1
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Wada Y, Ueno T, Umeshita K, Hagiwara K. Challenges in decision-making support processes regarding living kidney donation: A qualitative study. J Ren Care 2024. [PMID: 38597794 DOI: 10.1111/jorc.12494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 02/11/2024] [Accepted: 03/28/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Previous studies on decision-making of living kidney donors have indicated issues regarding donors' autonomy is inherent in decision-making to donate their kidney. Establishing effective decision-making support that guarantees autonomy of living kidney donor candidates is important. OBJECTIVES The aim of this study was to identify the difficulties in the decision-making support when clinical transplant coordinators advocating for the autonomy of donor candidates of living donor kidney transplantation and to identify the methods to deal with these difficulties. DESIGN A qualitative descriptive study. PARTICIPANTS Ten clinical transplant coordinators supporting living kidney donors. APPROACH Semi-structured interviews were conducted using an interview guide. The modified grounded theory approach was utilised to analyse. RESULTS Three categories related to difficulties were as follows: issues inherent to the interaction between coordinators, donor candidates and their families; issues regarding the environment and institutional background in which coordinators operate; and emotional labour undertaken by coordinators in the decision-making support process. Additionally, five categories related to methods were as follows: assessing the autonomy of donor candidates based on the coordinators nursing experience; interventions for the donor candidates and their family members based on the coordinators nursing experience; smooth coordination with medical staff; clarifying and asserting their views as coordinators; and readiness to protect the donor candidates. CONCLUSION The involvement of highly experienced coordinators with excellent and assertive communication skills as well as the ability to reflect on their own practices is essential. Moreover, we may need to fundamentally review the transplant community, where power domination is inherent.
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Affiliation(s)
- Yuri Wada
- Division of Health Science, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Takayoshi Ueno
- Division of Health Science, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Koji Umeshita
- Division of Health Science, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Kuniko Hagiwara
- Division of Health Science, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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2
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El-Khoury B, Yang TC. Reviewing Racial Disparities in Living Donor Kidney Transplantation: a Socioecological Approach. J Racial Ethn Health Disparities 2024; 11:928-937. [PMID: 36991297 PMCID: PMC10057682 DOI: 10.1007/s40615-023-01573-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/31/2022] [Accepted: 03/19/2023] [Indexed: 03/31/2023]
Abstract
Despite kidney transplantation having superior outcomes to dialytic therapies, disparities continue to exist among rates of kidney transplantation between Black and non-Hispanic White patients, which cannot be explained by differences in individual characteristics. To better evaluate the persistent Black/White disparities in living kidney transplantation, we review the extant literature and include the critical factors and recent development in living kidney transplantation in the socioecological approach. We also emphasize the potential vertical and hierarchical associations among factors in the socioecological model. Specifically, this review explores the possibility that the relatively low living kidney transplantation among Blacks may be a consequence of individual, interpersonal, and structural inequalities in various social and cultural dimensions. At the individual level, the Black/White differences in socioeconomic conditions and transplant knowledge may account for the low transplantation rates among Blacks. Interpersonally, the relatively weak social support and poor communication between Black patients and their providers may contribute to disparities. At the structural level, the race-based glomerular filtration rate (GFR) calculation that is widely used to screen Black donors is a barrier to receiving living kidney transplantation. This factor is directly related to structural racism in the health care system but its potential impact on living donor transplantation is underexplored. Finally, this literature review emphasizes the current perspective that a race-free GFR should be considered and a multidisciplinary and interprofessional perspective is necessary to devise strategies and interventions to reduce the Black/White disparities in living donor kidney transplantation in the U.S.
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Affiliation(s)
- Bashir El-Khoury
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, USA.
- Civilian Institution Programs, Air Force Institute of Technology, Wright-Patterson Air Force Base, OH, USA.
| | - Tse-Chuan Yang
- Department of Epidemiology, University of Texas Medical Branch, Galveston, USA
- Department of Sociology, University at Albany, State University of New York, Albany, USA
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3
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Crenshaw R, Woods C, Koizumi N, Dave HS, Gentili M, Saleem JJ. Understanding Barriers and Facilitators to Living Kidney Donation Within a Sociotechnical Systems Framework. Qual Health Res 2024:10497323231224706. [PMID: 38229412 DOI: 10.1177/10497323231224706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
The objective of this study was to investigate factors influencing one's decision to become a live kidney donor under the framework of sociotechnical systems, by expanding the focus to include larger organizational influences and technological considerations. Semi-structured interviews were conducted with live kidney donors who donated through University of Louisville Health, Trager Transplant Center, a mid-scale transplant program, in the years 2017 through 2019. The interview transcripts were analyzed for barriers and facilitators to live kidney donation within a sociotechnical system. The most salient facilitators included: having an informative, caring, and available care team; the absence of any negative external pressure toward donating; donating to a family or friend; and the ability to take extra time off work for recovery. The most recurrent barriers included: short/medium-term (<1 year) negative health impacts because of donation; the need to make minor lifestyle changes (e.g., less alcohol consumption) after donation; and mental health deterioration stemming from the donation process. The sociotechnical systems framework promotes a balanced system comprised of social, technical, and environmental subsystems. Assessing the facilitators and barriers from the sociotechnical system perspective revealed the importance of and opportunities for developing strategies to promote integration of technical subsystem, such as social media apps and interactive AI platforms, with social and environmental subsystems to enable facilitators and reduce barriers effectively.
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Affiliation(s)
- Rachel Crenshaw
- Department of Industrial Engineering, University of Louisville, Louisville, KY, USA
- Analytics, Planning, Strategy and Improvement, Brigham and Women's Hospital, Boston, MA, USA
| | - Cary Woods
- Department of Industrial Engineering, University of Louisville, Louisville, KY, USA
| | - Naoru Koizumi
- Schar School of Policy and Government, George Mason University, Fairfax, VA, USA
| | - Hitarth S Dave
- Division of Nephrology & Hypertension, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Monica Gentili
- Department of Industrial Engineering, University of Louisville, Louisville, KY, USA
| | - Jason J Saleem
- Department of Industrial Engineering, University of Louisville, Louisville, KY, USA
- Center for Human Systems Engineering, University of Louisville, Louisville, KY, USA
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4
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Grossi AA, Puoti F, Masiero L, Troni A, Cianchi T, Maggiore U, Cardillo M. Inequities in Organ Donation and Transplantation Among Immigrant Populations in Italy: A Narrative Review of Evidence, Gaps in Research and Potential Areas for Intervention. Transpl Int 2023; 36:11216. [PMID: 37636900 PMCID: PMC10450150 DOI: 10.3389/ti.2023.11216] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 07/19/2023] [Indexed: 08/29/2023]
Abstract
Immigrants from outside Europe have increased over the past two decades, especially in Southern European countries including Italy. This influx coincided with an increased number of immigrants with end-stage organ diseases. In this narrative review, we reviewed evidence of the gaps between native-born and immigrant populations in the Organ Donation and Transplantation (ODT) process in Italy. Consistent with prior studies, despite the availability of a publicly funded health system with universal healthcare coverage, non-European-born individuals living in Italy are less likely to receive living donor kidney transplantation and more likely to have inferior long-term kidney graft function compared with EU-born and Eastern European-born individuals. While these patients are increasingly represented among transplant recipients (especially kidney and liver transplants), refusal rates for organ donation are higher in some ethnic groups compared with native-born and other foreign-born referents, with the potential downstream effects of prolonged waiting times and inferior transplant outcomes. In the process, we identified gaps in relevant research and biases in existing studies. Given the Italian National Transplant Center's (CNT) commitment to fighting inequities in ODT, we illustrated actions taken by CNT to tackle inequities in ODT among immigrant communities in Italy.
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Affiliation(s)
- Alessandra Agnese Grossi
- Center for Clinical Ethics, Department of Biotechnologies and Life Sciences, University of Insubria, Varese, Italy
- Department of Human Sciences, Innovation and Territory, University of Insubria, Como, Italy
| | - Francesca Puoti
- Italian National Transplant Center (CNT), Istituto Superiore di Sanità, Rome, Italy
| | - Lucia Masiero
- Italian National Transplant Center (CNT), Istituto Superiore di Sanità, Rome, Italy
| | - Alessia Troni
- Italian National Transplant Center (CNT), Istituto Superiore di Sanità, Rome, Italy
| | - Tiziana Cianchi
- Italian National Transplant Center (CNT), Istituto Superiore di Sanità, Rome, Italy
| | - Umberto Maggiore
- Nephrology Unit, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Massimo Cardillo
- Italian National Transplant Center (CNT), Istituto Superiore di Sanità, Rome, Italy
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5
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Ahmed A, Winterbottom A, Ahmed S, Stoves J, Daga S. Decisional Needs of People From Minority Ethnic Groups Around Living Donor Kidney Transplantation: A UK Healthcare Professionals' Perspective. Transpl Int 2023; 36:11357. [PMID: 37554318 PMCID: PMC10405286 DOI: 10.3389/ti.2023.11357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/04/2023] [Indexed: 08/10/2023]
Abstract
Despite improved patient and clinical outcomes, living donor kidney transplantation is underutilized in the United Kingdom, particularly among minority ethnic groups, compared to deceased donor kidney transplantation. This may in part be due to the way in which kidney services present information about treatment options. With a focus on ethnicity, semi structured interviews captured the views of 19 kidney healthcare professionals from two renal centres in West Yorkshire, about the decisional needs and context within which people with advanced kidney disease make transplant decisions. Data were analysed using thematic analysis. Themes were categorized into three groups: 1) Kidney healthcare professionals: language, cultural awareness, trusted personnel, and staff diversity, 2) Patient information resources: timing and setting of education and suitability of patient-facing information and, 3) People with advanced kidney disease: knowledge, risk perception, and cultural/religious beliefs. To our knowledge, this is the first study in the United Kingdom to investigate in depth, healthcare professionals' views on living donor kidney transplantation decision making. Six recommendations for service improvement/delivery to support decision making around living donor kidney transplantation among minority ethnic groups are described.
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Affiliation(s)
- Ahmed Ahmed
- Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Anna Winterbottom
- Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Shenaz Ahmed
- Division of Psychological and Social Medicine, Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - John Stoves
- Department of Renal Medicine, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | - Sunil Daga
- Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
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6
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Horton A, Loban K, Nugus P, Fortin MC, Gunaratnam L, Knoll G, Mucsi I, Chaudhury P, Landsberg D, Paquet M, Cantarovich M, Sandal S. Health System-Level Barriers to Living Donor Kidney Transplantation: Protocol for a Comparative Case Study Analysis. JMIR Res Protoc 2023; 12:e44172. [PMID: 36881454 PMCID: PMC10031444 DOI: 10.2196/44172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND 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. OBJECTIVE 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. METHODS 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. RESULTS 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. CONCLUSIONS 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. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/44172.
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Affiliation(s)
- Anna Horton
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Katya Loban
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Peter Nugus
- Department of Family Medicine and the Institute of Health Sciences Education, McGill University, Montreal, QC, Canada
| | - Marie-Chantal Fortin
- Centre de recherche du Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
- Division of Nephrology, Department of Medicine, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Lakshman Gunaratnam
- Matthew Mailing Centre for Translational Transplant Studies, Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
- Division of Nephrology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Greg Knoll
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Istvan Mucsi
- Ajmera Transplant Center and Division of Nephrology, University Health Network, Toronto, ON, Canada
- Division of Nephrology, University of Toronto, Toronto, ON, Canada
| | - Prosanto Chaudhury
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - David Landsberg
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Michel Paquet
- Centre de recherche du Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
- Division of Nephrology, Department of Medicine, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Marcelo Cantarovich
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Shaifali Sandal
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
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7
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Horton A, Loban K, Fortin MC, Charbonneau S, Nugus P, Pâquet MR, Chaudhury P, Cantarovich M, Sandal S. Living Donor Kidney Transplantation in Quebec: A Qualitative Case Study of Health System Barriers and Facilitators. Can J Kidney Health Dis 2023; 10:20543581221150675. [PMID: 36704234 PMCID: PMC9871975 DOI: 10.1177/20543581221150675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/05/2022] [Indexed: 01/21/2023] Open
Abstract
Background 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. Objective 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. Design 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. Setting The setting for this case study was the province of Quebec, Canada. Participants 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. Methods 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. Results 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. Limitations Delineating the borders of a "case" 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. Conclusions 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.
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Affiliation(s)
- Anna Horton
- Research Institute of the McGill
University Health Centre, Montreal, QC, Canada
| | - Katya Loban
- Research Institute of the McGill
University Health Centre, Montreal, QC, Canada,Division of Nephrology, Department of
Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Marie-Chantal Fortin
- Centre de recherche du Centre
hospitalier de l’Université de Montréal, QC, Canada,Division of Nephrology, Department of
Medicine, Centre hospitalier de l’Université de Montréal, QC, Canada
| | | | - Peter Nugus
- Department of Family Medicine and
Institute of Health Sciences Education, McGill University, Montreal, QC,
Canada
| | - Michel R. Pâquet
- Centre de recherche du Centre
hospitalier de l’Université de Montréal, QC, Canada,Division of Nephrology, Department of
Medicine, Centre hospitalier de l’Université de Montréal, QC, Canada
| | - Prosanto Chaudhury
- Research Institute of the McGill
University Health Centre, Montreal, QC, Canada,Department of Surgery, McGill
University Health Centre, Montreal, QC, Canada
| | - Marcelo Cantarovich
- Research Institute of the McGill
University Health Centre, Montreal, QC, Canada,Division of Nephrology, Department of
Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Shaifali Sandal
- Research Institute of the McGill
University Health Centre, Montreal, QC, Canada,Division of Nephrology, Department of
Medicine, McGill University Health Centre, Montreal, QC, Canada,Shaifali Sandal, Research Institute of the
McGill University Health Centre, Royal Victoria Hospital Glen Site, D05-7176,
1001 boul Decarie, Montreal, QC H4A 3J1, Canada.
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8
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Horton A, Loban K, Nugus P, Fortin M, Gunaratnam L, Knoll G, Mucsi I, Chaudhury P, Landsberg D, Paquet M, Cantarovich M, Sandal S. Health System–Level Barriers to Living Donor Kidney Transplantation: Protocol for a Comparative Case Study Analysis (Preprint).. [DOI: 10.2196/preprints.44172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2023]
Abstract
BACKGROUND
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.
OBJECTIVE
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.
METHODS
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.
RESULTS
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.
CONCLUSIONS
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.
INTERNATIONAL REGISTERED REPORT
DERR1-10.2196/44172
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9
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Sandal S, Schiller I, Dendukuri N, Robert J, Katergi K, Alam A, Cantarovich M, Fiore JF, Suri RS, Landsberg D, Weber C, Fortin M. Identifying Modifiable System-Level Barriers to Living Donor Kidney Transplantation. Kidney Int Rep 2022. [DOI: 10.1016/j.ekir.2022.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/11/2022] [Accepted: 08/29/2022] [Indexed: 11/17/2022] Open
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10
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Wang C, Naylor KL, Luo B, Bota SE, Dixon SN, Yohanna S, Treleaven D, Elliott L, Garg AX. Using Administrative Health Care Databases to Identify Patients With End-Stage Kidney Disease With No Recorded Contraindication to Receiving a Kidney Transplant. Can J Kidney Health Dis 2022; 9:20543581221111712. [PMID: 35898578 PMCID: PMC9309776 DOI: 10.1177/20543581221111712] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 05/30/2022] [Indexed: 11/17/2022] Open
Abstract
Background Administrative health care databases can be efficiently analyzed to describe the degree to which patients with end-stage kidney disease (ESKD) have access to kidney transplantation. Measures of access to transplantation are better represented when restricting to only those patients eligible to receive a kidney transplant. The way administrative data can be used to assess kidney transplant eligibility in the absence of clinical data has not been well described. Objective To demonstrate a method that uses administrative health care databases to identify patients with ESKD who have no recorded contraindication to receiving a kidney transplant. Design and setting Population-based cohort study using linked administrative health care databases in Ontario, Canada. Patients Adult patients with ESKD approaching the need for dialysis (predialysis) or receiving maintenance dialysis between January 1, 2013 and March 31, 2015 in Ontario, Canada. Measurements Recipient of a kidney-only or kidney-pancreas transplant. Methods We assessed more than 80 baseline characteristics, including demographic information, comorbidities, kidney-specific characteristics, and referral and listing criteria for kidney transplantation. We compared these characteristics between patients who did and did not receive a kidney transplant. Results We included 23 642 patients with ESKD (11 195 who were predialysis and 12 447 receiving maintenance dialysis). Over a median follow-up of 3.2 years (25th, 75th percentile: 1.3, 5.6), 3215 (13.6%) received a kidney-only or kidney-pancreas transplant. Of the studied characteristics available in administrative databases, >97% of patients with one or more of these characteristics did not receive a kidney transplant during follow-up: ESKD-modified Charlson Comorbidity Index score ≥7 (a higher score represents greater comorbidity), home oxygen use, age above 75 years, dementia, living in a long-term care facility, receiving at least one physician house call in the past year, and a combination of select malignancies (ie, lung, lymphoma, cervical, colorectal, liver, active multiple myeloma, and bladder cancer). Using these combined criteria reduced the total number of patients from 23 642 to 12 539 with no recorded contraindications to transplant (a 47% reduction), while the proportion who received a kidney transplant changed from 13.6% (denominator of 23 642) to 24.9% (denominator of 12 539). Limitations Administrative databases are unable to capture all the complexities of determining transplant eligibility. Conclusion We identified several criteria available within administrative health care databases that can be used to identify patients with ESKD who have no recorded contraindications to kidney transplant. These criteria could be applied when reporting measures of access to kidney transplantation that require knowledge of transplant eligibility.
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Affiliation(s)
- Carol Wang
- Division of Nephrology, Western University, London, ON, Canada.,London Health Sciences Center, Victoria Hospital, London, ON, Canada
| | - Kyla L Naylor
- ICES, London, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | | | | | - Stephanie N Dixon
- ICES, London, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | | | - Darin Treleaven
- Division of Nephrology, McMaster University, Hamilton, ON, Canada
| | - Lori Elliott
- Ontario Renal Network, Ontario Health, Toronto, Canada
| | - Amit X Garg
- Division of Nephrology, Western University, London, ON, Canada.,ICES, London, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
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11
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Sandal S, Ahn JB, Cantarovich M, Chu NM, Segev DL, McAdams-DeMarco MA. Evolving Trends in Risk Profiles and Outcomes in Older Adults Undergoing Kidney Retransplantation. Transplantation 2022; 106:1051-1060. [PMID: 34115459 PMCID: PMC8636546 DOI: 10.1097/tp.0000000000003842] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In older adults (≥65), access to and outcomes following kidney transplantation (KT) have improved over the past 3 decades. It is unknown if there were parallel trends in re-KT. We characterized the trends, changing landscape, and outcomes of re-KT in older adults. METHODS Among the 44,149 older kidney-only recipients (1995-2016) in the Scientific Registry of Transplant Recipients, we identified 1743 who underwent re-KT. We analyzed trends and outcomes (mortality, death-censored graft failure [DCGF]) by eras (1995-2002, 2003-2014, and 2015-2016) that were defined by changes to the expanded criteria donors and Kidney Donor Profile Index policies. RESULTS Among all older kidney-only recipients during 1995-2002, 2003-2014, 2015-2016 the proportion that were re-KTs increased from 2.7% to 4.2% to 5.7%, P < 0.001, respectively. Median age at re-KT (67-68-68, P = 0.04), years on dialysis after graft failure (1.4-1.5-2.2, P = 0.003), donor age (40.0-43.0-43.5, P = 0.04), proportion with panel reactive antibody 80-100 (22.0%-32.7%-48.7%, P < 0.001), and donation after circulatory death (1.1%-13.4%-19.5%, P < 0.001) have increased. Despite this, the 3-y cumulative incidence for mortality (22.3%-19.1%-11.5%, P = 0.002) and DCGF (13.3%-10.0%-5.1%, P = 0.01) decreased over time. Compared with deceased donor retransplant recipients during 1995-2002, those during 2003-2014 and 2015-2016 had lower mortality hazard (aHR = 0.78, 95% confidence interval, 0.63-0.86 and aHR = 0.55, 95% confidence interval, 0.35-0.86, respectively). These declines were noted but not significant for DCGF and in living donor re-KTs. CONCLUSIONS In older retransplant recipients, outcomes have improved significantly over time despite higher risk profiles; yet they represent a fraction of the KTs performed. Our results support increasing access to re-KT in older adults; however, approaches to guide the selection and management in those with graft failure need to be explored.
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Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec
- Research Institute of the McGill University Health Centre, Montreal, Quebec
| | - JiYoon B. Ahn
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marcelo Cantarovich
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, Quebec
- Research Institute of the McGill University Health Centre, Montreal, Quebec
| | - Nadia M. Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mara A. McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Horton A, Nugus P, Fortin MC, Landsberg D, Cantarovich M, Sandal S. Health system barriers and facilitators to living donor kidney transplantation: a qualitative case study in British Columbia. CMAJ Open 2022; 10:E348-E356. [PMID: 35440483 PMCID: PMC9022938 DOI: 10.9778/cmajo.20210049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In patients with kidney failure, living donor kidney transplantation (LDKT) is the best treatment option; yet, LDKT rates have stagnated in Canada and vary widely across provinces. We aimed to identify barriers and facilitators to LDKT in a high-performing health system. METHODS This study was conducted using a qualitative exploratory case study of British Columbia. Data collection, conducted between October 2020 and January 2021, entailed document review and semistructured interviews with key stakeholders, including provincial leadership, care teams and patients. We recruited participants via purposive sampling and snowballing technique. We generated themes using thematic analysis. RESULTS After analysis of interviews conducted with 22 participants (5 representatives from provincial organizations, 7 health care providers at transplant centres, 8 health care providers from regional units and 2 patients) and document review, we identified the following 5 themes as facilitators to LDKT: a centralized infrastructure, a mandate for timely intervention, an equitable funding model, a commitment to collaboration and cultivating distributed expertise. The relationship between 2 provincial organizations (BC Transplant and BC Renal Agency) was identified as key to enabling the mandate and processes for LDKT. Five barriers were identified that arose from silos between provincial organizations and manifested as inconsistencies in coordinating LDKT along the spectrum of care. These were divided accountability structures, disconnected care processes, missed training opportunities, inequitable access by region and financial burden for donors and recipients. INTERPRETATION We found strong links between provincial infrastructure and the processes that facilitate or impede timely intervention and referral of patients for LDKT. Our findings have implications for policy-makers and provide opportunities for cross-jurisdictional comparative analyses.
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Affiliation(s)
- Anna Horton
- Research Institute of the McGill University Health Centre (Horton, Cantarovich, Sandal); Department of Family Medicine and Institute of Health Sciences Education (Nugus), McGill University; Division of Nephrology (Fortin), Department of Medicine, Centre hospitalier de l'Université de Montréal; Centre de recherche du Centre hospitalier de l'Université de Montréal (Fortin), Montréal, Que.; Department of Medicine (Landsberg), University of British Columbia, Vancouver, BC; Division of Nephrology (Cantarovich, Sandal), Department of Medicine, McGill University Health Centre, Montréal, Que
| | - Peter Nugus
- Research Institute of the McGill University Health Centre (Horton, Cantarovich, Sandal); Department of Family Medicine and Institute of Health Sciences Education (Nugus), McGill University; Division of Nephrology (Fortin), Department of Medicine, Centre hospitalier de l'Université de Montréal; Centre de recherche du Centre hospitalier de l'Université de Montréal (Fortin), Montréal, Que.; Department of Medicine (Landsberg), University of British Columbia, Vancouver, BC; Division of Nephrology (Cantarovich, Sandal), Department of Medicine, McGill University Health Centre, Montréal, Que
| | - Marie-Chantal Fortin
- Research Institute of the McGill University Health Centre (Horton, Cantarovich, Sandal); Department of Family Medicine and Institute of Health Sciences Education (Nugus), McGill University; Division of Nephrology (Fortin), Department of Medicine, Centre hospitalier de l'Université de Montréal; Centre de recherche du Centre hospitalier de l'Université de Montréal (Fortin), Montréal, Que.; Department of Medicine (Landsberg), University of British Columbia, Vancouver, BC; Division of Nephrology (Cantarovich, Sandal), Department of Medicine, McGill University Health Centre, Montréal, Que
| | - David Landsberg
- Research Institute of the McGill University Health Centre (Horton, Cantarovich, Sandal); Department of Family Medicine and Institute of Health Sciences Education (Nugus), McGill University; Division of Nephrology (Fortin), Department of Medicine, Centre hospitalier de l'Université de Montréal; Centre de recherche du Centre hospitalier de l'Université de Montréal (Fortin), Montréal, Que.; Department of Medicine (Landsberg), University of British Columbia, Vancouver, BC; Division of Nephrology (Cantarovich, Sandal), Department of Medicine, McGill University Health Centre, Montréal, Que
| | - Marcelo Cantarovich
- Research Institute of the McGill University Health Centre (Horton, Cantarovich, Sandal); Department of Family Medicine and Institute of Health Sciences Education (Nugus), McGill University; Division of Nephrology (Fortin), Department of Medicine, Centre hospitalier de l'Université de Montréal; Centre de recherche du Centre hospitalier de l'Université de Montréal (Fortin), Montréal, Que.; Department of Medicine (Landsberg), University of British Columbia, Vancouver, BC; Division of Nephrology (Cantarovich, Sandal), Department of Medicine, McGill University Health Centre, Montréal, Que
| | - Shaifali Sandal
- Research Institute of the McGill University Health Centre (Horton, Cantarovich, Sandal); Department of Family Medicine and Institute of Health Sciences Education (Nugus), McGill University; Division of Nephrology (Fortin), Department of Medicine, Centre hospitalier de l'Université de Montréal; Centre de recherche du Centre hospitalier de l'Université de Montréal (Fortin), Montréal, Que.; Department of Medicine (Landsberg), University of British Columbia, Vancouver, BC; Division of Nephrology (Cantarovich, Sandal), Department of Medicine, McGill University Health Centre, Montréal, Que.
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Ibelo U, Green T, Thomas B, Reilly S, King-Shier K. Ethnic Differences in Health Literacy, Self-Efficacy, and Self-Management in Patients Treated With Maintenance Hemodialysis. Can J Kidney Health Dis 2022; 9:20543581221086685. [PMID: 35356537 PMCID: PMC8958521 DOI: 10.1177/20543581221086685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/29/2022] [Indexed: 11/25/2022] Open
Abstract
Background: There is a gap in research investigating the potential impact of ethnicity on health literacy, self-efficacy, and self-management in patients treated with maintenance hemodialysis (MHD). Objective: To explore (1) the associations between health literacy, self-efficacy, and self-management among outpatients with kidney failure receiving treatment with MHD, and (2) the differences in health literacy and self-efficacy based on characteristics of ethnicity (ie, physical resemblance and proficiency in the language of the host population), known to be associated with health care access and health outcomes. Design: Cross-sectional Setting: Outpatients receiving MHD at 7 adult hemodialysis centers in Calgary, Alberta from September 2014 to December 2014. Patients: Participants were grouped into 2 groups based on a proposed 4-quadrant framework of a multicultural society. Quadrant 1 comprised outpatients with physical resemblance and first language of the host population (ie, white and English as a first language), whereas quadrant 4 participants comprised outpatients with physical resemblance and first language not of the host population (ie, non-white and first language other than English). A total of 78 patients (nQ1 = 44, nQ4 = 34) were included. Measurements: Heath literacy, self-efficacy, and self-management were measured using the Health Literacy Questionnaire (HLQ), Strategies Used by People to Promote Health (SUPPH), and Patient Activation Measure-13 (PAM-13), respectively. Methods: Convenience sampling was used to recruit participants at each of the 7 adult hemodialysis centers. All participants completed a study package, which included a demographic questionnaire, HLQ, SUPPH, and PAM-13. Spearman rho was calculated to identify correlations between patient activation level and HLQ and SUPPH scores. Independent t tests were performed to identify differences in HLQ and SUPPH scores between Q1 and Q4 participants. Stepwise regression was performed in other analyses to identify predictor variables of patient activation level. Results: Statistically significant correlations were identified between patient activation level and the health literacy domains of “ability to actively engage with health care providers” (rHLQ6= .535, P < .001), “ability to find good health information” (rHLQ8 = .611, P < .001), and “understanding health information well enough to know what to do” (rHLQ9 = .712, P < .001). There was a statistically significant difference between Q1 and Q4 participants in the health literacy domain of “ability to find good health information” (P = .048). “Understanding health information well enough to know what to do” and “actively managing health” were included in the final stepwise regression model, F(2, 72) = 32.232, P < .001. Limitations: The cross-sectional design limits the generalizability of the results. The small sample size limits the power to identify significant associations and differences. Although English was not the first language of Q4 participants, all were proficient in English, meaning potential differences of a key subgroup of Q4 (ie, those who did not speak any English) were not captured. Conclusion: The HLQ allowed for the creation of a health literacy profile of patients with end-stage kidney disease receiving treatment with MHD. The findings suggest possible associations between specific domains of health literacy and patient activation. Outpatients’ representative of Q4 receiving treatment with MHD appear to struggle more with finding good health information, which may leave them at a disadvantage in the early phases of their self-management efforts. The findings highlight potential opportunities to better tailor patient care to support patients in their self-management, particularly for patients from ethnic minority backgrounds.
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Affiliation(s)
| | - Theresa Green
- School of Nursing Midwifery and Social Work, The University of Queensland, Brisbane Saint Lucia, Australia
- Faculty of Nursing, University of Calgary, AB, Canada
| | - Bejoy Thomas
- Cumming School of Medicine, University of Calgary, AB, Canada
| | - Sandra Reilly
- Faculty of Nursing, University of Calgary, AB, Canada
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Asghari M, Nielsen J, Gentili M, Koizumi N, Elmaghraby A. Identifying internet comments related to living kidney donation: A machine-learning classification approach (Preprint). JMIR Med Inform 2022; 10:e37884. [DOI: 10.2196/37884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/18/2022] [Accepted: 09/19/2022] [Indexed: 11/13/2022] Open
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15
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Sandal S, Horton A, Fortin MC. Advancing a Paradigm Shift to Approaching Health Systems in the Field of Living-Donor Kidney Transplantation: An Opinion Piece. Can J Kidney Health Dis 2022; 9:20543581221079486. [PMID: 35237443 PMCID: PMC8882925 DOI: 10.1177/20543581221079486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 01/20/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- The Metabolic Disorders and Complications Program, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Anna Horton
- The Metabolic Disorders and Complications Program, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Marie-Chantal Fortin
- Division of Nephrology, Department of Medicine, Centre hospitalier de l’Université de Montréal, QC, Canada
- Centre de recherche du Centre hospitalier de l’Université de Montréal, QC, Canada
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16
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Bailey PK, Lyons H, Caskey FJ, Ben-Shlomo Y, Al-Talib M, Babu A, Selman LE. Expectations of a new opt-out system of consent for deceased organ donation in England: A qualitative interview study. Health Expect 2021; 25:607-616. [PMID: 34951093 PMCID: PMC8957744 DOI: 10.1111/hex.13394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/03/2021] [Accepted: 10/10/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction In 2020 England moved to an opt‐out deceased donation law. We aimed to investigate the views of a mixed stakeholder group comprising people with kidney disease, family members and healthcare practitioners towards the change in legislation. We investigated the expected impacts of the new legislation on deceased‐donor and living‐donor transplantation, and views on media campaigns regarding the law change. Methods We undertook in‐depth qualitative interviews with people with kidney disease (n = 13), their family members (n = 4) and healthcare practitioners (n = 15). Purposive sampling was used to ensure diversity for patients and healthcare practitioners. Family members were recruited through snowball sampling and posters. Interviews were audio‐recorded and transcribed verbatim. Transcripts were analysed using thematic analysis. Results Three themes with six subthemes were identified: (i) Expectations of impact (Hopeful patients; Cautious healthcare professionals), (ii) Living‐donor transplantation (Divergent views; Unchanged clinical recommendations), (iii) Media campaigns (Single message; Highlighting recipient benefits). Patients expected the law change would result in more deceased‐donor transplant opportunities. Conclusions Clinicians should ensure patients and families are aware of the current evidence regarding the impact of opt‐out consent: expectations of an increased likelihood of receiving a deceased‐donor transplant are not currently supported by the evidence. This may help to prevent a decline in living‐donor transplantation seen in other countries with similar legislation. Media campaigns should include a focus on the impact of organ receipt. Patient or Public Contribution Two patient representatives from the Kidney Disease Health Integration Team, Primrose Granville and Soumeya Bouacida, contributed to the content and design of the study documents.
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Affiliation(s)
- Pippa K Bailey
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Department of Renal Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Hannah Lyons
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Leeds School of Medicine, University of Leeds, Leeds, UK
| | - Fergus J Caskey
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Department of Renal Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Yoav Ben-Shlomo
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mohammed Al-Talib
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Department of Renal Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Adarsh Babu
- Department of Renal Medicine, Gloucestershire Royal Hospital, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Lucy E Selman
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Whelan AM, Johansen KL, McCulloch CE, Adelmann D, Niemann CU, Roll GR, Siyahian S, Grimes B, Ku E. Longer Distance From Dialysis Facility to Transplant Center Is Associated With Lower Access to Kidney Transplantation. Transplant Direct 2020; 6:e602. [PMID: 33134482 DOI: 10.1097/TXD.0000000000001048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 06/26/2020] [Indexed: 11/26/2022] Open
Abstract
Rates of kidney transplantation vary substantially across dialysis facilities in the United States. Whether distance between the dialysis facility and transplant center associates with variations in transplantation rates has not been examined.
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