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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 2009&#44; the Framework Document on Managing Chronic Kidney Disease Care in Aragon was drafted by a multidisciplinary working group that comprised healthcare professionals&#44; healthcare management professionals and members of kidney patient associations &#40;ALCER Aragon&#41;&#46; A structured&#44; decentralised clinical management model was established based on grouping patients by diseases&#44; identifying opportunities for improvement and describing activities through their processes&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a> The patient and family were placed at the centre of the process map&#44; and a continuous improvement cycle was introduced&#46; Moreover&#44; a series of indicators&#8212;both technical and perceived&#8212;were monitored to periodically assess the patient&#39;s evolution&#46; This systematic and planned measurement of quality indicators&#44; together with feedback and benchmarking&#44;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a> enabled us to achieve the objectives&#46; Moreover&#44; activities that are unrelated to the final process were also taken into account&#46; These are information to patients and healthcare personnel&#44; collection of management and indicator data&#44; training of personnel and inspection of facilities&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a> In this document&#44; we evaluate the response to this intervention by means of monitoring the main indicators&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Improvement programmes centred on the following strategic plans were established at all nephrology units&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0015" class="elsevierStylePara elsevierViewall">Recovery of the patient&#39;s role in decision-making&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0020" class="elsevierStylePara elsevierViewall">Improvement of information systems&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">Designing a registry of patients undergoing renal replacement therapy in the autonomous community&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">Resolution of structural limitations&#58; installing water treatment units to obtain ultrapure water in hospitals lacking the same and renewing equipment at dialysis centres&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">Increasing the percentage of patients on special techniques&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">Improving the critical points of the care process&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Optimisation of management of patients with ACKD&#58; equity&#44; reduction in variability&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Promoting kidney transplants from living donors&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Promoting home dialysis techniques&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Promoting conservative kidney management&#46;</p></li></ul></p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">Analysing the main indicators after the development and implementation of the management process has allowed us to observe a significant improvement&#46; The various clinical&#44; nutritional&#44; analytical and evolution-related parameters in the different RRT techniques have reached similar ranges to routine nephrology practice and are even higher than the national averages in some aspects&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> A brief selection of the changes among the other indicators is reflected in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">We feel that the involvement of healthcare personnel and patients in management and the collaboration of the healthcare authorities facilitates the implementation of programmes that may improve healthcare&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a> The implementation of the above-mentioned processes was especially difficult due to being performed at the time of the economic crisis&#44; with significant financial limitations&#46; The fact that the processes performed are effective &#40;they truly improve the patients&#8217; situations&#41; and efficient &#40;they improve them with a reasonable investment and in many cases actually save money&#41; has facilitated the creation of these units and treatment techniques&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Lou Arnal LM&#44; Berni Wennekers A&#44; Gracia Garc&#237;a O&#44; Logro&#241;o Gonz&#225;lez JM&#44; Gasc&#243;n Mari&#241;o A&#44; Garc&#237;a Mena M&#44; et al&#46; Utilidad de un programa de calidad asistencial para la gesti&#243;n cl&#237;nica de las enfermedades nefrol&#243;gicas en Arag&#243;n&#46; Nefrolog&#237;a&#46; 2017&#59;37&#58;345&#8211;347&#46;</p>"
      ]
    ]
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      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">UK&#58; unknown&#46;</p>"
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                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" style="border-bottom: 2px solid black">&nbsp;\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">2010&nbsp;\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">2011&nbsp;\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">2012&nbsp;\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">2013&nbsp;\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">2014&nbsp;\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">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Patients undergoing HD with ultrapure water&#44; &#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Monitors over 10 years old&#44; &#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Patients undergoing HD with special techniques&#44; &#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">HD initiated on a scheduled basis in ACKD&#44; &#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Information on RRT modalities in ACKD&#44; &#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleItalic">Origin of RRT patients</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ACKD&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">31&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Not ACKD&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">42&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Unscheduled&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleItalic">HD initiated with definitive vascular access</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ACKD&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">76&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">81&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Not ACKD&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Unscheduled&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">eGFR at the beginning of RRT ml&#47;min&#47;1&#46;73</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">ACKD patients under conservative management&#44; &#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">UK&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">UK&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Living donor KTx&#44; &#37;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">93&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;41&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;38&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;43&#46;6&nbsp;\t\t\t\t\t\t\n
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Journal Information
Vol. 37. Issue. 3.May - June 2017
Pages 229-356
Vol. 37. Issue. 3.May - June 2017
Pages 229-356
Letter to the Editor
Open Access
The use of a quality care programme for the management of renal disease in the Aragon region
Utilidad de un programa de calidad asistencial para la gestión clínica de las enfermedades nefrológicas en Aragón
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6122
Luis Miguel Lou Arnala,
Corresponding author
lmlou@salud.aragon.es

Corresponding author.
, Ana Berni Wennekersb, Olga Gracia Garcíac, José Manuel Logroño Gonzálezd, Antonio Gascón Mariñoe, Mercedes García Menaf, Rosario Moreno Lópezg, Samia Etaaboudih, Orlando Martinsi, Angel Blasco Forcéna, José Esteban Ruiz Laiglesiab, On behalf of the Sociedad Aragonesa de Nefrología
a Servicio de Nefrología, Hospital Universitario Miguel Servet, Zaragoza, Spain
b Servicio de Nefrología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
c Servicio de Nefrología, Hospital Alcañiz, Teruel, Spain
d Servicio de Nefrología, Hospital General San Jorge, Huesca, Spain
e Servicio de Nefrología, Hospital Obispo Polanco, Teruel, Spain
f Servicio de Nefrología, Hospital San Juan de Dios, Zaragoza, Spain
g Servicio de Nefrología, Hospital de la Defensa, Zaragoza, Spain
h Servicio de Nefrología, Hospital Ernest Lluch, Calatayud, Zaragoza, Spain
i Servicio de Nefrología, Hospital de Barbastro, Barbastro, Huesca, Spain
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Table 1. Evolution of the main technical quality indicators.
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Dear Editor,

In 2009, the Framework Document on Managing Chronic Kidney Disease Care in Aragon was drafted by a multidisciplinary working group that comprised healthcare professionals, healthcare management professionals and members of kidney patient associations (ALCER Aragon). A structured, decentralised clinical management model was established based on grouping patients by diseases, identifying opportunities for improvement and describing activities through their processes.1–3 The patient and family were placed at the centre of the process map, and a continuous improvement cycle was introduced. Moreover, a series of indicators—both technical and perceived—were monitored to periodically assess the patient's evolution. This systematic and planned measurement of quality indicators, together with feedback and benchmarking,4,5 enabled us to achieve the objectives. Moreover, activities that are unrelated to the final process were also taken into account. These are information to patients and healthcare personnel, collection of management and indicator data, training of personnel and inspection of facilities.6,7 In this document, we evaluate the response to this intervention by means of monitoring the main indicators.

Improvement programmes centred on the following strategic plans were established at all nephrology units:

  • -

    Recovery of the patient's role in decision-making.

  • -

    Improvement of information systems.

  • -

    Designing a registry of patients undergoing renal replacement therapy in the autonomous community.

  • -

    Resolution of structural limitations: installing water treatment units to obtain ultrapure water in hospitals lacking the same and renewing equipment at dialysis centres.

  • -

    Increasing the percentage of patients on special techniques.

  • -

    Improving the critical points of the care process:

    • Optimisation of management of patients with ACKD: equity, reduction in variability.

    • Promoting kidney transplants from living donors.

    • Promoting home dialysis techniques.

    • Promoting conservative kidney management.

Analysing the main indicators after the development and implementation of the management process has allowed us to observe a significant improvement. The various clinical, nutritional, analytical and evolution-related parameters in the different RRT techniques have reached similar ranges to routine nephrology practice and are even higher than the national averages in some aspects.8 A brief selection of the changes among the other indicators is reflected in Table 1.

Table 1.

Evolution of the main technical quality indicators.

  2010  2011  2012  2013  2014  2015 
Patients undergoing HD with ultrapure water, %  64  62  63  68  62  100 
Monitors over 10 years old, %  36  30  25  10 
Patients undergoing HD with special techniques, %  12  16  19  18  17  22 
HD initiated on a scheduled basis in ACKD, %  –  70  82  84  86  88 
Information on RRT modalities in ACKD, %  –  90  100  100  100  100 
Origin of RRT patients
ACKD, %  –  31.4  35.6  50.8  64.4  57.4 
Not ACKD, %  –  42.7  37.3  21.1  15.6  19.2 
Unscheduled, %  –  26.6  27.1  28.1  20  23.4 
HD initiated with definitive vascular access
ACKD, %  –  76.3  85.7  65.5  75.8  81.5 
Not ACKD, %  –  26.2  36.5  75  71.4  33.3 
Unscheduled, %  –  14  27.1  28.1  20  16 
eGFR at the beginning of RRT ml/min/1.73m2  –  14  12  9.6  10  9.4 
ACKD patients under conservative management, %  UK  UK  12  16  22  20 
Living donor KTx, %  5.3  9.4  14.7  12.9  17.9  4.7 
Peritoneal dialysis, %  8.9  18.9  22.4  32.2  28.7  28.2 
Kt/V in PHD >1.3, %  32  37  34  36  46  53 
At 3 and 6 months, %  52  53  50  58  64  78 
Working peritoneal catheters per year, %  91  93  92  88  94  93 
Peritonitis per months of treatment  1/31.2  1/34.3  1/41.2  1/38.4  1/43  1/43.6 

UK: unknown.

We feel that the involvement of healthcare personnel and patients in management and the collaboration of the healthcare authorities facilitates the implementation of programmes that may improve healthcare.9,10 The implementation of the above-mentioned processes was especially difficult due to being performed at the time of the economic crisis, with significant financial limitations. The fact that the processes performed are effective (they truly improve the patients’ situations) and efficient (they improve them with a reasonable investment and in many cases actually save money) has facilitated the creation of these units and treatment techniques.

References
[1]
Sociedad Española de Nefrología.
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[2]
Sociedad Española de Nefrología.
El libro blanco de la nefrología española (II).
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[3]
Sociedad Española de Nefrología.
El libro blanco de la nefrología española (III).
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[4]
C. Kiefe, J.J. Allison, O.D. Williams, S.D. Person, M.T. Weaver, N.W. Weissman.
Improving quality improvement using achievable benchmarks for physician feedback: a randomized controlled trial.
JAMA, 285 (2001), pp. 2871-2879
[5]
M.D. Arenas, F. Álvarez-U de, A. Moledous, T. Malek, M.T. Gil, A. Soriano, et al.
¿Es posible mejorar nuestros resultados en hemodiálisis? Establecimiento de objetivos de calidad, retroalimentación (feedback) y benchmarking.
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[6]
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Changing physicians’ behavior: what works and thoughts on getting more things to work.
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[7]
H.M. Hearnshaw, R.M. Harker, F.M. Cheater, R.H. Baker, G.M. Grimshaw.
Expert consensus on the desirable characteristics of review criteria for improvement of health care quality.
Qual Health Care, 10 (2001), pp. 173-178
[8]
P. Aljama.
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[9]
J. Pascual, M. Rivera, M. Fernández, A. Tato, T. Cano, M.T. Tenorio.
Funciones del facultativo especialista de área de nefrología y su importancia en el sistema sanitario.
Nefrologia, 23 (2003), pp. 200-210
[10]
M. Santiñá, P. Arrizabalaga, A. Prat, A. Alcaraz, J.M. Campistol, A. Trilla.
Instituto de gestión clínica para las enfermedades nefrourológicas: utilidad de un programa de calidad asistencial.

Please cite this article as: Lou Arnal LM, Berni Wennekers A, Gracia García O, Logroño González JM, Gascón Mariño A, García Mena M, et al. Utilidad de un programa de calidad asistencial para la gestión clínica de las enfermedades nefrológicas en Aragón. Nefrología. 2017;37:345–347.

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