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Article

Costs Analysis of Kidney Transplantation in Spain: Differences Between Regional Health Services

by
Lorena Agüero-Cobo
1,
José Luis Cobo-Sánchez
2,3,4,*,
Noelia Mancebo-Salas
5,* and
Zulema Gancedo-González
6
1
Gerencia de Atención Primaria, Servicio Cántabro de Salud, 39011 Santander, Spain
2
Innovation and Research Unit, Hospital Universitario Marqués de Valdecilla-IDIVAL, 39008 Santander, Spain
3
Immunopathology Research Group, Marqués de Valdecilla Institute for Health Research (IDIVAL), 39011 Santander, Spain
4
University Nursing School Hospital Mompía, Universidad Católica de Ávila, 39100 Santa Cruz de Bezana, Spain
5
Dirección General de Servicios Sociales, Consejería de Familia, Juventud y Política Social, Comunidad de Madrid, 28001 Madrid, Spain
6
Concejalía de Servicios Sociales, Familia, Salud, Autonomía Personal e Igualdad, Ayuntamiento de Santander, 39002 Santander, Spain
*
Authors to whom correspondence should be addressed.
Kidney Dial. 2024, 4(4), 203-213; https://doi.org/10.3390/kidneydial4040017
Submission received: 31 July 2024 / Revised: 5 October 2024 / Accepted: 21 October 2024 / Published: 24 October 2024
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Abstract

:
Background: For our society, chronic kidney disease is a major public health problem associated with high mortality, morbidity, reduced quality of life and a progressive increase in health costs. The aim of this study was to analyze and compare the current cost of kidney transplantation (KT) and kidney–pancreas transplantation (KPT) among the different Regional Health Services (RHS) in Spain. Methods: A descriptive comparative study analyzing the public prices of RHS in Spain. The Official Gazette of the different communities was consulted, where the latest available order on this type of cost was sought. A descriptive analysis was made of the stipulated cost of the KT and KPT, for each degree of severity, RHS, year of publication and cost calculation method. Mean cost and standard deviation were calculated. Results: KT prices were found for 15 of the 18 RHS (83.33%). The average cost of KT in Spain was EUR 33,926.53 ± 6950.053 (range from EUR 23,140.37 in the Canary Islands to EUR 48,205.75 in Catalonia). For KPT, costs were found for 5 of the 18 RHS (27.8%). The mean cost of KPT was EUR 65,792.38 ± 11,273.12 (ranging from EUR 49,418.81 in Navarra to EUR 78,363.20 in Andalusia). Conclusions: There is a large variability in KT and KPT costs in Spain between RHS. Our study underlines the importance of adopting standardized and updated costing methods for KT and KPT.

Graphical Abstract

1. Introduction

In terms of survival, renal transplantation is the therapeutic alternative of choice for patients with advanced chronic kidney disease, provided that the patient selection is adequate [1]. According to the 2021 report of the Spanish Registry of Renal Patients, there was an increase in renal transplants in 2021 by 9% compared to 2020 (2950 transplants—62.3 pmp vs. 2702—56.9 pmp) but without reaching the activity levels of 2017–2019 (above 3000 transplants) [2]. This reduction was due to the COVID-19 pandemic situation during 2020 [3]. Likewise, the report indicates that transplants from deceased donors in circulatory arrest have been consolidated in the last 3 years at values ≥30% of the total number of kidney transplants performed [2].
According to data from the Global Observatory on Donation and Transplantation in 2021, 92,532 kidney transplants were performed worldwide, with Spain performing 62.3 transplants per million population (pmp), ranking second after the United States [4].
Renal transplantation has been associated not only with improved patient survival and quality of life, but also with significant cost savings compared to dialysis [5]. A study by Chan et al. indicates that increasing deceased kidney donation by 5% would save $4.7 billion and gain 30,870 quality-adjusted life-years over the lifetime of an open cohort of dialysis patients on the waiting list for kidney transplantation [6].
Spain has a universal and free National Health System financed by citizens’ taxes, which is managed through 17 Regional Health Services and the National Institute of Health Management (INGESA) for the autonomous cities of Ceuta and Melilla: 96.5% of the population participates in this system, while mutual insurance with a private provider accounts for 3.5% [7]. A significant proportion of the population has double coverage, benefiting from both public healthcare and private insurance, which reflects the increasing role of private healthcare providers within the national health system [8].
Adequate decision-making is essential in renal care, as the successful implementation and continuity of treatment are vital for extending patient survival and enhancing quality of life. Additionally, renal replacement therapy places a substantial strain on limited healthcare resources; in Europe, RRT accounts for 2% of healthcare spending despite serving only 0.1% of the population, with an annual estimated cost of EUR 15 billion. Economic evaluations generally aim to predict the potential value of an intervention compared to existing practices. These assessments typically guide national-level decision-making, which then affects local policies and individual clinical choices. However, the cost-effectiveness framework often applies to an intervention at a specific stage of care for a typical patient, limiting its ability to address the complex realities faced by patients with chronic conditions like end-stage renal disease [9].
Healthcare cost estimation is a critical component of health economics, providing insights into resource allocation, budget planning and policy-making. Globally, various methodologies have been developed to estimate healthcare costs, each with distinct advantages and limitations. These include Activity-Based Costing (ABC), which allocates costs based on the activities required to deliver healthcare services, and Diagnosis-Related Group (DRG) systems, which classify hospital cases to estimate costs and allocate resources. These methodologies have been widely adopted to improve accuracy and transparency in healthcare budgeting [10]. In Spain, the healthcare system’s decentralized structure has led to the adoption of multiple costing methods across its 17 autonomous communities, complicating cost comparisons and economic evaluations. The Diagnostic-Related Groups and All Patient Refined systems (APR-DRG) are widely used in healthcare cost estimation. The APR-DRG system utilizes diagnosis and surgical procedure codes, which are collected through chart abstraction, as its primary input. Using a sophisticated multi-step algorithm, the APR-DRG grouper assigns a DRG along with two modifiers: Risk of Mortality (ROM) and Severity of Illness (SOI). SOI refers to “the degree of organ system dysfunction or physiologic instability” and is classified into four levels: minor, moderate, major and extreme. ROM represents the probability of in-hospital death, determined by factors such as secondary diagnoses, age, primary diagnosis and whether certain procedures were performed. It is important to note that ROM and SOI operate independently. For instance, a condition like acute cholecystitis may be associated with high SOI but low ROM [9,11]. This process is carried out through communication between the Regional Health Departments of the Autonomous Communities and the General Subdirectorate of Health Information and Innovation of the Ministry of Health, following certain recommendations [12]. Additionally, the use of both actual clinical costs and standardized public pricing leads to a wide variation in cost estimation practices across different regions in Spain [13]. Despite these benefits, the costs associated with kidney transplants can be substantial and vary significantly between regions. Although the initial costs of kidney transplantation are high, in the long term it proves to be more cost-effective than dialysis, particularly after the first 2–3 years [14].
In Spain, the cost of kidney and kidney–pancreas transplants varies widely across the autonomous communities, reflecting differences in cost estimation methods and healthcare management practices. This variability can hinder equitable access to transplant services and affect the overall efficiency of the health system. Standardizing cost estimation practices could enhance transparency, facilitate more accurate budgeting and ensure that all regions provide high-quality, cost-effective transplant services.
The aim of this study is to analyze and compare the costs of kidney and kidney–pancreas transplantation across the Regional Health Services of Spain’s autonomous communities, with the objective of identifying regional disparities and exploring opportunities for improving cost efficiency in transplantation practices, rather than establishing a cost threshold.

2. Materials and Methods

2.1. Study Design

A descriptive comparative study was carried out by analyzing the public prices of Regional Health Services in the Autonomous Communities of Spain and in the INGESA.

2.2. Data Source

The Official Gazette of the different communities and the National Official State Gazette for INGESA were consulted, where the latest available order on this type of cost was searched. The search engine on the website of each official gazette was used, using the keywords “public prices”, “kidney transplant” and/or “health services prices”. The searches were carried out in April 2024. The Official Gazette refers to the government-published legal and regulatory documents that include health-related orders and policies.
The stipulated cost of kidney transplantation was extracted from each Official Gazette, for each degree of severity, Regional Health Service, year of publication and cost calculation method.

2.3. Definition of Variables

The degree of severity was defined according to the characteristics of the patient, the secondary diagnoses of the episode and the procedures envisaged, and is stratified into four levels, according to the extent of the disease, the extent of the physiological decompensation or the loss of function of a system or organ: minor (severity 1), moderate (severity 2), major (severity 3) and extreme (severity 4) [15]. If the Official Gazette did not distinguish by degree of severity, the unit cost per kidney transplant was collected, assigning this cost to those with severity 1 (on the understanding that the price assigned is for the least complex kidney transplant). When the cost of the kidney-pancreas transplant was available, it was included in the analysis.

2.4. Data Analysis

Based on these data, the mean cost of kidney and kidney-pancreas transplantation was calculated as the sum of costs for each degree of severity/4 (except for those for which the degree of severity was not recorded) by the Autonomous Community and for Spain as a whole. The standard deviation was also calculated. A descriptive analysis was performed with these variables.

3. Results

3.1. Years of Publication and Methods of Analysis of Public Prices

Prices were found for 15 out of 18 Health Services (83.33%). Prices were not available for Asturias, Aragón and Extremadura. Ten out of the fifteen available prices (67.82%) were calculated using all patient refined diagnosis related groups (APR-DRG) method (Table 1). By years of publication: 2005 6.6% (n = 1), 2010 6.6% (n = 1), 2013 6.6% (n = 1), 2014 13.3% (n = 2), 2017 20% (n = 3), 2019 6.6% (n = 1), 2021 6.6% (n = 1), 2022 27.1% (n = 4), 2023 6.6% (n = 1).

3.2. Kidney Transplantation Costs

The costs in euros of kidney transplantation according to severity by Autonomous Community and mean by Autonomous Community and nationally are showed in Table 2. Andalucía [16], Castilla La Mancha [18], Castilla y León [19], Galicia [21], INGESA [22], Murcia [27] and the Valencian Community [30] did not distinguish cost by degree of severity (44.44%, n = 7). The average costs ranged from EUR 23,140.37 in the Canary Islands [24] to EUR 48,205.75 in Catalonia [20], with a national mean cost of EUR 33,926.53 ± 6950.053 euros. By degree of severity, the average costs were as follows: severity 1 EUR 28,294.94 ± 6876.68 euros, severity 2 EUR 27,563.87 ± 6808.07, severity 3 EUR 33,958.74 ± 6800.35 and severity 4 EUR 58,206.74 ± 11,443.04.

3.3. Kidney–Pancreas Transplantation Costs

Only 5 of the 18 Health Services have published their costs: Andalucía [16], Galicia [21], INGESA [22], Murcia [27] y Navarra [28] (27.8% of total). The mean cost of kidney-pancreas transplantation was EUR 65,792.38 ± 11,273.12, with a range from EUR 49,418.81 in Navarra [28] to EUR 78,363.20 in Andalucía [16] (Table 3).

4. Discussion

To our knowledge, this is the first study to analyze and compare the differences in kidney and kidney-pancreas transplantation costs between the different Regional Health Services in Spain. The analysis of kidney transplantation costs in the different Autonomous Communities of Spain has revealed considerable variability. Firstly, our results show that the mean cost of kidney transplantation in Spain is EUR 33,926.53, while the cost of kidney-pancreas transplantation is EUR 65,792.38. However, individual costs vary significantly between communities, with Catalonia having one of the highest costs and the Canary Islands one of the lowest. This finding is consistent with previous studies that have documented variations in the costs of medical procedures within decentralized health systems [13,31]. Lorenzo-Sellares et al. [13] studied the annual cost of different renal replacement therapy options, using direct healthcare costs attributable to the existence of the disease, at the University Hospital of the Canary Islands. They estimated the mean cost of kidney transplantation in the year studied at EUR 14,011 ± 10,375, and for kidney-pancreas transplantation at EUR 13,891 ± 8166. However, these costs are very similar to the cost estimated by the Canary Islands Health Service for severity 1 (EUR 14,767.51), but very far from the average cost in that community (EUR 23,140.37), calculated by APR-DRG method.
The higher costs observed in Catalonia, despite its efficiency and high volume of procedures, may be attributed to several factors beyond the number of procedures and system efficiency. One possible explanation is the complexity of the cases managed in this region, with Catalonia often handling a greater proportion of high-risk or more complicated transplant cases, which typically require longer hospital stays and more intensive care, thus increasing overall costs. Additionally, Catalonia has invested heavily in healthcare infrastructure and technology, which, while improving patient outcomes, also contributes to higher operational costs. Studies have demonstrated that regions with more advanced healthcare systems and specialized centers often report higher costs due to the use of cutting-edge medical technologies and highly specialized care protocols [32]. These factors combined could explain why Catalonia, despite its recognized efficiency, exhibits higher costs compared to other regions.
This study describes the differences in the costs of kidney transplantation in the different Autonomous Communities in Spain, according to the publications in the official bulletins issued by the different regional Health Services. The costs reflected correspond to those approved by the health system in each autonomous community, based on public estimates, and not necessarily the actual costs derived from clinical practice. This is due to the fact that the National Health System in Spain has decentralized economic management, so there are as many Health Departments as there are Autonomous Communities in Spain, 17 plus INGESA (the National Institute of Health Management is an entity dependent on the Spanish Ministry of Health that manages the public health provision of the autonomous cities of Ceuta and Melilla). Each Autonomous Community manages its Health Service, in many cases estimating the costs of each health process differently, and we must bear in mind that each Community updates public prices as it deems appropriate. To enable a meaningful comparison, we are taking into account only the Communities that calculate these costs using the APR-DRG method. According to the data published by the different Regional Health Services in their respective official bulletins, those communities that use the APR-DRG cost estimation method distinguish the costs of kidney transplantation by degrees of severity, dividing them into four levels. These data are current, taking into account that the oldest data are from Cantabria, year 2017, and the most current data are from 2023, offered by La Rioja. The difference in publication years may influence the comparisons.
The variability in costs can be attributed to several factors. Firstly, the costing methodology differs between autonomous communities. For example, the use of the APR-DRG method in some regions may provide a more accurate assessment of costs when considering patient severity [9]. In contrast, other communities use less sophisticated methods or base their calculations on historical prices, which may not accurately reflect current costs. In addition, the costing method has a significant impact on outcomes. The use of the APR-DRG method allows for a more detailed and accurate assessment of costs by considering patient severity and resources used. This contrasts with methods that do not distinguish by severity, which can lead to an underestimation or overestimation of actual costs. Variability in costing methods has been documented as a source of discrepancies in costing studies internationally [33,34].
International comparisons of kidney transplantation costs reveal significant variability across regions and countries, driven by differences in healthcare system structure, pricing methodologies and case mix. For instance, studies from the United States and Europe have shown that kidney transplantation costs can vary widely, even for similar procedures, due to differences in resource allocation, labor costs and post-operative care intensity [35,36]. In our study, we observe that certain regions in Spain spend nearly double the amount on the same procedure compared to others. These disparities can be partly explained by regional differences in cost calculation methodologies, such as the inclusion of indirect costs or the use of varied pricing models, as well as differences in the severity of the cases handled. Transplantation waiting list size and comorbidities were associated with an increase in kidney transplantation-related Organ Acquisition Cost Center cost per transplant [35]. Standardizing cost calculation methods across regions, as seen in some European countries, may help reduce these discrepancies and provide more accurate comparisons [37].
Another relevant factor is the frequency of cost updates. Some communities update their public prices more frequently, adjusting for inflation and changes in operating costs, while others may not update their tariffs regularly, resulting in significant discrepancies when comparing current costs [5]. The latest available data from the Ministry of Health of the Government of Spain indicate as reference costs for kidney transplantation severity 1 EUR 21,699.86, severity 2 EUR 23,980.21, severity 3 EUR 29,971.11 and severity 4 EUR 46,011.02 (average cost EUR 31,397.54) [38]. This report does not include the average cost for combined kidney-pancreas transplantation. According to our data, the average cost has increased by 7.5% for kidney transplantation in Spain. The report includes an average hospital stay for kidney transplantation in 2021 of 19.86 days and 18.07 days for the adjusted average stay (excluding extreme stays) [38]. This variability in hospital stay also influences the cost of this process. The length of hospital stay is almost four times longer than in the United States, where the average length of stay is 5.5 days [39]. The characteristics of the Spanish Public Health System show that the greater acceptance of older recipients with comorbidities and the increasing proportion of donors with extended criteria with a very small number of living donors may explain these differences. The early hospital readmission rate, a well-accepted metric of hospital quality, should also be considered. In a study conducted in the Autonomous Community of Madrid, these early readmissions following discharge from hospital after kidney transplantation were almost half that of the United States (15% vs. 30%) [39,40]. In addition, differences in healthcare infrastructure, operational efficiency and available resources may influence costs. Communities with highly efficient hospitals and better infrastructure may achieve lower operating costs, while those with fewer resources may face higher costs due to lower economies of scale and higher administrative expenses [41]. This is consistent with international studies that have found that differences in hospital management and efficiency are key determinants of cost variation [42,43].
Reasons for these differences also include variability in workload and volume of transplants performed. Communities with a higher volume of transplants can benefit from greater experience and efficiency, reducing costs per procedure [44]. This phenomenon has been observed in other medical settings, where a higher volume of procedures is associated with lower costs and better outcomes [34]. The limitations of our study are diverse. Firstly, it has not been possible to obtain data from all the Autonomous Communities due to the lack of publication of data from the different administrations. Secondly, it has not been possible in all cases to use completely homogeneous allocation criteria due to the fact that some centers present a cost calculation under different criteria.
According to data from the Ministry of Health, as of 2023, Spain has 13 authorized centers (in 9 autonomous communities) with an active pancreas transplant program, which also perform combined kidney-pancreas transplants: Andalusia (2 centers), Canary Islands (1 center), Cantabria (1 center), Castilla y León (1 center), Catalonia (2 centers), Valencian Community (1 center), Galicia (2 centers), Madrid (2 centers) and the Region of Murcia (1 center) [45]. In our review, we only found available cost data for kidney-pancreas transplants in five health services: Andalusia, Galicia, Murcia, Navarra and INGESA. However, the other four health services have published the cost of pancreas transplants and have active kidney-pancreas transplant programs [46]. It is possible that the cost of kidney-pancreas transplants has not been published in some regions due to variations in how the data are reported, or because this information is included within broader transplant cost reports.
Finally, we understand that the need to resort to an estimated average cost to determine the costs of kidney transplantation in Spain constitutes a serious limitation for discriminating costs between different centers, since this system tends to equalize them, so we have preferred to use them only for the purpose of assessing overall costs.
Based on the results presented, the first point to note is that since kidney transplantation is a technique with a mean cost in Spain of EUR 33,926.53, the different administrations should guarantee this therapy and bring its costs and calculations closer to the national mean, analyzing and threshing why there is such a difference between some communities and others, ensuring users a good quality and guarantee of the process and that professionals have at their disposal all the necessary means for it to function properly.

5. Conclusions

In conclusion, our study underlines the importance of adopting standardized and updated methods for cost calculation in kidney transplantation. Standardization would allow a more accurate comparison between communities and improve the transparency and efficiency of the healthcare system. Furthermore, it is essential to consider not only direct costs, but also indirect and non-health costs for a comprehensive evaluation. Future studies should focus on developing and applying homogeneous costing methodologies and assessing the impact of different management practices on the costs of kidney transplantation.

Author Contributions

L.A.-C., J.L.C.-S., N.M.-S. and Z.G.-G. contributed to study conceptualization, study design, data curation, formal analysis, investigation, methodology, project administration, funding acquisition, validation, visualization and writing of the original draft. L.A.-C. and J.L.C.-S. contributed to data curation and data collection. L.A.-C., J.L.C.-S., N.M.-S. and Z.G.-G. contributed to reviewing and editing of the manuscript. L.A.-C., J.L.C.-S., N.M.-S. and Z.G.-G. read and approved the final version of the manuscript, had full access to all the data in the study and had final responsibility for the decision to submit for publication. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Data derived from public domain resources.

Conflicts of Interest

The authors declare no conflicts of interest.

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Table 1. Methods of analysis of public prices of Regional Health Services in Spain, used by the different Autonomous Communities and INGESA.
Table 1. Methods of analysis of public prices of Regional Health Services in Spain, used by the different Autonomous Communities and INGESA.
Autonomous CommunityYear of Publication in the Official GazetteCost Analysis Method
Andalucía [16]2005Cost price
AragónNANA
Principality of AsturiasNANA
Cantabria [17]2017APR-DRG
Castilla La Mancha [18]2014Cost price
Castilla-León [19]2010NA
Catalonia [20]2022APR-DRG
ExtremaduraNANA
Galicia [21]2014Real Cost
INGESA [22]2013APR-DRG
Balearic Islands [23]2021APR-DRG
Canary Islands [24]2022APR-DRG
La Rioja [25]2023APR-DRG
Madrid [26]2017APR-DRG
Murcia [27]2022APR-DRG
Navarre [28]2019APR-DRG
Basque Country [29]2022APR-DRG
Valencian Community [30]2017Actual costs
Abbreviations: NA: Not available. INGESA: National Institute of Health Management. APR-DRG: all patient refined diagnosis related groups.
Table 2. Cost in euros of kidney transplantation according to severity by Autonomous Community and mean by Autonomous Community and nationally.
Table 2. Cost in euros of kidney transplantation according to severity by Autonomous Community and mean by Autonomous Community and nationally.
Autonomous CommunityYear of Publication in the Official GazetteSeverity 1Severity 2Severity 3Severity 4MeanStandard Deviation
Andalucía [16]2005EUR 39,181.4 *---EUR 39,181.4
AragónNA-----
Principality of AsturiasNA-----
Cantabria [17]2017EUR 22,196 EUR 24,592EUR 29,307EUR 50,846EUR 31,735.25±EUR 11,326.30
Castilla La Mancha [18]2014EUR 28,296.45 *---EUR 28,296.45
Castilla-León [19]2010EUR 25,368 *---EUR 25,368
Catalonia [20]2022EUR 37,687EUR 39,592EUR 44,591EUR 70,593EUR 48,205.75±EUR 13,372.96
ExtremaduraNA-----
Galicia [21]2014EUR 34,030 *---EUR 34,030
INGESA [22]2013EUR 26,446.72 *---EUR 26,446.72
Balearic Islands [23]2021EUR 27,780EUR 31,702EUR 41,902EUR 74,781EUR 44,041.25±EUR 18,481.03
Canary Islands [24]2017EUR 14,767.51EUR 17,001.99EUR 23,098.9 EUR EUR 37,693.09EUR 23,140.37±EUR 8938.23
La Rioja [25]2023EUR 26,515EUR 29,378EUR 35,011EUR 60,742EUR 37,911.5±EUR 13,530.94
Madrid [26]2017EUR 16,573EUR 18,839EUR 26,964EUR 47,806EUR 27,545.5±EUR 12,318.94
Murcia [27]2022EUR 28,199.36 *---EUR 28,199.36
Navarre [28]2019EUR 26,946EUR 29,856EUR 35,580EUR 61,730EUR 38,528±EUR 13,751.09
Basque Country [29]2022EUR 26,672EUR 29,550EUR 35,216EUR 61,099EUR 38,134.25±EUR 13,610.37
Valencian Community [30]2017EUR 32,879.25 *---EUR 32,879.25
National mean-EUR 28,294.94EUR 27,563.87EUR 33,958.74EUR 58,206.26EUR 33,926.53±EUR 12,487.73
National standard deviation-±EUR 6876.68±EUR 6808.07±EUR 6800.35±EUR 11443.04±EUR 6950.05
Abbreviations: NA: Not available, INGESA: Instituto Nacional de Gestión Sanitaria (National Institute of Health Management). * This does not include cost per severity. The unit cost per kidney transplant has been included.
Table 3. Cost in euros of kidney-pancreas transplantation by the Autonomous Community in which it was available, and national average.
Table 3. Cost in euros of kidney-pancreas transplantation by the Autonomous Community in which it was available, and national average.
Autonomous CommunityYear of Publication in the Official GazetteCost
Andalucía [16]2005EUR 78,363.20
Galicia [21]2014EUR 68,060.30
INGESA [22]2013EUR 76,633.89
Murcia [27]2022EUR 56,485.68
Navarre [28]2019EUR 49,418.81
National mean-EUR 65,792.38
National standard deviation-±EUR 11,273.12
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Agüero-Cobo, L.; Cobo-Sánchez, J.L.; Mancebo-Salas, N.; Gancedo-González, Z. Costs Analysis of Kidney Transplantation in Spain: Differences Between Regional Health Services. Kidney Dial. 2024, 4, 203-213. https://doi.org/10.3390/kidneydial4040017

AMA Style

Agüero-Cobo L, Cobo-Sánchez JL, Mancebo-Salas N, Gancedo-González Z. Costs Analysis of Kidney Transplantation in Spain: Differences Between Regional Health Services. Kidney and Dialysis. 2024; 4(4):203-213. https://doi.org/10.3390/kidneydial4040017

Chicago/Turabian Style

Agüero-Cobo, Lorena, José Luis Cobo-Sánchez, Noelia Mancebo-Salas, and Zulema Gancedo-González. 2024. "Costs Analysis of Kidney Transplantation in Spain: Differences Between Regional Health Services" Kidney and Dialysis 4, no. 4: 203-213. https://doi.org/10.3390/kidneydial4040017

APA Style

Agüero-Cobo, L., Cobo-Sánchez, J. L., Mancebo-Salas, N., & Gancedo-González, Z. (2024). Costs Analysis of Kidney Transplantation in Spain: Differences Between Regional Health Services. Kidney and Dialysis, 4(4), 203-213. https://doi.org/10.3390/kidneydial4040017

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