This study takes the form of a comparative case study analysis as described by Yin [28,29] and illustrated in Figure 1. Case study research is an in-depth, noninterventional examination of a single case over time to investigate a contemporary phenomenon in its natural context [29,30]. Case studies have been identified as the preferred methodology for examining high-performing health systems [31-39]. As quantitative data concerning rates of LDKT across provinces have been well-documented elsewhere [40-4], our study follows a qualitative design to investigate how and why these differences in performance exist. Qualitative methods have established relevance to answering these questions in health research [43]. Understanding the system as an integrated whole lies in understanding the patterns and relationships between its levels and key players [44]. Our qualitative design will investigate these real-world behaviors and perspectives at multiorganizational levels, in order to understand full system function. Thus, our case study analysis will be explanatory because it will explore and connect how certain attributes and processes of a provincial health system are linked to the provision of LDKT [28]. It will be inductive—that is, allowing themes and explanations to be derived primarily from a close reading of the data—without trying to fit it into a priori concepts.

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” [45]. A provincial health system that delivers LDKT can be understood as a CAS, in that, it is a multilevel, interconnected system that involves nonlinear interactions between people and organizations, operating within a loosely bounded network. CAS approaches have been used increasingly as an analysis and research development tool in health care, with favorable results [44,46,47].

There also exists a tight fit between a CAS approach and case study methodology [44]. Researchers have identified that multiple methods that are often used in case study research lend themselves to understanding emergent elements and system dynamics [44]. Complexity theory also suggests that comparing the best to the worst in multiple case comparison can be a fruitful way of understanding the source of new structural arrangements and patterns of behavior [44,48]. Accordingly, our comparative method entails the comparison and synthesis of the similarities, differences, and patterns across multiple cases that share a common goal [39,49].

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 [50] we mapped a whole-system model of LDKT, composed of macro-, meso-, and microlevels of practice that are interconnected, dynamic, and nested, with the patient at its core (Figure 2) [51]. These levels include organizations, service providers, recipients, and donors, representing the human and nonhuman agents that are implicated in the delivery of LDKT and thus form the elements for our analysis.

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 [11]. These three provinces represent 75% of Canada’s population, and over 70% of the patients with end-stage renal disease reside in these provinces. Thus, performance in these provinces significantly influences the country’s overall transplant results. Additionally, since these provinces have low, moderate, and high rates of LDKT, we have an ideal case mix to facilitate interprovincial learning, as well as for theoretical replication, reliability, and external validity [28].

Our study follows sequential stages of data collection and analysis (Figure 1). We have conducted independent case studies of the health systems in British Columbia, Ontario, and Quebec using the data collection methods discussed below. Following data collection and independent analysis in all 3 provinces, we have recently conducted focus groups with stakeholders from across Canada, asking their opinions and experiences of the themes derived from the preliminary analysis of these cases. We will now conduct a comparative case study of British Columbia, Ontario, and Quebec. We will use the focus group data to develop and refine the themes from our comparative case study to form a final analysis.

Participants from different levels of the health system, as shown in Figure 2, were recruited for interviews. As LDKT is organized largely by each province, representatives from federal bodies were invited to participate in focus groups, where we discussed and refined the national relevance of our findings. Table 1 shows a breakdown of participants invited for an interview. The composition of interviewees seen in Table 1 comprises an approach to “studying through,” tracing relations among actors, institutions, and discourses across spaces through interview data [52,53]. In accordance with our CAS approach, our participants represent macro-, meso-, and microlevels of practice. As the organizations implicated in LDKT vary among British Columbia, Ontario, and Quebec—for example, Quebec does not have a provincial renal program—the list of participants invited was adjusted accordingly.

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 [52,55]. Data gathering continued until data saturation was reached; that is, when new interviews and document reviews did not provide additional information [56].

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 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 [11], we are using qualitative methods to explain these differences. We want to identify the attributes and processes that facilitate or create barriers to LDKT using the RBT. Our preliminary findings suggest that barriers to effective LDKT delivery exist at different organizational levels of the health system and, critically, in the relationships between these organizations. LDKT delivery is aided by supportive governance organizations with a provincial overview, which increase the collaborative capacities of the system, boost organizational capacity, and generate value for LDKT across the different organizations involved [72,73].

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 [25,51], missing the important influence of meso- and macropractices and the dynamic interdependencies that exist between these levels of a health system [51]. Our findings will build on other studies that focus on implementing interventions to improve patient education and comfort on LDKT [16,74-78], and will help reenforce it by informing effective implementation strategies that encompass all levels of a health system.

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 [79], and in the complex field of health care, it may be difficult to differentiate between organizational and system boundaries and their environments [80]. We have delineated our cases by drawing on the extensive expertise of our team and collaborators, many of whom are practitioners in this field, as well as following a snowballing technique to iteratively identify the actors and organizations implicated in LDKT delivery. However, some perspectives may have been missed in this process, for example, family physicians who are primarily involved in living donor care for and may exercise influence over the LDKT process. To mitigate this challenge, we will situate our analysis in a detailed discussion of factors external to the boundaries of our case, which impact LDKT delivery. Where relevant, we will highlight areas for further research. Relatedly, there is some variation in our sample size and organizational representation between cases, given the heterogeneity in how care is structured in different provinces. This may have some impact on how we are able to compare across provinces. Our analysis will include an in-depth discussion of the structural differences in renal care among British Columbia, Ontario, and Quebec to situate our findings. Finally, though we believe our document review serves as useful complementary data collection and triangulation with interview data, we acknowledge that it may not be exhaustive.

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.