the lack of enthusiasm presented by some physicians for this technique&#44; which could increase significantly until all of Spain reaches mean values such as those from Galicia&#44; Cantabria&#44; and Basque Country&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Drug prescriptions</span></p><p class="elsevierStylePara">The concept of cost-effectiveness is still far from being universally adopted by the medical community&#44; and especially so by nephrologists&#46; The problem we deal with is not based on whether or not a drug should be financed&#44; or the financing of drugs that have demonstrated costs and benefits&#44; but rather the financing of drugs that have not demonstrated them&#46;<span class="elsevierStyleSup">7</span> A very clear example is that of phosphate binders&#46;<span class="elsevierStyleSup">8</span> The decision made by a nephrologist can imply a cost that varies between &#8364;61 &#40;calcium carbonate&#41;&#44; &#8364;219 &#40;calcium acetate&#41;&#44; &#8364;410 &#40;calcium acetate and magnesium carbonate&#41;&#44; &#8364;2178 &#40;lanthanum carbonate&#41;&#44; and &#8364;2512 &#40;Sevelamer&#41;&#46; Along with other authors&#44;<span class="elsevierStyleSup">9</span> we have defended the stance that agents based on calcium compounds should be the first choice in binders used for dialysis patients&#44; since these are the cheapest and best tolerated compounds in the treatment of hyperphosphataemia&#44; with similar results to other binders&#46; Sevelamer and lanthanum carbonate have not been shown to be superior to calcium-based products&#46; They are much more expensive and are also associated with more side effects&#46; In the absence of a clear clinical benefit proven by these compounds&#44; they should not be recommended as an initial therapy&#46; The calcium issue can be easily resolved using calcium acetate with or without magnesium carbonate &#40;this reduces the quantity of calcium with proven efficacy&#41;&#46;<span class="elsevierStyleSup">10</span> In 2008&#44; we spent many millions of Euros in Spain on non-calcium binders in order to control hyperphosphataemia&#44; even when other cheaper and more effective options were available&#46; A recent Cochrane review on phosphate binders also concluded that the most expensive compounds were no better than the cheapest ones&#46;<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara">This is simply one example&#44; and we could also discuss other concepts such as erythropoietic products&#44; vitamin D compounds&#44; etc&#46; The point is that there are many ways to reduce costs&#46; In a study from 2009 with dialysis patients&#44; the greatest economic burden was erythropoietin &#40;&#8364;22&#46;6 per patient per day&#41;&#44; approximately 68&#37; of total drug costs&#46;<span class="elsevierStyleSup">12</span> A more recent estimate from the region of Murcia<span class="elsevierStyleSup">13</span> showed that&#44; from a total cost of &#8364;197 per patient per week&#44; 34&#37; went towards phosphate binders&#44; 25&#37; was for erythropoietin&#44; 16&#37; for calcimimetics&#44; 3&#37; for iron&#44; 5&#37; for vitamin D&#44; and 16&#37; for other drugs&#46; These values have changed somewhat since then&#44; with an increase in calcimimetics and a decrease in erythropoietin&#44; and there is room for the nephrologist to manoeuvre&#44; adjusting and controlling the costs derived from prescribed medications&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Integrated management</span></p><p class="elsevierStylePara">This is a new process with as yet undemonstrated results&#44; but that initially appears to positively influence the costs of renal replacement therapy&#46; The Health Department of the region of Murcia is developing this methodology&#44; which requires tight cooperation between the company in charge of managing dialysis care and the nephrology department from the reference hospital&#46;</p><p class="elsevierStylePara">An integrated management contract would mean state-subsidised treatment with regard to&#58;</p><p class="elsevierStylePara">1&#46; Dialysis treatment of any kind &#40;haemodialysis&#44; on-line haemodiafiltration&#44; peritoneal dialysis&#44; daily haemodialysis&#41;&#44;</p><p class="elsevierStylePara">2&#46; Medications &#40;intra- and extra-dialysis&#41;&#44;</p><p class="elsevierStylePara">3&#46; Laboratory analyses&#44;</p><p class="elsevierStylePara">4&#46; Other diagnostics and tests&#44;</p><p class="elsevierStylePara">5&#46; Vascular and peritoneal access&#44;</p><p class="elsevierStylePara">6&#46; Patient transportation&#46;</p><p class="elsevierStylePara">As we have seen&#44; all types of dialysis are included in this type of integrated contract&#44; which allows the nephrology department in the reference hospital to treat the patient being limited only by the clinical characteristics and condition of the patient&#44; and keeping in mind the objectives set forth regarding quality&#46;</p><p class="elsevierStylePara">Among the benefits provided is the indication of the type of treatment&#44; a greater ease of administering home treatment when indicated&#44; which includes better clinical results and lower overall costs&#44; and an agreement that efficiency is not attained at the cost of lower quality of treatment&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DIALYSIS FOR END-STAGE PATIENTS</span></p><p class="elsevierStylePara">When dialysis programmes were started&#44; the objective was to facilitate the return of relatively healthy patients to work and society&#46; The reality is that many patients older than 75 years with advanced renal failure have three or more comorbidities and very low life expectancy&#46; The ethical issues must be approached with courage and honesty&#58; should dialysis be for everyone&#63;</p><p class="elsevierStylePara">Currently&#44; developed countries have no limitations in the application of renal replacement therapy&#46; This situation frequently implies that the suitability of treatment for each particular patient may not be adequately evaluated&#44; although it is evident that not all patients can receive the same benefits from this treatment&#46; Some studies have retrospectively analysed the survival of patients older than 75 years with stage 5 chronic kidney disease in specialised clinics for this pathology&#44; finding that the advantages provided by dialysis are substantially reduced by comorbidities in these patients&#44; and by ischaemic heart disease in particular&#46;<span class="elsevierStyleSup">14</span> The study performed by Couchoud et al<span class="elsevierStyleSup">15</span> was a truly practical assessment of this subject&#44; and using a simple grading system for comorbidity&#44; they were able to predict the short-term prognosis of patients older than 75 years starting dialysis&#46; In many of these cases&#44; conservative treatment produces equal survival and a better quality of life for the patient and his&#47;her family&#46; This is not simply a question of making renal replacement therapy sustainable&#44; but there is also an ethical issue in protecting a severely incapacitated sick person and the patient&#8217;s family from prolonged agony&#46; End-stage dialysis should be reconsidered against medical treatment without dialysis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">SUSTAINABILITY OF THE SPANISH NATIONAL HEALTH SYSTEM</span></p><p class="elsevierStylePara">All the measures that nephrologists may take to control the costs derived from renal replacement therapy will be very ineffective if not accompanied by a restructuring of our current NHS model&#46; This restructuring cannot logically be discussed in this brief editorial&#44; but the Spanish society&#44; and we especially&#44; the professionals working in the health sector&#44; must express ourselves clearly regarding the current state of affairs&#46; We will comment on just a few of these aspects&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Co-payment</span></p><p class="elsevierStylePara">Current data indicate that the rate of patients seeking medical attention in Spain is 40&#37; greater than the mean for the 15 European Union countries&#46;<span class="elsevierStyleSup">3</span> The logical consequences are a saturation of health services and an increase in expenditure&#46;</p><p class="elsevierStylePara">The <span class="elsevierStyleItalic">Comisi&#243;n de An&#225;lisis y Evaluaci&#243;n del Sistema Nacional de Salud</span> &#40;analysis and evaluation committee of the NHS&#41; &#40;Abril&#8217;s Committee&#41; from 1991 produced an excellent report elaborated by all sectors of Spanish society&#46;<span class="elsevierStyleSup">16</span> This report informed that we must adopt measures that limit the over-prescription of drugs&#46; Acknowledging that these measures would be unpopular&#44; participation in assuming these costs and compensation in other sectors such as pensions and fiscal reimbursements was recommended&#46; The rule of thumb would be participation in assuming costs&#44; except for certain groups when deemed necessary&#46; If&#44; for political reasons&#44; it were not convenient to globally implement cost participation&#44; expenditure could be analised and later reimbursements of 40&#37; could ensue&#46;</p><p class="elsevierStylePara">The majority of European countries use health care co-payment and drug payment plans &#40;Germany&#44; Belgium&#44; France&#44; Italy&#44; Portugal&#44; and Sweden&#41;&#44; although with one exception &#40;United Kingdom&#41;&#46; This idea has always been rejected in Spain with arguments of social protection and elevated management costs&#46; In our opinion&#44; it would be unlikely that a political group would assume this idea due to the impact it would have on elections&#44; but we must abandon the idea of &#8220;political opportunity&#44;&#8221; and instead adopt a concept of &#8220;social opportunity&#46;&#8221;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Government health agreement</span></p><p class="elsevierStylePara">Professor Segovia de Arana&#44; one of the main actors in developing the current excellence provided by the Spanish health system &#40;founder of the internal medicine residency programme&#41;&#44; has worked along with other very important representatives of Spanish medicine in the European Academy of Sciences and Arts to edit a <span class="elsevierStyleItalic">Libro Blanco sobre el Sistema Nacional de Salud </span>&#40;white paper on the Spanish health system&#41;&#46; They predict that if the political parties in Spain do not come to an agreement&#44; the Spanish health system as we know it will be drowned in the sustainability issues that plague it&#46;</p><p class="elsevierStylePara">On September 30<span class="elsevierStyleSup">th</span> 2010&#44; President of the House of Commons&#8217; health committee Gaspar Llamazares concluded that two years of work had been a failure in the attempt to reach a government agreement in order to safeguard the viability of the NHS&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Governmental restructuring</span></p><p class="elsevierStylePara">The debt for health products and medications on 31 December 2010 was 8&#46;739 billion Euros&#44; of which the Communities of Andalusia&#44; Valencia&#44; and Castile and Leon made up more than 35&#37;&#46; Many health care providers have to wait up to 600 days to receive payment&#44; with the greatest delays produced in the Communities of Cantabria &#40;709 days&#41;&#44; Baleares &#40;645 days&#41;&#44; and Murcia &#40;612 days&#41;&#46;<span class="elsevierStyleSup">17</span> Although some of these areas already have a disbursement centre within their territory&#44; it is surprising the frivolousness with which the concept of economies of scale is ignored&#46; Very wide ranges of prices are charged for the same product&#44; causing a rupture in the equity of the system&#46;</p><p class="elsevierStylePara">The existence of different vaccine calendars among Autonomous Communities is a clear expression of the idiocy that permeates our health system&#46; There are also different models for financing certain drugs for particular patient groups&#46; For example&#44; in Castile and Leon&#44; a decreased amount is paid for antifungal and antiviral medications in cancer patients&#59; in Extremadura&#44; the overall cost of drugs is financed when prescribed to large families and patients with chronic diseases that are younger than 14 years of age&#44; and in Valencia&#44; the full cost of treatment for tuberculosis is financed&#46;<span class="elsevierStyleSup">18</span></p><p class="elsevierStylePara">It would be logical to restructure the system in such a way that would concentrate resources&#44; make purchases cheaper&#44; pay for services on time&#44; and ensure equity in the health services provided to any Spanish citizen&#46; Currently&#44; the financing of our health system shows major differences between the Autonomous Communities&#44; with a &#8364;560 difference between the territory with the highest per capita budget &#40;Basque Country&#41; and the lowest &#40;Baleares&#41;&#46;<span class="elsevierStyleSup">18</span></p><p class="elsevierStylePara">Structural changes that involve the concept of concentration&#44; such as attempts at synergy&#44; shared diagnostic platforms &#40;both imaging and laboratory&#41;&#44; restructuring of diagnostic and therapeutic indications&#44; and improved management &#40;human resources&#44; information&#44; equipment&#44; etc&#46;&#41; could be implemented in order to save costs&#46;<span class="elsevierStyleSup">18</span></p><p class="elsevierStylePara">In our opinion&#44; a restructuring of the NHS along with a Government Agreement is necessary for ensuring sustainability&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Need for leadership</span></p><p class="elsevierStylePara">Our NHS has a general lack of leadership&#44; and this is mirrored in all of the institutions that compose it&#46; Nor does it have a governmental entity that must be answered to and that requires proper use of public resources&#44; whether centralised or autonomic&#46; For this&#44; we must have a government that ensures the sustainability of our health system&#44; and therefore&#44; of renal replacement therapy&#46; This government would have to exert political&#44; economic&#44; and knowledgeable authority for the management of national affairs&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusion</span></p><p class="elsevierStylePara">Although the nephrology service provided in Spain is cost-effective and of very high quality&#44; some measures which have been discussed here could be incorporated by nephrologists into our daily practice in order to ensure the sustainability of renal replacement therapy&#46; However&#44; our compliance with our responsibilities as vectors for health costs will be for nothing if it is not accompanied by changes in our NHS&#46; Several of these necessary changes will not come about simply due to the electoral interests of politicians&#46; Perhaps the first step we must take is to demand a global accord to ensure the sustainability of our NHS&#44; both in its social &#40;equity&#41; and economic aspects&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10933&#95;108&#95;17292&#95;en&#95;t110933&#46;jpg" class="elsevierStyleCrossRefs"><img src="10933_108_17292_en_t110933.jpg" alt="Mean dialysis costs in 2010 in Spain &#40;&#191;&#41;"></img></a></p><p class="elsevierStylePara">Table 1&#46; Mean dialysis costs in 2010 in Spain &#40;&#191;&#41;</p>"
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Article information
ISSN: 20132514
Original language: English
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?