The Dynamics of Deceased Donor Kidney Transplant Decision-Making: Insights from Studying Individual Clinicians' Offer Decisions.

Abstract

Despite the high demand, over 7,500 recovered kidneys annually go unused, with transplant centers showing significant variation in their offer acceptance practices. However, it remains unclear how much of this variation occurs between individual clinicians within the same center and its impact on allocation efficiency and equity. This study quantified the variability in kidney offer acceptance decisions attributable to clinicians versus enters and examined the role of donor quality in acceptance decisions. We analyzed national transplant registry data (Jan. 2016-Dec. 2020) linked to on-call records from 15 transplant centers, creating a clinician-level dataset with 344,678 deceased donor kidney offers. The primary outcome was the variability in offer acceptance attributable to clinicians versus centers, quantified via hierarchical, mixed effects logistic regression models. To complement KDPI as a measure of donor quality, we incorporated Expected Acceptance Probability (EAP), which adjusts for a broader set of donor characteristics and also recipient factors. Both center-level (0.35, 95% CI: 0.15-0.79) and clinician-level variance (0.10, 95% CI: 0.06-0.18) were significant, with heterogeneity in the KDPI-acceptance association among clinicians. These results underscore the need for further research into the mechanisms driving the clinician-level variation and its implications for organ allocation efficacy, equity, and patient outcomes.