*Purpose: Improving organ allocation efficiency has been a focus of the OPTN. While the use of provisional yes (PY) by transplant centers has received recent attention, little is known about these usage and variability of these practices. Our objective was to describe transplant center PY practices at the transplant center and donor level. What is the variability between centers in terms of rate of PY usage? What is the variability in terms of acceptance rates given PY between transplant centers?

*Methods: We collected kidney PTR data from 2015 to 2019 retaining all match runs with at least one kidney accepted. We applied logic to remove offers associated with multi-listed candidates, bypassed offers, and offers beyond the final acceptance. Only the first donor recipient pair was retained. We calculated the number of donors offered to each center, how often each center put in a PY for at least one of their candidates for an offered donor, and how often a transplant center accepted a donor organ given a PY was put in for a given donor.

*Results: The median PY frequency for transplant centers was 40.22% [IQR: 28.90% to 49.53%]. Demonstrated in figure 1, final acceptance given provisional exhibited variability; the median transplant center acceptance rate given a PY, for at least one of their candidates for a given donor, was 20.09% [IQR: 14.42% to 27.86%]. There were centers with an acceptance rate less than 10% and greater than 40%. While large centers tended to be within the IQR, larger centers are not necessarily associated with lower acceptance rates given a PY. That said figure 2 illustrates a weak relation between the number of donors a provisional yes was inputted and provisional yes rate.

*Conclusions: The variability in PY to acceptance rate requires further introspection. While PY rates do not necessarily indicate a metaphorical “rubber stamp”, the variability in acceptance rates combined with some low acceptance rates could indicate room for improvement. Understanding drivers of PY variation, i.e. time of day, missing information, and offer decision making practices, could enable work groups examining this phenomena to develop better solutions to increase system efficiency.

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