[The value of early referral in the management of chronic kidney disease: NephroCare's eight years of interaction with general practitioners]. / L'early referral nella gestione della malattia renale cronica: l'esperienza della NephroCare di 8 anni di interazione con i medici di medicina generale.

It has been demonstrated that early diagnosis of chronic kidney disease (CKD) is important in containing the morbidity and mortality of this disease. It postpones the initiation of hemodialysis treatment and reduces the risk of complications. General practitioners (GPs) have a relevant part in this process because they are the first point of contact for persons in risk categories (e.g., diabetic and hypertensive patients). In 2002 NephroCare started a collaboration with GPs in the Italian region of Campania. This program, called Nephro Day, is aimed at screening patients with hypertension and diabetes, and identifying patients with CKD to reduce the late referral phenomenon. Meetings between GPs and Nephrocare nephrologists were held in which the etiology, pathology and risk factors associated with CKD as well as the screening options were discussed. Strong emphasis was placed on the importance of assigning CKD patients with hypertension and diabetes to 1 of the 5 stages of the DOQI guidelines. A clear positive correlation was observed between the age of diabetic and hypertensive patients and the risk of CKD. In the current situation of limited budgets and a limited number of nephrologists, the collaboration between GPs and specialists offers an unique opportunity to handle the problem of late referral, allowing timelier and more adequate treatment of patients with CKD and thus leading to substantial cost savings.

Managing complexity at dialysis service centers across Europe.

INTRODUCTION: Dialysis is probably one of the areas of medicine with more guidelines than any other. Issues such as dialysis dose are dealt with in those guidelines, and minimum values to be reached are defined. A target has to be set and reached by using a data-driven continuous quality improvement (CQI) approach. Data collection must be programmed and structured from the beginning. METHODS: Fresenius started its activities as a dialysis provider in 1996, following the merger of its dialysis business with the leading service provider in the US, National Medical Care. Currently Fresenius Medical Care's European activities involve more than 320 dialysis centers located in 15 countries and treating more than 24,000 patients. Management is based on a bi-dimensional organization where line managers can rely on international functional departments. Under this framework, the CQI techniques are applied in conjunction with benchmarking in a system driven by quality targets. In order to combine clinical governance with management targets, the Balanced ScoreCard system was selected. The Balanced ScoreCard monitors the efficiency of each dialysis center compared to an ideal model, targeting maximum possible efficiency whilst having a unique target for patient outcomes. CONCLUSION: A clear definition of targets is fundamental and activities need to be monitored and continuously improved; scientific collection of clinical data is the key.