Difference-making factors in implementing a quality improvement program for sleep apnea in stroke/TIA patients

Area of Science:

• Quality Improvement in Healthcare
• Sleep Medicine and Neurology
• Health Services Research

Background:

• Obstructive sleep apnea (OSA) is a prevalent, underdiagnosed risk factor in ~70% of stroke/TIA patients, linked to poor recovery and increased mortality.
• Despite guidelines, early OSA screening post-stroke/TIA is infrequent, hindering effective risk factor management and prevention of recurrent events.
• This study addresses the implementation of a quality improvement intervention for OSA management within the Department of Veterans Affairs (VA) healthcare system.

Purpose of the Study:

• To explore the implementation of a multidisciplinary quality improvement intervention for obstructive sleep apnea (OSA) management in stroke and TIA patients.
• To identify contextual factors influencing the success of implementing an acute sleep service across six VA medical centers.
• To determine conditions associated with successful OSA diagnosis and treatment adoption in post-stroke/TIA populations.

Main Methods:

• Utilized data from the Addressing Sleep Apnea Post-Stroke/TIA (ASAP) stepped-wedge cluster-randomized clinical trial (NCT04322162).
• Employed mixed-methods, including qualitative provider interviews and quantitative configurational comparative methods (CCMs).
• Assessed implementation success using the Group Organization (GO) score, measuring team cohesion and activation in OSA care.

Main Results:

• Successful implementation (GO score ≥ 6) was achieved at four out of six participating VA medical centers.
• Four specific conditions were identified as sufficient for implementation success: sleep test ordering, process monitoring, post-discharge care coordination, and champion influence.
• These factors significantly distinguished between sites that successfully implemented the OSA intervention and those that did not.

Conclusions:

• Successful implementation of acute sleep services hinges on the interplay between local context and the adoption of new clinical practices.
• Four key 'difference-makers' were identified, providing actionable insights for optimizing implementation strategies for OSA management in stroke patients.
• Findings offer guidance for tailoring and timing interventions to improve the adoption of OSA screening and treatment in cerebrovascular patient populations.