BACKGROUND Lung transplantation offers a survival benefit for patients with end-stage lung disease. When suitable donors are identified, centers must accept or decline the offer for a matched candidate on their waitlist. The degree to which variability in per-center offer acceptance practices impacts candidate survival is not established. The purpose of this study was to determine the degree of variability in per-center rates of lung transplantation offer acceptance and to ascertain the associated contribution to observed differences in per-center waitlist mortality. METHODS We performed a retrospective cohort study of candidates waitlisted for lung transplantation in the US using registry data. Logistic regression was fit to assess the relationship of offer acceptance with donor, candidate, and geographic factors. Listing center was evaluated as a fixed effect to determine the adjusted per-center acceptance rate. Competing risks analysis employing the Fine-Gray model was undertaken to establish the relationship between adjusted per-center acceptance and waitlist mortality. RESULTS Of 15,847 unique organ offers, 4,735 (29.9%) were accepted for first-ranked candidates. After adjustment for important covariates, transplant centers varied markedly in acceptance rate (9%-67%). Higher cumulative incidence of 1-year waitlist mortality was associated with lower acceptance rate. For every 10% increase in adjusted center acceptance rate, the risk of waitlist mortality decreased by 36.3% (sub-distribution hazard ratio 0.637; 95% confidence interval 0.592-0.685). CONCLUSIONS Variability in center-level behavior represents a modifiable risk factor for waitlist mortality in lung transplantation. Further intervention is needed to standardize center-level offer acceptance practices and minimize waitlist mortality.

中文翻译：

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供体器官的变异性提供了可接受性和肺移植的存活率。

背景技术肺移植为患有终末期肺病的患者提供了生存益处。当确定合适的捐助者时，中心必须接受或拒绝其候补名单上匹配候选人的报价。尚未确定每个中心的要约接受实践中的可变性影响候选人生存的程度。这项研究的目的是确定接受肺移植的每个中心比率的可变性程度，并确定对每个中心等待名单死亡率观察差异的相关贡献。方法我们使用登记数据对美国等待肺移植的候选人进行了一项回顾性队列研究。Logistic回归适合评估要约接受程度与捐助者，候选人和地理因素之间的关系。将上市中心作为固定效应进行评估，以确定调整后的每个中心的接受率。进行了采用Fine-Gray模型的竞争风险分析，以建立调整后的每中心接受度和候补名单死亡率之间的关系。结果在15,847个独特的器官提议中，排名第一的候选人接受了4,735（29.9％）。在对重要的协变量进行调整后，移植中心的接受率显着不同（9％-67％）。1年候补名单死亡率的较高累积发生率与较低的接受率相关。调整后的中心接受率每增加10％，候补名单死亡率降低36.3％（子分布风险比0.637； 95％置信区间0.592-0.685）。结论中心水平行为的差异代表肺移植中等待名单死亡率的可改变危险因素。需要采取进一步干预措施，以标准化中心水平的报价接受做法并最大程度地降低候补名单死亡率。