PURPOSE: Practice standardization may decrease donor lung shortages, however, the cause of organ acceptance pattern variation is not known. Our objective was to compare donor call practices in diverse settings. METHODS: This was a prospective, multi-center study of 10 centers from 6 distinct regions. Characteristics of consecutive, first-recipient eligible, donor offers (aged ≥13) received by participating centers with definitive decisions from May 1, 2016 to October 31, 2016 were abstracted along with reasons for organ offer turn downs (as applicable) and final organ disposition. A discrepant decision was defined as a donor lung offer declined by one center that was then accepted for transplant by an alternate center. RESULTS: We evaluated 2,000 consecutive offers; the majority (89.9%) were brain dead donors (BDD). Mean transplant volume was 33 transplants/year (range 11-98). Most centers had ex vivo lung perfusion and all had extra-corporeal membrane oxygenation bridging programs. Surgeons made final acceptance determinations at all centers. Declined organs had a mean donor age of 39 years, with a mean PaO2 to FiO2 (P/f) ratio of 352. The most common primary reason for offer decline was abnormal imaging followed by a low or decreasing P/f ratio. There were 412 (20.7%) discrepant offer decisions (8.1 to 41.2% of offers depending on center). Discrepant decisions significantly differed from non-discrepant decisions by transplant center mean annual volume, donor age, absolute and decreasing P/f ratio, and donor type (BDD versus circulatory death) (p<0.001 in all cases). Age was associated with an increased odds of discrepant offer (OR 3.5, 95% CI 2.2-5.7, p<0.001). For every 10-year increase in donor age, the odds of a discrepant decision increased 1.23 fold. Conversely, for every 50-unit increase in P/f ratio, the odds of a discrepant decision decreased (OR 0.79, 95% CI 0.75-0.84; p<0.001.) Although donor smoking status was not different between discrepant and non-discrepant decisions, for every 5-pack-year increase in donor smoking history the odds of a discrepant decision increased by 1.22 fold. (95% CI 1.1-1.36; p<0.001). CONCLUSION: One in five donor offers that were initially declined by one transplant center were accepted for transplantation by another, highlighting significant variability in donor practices . Key donor and center factors were associated with discrepant decisions.