{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,29]],"date-time":"2026-04-29T22:56:10Z","timestamp":1777503370396,"version":"3.51.4"},"reference-count":51,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2023,1,1]],"date-time":"2023-01-01T00:00:00Z","timestamp":1672531200000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100005160","name":"American Society of Transplantation","doi-asserted-by":"publisher","award":["Gift of Life Institute Clinical Faculty Developmen"],"award-info":[{"award-number":["Gift of Life Institute Clinical Faculty Developmen"]}],"id":[{"id":"10.13039\/100005160","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000191","name":"Kidney Foundation of Canada","doi-asserted-by":"publisher","award":["Health Research Grant"],"award-info":[{"award-number":["Health Research Grant"]}],"id":[{"id":"10.13039\/501100000191","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Can J Kidney Health Dis"],"published-print":{"date-parts":[[2023,1]]},"abstract":"<jats:sec>\n                    <jats:title>Background:<\/jats:title>\n                    <jats:p>Patients with kidney failure represent a major public health burden, and living donor kidney transplantation (LDKT) is the best treatment option for these patients. Current work to optimize LDKT delivery to patients has focused on microlevel interventions and has not addressed interdependencies with meso and macro levels of practice.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective:<\/jats:title>\n                    <jats:p>We aimed to learn from a health system with historically low LDKT performance to identify facilitators and barriers to LDKT. Our specific aims were to understand how LDKT delivery is organized through interacting macro, meso, and micro levels of practice and identify what attributes and processes of this health system facilitate the delivery of LDKT to patients with kidney failure and what creates barriers.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design:<\/jats:title>\n                    <jats:p>We conducted a qualitative case study, applying a complex adaptive systems approach to LDKT delivery, that recognizes health systems as being made up of dynamic, nested, and interconnected levels, with the patient at its core.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting:<\/jats:title>\n                    <jats:p>The setting for this case study was the province of Quebec, Canada.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants:<\/jats:title>\n                    <jats:p>Thirty-two key stakeholders from all levels of the health system. This included health care professionals, leaders in LDKT governance, living kidney donors, and kidney recipients.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods:<\/jats:title>\n                    <jats:p>Semi-structured interviews with 32 key stakeholders and a document review were undertaken between February 2021 and December 2021. Inductive thematic analysis was used to generate themes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>Overall, we identified strong links between system attributes and processes and LDKT delivery, and more barriers than facilitators were discerned. Barriers that undermined access to LDKT included fragmented LDKT governance and expertise, disconnected care practices, limited resources, and regional inequities. Some were mitigated to an extent by the intervention of a program launched in 2018 to increase LDKT. Facilitators driven by the program included advocacy for LDKT from individual member(s) of the care team, dedicated resources, increased collaboration, and training opportunities that targeted LDKT delivery at multiple levels of practice.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Limitations:<\/jats:title>\n                    <jats:p>Delineating the borders of a \u201ccase\u201d is a challenge in case study research, and it is possible that some perspectives may have been missed. Participants may have produced socially desirable answers.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions:<\/jats:title>\n                    <jats:p>Our study systematically investigated real-world practices as they operate throughout a health system. This novel approach has cross-disciplinary methodological relevance, and our findings have policy implications that can help inform multilevel interventions to improve LDKT.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/20543581221150675","type":"journal-article","created":{"date-parts":[[2023,1,20]],"date-time":"2023-01-20T06:35:02Z","timestamp":1674196502000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":4,"title":["Living Donor Kidney Transplantation in Quebec: A Qualitative Case Study of Health System Barriers and Facilitators"],"prefix":"10.1177","volume":"10","author":[{"given":"Anna","family":"Horton","sequence":"first","affiliation":[{"name":"Research Institute of the McGill University Health Centre, Montreal, QC, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Katya","family":"Loban","sequence":"additional","affiliation":[{"name":"Research Institute of the McGill University Health Centre, Montreal, QC, Canada"},{"name":"Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8437-0556","authenticated-orcid":false,"given":"Marie-Chantal","family":"Fortin","sequence":"additional","affiliation":[{"name":"Centre de recherche du Centre hospitalier de l\u2019Universit\u00e9 de Montr\u00e9al, QC, Canada"},{"name":"Division of Nephrology, Department of Medicine, Centre hospitalier de l\u2019Universit\u00e9 de Montr\u00e9al, QC, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sylvie","family":"Charbonneau","sequence":"additional","affiliation":[{"name":"Kidney Foundation of Canada, Montreal, QC, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Peter","family":"Nugus","sequence":"additional","affiliation":[{"name":"Department of Family Medicine and Institute of Health Sciences Education, McGill University, Montreal, QC, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michel R.","family":"P\u00e2quet","sequence":"additional","affiliation":[{"name":"Centre de recherche du Centre hospitalier de l\u2019Universit\u00e9 de Montr\u00e9al, QC, Canada"},{"name":"Division of Nephrology, Department of Medicine, Centre hospitalier de l\u2019Universit\u00e9 de Montr\u00e9al, QC, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Prosanto","family":"Chaudhury","sequence":"additional","affiliation":[{"name":"Research Institute of the McGill University Health Centre, Montreal, QC, Canada"},{"name":"Department of Surgery, McGill University Health Centre, Montreal, QC, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marcelo","family":"Cantarovich","sequence":"additional","affiliation":[{"name":"Research Institute of the McGill University Health Centre, Montreal, QC, Canada"},{"name":"Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1941-0598","authenticated-orcid":false,"given":"Shaifali","family":"Sandal","sequence":"additional","affiliation":[{"name":"Research Institute of the McGill University Health Centre, Montreal, QC, Canada"},{"name":"Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"179","published-online":{"date-parts":[[2023,1,20]]},"reference":[{"key":"bibr1-20543581221150675","doi-asserted-by":"publisher","DOI":"10.1016\/j.semnephrol.2009.06.010"},{"key":"bibr2-20543581221150675","doi-asserted-by":"publisher","DOI":"10.2215\/CJN.03350313"},{"key":"bibr3-20543581221150675","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.13490"},{"key":"bibr4-20543581221150675","volume-title":"USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States","author":"US Renal Data System","year":"2018"},{"key":"bibr5-20543581221150675","doi-asserted-by":"publisher","DOI":"10.1007\/s10754-007-9022-y"},{"key":"bibr6-20543581221150675","unstructured":"Canadian Blood Service. 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