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

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Abstract Background Effective prevention of ischemic stroke and transient ischemic attack (TIA) involves timely, guideline-concordant risk factor management. Obstructive sleep apnea (OSA), a significant but underdiagnosed cerebrovascular risk factor, affects approximately 70% of stroke and TIA patients. Untreated OSA is linked to impaired post-stroke recovery, recurrent vascular events, and increased mortality. Despite guideline recommendations to consider early post-stroke/TIA OSA screening, few patients receive sleep studies. This study explores the implementation of a multidisciplinary quality improvement intervention for OSA management at six Department of Veterans Affairs medical centers between 2021 and 2024, focusing on contextual factors influencing implementation success. Methods This mixed-methods study used data from the Addressing Sleep Apnea Post-Stroke/TIA (ASAP) stepped-wedge cluster-randomized clinical trial (NCT04322162). We conducted qualitative analyses of provider interviews and quantitative assessments via configurational comparative methods (CCMs) to identify difference-making conditions for successful implementation. The Group Organization (GO) score, a facility-level measure indicating team cohesion and activation in diagnosing and treating OSA among patients with acute cerebrovascular events, served as the primary implementation outcome. Results Successful implementation, defined by a GO score of ≥ 6, was achieved at four of the six facilities. Four conditions were sufficient by themselves for implementation success: implementation of sleep test ordering, monitoring sleep testing processes, post-discharge care coordination, and positive influence of champions during implementation. Conclusions This study highlights the interplay between local context and novel clinical practices in successful program implementation of an acute sleep service. Four difference-makers perfectly distinguished between sites with and without implementation success. These findings provide actionable insights for tailoring and timing implementation strategies to improve adoption. Trial registration ClinicalTrials.gov NCT04322162.

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