The dynamics of deceased donor kidney transplant decision making: insights from studying individual clinicians' offer decisions

Despite the high demand, >7500 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 vs centers and examined the role of donor quality in acceptance decisions. We analyzed national transplant registry data (from January 2016 to December 2020) linked to on-call records from 15 transplant centers, creating a clinician-level data set with 344 678 deceased donor kidney offers. The primary outcome was the variability in offer acceptance attributable to clinicians vs centers, quantified via hierarchical, mixed-effect logistic regression models. To complement kidney donor profile index as a measure of donor quality, we incorporated expected acceptance probability, adjusting for a broader set of donor characteristics and recipient factors. Both center-level (0.35; 95% CI: 0.15-0.79) and clinician-level (0.10; 95% CI: 0.06-0.18) variances were significant, with heterogeneity in the kidney donor profile index-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.