Bringing a Systems Approach to Living Donor Kidney Transplantation

Abstract

BackgroundLiving donor kidney transplantation (LDKT) is the best treatment option for patients with kidney failure. Efforts to increase LDKT have focused on micro-level 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. MethodsWe conducted a qualitative comparative case study analysis of three Canadian provincial healthcare systems with variable LDKT performance (Quebec:low, Ontario:moderate-high, British Columbia:high). Data collection entailed semi-structured interviews (n=91), document review (n=97) and focus groups (n=5 with 40 participants), analyzed using inductive thematic analysis. ResultsOur findings showed a strong relationship between the degree of centralized coordination between governing organizations and the capacity to deliver LDKT: 1) Macro-level coordination between governing organizations in British Columbia and Ontario increased capacities, while Québec was seen as decentralized with little formal coordination; 2) 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 Québec resource deployment relied on hospital budgets leading to competition for resources and reduced capacity of initiatives; 3) Informal resource sharing through strong communities of practice and local champions facilitated LDKT in Ontario and British Columbia and was limited in Québec. ConclusionOur 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 towards increasing LDKT and mitigating the global burden of kidney failure.