<p><strong>BACKGROUND: </strong>To date, no study has evaluated the effects of low center performance evaluations (CPE) on pediatric heart transplant center behavior. We sought to assess the impact of low CPE flags on pediatric heart transplant center listing and transplant volumes and center recipient and donor characteristics.</p>

<p><strong>METHODS: </strong>We included centers performing at least 10 pediatric (age &lt;18 years) transplants during the Scientific Registry of Transplant Recipients reporting period January 2009-June 2011 and evaluated consecutive biannual program specific reports until the last reporting period January 2016-June 2018. We evaluated changes in center behavior at following time points: a year before flagging, a year and two years after the flag; and at last reporting period.</p>

<p><strong>RESULTS: </strong>During our study period, 24 pediatric centers were non-flagged and 6 were flagged. Compared to non-flagged centers, there was a decline in candidate listings in flagged centers at the last reporting period (mean increase of 5.5 ± 12.4 listings vs"?&gt; mean decrease of 14.0 ± 14.9 listings; p&nbsp;=&nbsp;.003). Similarly, the number of transplants declined in flagged centers (mean increase of 2.6 ± 9.6 transplants vs"?&gt; mean decrease of 10.0 ± 12.8 transplants; p&nbsp;=&nbsp;.012). Flagged centers had declines in listings for patients with restrictive cardiomyopathy, re-transplant, renal dysfunction, those on mechanical ventilation and extracorporeal membrane oxygenation. There was no significant change in donor characteristics between flagged and non-flagged centers.</p>

<p><strong>CONCLUSIONS: </strong>Low CPE may have unintended negative consequences on center behavior leading to declines in listing and transplant volumes and potentially leading to decreased listing for higher risk recipients.</p>