Kidney offer acceptance at programs undergoing a Systems Improvement Agreement

Mary G. Bowring, Allan B. Massie, Rebecca Craig-Schapiro, Dorry L. Segev, Lauren Hersch Nicholas

Research output: Contribution to journalArticlepeer-review


In the United States, the Centers for Medicare and Medicaid Services (CMS) use Systems Improvement Agreements (SIAs) to require transplant programs repeatedly flagged for poor-performance to improve performance or lose CMS funding for transplants. We identified 14 kidney transplant (KT) programs with SIAs and 28 KT programs without SIAs matched on waitlist volume and characterized kidney acceptance using SRTR data from 12/2006-3/2015. We used difference-in-differences linear regression models to identify changes in acceptance associated with an SIA independent of program variation and trends prior to the SIA. SIA programs accepted 26.9% and 22.1% of offers pre- and post-SIA, while non-SIA programs accepted 33.9% and 44.4% of offers in matched time periods. After adjustment for donor characteristics, time-varying waitlist volume, and secular trends, SIAs were associated with a 5.9 percentage-point (22%) decrease in kidney acceptance (95% CI: −10.9 to −0.8, P =.03). The decrease in acceptance post-SIA was more pronounced for KDPI 0-40 kidneys (12.3 percentage-point decrease, P =.007); reductions in acceptance of higher KDPI kidneys occurred pre-SIA. Programs undergoing SIAs substantially reduced acceptance of kidney offers for waitlisted candidates. Attempts to improve posttransplant outcomes might have the unintended consequence of reducing access to transplantation as programs adopt more restrictive organ selection practices.

Original languageEnglish (US)
Pages (from-to)2182-2188
Number of pages7
JournalAmerican Journal of Transplantation
Issue number9
StatePublished - Sep 2018


  • Organ Procurement and Transplantation Network (OPTN)
  • Scientific Registry for Transplant Recipients (SRTR)
  • clinical decision-making
  • clinical research/practice
  • ethics and public policy
  • kidney transplantation/nephrology
  • organ acceptance
  • organ procurement and allocation

ASJC Scopus subject areas

  • Immunology and Allergy
  • Transplantation
  • Pharmacology (medical)

Fingerprint Dive into the research topics of 'Kidney offer acceptance at programs undergoing a Systems Improvement Agreement'. Together they form a unique fingerprint.

Cite this