The Impact of Pre-Transplant Mortality Ratio Metric Implementation: A National Survey

Daniel Katz; Shengliang He; Mary Charlton

doi:10.1016/j.ajt.2025.12.271

Background:In July 2024, the United Network for Organ Sharing implemented a new performance metric focusing on pre-transplant wait-list mortality. This metric complements existing measures such as post-transplant survival and plays an important role in how transplant programs are evaluated and held accountable. This study aimed to assess the perceived impact of the new metric on listing practices and organ utilization, particularly in the context of pressures to increase organ utilization to reduce waitlist deaths. Methods:An anonymous survey was distributed to American Society of Transplant Surgeons members via email over four consecutive weeks with weekly reminders. The study was approved by the University of Iowa Institutional Review Board (IRB #202506618). Results:The overall response rate was 8.9% (106/1186). Nearly all respondents were surgeons (97%), and 64% were surgical or medical directors at their transplant center. Most respondents (85%) worked in academic centers. Over 40% indicated the metric influenced decisions to list fewer high-risk patients, while 13% reported adding restrictions to waitlist eligibility. Twelve percent believed the primary goal of the metric was to encourage less aggressive listing practices, and 16% reported modifying listing practices in response. However, 39% noted they only occasionally had the ability to influence waitlist mortality, and 22% felt they had no influence at all. Nineteen percent of respondents were unaware of the metric’s implementation. Knowledge gaps were also evident: only 20% correctly identified the observation period used, and 33% were unsure whether inactive patients were included in mortality calculations. Open-ended responses highlighted concerns that the metric could encourage more conservative listing practices, penalize programs for outcomes outside their control, and disproportionately challenge centers serving regions with poorer overall healthcare outcomes, such as the rural areas, and lower-income populations. Conclusion:A substantial proportion of respondents indicated that the pre-transplant mortality ratio metric implemented in July 2024 may drive more conservative listing practices and restrict access for patients in underserved healthcare systems. The survey highlighted limited understanding within the transplant community regarding the metric’s design and application.

The Impact of Pre-Transplant Mortality Ratio Metric Implementation: A National Survey

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