Appendix to dialysis centre guidelines: recommendations for the relationship between outpatient haemodialysis centres and reference hospitals. Opinions from the Outpatient Dialysis Group. Grupo de Trabajo de Hemodiálisis Extrahospitalaria.

INTRODUCTION: The different clinical guidelines backed by the Spanish Society of Nephrology (SEN) attempt to homogenise the monitoring of renal patients. However, this effort to homogenise treatment has been obstructed in the case of renal replacement therapy patients on haemodialysis due to, among other reasons, the existence of several different dialysis providers, with private centres located in many cities, each with their own reference hospitals and different criteria for treatment based on the existing outsourcing services agreements with the public health service, which also differ between regions. A good relationship between a private dialysis centre and its reference hospital would lead to equal treatment for all dialysis patients, at least at that particular town. The SEN, through the efforts of the Grupo de Trabajo de Hemodiálisis Extrahospitalaria (Outpatient Haemodialysis Group), has prioritised a close relationship and good communication between reference hospitals and dialysis centres in order to guarantee proper continuity of the health care given to these patients. STRATEGIES FOR IMPROVEMENT: Conditions for referring patients from one centre to another. A patient that starts a haemodialysis programme should be referred from a reference hospital with a definitive vascular access for optimising treatment, with a full report updated within 24-48 hours before the transferral, including essential information for providing proper nephrological treatment: primary pathology, recent viral serology (including hepatitis B and C virus [HBV and HCV] and human immunodeficiency virus [HIV]), parameters for anaemia and calcium-phosphorus metabolism, and ions, date of the first session of dialysis, and the number and dates of blood transfusions received. Furthermore, patients referred from the dialysis centre to the hospital, whether for programmed visits or emergency hospitalisation, should be accompanied by an updated report indicating the primary diagnoses, recent events, viral serology and laboratory analyses, updated haemodialysis and treatment regimens used, and the reason for transferral to the hospital. A single, digital clinical history that is accessible by both institutions would facilitate this situation, although this option is not completely available to all centres and hospitals. There are also legal issues to resolve in this aspect. Continued care for dialysis patients. Good communication between dialysis centres and hospitals is fundamental for achieving a proper level of care for dialysis patients, and not only with the nephrology department. The interconsultations of dialysis patients at each private centre, as well as the requests for diagnostic tests, should be able to be requested by the centre directly. The results and reports from these interconsultations should also be sent to the centre. It would also be best if the reference hospitals and their private dialysis centres shared common treatment protocols. These protocols should include basic aspects of the treatment of renal patients (anaemia, mineral metabolism, vascular accesses including catheter infections, etc., and laboratory tests), transplant protocols, complementary tests, and other components specific to each area. Not only would this generalise and unify the approach taken with dialysis patients regardless of where they are treated, it would also facilitate access to data on all patients regarding clinical trials and research studies. Access to medication. Dialysis patients require medications that are only given in the hospital setting, which is normally provided by the reference hospital, as per the agreement between institutions. It would also be recommendable that any other medications not included in the agreement (antibiotics, urokinase, nutritional supplements, etc.) be dispensed in a similar manner. Access to kidney transplant. The management of the transplant waiting list, once a patient starts renal replacement therapy, should be controlled from the dialysis centre, as in any other procedure. As such, the nephrologists from each centre should be familiar with the existing protocols and new developments in this context, and should participate in meetings with nephrology and urology departments in each hospital. The transplant protocol at each town/region should be followed for all patients, whether dialysis is undergone in a hospital or private centre. Characteristics of the work at dialysis centres. The doctor attending patients at each dialysis centre must be a specialist in nephrology. This complicated issue must be a requirement for agreements within the regional health system in order to guarantee a proper and equitable treatment of patients that receive dialysis in private centres. Only in the case of an absence of a nephrologist should a general practitioner be used, and this doctor must have adequate training in haemodialysis. This training should also be standardised. Over 75% of nephrologists that work at these centres are alone during the workday, and 40% never see another colleague during the whole shift. The administrators of these centres should seek out protocols that provide professional contact, both with the hospital staff and nephrologists from other centres, which would facilitate an exchange of ideas. Training. The nephrologists at each centre have the right and the obligation to perform research and to continuously expand their training, so as to develop and improve health care provision. Since the majority of patients in haemodialysis programmes are treated in outpatient centres that depend on reference hospitals, we might suggest a minimal rotation of nephrology residents in private outpatient dialysis centres, once accreditation has been given for providing this training.

Service collaboration and hospital cost performance: direct and moderating effects.

BACKGROUND: Growing reliance on service provision through systems and networks creates the need to better understand the nature of the relationship between service collaboration and hospital performance and the conditions that affect this relationship. OBJECTIVE: We examine 1) the effects of service provision through health systems and health networks on hospital cost performance and 2) the moderating effects of market conditions and service differentiation on the collaboration-cost relationship. RESEARCH DESIGN: We used moderated regression analysis to test the direct and moderating effects. Data on 1368 private hospitals came from the 1998 AHA Annual Survey, Medicare Cost Reports, and Solucient. MEASURES: Service collaboration was measured as the proportion of hospital services provided at the system level and at the network level. Market conditions were measured by the levels of managed care penetration and competition in the hospital's market. RESULTS: The proportion of hospital services provided at the system level had a negative relationship with hospital cost. The relationship was curvilinear for network use. Degree of managed care penetration moderated the relationship between network-based collaboration and hospital cost. CONCLUSION: The benefits of service collaboration through systems and networks, as measured by reduced cost, depend on degree of collaboration rather than mere membership. In loosely structured collaborations such as networks, costs reduce initially but increase later as the extent of collaboration increases. The effect of network-based collaboration is also tempered by managed care penetration. These effects are not seen in more tightly integrated forms such as systems.