Horton Anna, Loban Katya, Nugus Peter, Fortin Marie-Chantal, Gunaratnam Lakshman, Knoll Greg, Mucsi Istvan, Chaudhury Prosanto, Landsberg David, Pâquet Michel R, Cantarovich Marcelo, Sandal Shaifali
Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
Institute of Health Sciences Education, McGill University, McGill University, Montreal Quebec, Canada.
Kidney Int Rep. 2024 Jul 25;9(10):2915-2926. doi: 10.1016/j.ekir.2024.07.014. eCollection 2024 Oct.
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.
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.
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.
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.
活体供肾移植（LDKT）是肾衰竭患者的最佳治疗选择。增加LDKT的努力主要集中在微观层面的干预措施上，并且系统思维的必要性也得到了强调。我们旨在识别和比较卫生系统层面促进和阻碍LDKT的属性及流程。
我们对加拿大3个省级医疗系统进行了定性比较案例研究分析，这些系统的LDKT表现各不相同（魁北克：低，安大略：中高，不列颠哥伦比亚：高）。数据收集包括半结构化访谈（n = 91）、文件审查（n = 97）和焦点小组（5个小组，共40名参与者），采用归纳主题分析法进行分析。
我们的研究结果表明，管理组织之间的集中协调程度与开展LDKT的能力之间存在密切关系，具体如下。（i）不列颠哥伦比亚省和安大略省管理组织之间的宏观层面协调提高了能力，而魁北克则被视为分散管理，几乎没有正式协调；（ii）更高程度的集中协调有助于在不列颠哥伦比亚省和安大略省以人力资源和举措的形式更有效地部署资源，而在魁北克，资源部署依赖于医院预算，导致资源竞争和举措能力下降；（iii）通过强大的实践社区和当地倡导者进行的非正式资源共享促进了安大略省和不列颠哥伦比亚省的LDKT，在魁北克则受到限制。
我们的研究结果表明，考虑全系统功能的干预措施，特别是管理组织之间的宏观层面协调，可以改善LDKT服务的提供。研究结果可用于指导有组织的变革，以增加LDKT并减轻肾衰竭的全球负担。
