Bringing a Systems Approach to Living Donor Kidney Transplantation.
Anna Horton, Katya Loban, Peter Nugus, Marie-Chantal Fortin, Lakshman Gunaratnam, Greg Knoll, Istvan Mucsi, Prosanto Chaudhury, David Landsberg, Michel R P��quet, Marcelo Cantarovich, Shaifali Sandal
Author Information
Anna Horton: Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
Katya Loban: Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
Peter Nugus: Institute of Health Sciences Education, McGill University, McGill University, Montreal Quebec, Canada.
Marie-Chantal Fortin: Centre de recherche du Centre hospitalier de l'Universit�� de Montr��al, Montreal, Quebec, Canada.
Lakshman Gunaratnam: Matthew Mailing Centre for Translational Transplant Studies, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada.
Greg Knoll: Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
Istvan Mucsi: Ajmera Transplant Center and Division of Nephrology, University Health Network, Toronto, Ontario, Canada.
Prosanto Chaudhury: Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
David Landsberg: Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
Michel R P��quet: Centre de recherche du Centre hospitalier de l'Universit�� de Montr��al, Montreal, Quebec, Canada.
Marcelo Cantarovich: Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
Shaifali Sandal: Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
Introduction: Living donor kidney transplantation (LDKT) is the best treatment option for patients with kidney failure. Efforts to increase LDKT have focused on microlevel interventions and the need for systems thinking has been highlighted. We aimed to identify and compare health system-level attributes and processes that are facilitators and barriers to LDKT. Methods: We conducted a qualitative comparative case study analysis of 3 Canadian provincial health care systems with variable LDKT performance (Quebec: low, Ontario: moderate-high, British Columbia: high). Data collection entailed semistructured interviews ( = 91), document review ( = 97) and focus groups ( = 5 with 40 participants), analyzed using inductive thematic analysis. Results: Our findings showed a strong relationship between the degree of centralized coordination between governing organizations and the capacity to deliver LDKT as follows. (i) macro-level coordination between governing organizations in British Columbia and Ontario increased capacities, whereas Qu��bec was seen as decentralized with little formal coordination; (ii) a higher degree of centralized coordination facilitated more effective resource deployment in the form of human resources and initiatives in British Columbia and Ontario, whereas in Qu��bec resource deployment relied on hospital budgets leading to competition for resources and reduced capacity of initiatives; (iii) informal resource sharing through strong communities of practice and local champions facilitated LDKT in Ontario and British Columbia and was limited in Qu��bec. Conclusion: Our findings suggest that interventions that account for full-system function, particularly macro-level coordination between governing organizations can improve LDKT delivery. Findings may be used to guide structured organizational change toward increasing LDKT and mitigating the global burden of kidney failure.
