Spotlight paper in the Canadian Journal of Kidney Health and Disease: Anna Horton

The CDTRP would like to congratulate Anna Horton, a qualitative researcher at the Research Institute of the McGill University Health Centre, for her recent publication entitled: “Living Donor Kidney Transplantation in Quebec: A Qualitative Case Study of Health System Barriers and Facilitators” in the Canadian Journal of Kidney Health and Disease!

Our Communications Manager, Stéphanie Larivière, asked Anna a few questions about the publication that you can read below.

Of all individuals you interviewed, what surprised you the most?

Our interviews with stakeholders across the healthcare system revealed that there are attributes of the system that operate to undermine the facilitation of living donor kidney transplantation (LDKT) in Quebec. Given the presence of significant structural barriers, it was surprising and galvanizing to hear about the substantial positive impacts that local champions of LDKT could have in care teams. Participants, particularly in dialysis and pre-dialysis clinics, described how having a ‘pivotal’ member of the team who is knowledgeable about LDKT and advocates for it, helps to increase the capacity of the full team to facilitate LDKT for their patients. We think it is also important to mention how pleasantly surprised we were by the response rate of the participants that we contacted for recruitment, particularly as data collection was conducted during a peak of the COVID-19 pandemic. We would like to sincerely thank our participants for making the time to be interviewed, and for their valuable contributions!

Why is it important to raise awareness on LDKT, especially in the province of Québec?

LDKT is the best treatment option for patients with kidney failure, so it is important to raise awareness and improve access to this treatment for as many patients as possible. Despite being the best treatment option, Quebec has the lowest rates of LDKT in Canada. It is important that we understand if there are attributes of the health system in Quebec that are contributing to these low rates, in order to address these and advance equitable access to gold-standard care for patients across Canada.

How do you think research will advance the field?

Accessing and delivering LDKT involves a multitude of organizations and care teams, as well as, of course, patients and donors. Given the complex interplay of these different people and places, our qualitative approach is apt to understanding why and how LDKT rates are low in Quebec. Our research team draws together the combined expertise of social scientists, practicing nephrologists and patient partners towards this goal. By interviewing stakeholders across the healthcare system – from macro-level governance to the frontlines of care practice – our approach advances understanding of the contingent relationships between different elements of the healthcare system involved in delivering LDKT. Understanding these contingencies is critical for guiding pragmatic and effective interventions.

What are the next steps and how could the CDTRP support the future directions of this work?

Our case study of Quebec forms part of a larger research project which compares how provincial health systems deliver LDKT across Canada. We are drawing together case studies of Quebec, Ontario and British Columbia, as well as data from other provinces, in order to understand what aspects of a provincial system may help or hinder the delivery of LDKT. We have been very lucky to benefit from the continued support of the CDTRP throughout this project in terms of funding, as well as their help with recruitment efforts and facilitating the involvement of patient partners. We hope to engage the CDTRP network to informing the next steps of our work and ultimately improving the care of patients with kidney failure across Canada.


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.

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.

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.

The setting for this case study was the province of Quebec, Canada.

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.

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.

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.

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.

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.

Read the full paper here.

About Anna Horton

Anna Horton holds an undergraduate degree in Social Anthropology from Edinburgh University and an MSC in Family Medicine from McGill University. She is a qualitative researcher at the Research Institute of the McGill University Health Centre, where she applies her background in social sciences to research in transplant nephrology.