Original Title: État des pratiques : La transplantation d’organes solides – Volet 2 - Portrait de la transplantation hépatique au Québec

Authors' objectives: Organ transplantation is the gold standard or last-resort treatment option capable of improving survival in patients diagnosed with end-stage organ failure. It is also an alternative to cardiac support devices and to dialysis in cases of renal failure. Transplantation is a complex procedure performed in individuals at an advanced stage of a medical condition and requires numerous types of expertise before, during and after the intervention. In this context, the quality of care and the clinical outcomes depend on several structural and organizational parameters. In recent years, much thought has been given and work done to improve the organization of donation and transplant services in Québec, including the development of organ allocation protocols. However, the current picture of organ transplantation activities and their outcomes is not clearly known, which is hindering an assessment of the entire donation and transplantation care and services continuum. At the request of the Ministère de la Santé et des Services sociaux (MSSS) and the healthcare system, the Institut national d'excellence en santé et en services sociaux (INESSS) has prepared a state-of-practice report aimed, on the one hand, at highlighting the organizational aspects of care and services recognized or recommended in the liver transplantation literature and at comparing them to those in place at Québec’s designated transplant centres, and secondly, at constructing, using selected variables, a descriptive overview of the use of certain clinical and clinico-administrative outcomes of the transplantation activities between 2009 and 20181. The goal of this exercise is to support the improvement of the management of patients who are waiting for or who have undergone a transplant and to improve the quality of liver transplant outcomes in Québec. The mandate is divided into three sections, each presented in a separate statement-ofpractice report: Section 1) Heart and lung transplantation; Section 2) Liver transplantation (the present overview); and Section 3) Renal and pancreatic transplantation

Authors' results and conclusions: RESULTS: (#1: Guidance documents): A limited number of guidance documents published by health authorities, professional associations or organizations, and organizations in the field of transplantation, and few items describing organizational practices in countries or provinces comparable to Québec were identified. No recent guidance documents from Québec were found. Moreover, even though most of the guidance documents identified are based on expert consensus, sometimes supported by a more or less extensive literature review, one does find certain structural elements and organizational processes about which there seems to be a consensus in the organ transplantation community, this across all three sections: • A medical director, a transplant coordinator and a qualified interdisciplinary team on site, and the availability of adequate physical and technological resources; • The use of various clear processes to support the different stages of the patient care continuum at various times: during the waiting period (clinical assessment, ongoing information); during hospitalization for the transplant (admission, preoperative assessment, interdisciplinary follow-up, patient education, discharge and transfer); and after hospital discharge (medical follow-up and intra- and interinstitutional coordination); • Support for care coordination and continuity throughout the care continuum, and support for patients and their families; • The use of mechanisms and procedures for evaluating and improving the quality of interventions and care. (#2: Service organization and organizational practices at Québec’s transplant centres): The consultations with Québec’s transplant centres brought to light various structural and organizational arrangements, many of which are consistent with the organizational practices recognized in the literature. The ensuing overall results are reported in the state-of-practice report for each section, with details on the liver transplant program reported as well: • Access to transplantation is protocol-based and centralized, and the referral of potential transplant candidates is supported by information mechanisms with the clinical teams and memoranda of understanding and initiatives between the transplant centres and regional facilities; (#3: Portrait of patients who underwent a liver transplant in Québec between 2009 and 2018): Exploring the CADs enabled us to draw a first descriptive portrait of patients who underwent a liver transplant in Québec between 2009 and 2018: 883 adult patients and 73 pediatric patients. Despite the limitations of this exercise, particularly with respect to the validity of the clinical information, the following highlights emerged and, when possible, were assessed in light of available national and international data. • There is a steady demand for liver transplants, All things considered, the volume of liver transplants performed in Québec is generally similar to that performed in other Canadian provinces and internationally. • The sociodemographic profile of the patients who underwent a liver transplant was fairly similar to what is observed internationally: adults of around 57 years of age or young children, predominantly male. ISSUES, CHALLENGES AND OPPORTUNITIES: Certain organizational and population-level concerns and challenges were identified when examining the literature data or registry data or were raised during the consultations with clinicians and the liver transplant program directors. These concerns and challenges are very similar across the different organ transplant programs, as seen in the other two transplantation overviews: Section 1 (heart and lung) and Section 3 (kidney and pancreas). One potential issue concerns access to transplantation. The geographic concentration of liver transplant centres in Montréal might raise the question of access to a transplant for patients from certain health and social services regions. The distribution of patients who received a transplant compared to that of the Québec population by health and social services region does not, however, generally suggest that certain regions are significantly over- or underrepresented. However, this assessment has numerous limitations that could not be examined in this report. In particular, a careful examination of the population’s needs could contribute to the discussion on the relevance of implementing mechanisms to support equity of access. CONCLUSION: Despite a number of limitations, this initial Québec overview suggests that the clinicoadministrative outcomes of liver transplantation activities in Québec are, on the whole, comparable to those obtained in other countries or provinces similar to Québec in North America and elsewhere. These data will serve to guide the discussion regarding the implementation and ranking of variables of interest for monitoring and assessing the quality of transplant program activities. It would also be interesting to examine the clinico-administrative data collected during the years of the COVID-19 pandemic in order to assess its impact on transplantation activities. The findings from the exploration of the CADs for the purposes of this descriptive overview, and those concerning heart and lung, and renal and pancreatic transplantation will be the subject of a future publication. Lastly, work by the Canadian Institute for Health Information (CIHI) on the monitoring and optimization of transplantation activities ‒ in which certain Québec experts are participating ‒ is also underway with a view to proposing quality monitoring indicators. All of these initiatives will eventually lead to a more complete update of the present overview.

Authors' methods: The scientific and grey literature (from 2009 to 2021) were reviewed to identify the current guidelines and organizational practices in countries or provinces comparable to Québec in terms of their healthcare system. The websites of the health authorities in different countries and Canadian provinces and the websites of professional associations and bodies in the field of transplantation were consulted. Countries and provinces that have an action plan for the organization of solid organ transplantation care and services, that have developed transplantation care policies or that have put mechanisms in place to evaluate transplantation care performance and strategies were targeted. The practice overview of Québec’s transplant centres was constructed from data in Québec’s clinical administrative databases (CADs), a questionnaire (common to all three sections), and consultations with the clinical teams at the different designated liver transplant centres (Royal Victoria Hospital/McGill University Health Centre, Centre hospitalier de l'Université de Montréal and Centre hospitalier universitaire Sainte-Justine) and with patients and caregivers.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/la-transplantation-dorganes-solides-volet-2-portrait-de-la-transplantation-hepatique-au-quebec.html

Year Published: 2022

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/la-transplantation-dorganes-solides-volet-2-portrait-de-la-transplantation-hepatique-au-quebec.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec