*Purpose: There is growing recognition that efforts to increase living donor kidney transplantation (LDKT) should focus on health system-level inefficiencies. While previous studies focused on the perspective of patients, health professionals (HPs) may provide relevant insights into health system-level barriers to delivering LDKT. We aimed to quantify system-level barriers that HPs have identified in our previous qualitative work and compare them by LDKT performance.

*Methods: We conducted a cross-sectional survey of HPs across different transplant jurisdictions with variable LDKT performance. Participants were asked to rate several statements on a Likert scale and rate priorities to increase LDKT. Levels of agreement were assessed according to jurisdiction LDKT performance and HP characteristics.

*Results: We obtained 353 complete responses. When compared with HPs from higher LDKT performing jurisdictions, HPs from lower-performing jurisdictions had lower odds of agreeing that their jurisdiction actively promoted LDKT (aOR=0.27, 95%CI:0.16-0.48) and higher odds of agreeing that if they had more resources, they would discuss LDKT more with patients (aOR=2.06, 95%CI:1.25-3.40) (Table 1). The theme of poor role perception also emerged as a notable finding. HP from lower-performing jurisdictions had lower odds of initiating discussions about LDKT with their patients (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). Also, non-physicians experienced significantly more barriers across several domains. HPs ranked the following three as top priorities to increase LDKT: 1) create standardized referral and evaluation guidelines; 2) organize and streamline evaluation; and 3) provide more education and training to HPs.

*Conclusions: We report that barriers related to resources, LDKT promotion, and role perception were more prominent in lower-performing jurisdictions. HPs identified improving system-level inefficiencies and educating and training HPs as priorities to increasing LDKT. Our findings have practice and policy implications and can inform system-level interventions to improve LDKT.

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