In the Journal of Hepatology, David Goldberg and colleagues, including Benjamin French, James Lewis and Scott Halpern, explore whether transplant centers vary in their propensities to decline organs for the highest priority patients, and how these decisions impact patient outcomes. The authors analyzed Organ Procurement and Transplantation Network (OPTN) data from 2007-2013, and evaluated acceptance rates of liver offers for the highest ranked patients and their subsequent waitlist mortality. Even after adjusting for organ quality and recipient severity of illnesses, the study finds wide variation in the percentage of organ offers transplant centers accepted for the highest priority patients. Furthermore, odds of waitlist mortality increased 27% for every 5% decrease in a center’s adjusted organ offer acceptance rate. The findings suggest that in addition to optimizing allocation of organs based on the acuity level of patients’ needs, center-specific differences in decision-making must be addressed to decrease patients’ odds of dying on the waitlist without transplant.