Transforming renal care: from reactivity to integrated public value.

Szymon Brzósko, Robert Mołdach

Diagnosis of the Supreme Audit Office

The 2025 report of the Supreme Audit Office (NIK) on the organization of care for people with chronic kidney disease (CKD) highlights the scale of the structural gaps that prevent the Polish healthcare system in this area from embarking on a trajectory of modern, planned, and proactive care [1]. NIK emphasized, in particular:

• Too low a rate of early diagnosis (a large difference between the number of people actually diagnosed and the epidemiologically estimated population),
• lack of uniform treatment pathways during the predialysis period,
• late referral to a nephrologist,
• high rates of renal replacement therapy (RRT) initiated urgently,
• excessive reliance on temporary central venous catheters (CVCs) at the start of hemodialysis,
• limited use of peritoneal dialysis (PD) as a home treatment method, and
• persistent regional differences in the availability of transplant preparation.

The report highlighted coordination deficits between primary care and nephrology, insufficient systemic patient education, fragmented digitalization (lack of interoperable, consistent clinical and administrative data streams), staffing shortages, and the lack of a coherent set of publicly reported clinical quality indicators. In the background, there remains a high burden of premature deaths and costs that could be avoided with optimal and earlier implementation of nephroprotective therapies. This is not a collection of isolated shortcomings – rather, it reflects a system focused, albeit ineffectively, on the end-stage stage of the disease, rather than on effective management of the chronic kidney disease (CKD) continuum from the early stages of the disease [1,2].

The Public Value Triangle of CKD Diagnosis and Treatment

In the context of the Supreme Audit Office (NIK) diagnosis, the Public Value approach, as conceptualized by Mark H. Moore [3], provides a methodological framework that provides direction for the transformation of the system for the diagnosis and treatment of patients with CKD. This framework spans the three corners of Moore’s strategic triangle. The first corner is created by identified, agreed-upon public value, shared by all stakeholders, beneficiaries, and also bondholders bearing the cost of the necessary transformation. The second corner is the political legitimization of public value – recognizing it as a significant socio-economic problem that deserves the financial and organizational support from state institutions necessary to achieve the assumed goals. The third corner represents the implementation capabilities of the state and stakeholders necessary to transform intentions into real actions on a scale that changes the status quo.

From this perspective, the first question that should be asked is whether the diagnosis and treatment of patients with CKD constitute a collectively valued public value. Although the clinical answer seems obvious, the Supreme Audit Office (NIK) report states:

In Poland, there were no programs or organizational standards for the care of patients with chronic kidney disease specifically aimed at early detection of this disease.

While the mere existence of appropriate CKD care programs could be considered an element of legitimization, support, and the state’s enforcement capacity, the development of organizational standards is an element of the process of identifying and agreeing on public value. If solving the problems of patients with CKD were indeed a collectively valued public value, such standards would be developed and agreed upon by stakeholder groups, including those with differing perspectives on how to address the problem. The reasons for the lack of consensus on these standards lie in the predominance of vested interests and the lack of political will to address this challenge, which constitutes what Moore calls Public Spirit—the indispensable willingness and enthusiasm of citizens or stakeholders to actively contribute to the achievement of a defined public goal.

As was to be expected, these phenomena impacted the legitimization and support of public value. The problems and limitations of early diagnosis and care for patients with CKD were not addressed in the state’s strategic documents. The Supreme Audit Office (NIK) describes this as follows.

Despite the Health Needs Maps diagnosing a problem with early CKD diagnosis and care for patients with this disease, this issue was not addressed in the national strategic documents prepared based on this Map, and organizational standards related to the care of patients with CKD were not introduced. The National Transformation Plan for 2022–2026 addresses kidney disease only in the context of palliative and hospice care, indicating that the scope of conditions eligible for treatment in this area should be expanded to include heart failure and chronic renal failure as a priority. However, it did not sufficiently address preventive measures aimed at detecting this disease in its early stages. Furthermore, kidney disease was included in the document “Healthy Future. Strategic Framework for the Development of the Healthcare System for 2021–2027, with an Outlook to 2030” under the category of other diseases important to public health.

Finał tych zdarzeń na poziomie zdolności wykonawczych państwa był na gruncie teorii Moore’a łatwy do przewidzenia. Chociaż, jak informuje raport NIK, między 2021 a 2024 rokiem liczba poradni nefrologicznych wzrosła o 10%, to średni czas oczekiwania na wizytę w poradniach: nefrologicznej oraz nefrologicznej dla dzieci w tym czasie istotnie wydłużył się, zarówno dla przypadków stabilnych, jak i pilnych. W przypadku tych ostatnich u dzieci ten czas wzrósł z 40 do 70 dni, a dorosłych 27 do 55 – to dwukrotny wzrost czasu oczekiwania. Jeżeli nałożyć na ten obraz nierównomierne rozłożenie poradni nefrologicznych, gdzie w województwie małopolskim na jedną poradnię przypadało 245 tys. mieszkańców, a w województwie łódzkim 124 tys., z jeszcze większymi dysproporcjami w zakresie leczenia nefrologicznego w oddziałach nefrologicznych, gdzie cztery województwa nie posiadały żadnego oddziału szpitalnego, możemy dostrzec, jak bardzo są ograniczone zdolności państwa realizacji polityki publicznej w zakresie diagnostyki i leczenia PChN.

Given the lack of an agreed-upon public value for CKD, competing health priorities, and limited state implementation capacity, it is hardly surprising that changes in the organization of care for patients with CKD receive only partial support from the Ministry of Health. Changing this situation requires, first, agreement on collectively valued outcomes and methods for achieving them, including support from groups not directly interested in reforming this area due to limited public funds, the costs of transformation, and the political attention that would be required to legitimize the proposed changes.

Public value is not just about improving individual clinical indicators, but also the simultaneous achievement of: (1) measurable health benefits for the CKD population (slowing down the rate of decline in renal filtration function (eGFR); reducing hospitalization rates; increasing the proportion of planned, safe RRT starts), (2) reducing regional and social inequalities, and (3) building legitimacy—that is, the acceptance and trust of stakeholders—along with establishing the operational capacity to sustainably deliver these outcomes. Expert statements emphasize that without parallel investment in legitimization (transparent data, co-creation of quality indicators that incorporate the patient’s perspective and experience) and operational efficiency and effectiveness (coordination of care for patients with CKD, data infrastructure), even the best declarations “disappear into organizational silos” devoid of real collaboration [2,4,5].

Value-Based Healthcare and Public Value

The concept of value-based healthcare (VBHC) expands this approach with precise measurement logic and a multidimensional definition of value, based on four interrelated perspectives (the so-called Quadruple Value Model). According to the EXPH report [6,7], value in VBHC is not only the relationship between clinical outcomes and costs, but a comprehensive construct encompassing: (1) personal value – providing appropriate care tailored to the patient’s individual goals and preferences, measured, among other things, by: through Patient-Reported Outcome Measures (PROMs) and Patient-Reported Experience Measures (PREMs), which emphasizes the importance of shared decision-making and avoiding unnecessary interventions; (2) technical value – achieving the best possible results with available resources for the entire group of patients with a given disease, using indicators such as Quality-Adjusted Life Years (QALYs) or Incremental Cost-Effectiveness Ratios (ICERs), in order to minimize waste and unjustified variability in clinical practices; (3) allocative value – fair distribution of resources between different patient groups and diseases, eliminating “inequity by disease” and socio-demographic disparities, assessed qualitatively at the level of social dialogue and quantitatively through budget measures and indicators of disparities in clinical outcomes; and (4) societal value – the contribution of healthcare to social cohesion, participation, and solidarity, measured, for example, through Health Impact Assessments (HIAs) and social productivity indicators, which emphasizes the role of health as a source of collective well-being.

In the context of chronic kidney disease, the value-formation cycle does not begin with the first dialysis or the entry into stage 5 of the disease, but much earlier, with established albuminuria, a persistent reduction in eGFR <60 ml/min, or an accelerated rate of decline. This requires integrated care encompassing all the discussed VBHC perspectives, from early prevention to post-diagnosis social support.

Experts aptly note that “without integrated care for this demanding disease, there is no value, only firefighting.” This reflects not only the enormous cost and clinical variability of unplanned RRT starts [6,8] but also illustrates broader disparities, such as regional differences in access to nephrology care (including key elements such as ensuring testing for kidney transplantation and adequate vascular access for dialysis), highlighted in the Supreme Audit Office report [1]. Assessing challenges and resolving issues within the four perspectives of VBHC, however, is impossible without looking through the lens of public value as conceptualized by Mark H. Moore, whose strategic triangle—comprising agreed-upon public value, political legitimacy, and implementation capacity—gives direction and crystallizes actions in the context of social solidarity.

Starting from the personal perspective of VBHC, focused on tailoring care to individual patient goals, challenges such as late referrals to nephrologists and lack of patient education require not only measurement tools such as PROMs but also the mobilization of stakeholders and the enthusiasm of co-creating standards, which are an integral element of Moore’s Public Value Chain (PVC), a method for identifying and agreeing on public value [9]. In the analyzed case, this process unfolds spontaneously at the level of dialysis centers, outpatient clinics, and nephrology departments, but not in a structured manner at the strategic level of the Ministry of Health.

From a technical perspective, focused on the efficient use of funds and resources, waste results from errors in their distribution and fragmented processes. The lack of consistent indicators and data limits the state’s corrective and enforcement capacity. The lack of objective evidence also hinders the legitimization of complex decisions within Moore’s strategic triangle [3]. For example, the directors of the National Health Fund’s provincial branches did not have data on the distance patients travel to dialysis treatments because contracts did not require providers to report such data [1]. However, if data exchange at the national level and system interoperability, along with tailored quality indicators, were ensured, it would be possible to manage the territorial distribution of dialysis facilities. Similarly, a dialogue on public value, in the spirit of Moore [3,9], could enable more precise expenditure planning and avoid situations such as the 1273% overestimation of costs in 2021 and the incorrect financing of correction factors amounting to PLN 46.5 million for 2022–2024 in the “Prevention 40 PLUS” pilot program. These issues would simply become more important and could prompt legislators to adopt solutions that reduce the risk of wasting public funds.

The allocation perspective reveals regional disparities in nephrology clinics, as described in the introduction, and opens the door to a discussion about the distribution of funds within the National Health Fund budget. However, any change in this area requires strong political legitimacy, as defined by Moore’s strategic triangle [3]. This legitimacy will not be achieved unless, at the level of social dialogue between supporters and opponents of a given solution, there is consensus on the jointly valued outcomes that constitute public value. Increasing one element of financing limits the growth of financing in other areas. In conditions of conflicting interests, the only way to reconcile opinions is to conduct a Public Value Account, without which, in such a sensitive area as health care, change will be impossible [9]. This is the only way to avoid “inequity by disease” and effectively redirect resources from palliative care to prevention, or from other areas to nephrology care.

Ultimately, the social perspective of VBHC, crucial to the European model of solidarity, cannot be assessed without tools for evaluating and improving public policies. How can we measure the contribution of renal care to social cohesion, for example, by reducing the isolation of patients with CKD through home-based peritoneal dialysis (PD) or transplant preparation [10,8], without an agreed-upon public value that engages citizens and bondholders in building legitimacy? This should be done in an iterative process, divided into stages, where the first is the identification of good problems (Good Problems), understanding their complex nature and sources, and analyzing gaps at the level of the AAA triangle – acceptance of goals (Acceptance), authorization of solutions (Authorization), and the ability to implement such a public policy (Ability) [11]. The next step should be analyzing the solution map and selecting those with the appropriate degree of feasibility and effectiveness [12]. Without such an approach, incomplete public policies most often produce fragmented and unsustainable results [13], failing to translate, as in this case, into measurable population benefits, such as slowing the decline in eGFR or reducing complications and hospitalizations [14,15], and reducing them to mere “firefighting” in organizational silos [5].

Thanks to the aforementioned set of tools [3,9,11-13], VBHC in its four dimensions becomes a comprehensive method for realizing public value. The transformation of nephrology care – from reactivity to proactivity – gains not only clinical but, above all, collective consent and legitimacy, serving to strengthen the health system’s implementation capacity. Moore’s public value lens allows for the operationalization of the VBHC approach in the social and political dimensions, highlighting the interconnectedness of these conceptual frameworks in building a sustainable health system.

Integrated and Coordinated Nephrology Care

The core of the transformation should be integrated, coordinated nephrology care – a structure with a clearly defined clinical trigger for entering the “advanced/high-risk CKD” program (e.g., eGFR <45 ml/min/1.73 m² with moderate or severe albuminuria – A2/A3; eGFR <30 ml/min/1.73 m² regardless of albuminuria; documented rapid decline in filtration; persistent A3 albuminuria despite therapy). Once this criterion is met, the patient does not “drift” between visits and specialists, but the system initiates a structured package of interventions with a predetermined sequence and standard, addressing multiple but known clinical challenges. Without such a threshold and protocolized mechanism, the system always “delays intervention” – such a diagnosis well explains why so many actions are currently undertaken only in conditions of decompensation [8,10].

The task of coordination is not to administratively “send documents,” but to manage the value stream: ensuring that all modules are launched and closed at the appropriate time. These modules include, among others: optimizing nephroprotective therapy (renin-angiotensin-aldosterone system inhibitors (RAASi); sodium-glucose cotransporter type 2 inhibitors (SGLT2i); mineralocorticoid receptor antagonists (MRA); controlling metabolic acidosis; preventing and treating hyperkalemia, and others); in the later stages of the disease, treating renal anemia according to applicable guidelines; managing mineral metabolism disorders; preparing vascular access for dialysis or qualifying for PD; early transplantation qualification; nutritional interventions; frailty assessment and psychosocial support; and systematic education with elements of shared decision-making. It is essential and invaluable to shift competencies from passive CKD surveillance to active management of its complex continuum [8,10,14,16-18].

The mechanism for creating public value is multi-layered and mutually reinforcing. First, slowing progression (maintaining full doses of nephroprotective therapies, reducing albuminuria, controlling blood pressure and acid-base balance) postpones the initiation of renal replacement therapy and reduces cardiovascular risk. Second, planned preparation for the initiation of RRT (informed choice of therapy type, planned establishment of dialysis access, transplant qualification before initiation of dialysis, and the option of family transplantation) lowers the rate of emergency initiations and reduces CVC-related infections, hospitalizations, and their complications. Third, systematic collection of PROMs (e.g., quality of life, symptom severity, fatigue, pruritus, therapy burden) increases adherence because the patient sees that their experience is being measured and adjusted. Fourth, transparent reporting with risk adjustment enables the identification of areas with the greatest gaps and the targeting of corrective actions/expenditures (targeted equity interventions) there [2,4,5,6,14].

For such a framework to be credible, a data layer is essential. The term “nervous system” used by experts reflects the role of interoperable streams: laboratory data (eGFR, albuminuria), primary care data (list of medications used, comorbidities), payer data (hospitalizations, costs, frequency of use of individual services), clinical data from nephrology centers (type of renal replacement therapy, type and status of vascular access, transplant status), and PROMs (patient-reported outcomes). These data are used to create near-real-time monitoring mechanisms – for example, an alert for accelerated eGFR decline (defined as a rate of loss >5 ml/min/1.73 m²/year) or an alert for an “incomplete predialysis module” (no documentation of transplant qualification within a specified time window). Only such an architecture allows for reliable risk segmentation – that is, systematic grouping of patients according to the predicted probability of specific events (e.g., transition to RRT within 12 months, cardiovascular hospitalization, unplanned start of dialysis). Risk segmentation is not an end in itself; its function is to allocate resource intensity (e.g., emphasis on appropriate educational elements, prior surgical consultations, prioritization of dietary interventions, etc.) to those patients for whom the marginal benefit of additional intervention is greatest [2,4,5,8,14].

Order in the Logic of Intervention

At this point, it is worth explaining several key concepts that structure clinical management and measurement reliability:

1/ Undercoding clinical complexity refers to a situation in which the full spectrum of comorbidities, risk factors, or clinical parameters is not incorporated into coding systems (e.g., failure to record cardiovascular disease, diabetes with complications, frailty syndrome). This results in distorted risk models, inappropriate adjustments to results for patient clinical complexity, and potentially unfair evaluation of centers when comparing their treatment outcomes. Underreporting—if not monitored—can also create incentives for risky management behaviors (similar to “cream skimming,” i.e., selectively favoring less clinically challenging patients with fewer comorbidities) [2].

2/ Transparent indicator specifications are publicly available documents describing for each indicator: data sources, calculation algorithm (including inclusion and exclusion criteria), definitions of numerators and denominators, follow-up period, risk adjustment principles, and interpretation constraints. Their function is threefold: (a) enabling replication (each stakeholder can independently reproduce the result), (b) limiting the scope for data manipulation, and (c) strengthening trust and legitimacy in the reporting process. Without transparent specifications, even a valid indicator can be questioned at the communication level [2,5].

3/ Risk classification – as indicated above – is the process of assigning patients to homogeneous groups (in terms of their expected clinical course) using variables such as the rate of eGFR decline (slope), albuminuria, age, cardiovascular disease, diabetes, nutritional status indicators, frailty, laboratory parameters (e.g., hemoglobin, potassium, bicarbonate), and adherence indicators. In more advanced stages of the disease, machine learning models can be used, but in the pilot phase, point scales and simple thresholds (tiering) can be the basis [8,15].

Legitimization—that is, social and institutional agreement on how resources are allocated—increases when results are presented clearly and honestly. This is facilitated by a public, understandable dashboard with key indicators and by genuinely involving patients in choosing what we measure in PROMs and what we consider important treatment outcomes for the patient. Experts point out that such a dashboard “embodies” the promise of coordination: it makes progress—or lack thereof—truly visible, instead of merely talking about it. [2,4,5]

The management model should simultaneously address four risks that often arise when implementing value systems: (a) selection of lower-risk patients (cream skimming), (b) underreporting of complexity (discussed above), (c) inflation or overload of the indicator set (leading to a dilution of priorities), and (d) erosion of trust due to a lack of transparency in methods. Countermeasures include: explicit clarification of indicator definitions; auditing of key indicators – e.g., the rate of emergency RRT starts, CVC participation by day 90 of therapy, the percentage of patients with a complete “predialysis” module; a stakeholder council (patients, clinicians, analysts, payer, social organizations), and periodic reviews of risk adjustment methods. Transparency is not a PR perk, but the “fuel of legitimization” [2,5].

Public Value Roadmap

As a result, the proposed change is not simply adding new procedures to the existing, reactive care stream, but redesigning the entire CKD continuum management cycle toward early capture of disease dynamics, planned preparation, and consistent and effective use of data. Public Value provides meaning, a social mandate, and a method for working on selected public policy; VBHC organizes the logic of measurement and comparative performance assessment; integrated coordinated care ensures day-to-day feasibility through roles (coordinator), modules (slowing down GFR decline, predialysis, planned RRT initiation, adequate access to dialysis, preemptive transplantation), and data (interoperable streams + PROMs). When these three layers converge operationally, slowing progression, reducing the need for sudden RRT initiations, increasing the use of home dialysis methods, improving patient satisfaction and safety, and reducing regional disparities will cease to be parallel ambitions – they will become mutually reinforcing elements of a single value-delivery system [2,4-6,8,10,14].

References

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