Background: SRTR program reports provide detailed information on transplant center performance relative to risk-adjusted expected values. These measures are utilized by the Centers for Medicare and Medicaid Services (CMS) for their Conditions of Participation (CoP). While the CMS CoP is designed to improve patient outcomes, transplant physicians may alter their selection of patients and donor organs in response to CMS CoP.

Methods: UNOS data on 187 high-volume transplant centers operating in the United States from 6/30/2007-6/30/2010 was used to analyze the utilization decisions resulting from 2,010,966 deceased donor kidney match run offers. Patient, donor and patient-donor matching characteristics were constructed for all match run offers. SRTR program reports were used to construct indicator variables for whether or not a center did not meet either the 1-year total graft survival or 1-year total patient survival CMS CoPs and were interacted with patient and donor risk factors used by SRTR risk adjustments. A series of probit regressions were conducted at the UNOS region level and 22 probit regression models were estimated.

Results: Substantial regional variation exists in transplant center responses to the CMS CoP. When the 1-year total patient graft survival CMS CoP was not met the probability of acceptance decreases with CVA for three regions (p-values <0.05), with donor creatinine levels for four regions (p-values < 0.05), with the patient-donor BMI ratio for three regions (p-values < 0.05), increases with patient age for four regions (p-values < 0.05) and if a patient has previously received a transplant in two regions (p-value < 0.10). When the 1-year total patient survival CMS CoP was not met, the probability of acceptance decreases with CVA for three regions (p-values < 0.10), if the donor has diabetes in three regions (p-values < 0.05), with donor creatinine levels for three regions (p-values < 0.05), with the patient-donor BMI ratio in four regions (p-values < 0.05) and with DCD kidneys in two regions (p-values < 0.05).

Conclusion: When a transplant center does not meet either the CMS CoP for 1-year total graft or patient survival the centers alter their mix of patients and donors by reducing the number of higher risk transplants, thus enabling the centers to increase outcome performance. Further study is needed to determine if this is a benefit to the larger transplant community.

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