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Heart failure is a growing health problem affecting nearly 6 million in the United States . Heart transplantation is the definitive therapy for the end-stage heart failure patients with the post-transplant survival rate of over 70% . However, the therapy is not available to many due to the severe shortage of donor hearts. The high rejection rate of donor heart offers is a factor that further aggravates the shortage . The paper investigated the causes of and regional variability in offer rejections of adult donor hearts.The UNOS data of the 1,526,306 adult-donor heart offers made between 2003 and 2015 were analyzed. Regional variability in offer rejections was tested using ANOVA. Spatial statistical and mapping analyses were performed to further examine the regional variability and to visualize the spatial pattern of the offer rejections. The likelihood of an offer rejection was estimated using a logistic regression. In the regression, the offer observations were grouped into clusters using donor ID to achieve robust standard errors.Of all offers made, 809,453 (53.03%) were rejected. The primary reason for declining the offers was the quality of donor hearts, accounting for 631,295 (41.36%) of all offers made, followed by donor size/weight (161,078 or 12.74%). ANOVA revealed significant variations in the rejection rate at the OPO (1.22- 46.95%, p < 0.001) and the regional (21.42%-35.11%, p < 0.001) levels. Some parts of the Northeastern US exhibited a higher rejection rate compared to other areas. The logistic regression indicated that a rejection is more likely when: 1) the candidate is male (OR = 1.16, p = 0.003); 2) the distance between a procuring donor hospital and the receiving transplant center is longer (1.002, p < 0.001); and donor is older (OR = 1.004, p < 0.001), female (OR = 1.22, p = 0.001) and African American (OR = 1.32, p < 0.001). The offers made within the same hospital (i.e., donor hospital is also the transplant center receiving the offer) was significantly less likely to be rejected (OR = 0.55, p < 0.001).Regional variability in access to a heart transplant and possible modifications to the current heart allocation system have been discussed. Our findings suggest that regional variability in the rejection rate of donor heart offers as well as donor and patient characteristics associated with such rejections need to be taken into account when modifications in the allocation system is considered.References:1. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statisticsd2013 update: a report from the American Heart Association. Circulation 2013;127:e6–245.2. Colvin‐Adams, M., et al. "OPTN/SRTR 2012 annual data report: heart." American Journal of Transplantation 14.S1 (2014): 113–138.3. Khush, K. K., et al. "National decline in donor heart utilization with regional variability: 1995-2010." American Journal of Transplantation 15.3 (2015): 642–649.