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[Investigation into the relationship between outpatient haemodialysis centres and referring hospitals in Spain].

INTRODUCTION
To guarantee continuity and equity in the clinical assistance of patients on hemodialysis in extrahospitalary centers (EC) a close relationship and a good level of communication between them and their reference hospitals (RH) is essential. The aim of this study was to assess the present situation of this relationship in our country (Spain) so as to be able to detect improvement opportunities.


METHODS
Descriptive and transversal study using two self-report anonymous surveys: one for EC (81 questions) and one for RH (56 questions) sent by e-mail to all Spanish EC and RH registered in the Spanish Society of Nephrology.


RESULTS
We received answers from 80 EC and 30 RH. 70% of the EC were managed by multinational companies; only 16 % EC were placed in a hospital. 64% of the EC need to employ non-nephrological medical staff. Nearly 40% of the EC nephrologists also go on duty at their RH. More than three quarters of the EC nephrologists are alone during their workday. Bidirectional telephone communication is very frequent between EC and RH. Around a third of the patients sent from RH to EC arrive without current viral serology and/or without a functioning vascular access. Most of the patients sent from EC to RH bring an up-to-date complete medical report. 41,3 % of the EC answered that they were usually consulted by their RH doctor colleagues about decisions to be taken regarding their patients. Routine blood and other medical protocol tests of CE are well defined in the formal agreement with their RH in 65 % of the cases, although they can be modified by the EC through consensus with the RH in more than 50 % of the cases. 60 % of the EC can directly consult other specialists in the RH but more than 50 % need to do so through the RH nephrologist. Parenteral medication used in the ECs is mostly supplied by their RH, but a third of ECs have some limitations with uncommon or not concert-specified parenteral drugs. RHs refer that most of the vascular accesses are done in the hospital, whereas ECs say that this is true only in half of the cases. More than a third of the fistulae of predialysis patients are done in the ECs as part of their collaboration with RHs. The majority of ECs can share the decision about patients' inclusion in renal transplant waiting list. In only a fifth of the cases is there a common database between CE and RH, and less than half share common protocols or objectives. 62,5% of CEs participate with RHs in clinical trials. More than half of the dialysis private companies provide continuous training and education to their ECs personnel, either directly through the company or facilitating assistance to courses or congresses.


CONCLUSIONS
Some of the relationship aspects that appear to be clearly improvable are: CEs nephrologist solitude and their limited access to continuous training and education, an adequate referral of the patients from the RHs, CEs nephrologist's autonomy at making consultations to specialists or their limitations when asking for hospital medications. A closer relationship between CEs and RHs is of the utmost importance in guaranteeing continuity and equity in the clinical assistance of our hemodialysis patients. The creation of a debate forum would favour discussion and common resolution of such aspects.