Racial Disparity in Length of Stay Following Implementation of a Bariatric Enhanced Recovery Program.

INTRODUCTION: Enhanced Recovery Programs (ERPs) mitigate racial disparities in postoperative length of stay (LOS) for colorectal populations. It is unclear, however, if these effects exist in the bariatric surgery population. Therefore, this study aimed to evaluate the racial disparities in LOS before and after implementation of bariatric surgery ERP. METHODS: A retrospective cohort study was performed using data from a single institution. Patients undergoing minimally invasive sleeve gastrectomy or Roux-en-Y gastric bypass from 2017 to 2019 (pre-ERP) or 2020-2022 (ERP) were included. Chi-square, Kruskal-Wallis, and analysis of variance were used to compare groups, and estimated LOS (eLOS) was assessed via multivariable regression. RESULTS: Seven hundred sixty four patients were identified, including 363 pre-ERPs and 401 ERPs. Pre-ERP and ERP cohorts were similar in age (median 44.3 years versus 43.8 years, P = 0.80), race (53.4% Black versus 56.4% Black, P = 0.42), and preoperative body mass index (median 48.3 versus 49.4, P = 0.14). Overall median LOS following bariatric surgery decreased from 2 days pre-ERP to 1 day following ERP (P < 0.001). Average LOS for Black and White patients decreased by 0.5 and 0.48 days, respectively. However, overall eLOS remained greater for Black patients compared with White patients despite ERP implementation (eLOS 0.21 days, P = 0.01). CONCLUSIONS: Implementation of a bariatric surgery ERP was associated with decreased LOS for both Black and White patients. However, Black patients did have slightly longer LOS than White patients in both pre-ERP and ERP eras. More work is needed to understand the driving mechanism(s) of these disparities to eliminate them.

Readability of patient education materials for bariatric surgery.

INTRODUCTION: Bariatric surgery is a successful treatment for obesity, but barriers to surgery exist, including low health literacy. National organizations recommend patient education materials (PEM) not exceed a sixth-grade reading level. Difficult to comprehend PEM can exacerbate barriers to bariatric surgery, especially in the Deep South where high obesity and low literacy rates exist. This study aimed to assess and compare the readability of webpages and electronic medical record (EMR) bariatric surgery PEM from one institution. METHODS: Readability of online bariatric surgery and standardized perioperative EMR PEM were analyzed and compared. Text readability was assessed by validated instruments: Flesch Reading Ease Formula (FRE), Flesch Kincaid Grade Level (FKGL), Gunning Fog (GF), Coleman-Liau Index (CL), Simple Measure of Gobbledygook (SMOG), Automated Readability Index (ARI), and Linsear Write Formula (LWF). Mean readability scores were calculated with standard deviations and compared using unpaired t-tests. RESULTS: 32 webpages and seven EMR education documents were analyzed. Webpages were overall "difficult to read" compared to "standard/average" readability EMR materials (mean FRE 50.5 ± 18.3 vs. 67.4 ± 4.2, p = 0.023). All webpages were at or above high school reading level: mean FKGL 11.8 ± 4.4, GF 14.0 ± 3.9, CL 9.5 ± 3.2, SMOG 11.0 ± 3.2, ARI 11.7 ± 5.1, and LWF 14.9 ± 6.6. Webpages with highest reading levels were nutrition information and lowest were patient testimonials. EMR materials were sixth to ninth grade reading level: FKGL 6.2 ± 0.8, GF 9.3 ± 1.4, CL 9.7 ± 0.9, SMOG 7.1 ± 0.8, ARI 6.1 ± 1.0, and LWF 5.9 ± 0.8. CONCLUSION: Surgeon curated bariatric surgery webpages have advanced reading levels above recommended thresholds compared to standardized PEM from an EMR. This readability gap may unintentionally contribute to barriers to surgery and affect postoperative outcomes. Streamlined efforts are needed to create materials that are easier to read and comply with recommendations.

The Living Donor Navigator Program Provides Support Tools for Caregivers.

INTRODUCTION: The Living Donor Navigator (LDN) program is one of several initiatives designed to help transplant candidates identify living donors with the help of a friend or family member advocate to speak on their behalf. More than half of advocates in the LDN program were the spouse or parent of the candidate and served in a caregiving role. Caregivers for patients awaiting transplantation have reported poorer quality of life than the general population, suggesting more support is needed for this vulnerable group. The purpose of this study was to understand whether the LDN program met the needs of advocates who were also caregivers for the transplant candidate. METHODS: We performed a supplementary secondary qualitative analysis of a parent study conducted December 2017-January 2018 with 9 advocates who participated in the LDN program. Transcripts were reanalyzed from focus group discussions, concentrating on comments about caregiving or made by caregivers. Using manual coding and reflexive thematic analysis, we identified broad codes and major themes. FINDINGS: Our re-analysis revealed one theme overlapping with our previous analysis (Support) and 2 new themes specific to caregiver advocates: Quality of Life and Fear. Caregivers agreed that the LDN program equipped them with tools to address these areas and best serve their simultaneous caregiver/advocate roles. DISCUSSION: These analyses demonstrated that those who served as advocate and caregiver derived a benefit from the LDN program but had distinct needs from other advocates. These findings can inform continued refinement of the program and expansion to support needs of caregiver.

Positive Crossmatch Kidney Transplantation: State of the Art and Future Perspectives.

The organ shortage for kidney transplantation remains a challenging issue worldwide. Incompatibility between donor-recipient pairs, commonly occurring among transplant candidates who were sensitized from prior antigen exposure, serves as a significant barrier to kidney transplantation. In efforts to overcome this obstacle, living and deceased donor kidney transplantation across human leukocyte antigen barriers following desensitization has been pursued via positive crossmatch transplantation. The goal of desensitization therapy is to remove or denigrate donor-specific alloantibodies prior to transplantation in order to permit transplantation across the human leukocyte antigen barrier and prevent rejection. Various desensitization regimens have been utilized, including the use of plasmapheresis, intravenous immunoglobulin, and or immunoadsorption. Although long-term allograft outcomes for positive crossmatch kidney transplantation following desensitization therapy have been shown to be inferior to compatible transplantation, particularly with increasing strength of the crossmatch, there is an established survival benefit for positive crossmatch transplant recipients compared with remaining on the transplant waitlist. However, positive crossmatch transplantation may confer higher risks of infection and malignancy. Despite the fact that some of these heightened risks, positive crossmatch transplantation has also been demonstrated to have cost-savings compared with remaining on dialysis and may, therefore, be a cost-effective treatment option for sensitized patients who would face long waiting times and may never be able to achieve compatible transplantation. This review highlights both the risks and benefits of positive crossmatch transplantation and its role in the broader field of kidney transplantation.

Geographic Differences in Population Health and Expected Organ Supply in the Gulf Coast Region of the United States Compared to Non-Gulf States.

BACKGROUND: The Final Rule aimed to reduce geographic disparities in access to transplantation by prioritizing the need for transplant over donor proximity. However, disparities in waiting times persist for deceased donor kidney transplantation. The kidney allocation system implemented in 2014 does not account for potential local supply based on population health characteristics within a donation service area (DSA). We hypothesized that regions with traditionally high rates of comorbid disease, such as the states located along the Gulf of Mexico (Gulf States), may be disadvantaged by limited local supply secondary to poor population health. METHODS: Using data from the Robert Wood Johnson Foundation County Health Rankings, the United States Renal Data System, and the Scientific Registry of Transplant Recipients, we compared population-level characteristics and expected kidney donation rates by Gulf States location. RESULTS: Prevalence of African American ethnicity, end-stage renal disease, diabetes, fair/poor self-rated health, physical inactivity, food insecurity, and uninsurance were higher among Gulf State DSAs. On unadjusted analyses, Gulf State DSAs were associated with 3.52 fewer expected kidney donors per 100 eligible deaths than non-Gulf States. After adjustment, there was no longer a statistically significant difference in expected kidney donation rate. CONCLUSIONS: Although Gulf State DSAs have lower expected donation rates, these differences appear to be driven by the prevalence of health factors negatively associated with donation rate. These data suggest the need to discuss population health characteristics when examining kidney allocation policy, to account for potential lower supply of donors and to further address geographic disparities in access to kidney transplantation.

Enhanced Advocacy and Health Systems Training Through Patient Navigation Increases Access to Living-donor Kidney Transplantation.

BACKGROUND: To date, no living donation program has simultaneously addressed the needs of both transplant candidates and living donors by separating the advocacy role from the candidate and improving potential donor comfort with the evaluation process. We hypothesized that the development of a novel program designed to promote both advocacy and systems training among transplant candidates and their potential living kidney donors would result in sustained increases in living-donor kidney transplantation (LDKT). To this end, we developed and implemented a Living Donor Navigator (LDN) Program at the University of Alabama at Birmingham. METHODS: We included adult patients awaiting kidney-only transplant in a retrospective cohort analysis. Using time-varying Cox proportional hazards regression, we explored likelihood of living donor screening and approval by participation in the LDN program. RESULTS: There were 56 LDN participants and 1948 nonparticipants (standard of care). LDN was associated with a 9-fold increased likelihood of living donor screenings (adjusted hazard ratio, 9.27; 95% confidence interval, 5.97-14.41, P < 0.001) and a 7-fold increased likelihood of having an approved living donor (adjusted hazard ratio, 7.74; 95% confidence interval, 3.54-16.93; P < 0.001) compared with the standard of care. Analyses by participant race demonstrated higher likelihood of screened donors and a similar likelihood of having an approved donor among African Americans compared with Caucasians. CONCLUSIONS: These data suggest that both advocacy and systems training are needed to increase actual LDKT rates, and that LDN programs may mitigate existing racial disparities in access to LDKT.

A Qualitative Assessment of the Living Donor Navigator Program to Identify Core Competencies and Promising Practices for Implementation.

INTRODUCTION: The best strategy to increase awareness of and access to living kidney donation remains unknown. To build upon the existing strategies, we developed the Living Donor Navigator program, combining advocacy training of patient advocates with enhanced health-care systems training of patient navigators to address potential living donor concerns during the evaluation process. Herein, we describe a systematic assessment of the delivery and content of the program through focus group discussion. METHODS: We conducted focus groups with 9 advocate participants in the Living Donor Navigator program to identify knowledge, skills, and abilities needed for both advocates and navigators. We focused on 2 organizational levels: (1) the participant level or the advocacy training of the advocates and (2) the programmatic level or the support role provided by the navigators and administration of the program. FINDINGS: From 4 common themes (communication, education, support, and commitment), we identified several core competencies and promising practices, at both the participant and programmatic levels. These themes highlighted the potential for several improvements of program content and delivery, the importance of cultural sensitivity among the Living Donor navigators, and the opportunity for informal caregiver support and accountability provided by the program. DISCUSSION: These competencies and promising practices represent actionable strategies for content refinement, optimal training of advocates, and engagement of potential living donors through the Living Donor Navigator program. These findings may also assist with program implementation at other transplant centers in the future.

Donation approval among obese living kidney donor candidates: The impact of metabolic syndrome.

BACKGROUND: The scarcity of organs available for transplantation has increased attempts to augment transplantation by utilizing obese living kidney donors. The literature has suggested that these donors have increased risks postdonation. Not surprising, the threshold for living kidney donor approval among obese persons is typically higher and the process more costly. Therefore, a screening tool to predict the likelihood of approval among obese living kidney donor candidates was created. METHODS: A single-center retrospective study was performed among obese (body mass index ≥ 30 kg/m2) living kidney donor candidates evaluated in clinic (January 1, 2012, to December 31, 2017). Approved candidates were compared with those not approved using multivariable logistic regression, and a prediction tool was generated. RESULTS: Among 389 obese living kidney donor candidates, there were no significant differences in sex or race and ethnicity by approval status. However, nonapproved candidates had a higher prevalence of metabolic syndrome. In the prediction model, glucose impairment and hypertension were most predictive of nonapproval. CONCLUSION: Among obese living kidney donor candidates, several metabolic syndrome components were associated with decreased odds of approval. This tool may serve as a useful initial screening for obese living kidney donor candidates, permitting more cost-effective evaluation processes. The tool could also be used to promote expeditious interventions in the preclinical setting, including weight management programs, to improve the likelihood of donation and postdonation outcomes.

Patient Perspectives on Weight Management for Living Kidney Donation.

BACKGROUND: Living kidney donors (LKDs) with obesity have increased perioperative risks and risk of end-stage renal disease after donation. Consequently, obesity serves as a barrier to donation, as many transplant centers encourage or require weight loss before donation for obese LKD candidates. Therefore, this study sought to assess patients' perspectives on weight management strategies before donation among obese LKD candidates. We hypothesized that willingness to participate in a weight loss program may be associated with donor-recipient relationship. MATERIALS AND METHODS: Obese (BMI ≥30 kg/m2) LKD candidates evaluated at a single institution from September 2017 to August 2018 were recruited. A survey was administered to assess LKD candidates' baseline exercise and dietary habits and their interest in weight management strategies for the purpose of donation approval. Participants were grouped by relationship to the recipient (close relatives: first-degree relatives or spouses [n = 29], compared with all other relationships [n = 21]). Descriptive statistics were used to summarize the data. RESULTS: 50 of 51 obese LKD candidates who were approached completed the survey. 90% of participants expressed willingness to lose weight if necessary to become eligible for donor nephrectomy. Compared with all other LKD candidates, close relatives were more likely to be interested in combined diet and exercise programs at our institution (P = 0.01). CONCLUSIONS: Among obese LKD candidates, there was an interest in weight loss for the purposes of living kidney donation approval, particularly among close relatives of potential recipients. Future programs designed to promote weight management efforts for obese LKD candidates should be considered.

Mitigating Racial and Sex Disparities in Access to Living Donor Kidney Transplantation: Impact of the Nation's Longest Single-center Kidney Chain.

OBJECTIVE: In this study, we sought to assess likelihood of living donor kidney transplantation (LDKT) within a single-center kidney transplant waitlist, by race and sex, after implementation of an incompatible program. SUMMARY BACKGROUND DATA: Disparities in access to LDKT exist among minority women and may be partially explained by antigen sensitization secondary to prior pregnancies, transplants, or blood transfusions, creating difficulty finding compatible matches. To address these and other obstacles, an incompatible LDKT program, incorporating desensitization and kidney paired donation, was created at our institution. METHODS: A retrospective cohort study was performed among our kidney transplant waitlist candidates (n = 8895). Multivariable Cox regression was utilized, comparing likelihood of LDKT before (era 1: 01/2007-01/2013) and after (era 2: 01/2013-11/2018) implementation of the incompatible program. Candidates were stratified by race [white vs minority (nonwhite)], sex, and breadth of sensitization. RESULTS: Program implementation resulted in the nation's longest single-center kidney chain, and likelihood of LDKT increased by 70% for whites [adjusted hazard ratio (aHR) 1.70; 95% confidence interval (CI), 1.46-1.99] and more than 100% for minorities (aHR 2.05; 95% CI, 1.60-2.62). Improvement in access to LDKT was greatest among sensitized minority women [calculated panel reactive antibody (cPRA) 11%-49%: aHR 4.79; 95% CI, 2.27-10.11; cPRA 50%-100%: aHR 4.09; 95% CI, 1.89-8.82]. CONCLUSIONS: Implementation of an incompatible program, and the resulting nation's longest single-center kidney chain, mitigated disparities in access to LDKT among minorities, specifically sensitized women. Extrapolation of this success on a national level may further serve these vulnerable populations.

Center Variation and Risk Factors for Failure to Complete 6 Month Postdonation Follow-up Among Obese Living Kidney Donors.

BACKGROUND: Living kidney donors in the United States who were obese at donation are at increased risk of end-stage renal disease and may benefit from intensive postdonation follow-up. However, they are less likely to have complete follow-up data. Center variation and risk factors for incomplete follow-up are unknown. METHODS: Adult living kidney donors with obesity (body mass index, ≥30 kg/m) at donation reported to the Scientific Registry of Transplant Recipients from January 2005 to July 2015 were included (n = 13 831). Donor characteristics were compared by recorded serum creatinine at 6 months postdonation, and multilevel logistic regression models were used to estimate odds of 6-month creatinine. RESULTS: After adjustment, older age, female sex, and donation after implementation of new center follow-up requirements were associated with higher odds of 6-month creatinine, with lower odds for obese donors with a history of smoking, biologically related donors, and at centers with higher total living donor volume. 23% of variation in recorded 6-month serum creatinine among obese donors was attributed to center (intraclass correlation coefficient: 0.232, P < 0.001). The adjusted probability of 6-month creatinine by center ranged from 10% to 91.5%. CONCLUSIONS: Tremendous variation in recorded 6-month postdonation serum creatinine exists among obese living donors, with high volume centers having the lowest probability of follow-up. Moreover, individual-level characteristics such as age, sex, and relationship to recipient were associated with recorded 6-month creatinine. Given increased risk for end-stage renal disease among obese living donors, center-level efforts targeted specifically at increasing postdonation follow-up among obese donors should be developed and implemented.

Obesity and long-term mortality risk among living kidney donors.

BACKGROUND: Body mass index of living kidney donors has increased substantially. Determining candidacy for live kidney donation among obese individuals is challenging because many donation-related risks among this subgroup remain unquantified, including even basic postdonation mortality. METHODS: We used data from the Scientific Registry of Transplant Recipients linked to data from the Centers for Medicare and Medicaid Services to study long-term mortality risk associated with being obese at the time of kidney donation among 119,769 live kidney donors (1987-2013). Donors were followed for a maximum of 20 years (interquartile range 6.0-16.0). Cox proportional hazards estimated the risk of postdonation mortality by obesity status at donation. Multiple imputation accounted for missing obesity data. RESULTS: Obese (body mass index ≥ 30) living kidney donors were more likely male, African American, and had higher blood pressure. The estimated risk of mortality 20 years after donation was 304.3/10,000 for obese and 208.9/10,000 for nonobese living kidney donors. Adjusting for age, sex, race/ethnicity, blood pressure, baseline estimated glomerular filtration rate, relationship to recipient, smoking, and year of donation, obese living kidney donors had a 30% increased risk of long-term mortality compared with their nonobese counterparts (adjusted hazard ratio: 1.32, 95% CI: 1.09-1.60, P = .006). The impact of obesity on mortality risk did not differ significantly by sex, race or ethnicity, biologic relationship, baseline estimated glomerular filtration rate, or among donors who did and did not develop postdonation kidney failure. CONCLUSION: These findings may help to inform selection criteria and discussions with obese persons considering living kidney donation.

Ethnic and Age Disparities in Outcomes Among Liver Transplant Waitlist Candidates.

BACKGROUND: Despite the increasing prevalence of end-stage liver disease in older adults, there is no consensus to determine suitability for liver transplantation (LT) in the elderly. Disparities in LT access exist, with a disproportionately lower percentage of African Americans (AAs) receiving LT. Understanding waitlist outcomes in older adults, specifically AAs, will identify opportunities to improve LT access for this vulnerable population. METHODS: All adult, liver-only white and AA LT waitlist candidates (January 1, 2003 to October 1, 2015) were identified in the Scientific Registry of Transplant Recipients. Age and race categories were defined: younger white (age <60 years), younger AA, older white (age, ≥60 years), and older AA. Outcomes were delisting, transplantation, and mortality and were modeled using Fine and Gray competing risks. RESULTS: Among 101 805 candidates, 58.4% underwent transplantation, 14.7% died while listed, and 21.4% were delisted. Among those delisted, 36.1% died, whereas 7.4% were subsequently relisted. Both older AAs and older whites were more likely than younger whites to be delisted and to die after delisting. Older whites had higher incidence of waitlist mortality than younger whites (subdistribution hazard ratio, 1.07; 95% confidence interval, 1.01-1.13). All AAs and older whites had decreased incidence of LT, compared with younger whites. CONCLUSIONS: Both older age and AA race were associated with decreased cumulative incidence of transplantation. Independent of race, older candidates had increased incidences of delisting and mortality after delisting than younger whites. Our findings support the need for interventions to ensure medical suitability for LT among older adults and to address disparities in LT access for AAs.

Optimal timing of hepatitis C treatment among HIV/HCV coinfected ESRD patients: Pre- vs posttransplant.

Patients with end-stage renal disease (ESRD) who are coinfected with hepatitis C virus (HCV) and human immunodeficiency virus (HIV) have access to effective treatment options for HCV infection. However, they also have access to HCV-infected kidneys, which historically afford shorter times to transplantation. Given the high waitlist mortality and rapid progression of liver fibrosis among coinfected kidney-only transplant candidates, identification of the optimal treatment strategy is paramount. Two strategies, treatment pre- and posttransplant, were compared using Monte Carlo microsimulation of 1 000 000 candidates. The microsimulation was stratified by liver fibrosis stage at waitlist addition and wait-time over a lifetime time horizon. Treatment posttransplant was consistently cost-saving as compared to treatment pretransplant due to the high cost of dialysis. Among patients with low fibrosis disease (F0-F1), treatment posttransplant also yielded higher life months (LM) and quality-adjusted life months (QALM), except among F1 candidates with wait times ≥ 18 months. For candidates with advanced liver disease (F2-F4), treatment pretransplant afforded more LM and QALM unless wait time was <18 months. Moreover, treatment pretransplant was cost-effective for F2 candidates with wait times >71 months and F3 candidates with wait times >18 months. Thus, optimal timing of HCV treatment differs based on liver disease severity and wait time, favoring pretransplant treatment when cirrhosis development prior to transplant seems likely.

Impact of the new kidney allocation system A2/A2B → B policy on access to transplantation among minority candidates.

Blood group B candidates, many of whom represent ethnic minorities, have historically had diminished access to deceased donor kidney transplantation (DDKT). The new national kidney allocation system (KAS) preferentially allocates blood group A2/A2B deceased donor kidneys to B recipients to address this ethnic and blood group disparity. No study has yet examined the impact of KAS on A2 incompatible (A2i) DDKT for blood group B recipients overall or among minorities. A case-control study of adult blood group B DDKT recipients from 2013 to 2017 was performed, as reported to the Scientific Registry of Transplant Recipients. Cases were defined as recipients of A2/A2B kidneys, whereas controls were all remaining recipients of non-A2/A2B kidneys. A2i DDKT trends were compared from the pre-KAS (1/1/2013-12/3/2014) to the post-KAS period (12/4/2014-2/28/2017) using multivariable logistic regression. Post-KAS, there was a 4.9-fold increase in the likelihood of A2i DDKT, compared to the pre-KAS period (odds ratio [OR] 4.92, 95% confidence interval [CI] 3.67-6.60). However, compared to whites, there was no difference in the likelihood of A2i DDKT among minorities post-KAS. Although KAS resulted in increasing A2/A2B→B DDKT, the likelihood of A2i DDKT among minorities, relative to whites, was not improved. Further discussion regarding A2/A2B→B policy revisions aiming to improve DDKT access for minorities is warranted.

Landscape of ABO-Incompatible Live Donor Kidney Transplantation in the US.

BACKGROUND: Widespread implementation of ABO-incompatible (ABOi) living donor kidney transplantation (LDKT) has been proposed as a means to partially ameliorate the national shortage of deceased donor kidneys. Acceptance of this practice has been encouraged by reports from experienced centers demonstrating acute rejection (AR) rates similar to those obtained with ABO-compatible (ABOc) LDKT. Acute rejection rate and graft survival after ABOi LDKT on a national level have yet to be fully determined. STUDY DESIGN: We studied adult (>18 years) LDKT recipients, from 2000 to 2015, reported to the Scientific Registry of Transplant Recipients. Acute rejection rates in the first post-transplant year (modified Poisson regression) and graft survival (Cox proportional hazards) were assessed by ABO compatibility status (ABOi: 930; ABOc: 89,713). RESULTS: Patients undergoing ABOi LDKT had an AR rate of 19.4% compared with 10.5% for ABOc recipients (p < 0.0001). After adjusting for recipient- and donor-related risk factors, patients undergoing ABOi LDKT were found to have a 1.76-fold greater risk for AR within 1 year of transplantation compared with ABOc LDKT recipients (adjusted relative risk [aRR] 1.76; 95% CI 1.54 to 2.01). Moreover, there was a 2.34-fold greater risk of death-censored graft loss at 1-year post-transplant among ABOi vs ABOc LDKT recipients (adjusted hazard ratio [aHR] 2.34; 95% CI 1.85 to 2.96). CONCLUSIONS: Based on these findings, the low rates of AR and excellent short-term graft survival presented in single center series may not be sustainable on a national level. These findings highlight the potential utility for identification of centers of excellence and regionalization of ABOi LDKT.

The psychosocial impact of inpatient management of monoamniotic twin gestations.

OBJECTIVE: Monoamniotic twins require unique considerations in clinical management that challenge both clinicians and patients. The aim of this study was to assess the psychosocial impact of inpatient antepartum versus outpatient management for these patients. METHODS: Women with a history of a monoamniotic twin pregnancy between 2002 and 2012 were identified through a social media group and invited to participate in an original survey regarding their clinical management and psychological well-being during gestation. Results between patients managed with inpatient versus outpatient protocols were compared using the Fisher exact test. RESULTS: Participants (n = 197) were multinational. Planned inpatient management after 23 weeks gestation was reported in 76.2% of respondents. Participants in both groups endorsed persistent feelings of hopelessness or despair related to their pregnancies (42.4% of inpatients versus 24.1% of outpatients, p = 0.089). Relationship strain between participants and their partners was similar in both the groups. Participants in the outpatient group were more likely to report feelings of guilt related to their infrequent monitoring (p = 0.01). Patient satisfaction with care was higher in the inpatient group. CONCLUSIONS: Inpatient management did not significantly increase measures of psychosocial stress as compared to outpatient management. Participants in the outpatient group reported feelings of guilt about their infrequent monitoring. Our findings provide increased understanding of the patient experience in these rare and challenging clinical circumstances.