{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,26]],"date-time":"2026-04-26T17:35:54Z","timestamp":1777224954952,"version":"3.51.4"},"reference-count":30,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2026,4,17]],"date-time":"2026-04-17T00:00:00Z","timestamp":1776384000000},"content-version":"vor","delay-in-days":16,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,4,1]],"date-time":"2026-04-01T00:00:00Z","timestamp":1775001600000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"funder":[{"DOI":"10.13039\/100013148","name":"Mendez National Institute of Transplantation Foundation","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100013148","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Clinical Transplantation"],"published-print":{"date-parts":[[2026,4]]},"abstract":"ABSTRACT<\/jats:title>\n \n Background<\/jats:title>\n Before KAS250 (circles\u2010based allocation), donor service area (DSA) of listing was\u00a0the largest contributor to deceased donor kidney transplantation (DDKT) rate disparities. Both before and after KAS250, it is unclear to what extent DSA\u2010level disparities are attributable to center\u2010level practice variation. We aimed to disentangle contributions to DDKT rate variation from: (1) center practices, (2) kidney distribution within sharp policy boundaries (DSAs, OPTN Regions), and (3) other geographic variation in kidney scarcity.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n With national transplant registry data, we studied transplant rate variation in the pre\u2010KAS250 era, which prioritized patients based on DSAs and Regions, and under KAS250, which prioritizes patients within 250 nautical mile circles. We modeled candidate DDKT rates with multilevel Poisson regression, adjusting for candidate factors, and calculated median incidence rate ratios (MIRR) to summarize variation attributable to DSAs, OPTN regions, states, census divisions, and to centers within those units.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n DSA\u2010level MIRR declined sharply from\n 1.31<\/jats:sub>\n 1.35\n 1.39<\/jats:sub>\n to\n 1.13<\/jats:sub>\n 1.17\n 1.21<\/jats:sub>\n after KAS250 implementation. Under KAS250, 93.4% of geographic variability in transplant rates was attributable to center\u2010level (within\u2010DSA) variation (MIRR: centers\n 1.76<\/jats:sub>\n 1.82\n 1.86<\/jats:sub>\n , DSAs\n 1.13<\/jats:sub>\n 1.17\n 1.21<\/jats:sub>\n ), while before KAS250, only 81.7% of geographic variability in transplant rates was attributable to center\u2010level (within\u2010DSA) variation (MIRR: centers\n 1.83<\/jats:sub>\n 1.89\n 1.95<\/jats:sub>\n , DSAs\n 1.31<\/jats:sub>\n 1.35\n 1.39<\/jats:sub>\n ). Adjusted center\u2010level DDKT rates under KAS250 were highly associated with offer acceptance rates (\n \u03c1<\/jats:italic>\n = 0.60,\n p<\/jats:italic>\n < 0.001).\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Though geographic disparities are driven primarily by center\u2010level practice differences including offer acceptance, KAS250 did reduce DSA\u2010level disparities. Further allocation policy changes are unlikely to substantially reduce geographic variation in DDKT rates.<\/jats:p>\n <\/jats:sec>","DOI":"10.1111\/ctr.70543","type":"journal-article","created":{"date-parts":[[2026,4,17]],"date-time":"2026-04-17T12:18:04Z","timestamp":1776428284000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Center Geography or Center Practice? Decomposing Geographic Variation in Access to Kidney Transplantation Before Versus After Circles"],"prefix":"10.1111","volume":"40","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0573-6597","authenticated-orcid":false,"given":"Luckmini N.","family":"Liyanage","sequence":"first","affiliation":[{"name":"Department of Surgery NYU Grossman School of Medicine New York New York USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6764-4842","authenticated-orcid":false,"given":"Darren E.","family":"Stewart","sequence":"additional","affiliation":[{"name":"Department of Surgery NYU Grossman School of Medicine New York New York USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3523-243X","authenticated-orcid":false,"given":"Tanveen","family":"Ishaque","sequence":"additional","affiliation":[{"name":"Department of Surgery NYU Grossman School of Medicine New York New York USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1924-4801","authenticated-orcid":false,"given":"Dorry L.","family":"Segev","sequence":"additional","affiliation":[{"name":"Department of Surgery NYU Grossman School of Medicine New York New York USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9923-7408","authenticated-orcid":false,"given":"Michal A.","family":"Mankowski","sequence":"additional","affiliation":[{"name":"Department of Surgery NYU Grossman School of Medicine New York New York USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5288-5125","authenticated-orcid":false,"given":"Allan B.","family":"Massie","sequence":"additional","affiliation":[{"name":"Department of Surgery NYU Grossman School of Medicine New York New York USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4530-8917","authenticated-orcid":false,"given":"Sommer E.","family":"Gentry","sequence":"additional","affiliation":[{"name":"Department of Surgery NYU Grossman School of Medicine New York New York USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2026,4,17]]},"reference":[{"key":"e_1_2_11_2_1","doi-asserted-by":"publisher","DOI":"10.1681\/ASN.2020030335"},{"key":"e_1_2_11_3_1","doi-asserted-by":"publisher","DOI":"10.1681\/ASN.2020121679"},{"key":"e_1_2_11_4_1","unstructured":"Notice of Implementation: Removal of DSA and Region From Kidney and Pancreas Allocation\u2014UNOSAccessed January 14 (2024) https:\/\/unos.org\/news\/implementation\u2010notice\u2010dsa\u2010region\u2010removal\u2010kidney\u2010pancreas\u2010allocation\/."},{"key":"e_1_2_11_5_1","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.14922"},{"key":"e_1_2_11_6_1","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.14622"},{"key":"e_1_2_11_7_1","doi-asserted-by":"publisher","DOI":"10.1007\/s40472\u2010022\u201000384\u2010z"},{"key":"e_1_2_11_8_1","unstructured":"Eliminate the Use of DSA and Region From Kidney Allocation Policy https:\/\/ww.hrsa.gov\/sites\/default\/files\/hrsa\/optn\/kidney\u2010removal\u2010of\u2010dsa\u2010policy\u2010notice.pdf."},{"key":"e_1_2_11_9_1","doi-asserted-by":"publisher","DOI":"10.1097\/SLA.0000000000006770"},{"key":"e_1_2_11_10_1","doi-asserted-by":"publisher","DOI":"10.1093\/biostatistics\/kxn014"},{"issue":"6","key":"e_1_2_11_11_1","first-page":"S811","article-title":"Geographic Inequity in Access to Donors Persists Under Ring\u2010Based Kidney Allocation","volume":"23","author":"Zeng S.","journal-title":"American Journal of Transplantation"},{"key":"e_1_2_11_12_1","doi-asserted-by":"publisher","DOI":"10.1097\/TXD.0000000000001886"},{"key":"e_1_2_11_13_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600\u20106143.2011.03789.x"},{"key":"e_1_2_11_14_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.kint.2016.03.007"},{"key":"e_1_2_11_15_1","doi-asserted-by":"publisher","DOI":"10.1097\/01.sla.0000124296.46712.67"},{"key":"e_1_2_11_16_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600\u20106143.2007.02098.x"},{"key":"e_1_2_11_17_1","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.15394"},{"key":"e_1_2_11_18_1","doi-asserted-by":"publisher","DOI":"10.1097\/MOT.0000000000000947"},{"key":"e_1_2_11_19_1","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.14907"},{"key":"e_1_2_11_20_1","doi-asserted-by":"publisher","DOI":"10.1097\/TP.0000000000001373"},{"key":"e_1_2_11_21_1","unstructured":"Enhance Transplant Program Performance Monitoring System_MPSC_Policy Notice. Notice of OPTN Bylaw Changes. January 29 (2026) https:\/\/www.hrsa.gov\/sites\/default\/files\/hrsa\/optn\/policy\u2010notice_tx\u2010prgm\u2010performance\u2010monitoring_dec\u20102021.pdf."},{"key":"e_1_2_11_22_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.ajkd.2024.07.014"},{"key":"e_1_2_11_23_1","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.14964"},{"key":"e_1_2_11_24_1","unstructured":"A. K.Glazier The Lung Lawsuit: A Case Study In Organ Allocation Policy and Administrative Law(2018) https:\/\/unos.org\/wp\u2010content\/uploads\/glazier\u2010article\u2010final.pdf."},{"key":"e_1_2_11_25_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600\u20106143.2010.03043.x"},{"key":"e_1_2_11_26_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1600\u20106143.2007.01785.x"},{"key":"e_1_2_11_27_1","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.15115"},{"key":"e_1_2_11_28_1","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.16859"},{"key":"e_1_2_11_29_1","doi-asserted-by":"publisher","DOI":"10.1097\/MOT.0000000000001049"},{"key":"e_1_2_11_30_1","doi-asserted-by":"publisher","DOI":"10.1097\/TP.0000000000002362"},{"key":"e_1_2_11_31_1","doi-asserted-by":"publisher","DOI":"10.1111\/ajt.16411"}],"container-title":["Clinical Transplantation"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/ctr.70543","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1111\/ctr.70543","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/ctr.70543","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,26]],"date-time":"2026-04-26T17:10:14Z","timestamp":1777223414000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/ctr.70543"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4]]},"references-count":30,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2026,4]]}},"alternative-id":["10.1111\/ctr.70543"],"URL":"https:\/\/doi.org\/10.1111\/ctr.70543","archive":["Portico"],"relation":{},"ISSN":["0902-0063","1399-0012"],"issn-type":[{"value":"0902-0063","type":"print"},{"value":"1399-0012","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4]]},"assertion":[{"value":"2025-09-30","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-04-06","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-04-17","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e70543"}}