Kidney transplant centers flagged twice by CMS for poor outcomes enter a Systems Improvement Agreement (SIA) if they fail to demonstrate mitigating factors. Motivated to improve outcomes, these centers might alter offer acceptance behaviors while undergoing an SIA. We quantified changes in offer acceptance at centers undergoing an SIA.

METHODS: Using 2008-2014 SRTR organ offer data, we identified 18,679 kidney offers made to SIA centers (n=14) 1 yr pre-SIA and 1 yr post-SIA. Two non-SIA centers were randomly selected as controls for each SIA center (n=28) and followed over the same time period to account for underlying time-dependent trends. Using fixed effects linear probability regression, an econometric method, we estimated changes in offer acceptance associated with entering an SIA.

RESULTS: The percent of offers accepted by SIA centers decreased from 13.4% pre-SIA to 8.8% post-SIA (p<0.001), while the percent remained unchanged at non-SIA centers from 14.1% to 13.5% (p=0.4), respectively (Table 1). Post-SIA, SIA centers were less likely to accept kidneys from younger or older donors, donors with history of hypertension or myocardial infarction, or donors with high or low KDPI. Post-SIA, the probability of accepting an offer decreased by 3.6 percentage points overall (p=0.047, Table 2); interestingly, and perhaps counterintuitively, the decrease was worse with better organs: the probability of accepting an offer decreased 9.7 percentage points for kidneys with KDPI<40, and 2.2 percentage points for kidneys with KDPI≥40 (Table 2, Figure 2).

CONCLUSION: Centers that entered SIAs were less likely to accept kidney offers for candidates on their waitlist. This decrease was counterintuitive: acceptance of better organs was affected the most. This side effect of an SIA and the implications on access to transplantation are important to recognize and consider in the context of SIA criteria.

CITATION INFORMATION: Bowring M, Nicholas L, Massie A, Segev D. Reduction in Kidney Offer Acceptance at Centers Undergoing Systems Improvement Agreements. Am J Transplant. 2017;17 (suppl 3).

« Back to 2017 American Transplant Congress