Clinical and System-Level Factors Driving Donor Lung Utilization Decisions: A Qualitative Study

<b>Rationale:</b> Key knowledge gaps exist in understanding what drives donor utilization decisions and contributes to the significant variability in organ offer acceptance rates. Defining and addressing the factors that explain variability in organ offer acceptance rates across U.S. transplant centers is a key area of need. <b>Objectives:</b> To identify the clinical and system-level factors that influence donor evaluation and graft acceptance decisions by lung transplant clinicians. <b>Methods:</b> We conducted semistructured interviews with lung transplant clinicians who actively participate in donor evaluation calls and make donor utilization decisions at a U.S. transplant center between December 2022 and September 2023. Interviews were thematically analyzed. <b>Results:</b> From 12 interviews with lung transplant pulmonologists (<i>n</i> = 6) and surgeons(<i>n</i> = 6) across eight different centers, we identified four main themes that represent distinct layers of influence on donor decision-making: <i>1</i>) variability in donor factors considered acceptable for transplant (i.e., donor age, smoking history, oxygenation, imaging) and how to consider donation after cardiac death donor offers; <i>2</i>) the complexity of matching critically ill and difficult-to-match (i.e., highly sensitized, rare blood type) candidates with offered organs; <i>3</i>) the influence of provider training and experience on decision-making; and <i>4</i>) the impact of multiple system factors, including organ allocation, transplant center experience, resources, logistics, donor data availability, donor management strategies, and collaboration with organ procurement organization staff. <b>Conclusions:</b> Our findings offer insight into clinical practice variability, identify areas that may be improved by policy change, highlight opportunities to improve clinical training, and identify directions for future research.