Bringing a Systems Approach to Living Donor Kidney Transplantation

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 (n = 91), document review (n = 97) and focus groups (n = 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 Québec 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 Québec 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 Québec.

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.