Identifying Modifiable System-Level Barriers to Living Donor Kidney Transplantation

Shaifali Sandal; Ian Schiller; Nandini Dendukuri; Jorane-Tiana Robert; Khaled Katergi; Ahsan Alam; Marcelo Cantarovich; Julio F Fiore; Rita S Suri; David Landsberg; Catherine Weber; Marie-Chantal Fortin

doi:10.1016/j.ekir.2022.08.028

Identifying Modifiable System-Level Barriers to Living Donor Kidney Transplantation

Kidney Int Rep. 2022 Sep 9;7(11):2410-2420. doi: 10.1016/j.ekir.2022.08.028. eCollection 2022 Nov.

Authors

Shaifali Sandal^{1

2}, Ian Schiller^{2

3}, Nandini Dendukuri^{2

3}, Jorane-Tiana Robert¹, Khaled Katergi¹, Ahsan Alam^{1

2}, Marcelo Cantarovich^{1

2}, Julio F Fiore^{2

4}, Rita S Suri^{1

2}, David Landsberg⁵, Catherine Weber¹, Marie-Chantal Fortin^{6

7}

Affiliations

¹ Division of Nephrology, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada.
² Research Institute of the McGill University Health Centre, Montréal, Québec, Canada.
³ Departments of Medicine and Epidemiology, Biostatistics and Occupational Health, McGill University Health Centre, Montréal, Québec, Canada.
⁴ Department of Surgery, McGill University Health Centre, Montréal, Québec, Canada.
⁵ Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
⁶ Division of Nephrology, Department of Medicine, Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
⁷ Centre de recherche du Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada.

Abstract

Introduction: Studying existing health systems with variable living donor kidney transplantation (LDKT) performance and understanding factors that drive these differences can inform comprehensive system-level approaches to improve LDKT. We aimed to quantify previously identified barriers and estimate their association with LDKT performance.

Methods: We conducted a cross-sectional survey of health professionals (HPs). Statements, rated on a Likert scale of "strongly disagree" to "strongly agree", captured themes related to communication; role perception; HP's education, training and comfort; attitudes; referral process; patient; as well as resources and infrastructure. The percentage who agreed with these statements was analyzed and compared by LDKT performance (living donation rates higher or lower than the national average) and participant characteristics.

Results: We obtained 353 complete responses. Themes related to poor communication, poor role perception, and HPs education or training or comfort emerged as barriers to LDKT. When compared with HPs from high-performing provinces, those from low-performing provinces had lower odds of agreeing that their province promoted LDKT (adjusted odd ratio [aOR] = 0.27, 95% confidence interval [CI]: 0.16-0.48). They also had lower odds of initiating discussions about LDKT (aOR = 0.30, 95% CI: 0.17-0.55), and higher odds of agreeing that the transplant team is best suited to discuss LDKT (aOR = 2.64, 95% CI: 1.60-4.33) and that more resources would increase LDKT discussions (aOR = 2.06, 95% CI: 1.25-3.40). Nonphysician role and less than 10 years of experience were associated with the level of agreement across several themes. Creating guidelines, streamlining evaluations, and improving communication were ranked as priorities to increase LDKT.

Conclusion: There are system-level barriers to LDKT and some were more prevalent in low-performing provinces. Interventions to eliminate them should be implemented in conjunction with patient-level interventions as part of a comprehensive system-level approach to increase LDKT.

Keywords: barriers; health professionals; health system; living donor kidney transplantation.