出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : The chronic kidney disease (CKD) is defined as a decreasing in renal function shown by a glomerular filtration rate (GFR) < 60 ml/min/1,73 m2 or the presence of kidney damage expressed by proteinuria or microhematuria for more than three months or the presence of histological lesions in the renal biopsy or abnormalities in imaging studies. The prevalence of CKD in Spain, reaches almost 10% of the grown population (EPIRCE study). The prevalence of CKD in the assisted population older than 18 years old in the Spanish primary care centers is 21,3%, almost 20% are in stage 3 (GFR 30-59 ml/min/1,73m) and 33,7 % are older than 70. More than 40% of the patients with CKD also suffer from high blood pressure (HBP), more than 50% dyslipidemia, 27% are diabetics and until 24% presents cardiovascular comorbidities (EUROCAP study). Description of the implemented practice : An outpatient nephrology program (ONP) has been started in order to give early attention to the chronic renal patient, as an alternative to hospital specialty exercise, to offer support to the physicians of the primary care teams (in Spanish, EAP) from “Consorci d’Atenció Primària de Salut de l’Eixample” (CAPSE) which is a public entity constituted by “Institut Català de la Salut” (ICS) and Clinic Hospital (HCP). Furthermore, another aim of this program is to contribute to the formative tasks regarding renal patients in the following Basic Health Areas (ABS): 4C (EAP Les Corts) since 2006, 2C (EAP Comte Borrell) and 2E (EAP Casanova) since 2007. A total population of 81793 adults, 20% of the older than 18 years belonging to AIS-BE (Integral Health Area of Barcelona Esquerra), all of them treated by a 57 primary care physicians team in 2013. This program used to offer a reference nephrologist for each EAP, establishing criteria for referral, consulting clinical cases and formative sessions. The consultancy was organized through the reference nephrologist by e-mail or in person involving a monthly movement of the specialist to the primary care centers. Results : This ONP has included fast consultancy, the use of clinical management applications, creation of databases of first visits and reports of discharge from external consultations. All this meant the healthcare continuation of the chronic renal patient and a better coordination between the primary care service and the nephrologists. Along 2008, the “clinical pathway of nephrology” has been designed. During 2010 the consensus document SEN-SEMFYC has been diffused, which contains the referral criteria from primary care to the specialist and a group of recommendations about renal patient in primary care ambit. In 2012 the consensus document SCN-CAMFiC-SCHTA-ACI-ACD i Departament Salut Generalitat Catalunya was published. Since 2007 a yearly update in nephrology, for primary care professionals, has been organized reaching its ninth edition in 2015. The impact of the ONP in the relationship between both healthcare levels can be seen in the table copied in this link (please copy it in your browser to see it): https://www.dropbox.com/s/k89990q8ano1a0o/16 %C3%A8. ICIC 2016 Abstract 278. Table.docx?dl=0 Discussion : The early detection and the confirmation of the CKD require monitoring by the family doctor, and the nephrologist, when it is needed. The ONP allowed us to spread the knowledge about the chronic kidney patient by the family doctor; it has facilitated the joint decision-making between different levels of care and to adjust the number of derivations. The effectiveness and efficiency of the implemented practice in CAPSE has encouraged the extension of the program to 8 EAP from AIS-BE in 2010. Conclusion : The precocity and the containment of the program bridges the gap between primary care and hospital care to respond to chronicity, aging and dependency.
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