Audit no. P/24/068/LKR
Efforts of the Minister of Health and the National Health Fund to improve access to early diagnostics of chronic kidney disease were insufficient and ineffective. Less than 20% of qualified persons took advantage of the pilot programme “Prevention 40 PLUS” which absorbed PLN 395 million. At the same time, over PLN 6 million was earmarked for the detection and treatment of chronic kidney disease, of which as much as 92% made up the costs of dialysis therapy and kidney transplants. High expenditures did not translate into quality care of patients with chronic kidney disease, though. In 2022-2024, the waiting time in nephrology outpatient clinics almost doubled. The access to kidney treatment nationwide was uneven, nephrology specialists were aging. Other problems included staff shortages and little interest in the nephrology major among young physicians.
According to estimates chronic kidney disease (CKD) is diagnosed only in 5% of patients. Experts say that approx. 80 thousand people die prematurely in Poland every year due to the diagnosis failure, which shortens the average life expectancy in Poland by over 2 years. In line with the estimated data in the Map of Health Needs the number of people suffering from chronic kidney disease in 2023 exceeded 4.5 million and in 2034 it should reach 5.2 million.
The national nephrology consultant has repeatedly pointed to low detectability of the disease by physicians: family doctors, diabetologists and cardiologists. Other problems include staff shortages among nephrology doctors and nurses and insufficient number of physicians specialising in nephrology.
More patients, longer waiting time
In 2021-2023, the number of patients with kidney failure went up by nearly 15% (from 105.6 thousand to 121 thousand persons). At the same time, the number of patients covered by outpatient specialist care in nephrology outpatient clinics and hospital nephrology wards increased by approx. 21%.
The increasing number of patients was one of the reasons why the waiting time in nephrology outpatient clinics (also for children) almost doubled in 2022-2024. For instance, in urgent cases the waiting time went up from 27 to 55 days in outpatient clinics for adults and from 40 to 70 days in children’s outpatient clinics.
Alarming data
In line with the forecasts as part of the Map of Health Needs, the number of deaths caused by chronic kidney disease in Poland in 2022–2024 was not to exceed 15 thousand. However, only in two years (2022-2023) as many as 154.5 thousand persons died for that reason. Despite the alarming data, kidney conditions were not included in the Map of Health Needs among the most burdensome health issues for the society. Challenges related to early diagnostics and care of patients with chronic kidney disease were also not included in strategic documents. In the National Transformation Plan for 2022–2026, the topic of kidney conditions was discussed only in the context of palliative and hospice care. However, the plan did not mention preventive measures to detect the disease in its early stages.
The total costs of diagnostic tests and treatment of patients with chronic kidney disease in 2021-2024 (until 30 June) exceeded PLN 6 billion, 92% of which were the costs of renal replacement therapy by means of dialysis or kidney transplant.
Aging doctors
A serious problem identified by NIK auditors was the aging staff of nephrologists. In 2021-2024, the number of nephrologists above 65 years of age increased from 14% to 20%, whereas in case of child nephrologists the percentage of elderly doctors went up from 10% to 14%. At the same time, the percentage of nephrologists of not more than 35 years old declined. In 2021, they represented 0.86% of all nephrologists and in 2024 it was only 0.48%. In the same period, the percentage of child nephrologists up to 35 years of age shrank from 3.5% to 0.8%. Efforts to prevent the progressive aging of nephrologists were ineffective.
Young doctors not interested in nephrology
The national nephrology and child nephrology consultants highlighted the issue of staff shortages and the lack of interest with these majors among medical graduates. Since 2023, the number of resident places in nephrology and child nephrology majors was increased. Due to a higher number of medical graduates it was forecasted that the number of people doing these majors will also increase. That was not the case, though. In case of nephrology approx. 22-23% places were occupied in 2023-2024, whereas as for child nephrology it was 20% and slightly above 41%, correspondingly. NIK has emphasised the need to include nephrology and child nephrology as a priority branch of medicine in the ordinance on priority branches of medicine. That was also a postulate of the national nephrology consultant.
Unequal access to treatment
The access to nephrology treatment Poland-wide was uneven. Half of nephrology wards and nearly half of nephrology outpatient clinics were located only in four provinces.
Considerable differences between provinces were also connected with the number of nephrologists and the number of patients per doctor. E.g. as for child nephrologists or doctors in the course of child nephrology specialisation, in 2024 the majority of doctors (34) provided healthcare services as part of the contract signed with the Mazowiecki Branch of the National Health Fund. At the same time, in two provincial branches of the NHF (Lubuski and Podkarpacki) not a single nephrologist provided healthcare services as part of the contract signed with the Fund.
Prevention only as part of pilot programme and coordinated care
NIK underlines that effective prevention helps reduce costs of CKD patient care. In the audited period in Poland, though, there was a shortage of programmes focused on early diagnostics of chronic kidney disease. Early detection of this condition was possible only as part of the pilot programme „Prevention 40 PLUS” and coordinated care services, including CKD diagnostics and treatment as part of the budget earmarked for coordinated care.
Coordinated care budget
This budget is earmarked for patients with diagnosed chronic conditions (e.g. chronic kidney disease) and is to facilitate access to prevention, diagnostics and treatment of specific diseases. According to the National Health Fund, “coordinated care gives numerous diagnosis and treatment opportunities in the most common diseases already at the stage of primary care. General Practitioners may refer their patients to diagnostic tests (in medically justified cases) which have been reserved for specialists to date. The treatment is based on an Individual plan of medical care and involves not only diagnostic tests but also consultations between the General Practitioner and a specialist as well as extra consultations, e.g. with a dietician. Who is it for? Coordinated care is designed for patients with diseases in the following fields: cardiology, diabetology, pulmonology, endocrinology and nephrology, the most common conditions among Polish people”.
NIK has positively evaluated providing CKD diagnostics and treatment as part of the coordinated care budget. This mechanism has made it easier to prevent, diagnose and treat chronic kidney disease. In the audited period, the number of primary care facilities providing these services went up systematically. So did the number of persons covered with CKD diagnostics and treatment as part of this budget. At the end of 2023, nearly 500 primary care facilities provided nephrology services as part of the coordinated care budget, whereas as of 30 September 2024 their number almost doubled. In the same period, the number of patients who received nephrology care soared by approx. 30% (from 95.3 thousand to 132.2 thousand persons).
Pilot programme “Prevention 40 PLUS”
The pilot programme “Prevention 40 PLUS” has been carried out since 1 July 2021. The programme was to evaluate the organisation and effectiveness of providing patients from 40 years of age with preventive diagnostics of the most common health conditions. As part of the programme patients were offered free diagnostic tests which enabled early detection of various civilisation diseases, including kidney diseases.
NIK stands in a position that the programme failed to fulfil its role as it did not help raise awareness concerning the need for early diagnostics of chronic kidney disease. The interest in the programme was low. Until 31 August 2024, less than 2 million out of 10 million people covered by health insurance, aged at least 40, took advantage of the programme. That was the case despite the fact that the approx. PLN 395 million was spent on this purpose. According to NIK insufficient promotion and education activities were the reason why the interest in the programme was so low. Since not many people enrolled in the programme, in 2024 the Ministry of Health decided to finance the so-called correction coefficients for primary care facilities which implemented the pilot programme. The mechanism was to “reward” the medical facilities which encouraged patients to have the diagnostic tests done as part of the programme.
In 2022–2024 (until 30 September), the National Health Fund transferred nearly PLN 46.5 million to medical facilities. The audit revealed that the Minister of Health provided funds for that purpose against the law.
NIK’s negative evaluation of the programme was also related to incorrect estimation of its costs and the failure to develop formal assumptions or conduct interim ratio analyses. Besides, NIK points out that the pilot programme “Prevention 40 PLUS” was not linked with obligatory examinations made as part of occupational medicine which would help enrol more people in the programme.
Recommendations
To the Minister of Health:
- take efforts to improve access to early diagnostics and care of patients with chronic kidney disease, in particular by linking the prevention programmes with occupational medicine tests;
- take action to increase the number of nephrologists and child nephrologists in the future, also consider if these specialisations should be included in the ordinance on priority branches of medicine;
- develop mechanisms to ensure contracting nephrology and child nephrology care, in the first place taking into account the regions with limited access to these services;
- conduct promotion and education activities to raise awareness of the causes and effects of chronic kidney disease and increase the number of patients covered by early diagnostics to detect this condition;
- take advantage of the experience gained while implementing the pilot programme “Prevention 40 PLUS” when providing the service “My health – health check-up of an adult” to reach the largest possible group of patients with active participation of primary care facilities in the efforts initiating the service use.
To the President of the National Health Fund:
- take promotion and education measures by the National Health Fund, correlated with the activity of the Ministry of Health to raise awareness of the causes and effects of chronic kidney disease and increase the number of patients offered with early diagnostics to detect this condition.
