PROJECT LEAD(S):
-Chiara Corbetta-Rastelli, MD
-Kate Swanson, MD
EXECUTIVE SPONSOR(S):
-Juan Gonzalez, MD, MS, PhD, Division Chief, UCSF Maternal Fetal Medicine
-Melissa Rosenstein, MD, Medical Director for Quality and Patient Safety for UCSF OB
ABSTRACT:
Vasa previa is a condition where fetal vessels unprotected by umbilical cord or placental tissue course through the membranes in close proximity to the internal cervical os. Before prenatal detection of vasa previa by ultrasound, this condition was associated with very high perinatal mortality rates. There is no difference in neonatal outcomes when comparing inpatient versus outpatient management of this condition. However, historically our practice at UCSF has been to admit all patients diagnosed with vasa previa between 28 – 32 weeks’ gestation, until delivery at 34 – 37 weeks’ gestation. This leads to prolonged hospital stays, resulting in patient-associated burden, but also significant resource utilization and healthcare systems costs. The aim of this proposed initiative is to reduce the proportion of vasa previa patients who are routinely admitted to the UCSF Birth Center by 50% in FY2026. Through a series of interventions including clinician and patient education, qualitative assessments, and system changes, this project will have an estimated direct cost savings of $286,870 during FY2026.
TEAM:
-Chiara Corbetta-Rastelli, MD, PGY-6 in Maternal Fetal Medicine, UCSF
-Kate Swanson, MD, Assistant Professor of Maternal Fetal Medicine, UCSF
-Juan Gonzalez, MD, MS, PhD, Division Chief, UCSF Maternal Fetal Medicine
-Melissa Rosenstein, MD, Medical Director for Quality and Patient Safety for UCSF OB
-Marley Rashad, MD, PGY-6 in Maternal Fetal Medicine, UCSF
PROBLEM:
Vasa previa is a rare condition in pregnancy that refers to unprotected fetal vessels running through the membranes in close proximity to the internal cervical os1,2. Before wide stream use of prenatal ultrasound and antenatal diagnosis, this condition was associated with a high perinatal mortality rate (~60%) due to fetal exsanguination when the membranes rupture or when the cervix dilates in labor3. Currently, neonatal survival is ~99% with excellent neonatal outcomes when vasa previa is diagnosed antenatally and delivery is performed by cesarean section (before rupture of membranes or labor)4.
Once a vasa previa is diagnosed in pregnancy, patients can be managed in the outpatient or inpatient setting. Outpatient monitoring involves serial growth and cervical length ultrasounds, along with twice weekly fetal heart rate monitoring. Inpatient monitoring involves admission to the hospital, as early as 28 weeks’ gestation, with daily (or twice daily) fetal heart rate monitoring, serial ultrasounds and monitoring for any symptoms or signs of vaginal bleeding, contractions, rupture of membranes which could prompt an urgent or emergent cesarean delivery. There are limited retrospective studies assessing whether inpatient versus outpatient management is preferrable – in general, available evidence has shown no difference in neonatal outcomes5–8. Outpatient monitoring is more highly associated with urgent cesarean delivery whereas inpatient monitoring is associated with iatrogenic preterm delivery. Both management options should be routinely offered, taking both patient and logistic risk factors into account. However, our current practice at UCSF is to admit most patients with vasa previa to our antepartum service, with very few providers even discussing outpatient monitoring as an option.
In the last two years (FY2023 and FY2024), approximately 18 patients were admitted to the UCSF Birth Center for “prophylactic” admission for vasa previa, resulting in a total of $1,286,823 direct costs to the hospital system. The average length of stay was 25 days. Given unclear benefit of prophylactic admission regarding clinical outcomes for vasa previa, there is an opportunity for education and system change to reduce inpatient admissions for those patients interested and eligible for outpatient management. Additionally, our Birth Center has struggled with increasing need for divert status, in part due to the limited number of antepartum monitored beds. In the last two years (2023-2024), our unit was on divert for 924 hours (38 days) resulting in 77 transports declined/diverted. By freeing up monitored antepartum beds by reducing these prolonged vasa previa admissions, we may also decrease the need for divert and provide greater access to patients who require transport to UCSF.
TARGET:
Our goal is to reduce the proportion of prophylactic inpatient admissions for vasa previa at the UCSF Birth Center by 50% by the end of FY2026 (ie. 4-5 patients admitted per year for this indication, rather than 9-10 patients). The goal of 50% was primarily chosen to meet the Caring Wisely goal of estimated ROI > $250,000. We also felt that this goal would be achievable; not all patients diagnosed with vasa previa are eligible for outpatient management, for instance, patients with a history of preterm birth or a short cervix would be recommended for inpatient monitoring since their a priori risk of preterm delivery is higher than the general population. Thus, only a subset of patients diagnosed with vasa previa will be offered outpatient management.
The quantitative benefit of this project is to reduce the direct costs associated with prophylactic inpatient admission of vasa previa patients. The total direct cost on average per patient admitted for vasa previa is $71,490. By reducing the number of patients admitted per year to approximately five, the total direct cost savings would be $357,450 (not accounting for outpatient monitoring costs, see below for additional details). Through this project, we would also plan to collect maternal and neonatal outcomes comparing the inpatient versus outpatient groups.
The qualitative benefits include patient satisfaction with an alternative to a prolonged inpatient admission; provider satisfaction with being able to provide alternative options to patients and engaging in a shared decision-making model; assessment of patient experience between inpatient and outpatient management through survey questions and focus groups; possibility of decreasing divert time for Birth Center which leads to improved access for transported patients and higher satisfaction for providers on the unit.
GAPS:
Educational Gaps
-MFM physicians’ lack of knowledge of and/or discomfort with offering outpatient management.
-Nursing lack of knowledge regarding outpatient management for vasa previa (as this is not common practice at UCSF).
-Patient misinformation or lack of understanding regarding vasa previa diagnosis and management.
-No available evidence regarding patient experience after vasa previa diagnosis and decision-making around inpatient versus outpatient monitoring.
Technological Gaps
-None identified.
System Gaps
-Lack of departmental standardized counseling regarding vasa previa management which leads to patient confusion and distrust in medical care team when they receive differing opinions/counseling.
-Lack of departmental standardized algorithm/approach for outpatient management of vasa previa.
INTERVENTION:
-Practice Setting: UCSF Birth Center (Inpatient), Prenatal Diagnostic Center (PDC) & Antenatal Testing Unit (Outpatient)
-Target Population: Pregnant patients diagnosed with vasa previa and planning delivery at UCSF
-Proposed Interventions, description and rationale: See table below
Intervention | Description | Rationale |
Educational sessions for physicians at MFM division meetings | At the start of the study and every 3 months, the project team will provide education regarding outpatient monitoring of vasa previa, reviewing the previously published evidence on this topic, counseling strategies, and eliciting feedback from clinicians throughout the study. | MFM clinicians may be unfamiliar with outpatient management option for vasa previa. |
Educational sessions for outpatient nurses at Operations meetings | At the start of the study and every 3 months, the project team will provide education regarding outpatient monitoring of vasa previa, reviewing what nurses should look out for when patients are presenting for fetal heart rate monitoring and serial ultrasound monitoring (and when to escalate to physician). | Outpatient nurses will be unfamiliar with outpatient monitoring of vasa previa, as this is not currently common practice at UCSF. |
Handout for patients who are diagnosed with vasa previa | Handout will contain general information about vasa previa, along with differences in outpatient versus inpatient management. It will be available to patients in their AVS after they are diagnosed with a vasa previa in the PDC. | Patients may be exposed to misinformation from unreliable sources. |
Patient survey and focus groups regarding experience with vasa previa diagnosis and management | Would request voluntary participation from patients to complete a brief qualitative survey regarding patient experience after vasa previa diagnosis, management, counseling, etc. Patients would be invited to participate in small focus groups / in-depth interviews to further elaborate on their experience. | No information regarding patient experience with this rare, highly stressful condition. No data on how patients decide on inpatient versus outpatient management. Will better aid clinicians in how to approach counseling. |
Handout for MFM clinicians regarding vasa previa management | Comprehensive information sheet would be created for clinicians to reference and utilize as a decision aid when counseling patients regarding management options for vasa previa. | No standardized approach or information regarding counseling on vasa previa management which leads to confusion for patients. |
Outpatient monitoring algorithm proposal | Flowchart that describes contraindications to outpatient management, along with monitoring plan and delivery timing recommendation for patients managed as outpatients. | Our department does not have an approach for managing these patients as outpatients, thus this algorithm can provide an initial framework for clinicians. |
-Barriers to Implementation: Clinicians and patients may have a strong preference for inpatient management of vasa previa. This proposal for outpatient management is not meant to force patients into outpatient monitoring, but to provide an alternative for both patients and clinicians, that is evidence-based and safe. We want to continue supporting shared decision-making and an individualized approach to counseling, but want to create a framework for how outpatient management may be conducted and offered.
-Adverse Outcomes: Although the evidence, albeit limited, does not support this, it is possible that we may see adverse neonatal outcomes with outpatient management. We will collect neonatal outcomes during this project to further assess the safety of outpatient management of vasa previa.
-Plan to measure and close equity gaps: We will collect race/ethnicity, socioeconomic information, highest education level achieved, and preferred language during this project and assess whether certain populations are being offered one management option over the other. If any inequities are identified, we will raise these at our educational meetings with MFM clinicians, and look into specific ways of addressing or closing these gaps. One inequity for recommending inpatient admission (rather than outpatient) is for patients who live far from UCSF. For this project we will identify other tertiary/quaternary hospitals with OB/MFM available 24/7 in Northern California. By identifying nearby hospitals capable of caring for both mother and preterm infant, patients living in more rural areas may still be eligible for outpatient management.
PROPOSED EHR MODIFICATIONS: None
RETURN ON INVESTMENT (ROI):
Inpatient costs
FY2023 – FY2024: 18 patients with vasa previa were admitted to the UCSF Birth Center for a “prophylactic” admission. The average length of stay per patient was 25 days. The average total direct cost per patient was $71,490, ranging between $25,943 to $117,765.
Outpatient costs
Outpatient monitoring would include serial cervical length monitoring (every 2 weeks starting at 28 weeks) and antenatal testing (ie fetal heart rate monitoring) twice weekly starting at 32 weeks until delivery. Cervical length ultrasounds cost $1,378 x 2 additional ultrasounds (compared to inpatient) = $2,756. Antenatal testing cost $1,420 x 8 sessions (2x/wk x 4wks on average) = $11,360. The average total charges per patient for outpatient monitoring would be $14,116.
If our goal is to reduce inpatient admissions by 50% for FY2026, we would aim to only admit 5 patients per year (rather than 10).
-$71,490 x 5 patients (inpatient) = $357,450
-$14,116 x 5 patients (outpatient) = $70,580
-Inpatient – outpatient cost = $357,450 – $70,580 = $286,870 direct cost savings to health system
SUSTAINABILITY:
If successful, these interventions will be sustained by the MFM division at UCSF led by Dr. Gonzalez. However, these interventions are primarily self-sustaining in that once the handout/information has been circulated and/or created it can be maintained within the department’s clinic and prenatal diagnosis center spaces. This outpatient management protocol can be emphasized during the onboarding process of new hires (specifically MFM physicians). The patient experience data can be summarized and circulated to the department to further guide patient-centered counseling strategies in the future.
BUDGET:
-Salary support for project co-leads for project implementation: $20,000 - $30,000
-Salary support for research assistant: $10,000
-Development of educational materials, data analytics: $5,000 - $10,000
-Patient compensation for survey/interview responses: 10 patients x $100 gift card = $1,000
REFERENCES:
1. Sinkey RG, Odibo AO, Dashe JS. #37: Diagnosis and management of vasa previa. American Journal of Obstetrics and Gynecology. 2015;213(5):615-619. doi:10.1016/j.ajog.2015.08.031
2. Oyelese Y, Javinani A, Shamshirsaz AA. Vasa Previa. Obstet Gynecol. 2023;142(3):503-518. doi:10.1097/AOG.0000000000005287
3. Oyelese Y, Catanzarite V, Prefumo F, et al. Vasa Previa: The Impact of Prenatal Diagnosis on Outcomes. Obstetrics & Gynecology. 2004;103(5 Part 1):937. doi:10.1097/01.AOG.0000123245.48645.98
4. Zhang W, Geris S, Al-Emara N, Ramadan G, Sotiriadis A, Akolekar R. Perinatal outcome of pregnancies with prenatal diagnosis of vasa previa: systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2021;57(5):710-719. doi:10.1002/uog.22166
5. Fishel Bartal M, Sibai BM, Ilan H, et al. Prenatal Diagnosis of Vasa Previa: Outpatient versus Inpatient Management. Am J Perinatol. 2019;36(4):422-427. doi:10.1055/s-0038-1669396
6. Villani LA, Al‐Torshi R, Shah PS, Kingdom JC, D’Souza R, Keunen J. Inpatient vs outpatient management of pregnancies with vasa previa: A historical cohort study. Acta Obstet Gynecol Scand. 2023;102(11):1558-1565. doi:10.1111/aogs.14595
7. Laiu S, McMahon C, Rolnik DL. Inpatient versus outpatient management of prenatally diagnosed vasa praevia: A systematic review and meta-analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2024;293:156-166. doi:10.1016/j.ejogrb.2023.11.033
8. Vasa Previa: Outpatient management in low-risk asymptomatic patients is reasonable. European Journal of Obstetrics & Gynecology and Reproductive Biology. Published online December 14, 2023. doi:10.1016/j.ejogrb.2023.12.017