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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.
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.
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.
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.
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.
DERR1-10.2196/44172
End-stage renal disease represents a major public health burden. Patients needing dialysis have extremely poor survival rates when compared with the general population [
Kidney transplantation, in particular living donor kidney transplant (LDKT), is widely regarded as the best therapeutic option for patients with kidney failure. When compared with patients undergoing dialysis, those who have undergone kidney transplantation experience a 64%-75% lower risk of death by the first year following transplantation [
Despite its significant benefits, LDKT rates in Canada have stagnated over the past decade and continue to average around 12-14 living donors per 1 million population. This is despite national efforts to increase LDKT, such as the paired kidney exchange program [
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 [
As such, the objective of the study described in this protocol is to generate a systemic interpretation of LDKT by identifying the attributes and processes that facilitate the delivery of LDKT in a provincial health system and those that create barriers. We also aim to identify the differences between these attributes and processes by comparing higher- and lower-performing systems. These objectives are contextualized within our broader goal of increasing rates of LDKT in Canada, particularly in lower-performing provinces. Our primary research question is the following: what are the attributes and processes of provincial health systems that account for variability in LDKT rates?
This study takes the form of a comparative case study analysis as described by Yin [
Conceptually, our approach is underpinned by an understanding of health systems as complex adaptive systems (CASs). The concept of CAS stems from the complexity theory and takes a dynamic systems approach. A CAS is “an entity composed of many different parts that are interconnected in a way that gives the whole capabilities that the parts don’t have on their own” [
There also exists a tight fit between a CAS approach and case study methodology [
Comparative case study analysis design (adapted from Yin’s [
In accordance with the CAS theory, we defined each provincial “case” as the health system involved in facilitating LDKT. Adapted from the 4-level model proposed by leading agencies [
Envisioning the health system that delivers living donor kidney transplantation to patients as a complex adaptive system (adapted from the 4-level model proposed by the National Academy of Engineering [United States] and Institute of Medicine [United States] Committee on Engineering and the Health Care System).
We will conduct a comparative case study between British Columbia, Ontario, and Quebec, which represent respectively high, moderate, and low performance in LDKT as defined by the percentage of LDKTs to all transplantation performed annually [
Our study follows sequential stages of data collection and analysis (
Participants from different levels of the health system, as shown in
Types of participants and the numbers that were targeted in each category in each province.
Participant category | Number for each province |
Ministry of Health representative | 1-2 |
Organ Donation Organization representatives | 2-3 |
Renal program representatives | 2-3 |
Health care professionals at transplant centers | 8-10 |
Health care professionals at nephrology clinics or dialysis centers | 8-12 |
Living donor kidney transplant recipients | 2-4 |
Living donors | 2-4 |
To recruit participants, purposive criterion sampling was used to invite key leadership at organ donation organizations, provincial renal programs, and transplant centers. Participants were considered to have key leadership roles if they held decision-making authority with interorganizational impact. Thereafter, snowball sampling was used to recruit providers from kidney care clinics and dialysis centers [
Semistructured interviews were conducted to understand the dynamic organization, governance, and care entailed in LDKT delivery and the interdependencies between the elements of each provincial health system. We also sought to understand what aspects of the system variously promoted or hindered patient access to LDKT. Interview guides for professional participants addressed their involvement in facilitating LDKT for patients, their interactions with other professionals in this process, their attitude toward LDKT, and which phenomena helped and which ones posed challenges in their work. Interview guides for donors and recipients of LDKT focused on their experiences of LDKT, their perception of care, and what helped and hindered their care path. Distinct interview guides with open-ended questions were developed for each category of participant with the combined expertise of our research team and preliminary document review (see sample guide in
Document review served as complementary data collection to inform our understanding of programs, policies, and resources concerning LDKT in each province and as means of triangulation with interview data [
Following data collection in all 3 provinces and the initial coding of individual case studies, we conducted 4 focus groups remotely with the purpose of gleaning opinions about our preliminary themes from key stakeholders (
Types of participants who were identified for participation in the focus group.
Focus group | Approximate number of participants | Participant types | Language of conduct |
1 | 10-12 | A health care professional working in transplantation or nephrology; or a representative from a provincial renal program, organ donation organization, or provincial health ministry, who has previously participated as an interviewee in this study | English |
2 | 4-6 | A health care professional working in transplantation or nephrology; or a representative from a provincial renal program, organ donation organization, or provincial health ministry, who works in a province outside of British Columbia, Ontario, and Quebec | English |
3 | 4-6 | An LDKTa recipient or living donor who has experienced LDKT in the last 7 years and whose preferred language of conduct is English | English |
4 | 4-6 | An LDKT recipient or donor who has experienced LDKT in the last 7 years and whose preferred language of conduct is French | French |
aLDKT: living donor kidney transplantation.
Data from each case study were analyzed using inductive thematic analysis [
Transcribed interview data were read and highlighted line-by-line to openly derive preliminary codes that emerged iteratively from the data set. These codes were organized into categories and subcodes to form an initial coding scheme. Codes were then compared across the data set for regularities and divergences and modified accordingly. Through this process of inductive analysis, a coding scheme evolved, which retained strong links with the original data set [
Our comparative analysis will operationalize the resource-based theory (RBT) to compare case study data and generate explanations for our research question. The RBT is a strategic management theory that provides a framework for explaining and predicting the basis of an organization’s competitive performance and advantage [
Following inductive coding and individual analysis of data collected from British Columbia, Ontario, and Quebec, we will use an RBT framework to analyze and compare our case study data and generate explanations for our research question. To do this, we will organize codebooks from each province into capabilities identified from the RBT literature, following questions stemming from these capabilities to guide our organization (
Resource-based theory capacities for comparative analysis.
Capacity | Guiding questions |
Resources | What, where, and how are resources deployed in LDKTa delivery? |
Competition for resources | What competition exists for resources to facilitate LDKT? |
Organizational capacity | What are the organizational capacities of the organizations involved in LDKT delivery? |
Collaborative capacity | What collaborative capacities exist in and between organizations? |
Value creation | What activities create value for LDKT? |
Dynamic capabilities | What are the dynamic capabilities of organizations? |
aLDKT: living donor kidney transplantation.
Ethics approval for this study was obtained from the McGill University Health Centre Research Ethics Committee (MP-37-2021-7126/LDKT Case Study). This study is being conducted in accordance with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (2014), and the Declaration of Istanbul.
This project was funded by a grant from a Gift of Life Institute, a Clinical Faculty Development Research Grant from the American Society of Transplantation from 2020 to 2021, and by a Health Research Grant from the Kidney Foundation of Canada. Individual case studies of British Columbia, Ontario, and Quebec were carried out between November 2020 and August 2022. The individual case study findings of LDKT delivery in British Columbia have been published [
This study aims to produce a system-level understanding of LDKT delivery in Canada’s 3 most populous provinces that have variable rates of LDKT, presenting a unique opportunity for comparative analysis. Informed by quantitative data [
To our knowledge, a comparative case analysis approach has not been used in the field of nephrology or kidney transplantation. Our approach has implications in these disciplines where there exists a poor understanding of system-level factors leading to inferior outcomes, inequities in access to therapy, and fractured transitions of care. This work also has global implications as LDKT is the main way to obtain a transplant in many countries that lack infrastructure for deceased donation. Based on our preliminary results and background work, we believe that to make significant improvements to LDKT delivery, interventions must target the dynamic relationships between different elements of a system. Much of the current work has focused on microlevel interventions to improve LDKT delivery [
The following limitations to our study may apply. First, our data collection largely pertains to 3 provinces of Canada and our findings may not be applicable to other regions and countries. Nonetheless, it should be noted that Quebec, Ontario, and British Columbia are Canada’s most populous provinces and represent 75% of the Canadian population, and our focus group data also go some way to establish the pertinence of our findings to other provinces. Our data also lay the foundations to extend our work across Canada and to other countries. Second, our research will not comprehensively explore the system-level factors leading to disparities in LDKT, such as gender and sex disparities and low rates of LDKT in Indigenous and other vulnerable populations. However, the data collected in this study will inform future systematic approaches needed to address this complex issue.
Another limitation may pertain to the challenge of delineating the “boundaries” of the health systems that form the basis for our cases. Identifying the unit of analysis for case study research has long been identified as a challenge [
LDKT is the optimal treatment option for patients with kidney failure; yet, rates of LDKT have stagnated in Canada and vary significantly across provinces. There is a need to better understand how health systems deliver LDKT to patients. Following our prior work that has suggested system-level differences contributing to variability in LDKT performance, we will generate a systemic interpretation of LDKT delivery by identifying the attributes and processes that facilitate or create barriers to the delivery of LDKT. We will also identify the differences between these attributes and processes by comparing higher- and lower-performing provincial health systems. This qualitative comparative case study analysis is informed by CASs, and data analysis will be carried out in accordance with the RBT. Our findings will have practice and policy implications and help inform specific strategies, regulations, and infrastructure that are transferrable competencies and conducive to promoting the service delivery of LDKT.
Peer-review report by La Fondation Canadienne du rein / Kidney Foundation - 2021 Kidney Health Scientific Committee (Montréal, Canada).
complex adaptive system
living donor kidney transplantation
resource-based theory
We would like to thank the Canadian Donation and Transplantation Research Program and the Organ and Tissue Donation and Transplantation committees of Canadian Blood Services for their support in recruitment and grant applications. SS was supported by the McGill University Health Centre Department of Medicine’s CAS research funding and now is supported by the Chercheuses-boursières cliniciennes - Junior 1 from the Fonds de recherche du Québec – Santé.
The data sets generated and analyzed during this study are not publicly available, as informed consent to share transcribed data for secondary use beyond this research was not obtained from the participants.
SS conceived, designed, and conceptualized the study. PN, AH, KL, and MCF advised on the methodology, design, and theoretical frameworks. IM, GK, LG, MC, DL, and MP helped with the methods and design and facilitated data collection. AH is the research coordinator and conducted interviews. AH and KL conducted focus groups and are conducting data analysis. AH wrote the first draft of the manuscript. SS contributed to the development of the paper and provided comments for improvement. All authors read and approved the final manuscript.
SS has received a grant from Amgen Canada to increase living donor kidney transplantation.