*Purpose: Previous studies have demonstrated decreased transplant rates among poor performing transplant centers meeting Centers for Medicare & Medicaid Services (CMS) flagging criteria. However, no studies have examined the risk of waitlist mortality in liver candidates listed at a low performance transplant center. Thus, we sought to evaluate the impact of center flagging for poor outcomes and risk of waitlist mortality and transplant in a contemporary cohort of liver candidates.

*Methods: 68,500 adult (>18 years) liver-only candidates were listed between 06/18/13 to 12/21/17) in the SRTR. Flagging was defined using CMS criteria for 1-year patient and graft survival. Fine and Gray competing risk models in which flagging was a time-dependent variable were constructed to determine risk of waitlist mortality and likelihood of transplant associated with flagging after adjustment for factors contained in the SRTR waitlist mortality risk-adjustment model.

*Results: Of the 123 centers evaluated, 28 (22.8%) were flagged at least once for low performance. Baseline demographics showed centers that were ever flagged had candidates that were more likely to be African American, Hispanic, and diabetic. After adjusting for demographics, flagging of a transplant center was found to be associated with 30% increased risk of waitlist mortality in liver candidates (adjusted HR (aHR): 1.30, 95%CI: 1.09-1.56). After accounting for the competing risks of waitlist mortality or removal from the waitlist, candidates were 15% less likely to be transplanted at a flagged center as compared to a non-flagged center (aHR: 0.85, 95% CI: 0.76-0.96, p=0.01) (Figure).

*Conclusions: These data suggest that centers became more conservative after being flagged, resulting in higher risk of waitlist mortality and decreased likelihood of transplant. Further research is needed to determine if there is a disproportionate impact on vulnerable populations such as racial or ethnic minorities.

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