Implementing the Lung Donor (LUNDON) acceptability score in U.S. donor management and transplant decision-making: A multi-aim, mixed-methods protocol

Background: Despite advances in transplantation science, a persistent shortage of donor lungs continues to limit access to life-saving lung transplants. The Lung Donor (LUNDON) Acceptability Score is a validated tool that predicts donor lung utilization and post-transplant recipient outcomes, but integration into practice remains limited. This study will evaluate determinants of LUNDON score adoption, its impact on clinical decision-making, and develop tools to support its implementation. Methods: This is a multi-aim mixed-methods pre-implementation study that will be conducted across U.S. Organ Procurement Organizations (OPOs) and lung transplant centers. Aim 1 will identify barriers and facilitators of LUNDON score adoption through surveys (n = 242 participants) and interviews (n = 60 participants) of OPO and transplant providers. Aims 2 and 3 will evaluate the impact of the LUNDON score on donor management and organ acceptance using simulation-based experiments with OPO coordinators, OPO clinical leadership, transplant pulmonologists, and transplant surgeons (n = 120 total). Aim 4 will synthesize findings to develop and pilot implementation toolkits across three OPOs and three transplant centers. Two implementation frameworks [the Capability, Opportunity, and Motivation-Behavior (COM-B) model and the Theoretical Domains Framework (TDF)] will guide data collection and analysis, integrating quantitative and qualitative findings. Expected impact: Findings from this collaborative, nationally supported study involving partners from the United Network for Organ Sharing (UNOS) and the national lung transplant community will inform the development of toolkits to support LUNDON score adoption in clinical practice, with the goal of reducing variation in donor management and increasing donor lung utilization. Future studies will explore the effect of LUNDON score adoption on donor lung utilization and recipient outcomes.