Identifying Modifiable System-Level Barriers to Living Donor Kidney Transplantation

Sandal, Shaifali; Schiller, Ian; Dendukuri, Nandini; Robert, Jorane-Tiana; Katergi, Khaled; Alam, Ahsan; Cantarovich, Marcelo; Fiore, Julio F.; Suri, Rita S.; Landsberg, David; Weber, Catherine; Fortin, Marie-Chantal

doi:10.1016/j.ekir.2022.08.028

Cited by 7 publications

(3 citation statements)

References 44 publications

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“…Currently, the impetus of finding living donors is largely placed on the patient, and much of the present work to increase LDKT focuses on patients and addressing these microlevel barriers [ 25 ]. We conducted a qualitative study, exploring the perspectives of health professionals on the provision of LDKT [ 26 , 27 ] and identified poor communication between treating teams, absence of consistent guidelines, and lack of resources as barriers. Notably, some of these barriers were more prominent in provinces of Canada that have lower rates of LDKT.…”

Section: Introductionmentioning

confidence: 99%

Health System–Level Barriers to Living Donor Kidney Transplantation: Protocol for a Comparative Case Study Analysis

Horton¹,

Loban²,

Nugus³

et al. 2023

JMIR Res Protoc

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Background Living donor kidney transplantation (LDKT) is the best treatment option for patients with kidney failure and offers significant medical and economic advantages for both patients and health systems. Despite this, rates of LDKT in Canada have stagnated and vary significantly across Canadian provinces, the reasons for which are not well understood. Our prior work has suggested that system-level factors may be contributing to these differences. Identifying these factors can help inform system-level interventions to increase LDKT. Objective Our objective is to generate a systemic interpretation of LDKT delivery across provincial health systems with variable performance. We aim to identify the attributes and processes that facilitate the delivery of LDKT to patients, and those that create barriers and compare these across systems with variable performance. These objectives are contextualized within our broader goal of increasing rates of LDKT in Canada, particularly in lower-performing provinces. Methods This research takes the form of a qualitative comparative case study analysis of 3 provincial health systems in Canada that have high, moderate, and low rates of LDKT performance (the percentage of LDKT to all kidney transplantations performed). Our approach is underpinned by an understanding of health systems as complex adaptive systems that are multilevel and interconnected, and involve nonlinear interactions between people and organizations, operating within a loosely bounded network. Data collection will comprise semistructured interviews, document reviews, and focus groups. Individual case studies will be conducted and analyzed using inductive thematic analysis. Following this, our comparative analysis will operationalize resource-based theory to compare case study data and generate explanations for our research question. Results This project was funded from 2020 to 2023. Individual case studies were carried out between November 2020 and August 2022. The comparative case analysis will begin in December 2022 and is expected to conclude in April 2023. Submission of the publication is projected for June 2023. Conclusions By investigating health systems as complex adaptive systems and making comparisons across provinces, this study will identify how health systems can improve the delivery of LDKT to patients with kidney failure. Our resource-based theory framework will provide a granular analysis of the attributes and processes that facilitate or create barriers to LDKT delivery across multiple organizations and levels of practice. Our findings will have practice and policy implications and help inform transferrable competencies and system-level interventions conducive to increasing LDKT. International Registered Report Identifier (IRRID) DERR1-10.2196/44172

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Section: Introductionmentioning

confidence: 99%

Health System–Level Barriers to Living Donor Kidney Transplantation: Protocol for a Comparative Case Study Analysis

Horton¹,

Loban²,

Nugus³

et al. 2023

JMIR Res Protoc

Self Cite

View full text Add to dashboard Cite

show abstract

“…It is not easy to discuss living donations with family and friends . Overall, CKD programs need to better coordinate with transplant centers . There are too few kidneys from deceased donors, and living donation rates remain stagnant .…”

Section: Introductionmentioning

confidence: 99%

“…4 Overall, CKD programs need to better coordinate with transplant centers. 8 There are too few kidneys from deceased donors, and living donation rates remain stagnant. 9 In Ontario, CKD program staff traditionally placed little emphasis on transplant activity in their day-to-day work.…”

mentioning

confidence: 99%

Effect of a Novel Multicomponent Intervention to Improve Patient Access to Kidney Transplant and Living Kidney Donation

Garg,

Yohanna,

Naylor

et al. 2023

JAMA Intern Med

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ImportancePatients with advanced chronic kidney disease (CKD) have the best chance for a longer and healthier life if they receive a kidney transplant. However, many barriers prevent patients from receiving a transplant.ObjectivesTo evaluate the effect of a multicomponent intervention designed to target several barriers that prevent eligible patients from completing key steps toward receiving a kidney transplant.Design, Setting, and ParticipantsThis pragmatic, 2-arm, parallel-group, open-label, registry-based, superiority, cluster randomized clinical trial included all 26 CKD programs in Ontario, Canada, from November 1, 2017, to December 31, 2021. These programs provide care for patients with advanced CKD (patients approaching the need for dialysis or receiving maintenance dialysis).InterventionsUsing stratified, covariate-constrained randomization, allocation of the CKD programs at a 1:1 ratio was used to compare the multicomponent intervention vs usual care for 4.2 years. The intervention had 4 main components, (1) administrative support to establish local quality improvement teams; (2) transplant educational resources; (3) an initiative for transplant recipients and living donors to share stories and experiences; and (4) program-level performance reports and oversight by administrative leaders.Main Outcomes and MeasuresThe primary outcome was the rate of steps completed toward receiving a kidney transplant. Each patient could complete up to 4 steps: step 1, referred to a transplant center for evaluation; step 2, had a potential living donor contact a transplant center for evaluation; step 3, added to the deceased donor waitlist; and step 4, received a transplant from a living or deceased donor.ResultsThe 26 CKD programs (13 intervention, 13 usual care) during the trial period included 20 375 potentially transplant-eligible patients with advanced CKD (intervention group [n = 9780 patients], usual-care group [n = 10 595 patients]). Despite evidence of intervention uptake, the step completion rate did not significantly differ between the intervention vs usual-care groups: 5334 vs 5638 steps; 24.8 vs 24.1 steps per 100 patient-years; adjusted hazard ratio, 1.00 (95% CI, 0.87-1.15).Conclusions and RelevanceThis novel multicomponent intervention did not significantly increase the rate of completed steps toward receiving a kidney transplant. Improving access to transplantation remains a global priority that requires substantial effort.Trial RegistrationClinicalTrials.gov Identifier: NCT03329521

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A qualitative case study of health system barriers and facilitators to living donor kidney transplantation in Canada's most populous province

Horton,

Loban,

Nugus

et al. 2024

World Med & Health Policy

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Patients with kidney failure need dialysis or a kidney transplant to survive. Living donor kidney transplantation (LDKT) is the best therapeutic option, yet global rates of LDKT have minimally increased, and there are disparities in access. The need for a systems approach to improvement has been highlighted. We aimed to understand what elements of a relatively large health system interact to deliver LDKT and act as facilitators or barriers. This was an exploratory case study of Ontario, the most populous province in Canada that conducts 600–700 kidney transplantations annually, of which ~30% are LDKT. Data collection entailed interviews with multiple stakeholders (n = 37), and document review (n = 29) served as a means of triangulating the data. Data were analyzed using inductive thematic analysis. A multicomponent intervention to facilitate kidney transplantation was simultaneously being conducted which allowed us to capture its impact (EnAKT‐LKD). Eight themes were identified, that were separated into facilitators and barriers. Centralized leadership, directed resource deployment, dynamic communities of practice, and informal collaborations between various elements of the health system were found to facilitate LDKT. Barriers were inadequate donor and patient resources to support equitable access, lengthy and poorly coordinated workups for donors and recipients, and issues of jurisdictional control and competition for resources. The EnAKT‐LKD initiative was described as having boosted resource deployment and collaborative capacity and improved strategic alliances by establishing communities of practice. This case study has identified how individual elements in a health system interact to facilitate and impede the delivery of a therapy to patients.

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Identifying Modifiable System-Level Barriers to Living Donor Kidney Transplantation

Cited by 7 publications

References 44 publications

Health System–Level Barriers to Living Donor Kidney Transplantation: Protocol for a Comparative Case Study Analysis

Health System–Level Barriers to Living Donor Kidney Transplantation: Protocol for a Comparative Case Study Analysis

Effect of a Novel Multicomponent Intervention to Improve Patient Access to Kidney Transplant and Living Kidney Donation

A qualitative case study of health system barriers and facilitators to living donor kidney transplantation in Canada's most populous province

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