*Purpose: Increasing and standardizing the use of donors who do not meet the OPTN-defined eligibility criteria would increase the number of organs available for transplantation and could reduce waitlist morbidity and mortality. Ineligible donor use varies dramatically across organ procurement organizations (OPOs) and transplant centers (TCs) in the United States. We aimed to analyze factors at the OPO and TC levels associated with ineligible donor use.

*Methods: We combined OPTN STAR file data with OPTN-provided data of all adult eligible deaths from 2008-2019. We calculated annual ineligible donors use rates across OPOs and TCs for heart, kidney, liver, lung, and pancreas transplants. We also calculated key features of OPOs and TCs, such as waitlist size, mean recipient BMI and age, DCD donation rate, living donor donation rate, overall transplant rate, organ discard rate, and the proportion of female and non-white donors. We analyzed which factors were significantly associated with ineligible donor use via a multi-variate beta regression model.

*Results: 98,348 adult donors met inclusion criteria. Ineligible donor use ranged from 5-39% across OPOs and from 0-47% across TCs. As expected, factors directly related to donor eligibility such as a higher mean donor age and BMI, as well as a higher DCD donation rate were each associated with higher ineligible donor use in both OPOs and TCs (p<0.01 for all). After controlling for these factors, higher proportions of non-white donors were associated with lower ineligible donor use for both OPOs and TCs (β=0.45, p<0.01; β=0.28, p<0.01, respectively). On a TC level, a larger waitlist and an annual increase in waitlist size were associated with higher use (β=0.55, p<0.01; β=0.54, p=0.03, respectively), however these factors were not significant on the OPO level (p=0.87, p=0.10, respectively). On an OPO level, higher discard rates were associated with higher ineligible use rates (β=1.08, p<0.01), while the overall transplant rate was not (p=0.64).

*Conclusions: We found that higher organ demand appears to be associated with ineligible donor use at a TC level. This association is lost at an OPO level, suggesting that OPO level interventions to improve utilization may rather depend on the practices at the TC level. Improving racial/ethnic disparities in ineligible organ utilization is a potential target for improving organ availability.

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