title: Liver transplant center variability in accepting organ offers and its impact on patient survival.
abstract: OBJECTIVE
  Despite an allocation system designed to give deceased-donor livers to the sickest patients, many transplantable livers are declined by U.S. transplant centers. It is unknown whether centers vary in their propensities to decline organs for the highest priority patients, and how these decisions directly impact patient outcomes.
  
  
  METHODS
  We analyzed Organ Procurement and Transplantation Network (OPTN) data from 5/1/07-6/17/13, and included all adult liver-alone waitlist candidates offered an organ that was ultimately transplanted. We evaluated acceptance rates of liver offers for the highest ranked patients and their subsequent waitlist mortality.
  
  
  RESULTS
  Of the 23,740 unique organ offers, 8882 (37.4%) were accepted for the first-ranked patient. Despite adjusting for organ quality and recipient severity of illness, transplant centers within and across geographic regions varied strikingly (p<0.001) in the percentage of organ offers they accepted for the highest priority patients. Among all patients ranked first on waitlists, the adjusted center-specific organ acceptance rates ranged from 15.7% to 58.1%. In multivariable models, there was a 27% increased odds of waitlist mortality for every 5% absolute decrease in a center's adjusted organ offer acceptance rate (adjusted OR: 1.27, 95% CI: 1.20-1.32). However, the absolute difference in median 5-year adjusted graft survival was 4% between livers accepted for the first-ranked patient, compared to those declined and transplanted at a lower position.
  
  
  CONCLUSIONS
  There is marked variability in center practices regarding accepting livers allocated to the highest priority patients. Center-level decisions to decline organs substantially increased patients' odds of dying on the waitlist without a transplant.
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, USA. Electronic address: david.goldberg@uphs.upenn.edu.
authors.forename: David S
authors.initials: DS
authors.lastname: Goldberg
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, USA.
authors.forename: Benjamin
authors.initials: B
authors.lastname: French
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, USA.
authors.forename: James D
authors.initials: JD
authors.lastname: Lewis
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, USA.
authors.forename: Frank I
authors.initials: FI
authors.lastname: Scott
authors.affiliation: Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, USA.
authors.forename: Ronac
authors.initials: R
authors.lastname: Mamtani
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Gilroy
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, USA; Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, USA.
authors.forename: Scott D
authors.initials: SD
authors.lastname: Halpern
authors.affiliation: Division of Transplantation, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Peter L
authors.initials: PL
authors.lastname: Abt
mesh_terms: D005260:Female; D006801:Humans; D016031:Liver Transplantation / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D012720:Severity of Illness Index; D009927:Tissue and Organ Procurement; D014850:Waiting Lists
keywords: Decline; Organ offer; Waitlist mortality