*Purpose: This study was designed to identify opportunities to improve UNOS organ allocation as well as providers’ decision-making process for cadaveric kidney offers. Using its DonorNet simulator, SimUNet, UNOS executed a single center focused study of an initial assessment of simulated organ offers which informed a subsequent re-assessment by the same providers. Seven providers (surgeons, nephrologist and physician assistants) from our Transplant team analyzed hypothetical organ offers to assess the impact of questionable biopsy results, donors with acute kidney injury (AKI), and the amount of cold ischemic time on their decision-making logic for accepting organ offers.

*Methods: All providers were sent 22 identical hypothetical kidney offers over a three-week period (7/29/2019-8/16/2019), each having different donor and potential recipient characteristics. Guided by the initial results, a reassessment of the same 22 offers was performed 3 months later, and reports were generated for both assessments. Only 5 providers completed both assessments used for this analysis. Our single center results were compared to a larger, multicenter UNOS study, which included 1,628 hypothetical offers sent out and 1,534 responses. The intent was to investigate both inter- and intra-rater variability in offer decision-making and standardize the decision-making process between providers.

*Results: The mean initial acceptance rate from the multicenter study was 55.5%, whereas Scripps’ initial acceptance rates were lower (42.7%), with provider-to-provider rates from 27.3 to 54.5%. After initial assessment, the providers reviewed the data and discussed ways to bring equity to the organ acceptance decision making process. On reassessment there was an increased mean acceptance rate (70.0%, range 59.1-81.8%). Acceptance rates were lower for offers with questionable biopsy findings and allografts; but AKI donors with a clean” biopsy compared to no biopsy had a nearly doubled acceptance rate.

*Conclusions: This study prompted an intense discussion about our acceptance criteria, which is the likely reason for the ~27% increase in offers accepted upon reassessment. Variability among providers can negatively impact organ allocation, leading to overly conservative assessment and low transplant rates. We believe that this study will bring equity to our decision-making logic on organ offers and lead to a standardized and balanced approach on organ offer acceptance practices at our center.

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