Health system barriers and facilitators to living donor kidney transplantation: a qualitative case study in British Columbia

Abstract

Patients with kidney failure have substantially higher morbidity and mortality than the general population and need high-cost treatments. [1][2][3][4][5][6] Patients currently on dialysis have extremely poor survival when compared with the general population (unadjusted survival rate at 5 yr is < 45% and 10 yr is < 15%). 4 In these patients, living donor kidney transplantation (LDKT) is the best therapeutic option, especially when done pre-emptively (i.e., before requirement for renal replacement therapy). 3,[7][8][9][10][11][12][13] Living donor kidney transplantation can provide early access to a transplant; the graft has a superior survival when compared with a graft from a deceased donor; and patients live longer and report a better quality of life. 1,2,4,14 Despite these well-known advantages to LDKT, the living donor rate in Canada has stayed the same since 2010 (about 15 donors per 1 000 000 population) and varies substantially across provinces (ranging from 6 to 23 donors per 1 000 000 population). 3,4,15,16 British Columbia is recognized to be a highperforming health system in this regard as their living donor rate has been consistently 20 donors or more per 1 000 000 population. 4,16,17 In addition, 50%-60% of all kidney transplantations performed annually in the province are from living donors. This is much higher than in Quebec or Ontario, for example, where this fraction is less than 15% and 30%-40%, respectively. 4 Even when analyzing national initiatives such as the Kidney Paired Donation Program managed by Canadian Blood Services, BC is a leader in contributing to this effort. British Columbia has the highest number of registered recipients per 1 000 000 population, total transplantations performed via the registry, total transplants to registered recipients and altruistic donors who come forward to participate in this program.

Identifying Modifiable System-Level Barriers to Living Donor Kidney Transplantation

“…54 , 55 Our recent work has expanded on how the province of British Columbia has achieved this by creating a commitment to collaboration and cultivating distributed expertise. 15 Working groups, committees and cross-provincial events in the province have created strong communities of practice and conveyed an awareness of and knowledge about LDKT. Collaborative networks have helped the development and circulation of educational resources about LDKT for not just patients and donors, but also HPs.…”

“…This indicates that current barriers to LDKT are at the level of implementation as pointed by 1 participant, “more funding is always helpful, however, it needs to be used appropriately.” We have explored the role of an activity-based funding model that was implemented in British Columbia as a facilitator to LDKT. 15 However, this model was implemented after an economic analysis in the province and may require a similar analysis in every transplant jurisdiction. Also, several responses varied by the race and gender of the HP.…”

“…We have explored the role of an activity-based funding model that was implemented in British Columbia as a facilitator to LDKT. 16 However, this model was implemented after an economic analysis in the province and may require a similar analysis in every transplant jurisdiction. Also, several responses varied by the race and gender of the HP.…”

“…However, the provision of services is under provincial mandates, which has led to real-life differences in LDKT performance. 15 The national living donor rates averages about 15 donors per million population annually, however, these rates range from 6 to 23 living donors per million population across provinces. 16 , 17 , 18 , 19 Some provinces have consistently outperformed the national average, while others have had consistently lower rates.…”

Advancing a Paradigm Shift to Approaching Health Systems in the Field of Living-Donor Kidney Transplantation: An Opinion Piece

“…5 The cause of this interprovincial disparity has not been systematically studied; however, our recent work has identified aspects of health system governance and organization that facilitate the delivery of LDKT to patients in BC. 14…”