# Quality Improvement Intervention to Increase Sleep Apnea Diagnostic Testing After Stroke and Transient Ischemic Attack: A Cluster Randomized Trial

## TL;DR

A quality improvement program significantly increased sleep apnea testing in stroke and TIA patients at VA hospitals.

## Contribution

A stepped-wedge cluster trial demonstrated that quality improvement strategies can boost sleep apnea diagnostic testing in acute cerebrovascular patients.

## Key findings

- OSA diagnostic testing rates rose from 2.1% to 29.1% during intervention implementation.
- Positive airway pressure treatment rates increased from 0.3% to 2.8% in intervention sites.
- No significant changes were observed in readmission or vascular event rates.

## Abstract

Can a quality improvement intervention improve sleep apnea diagnostic testing among patients who are hospitalized for acute ischemic stroke or transient ischemic attack?

In this stepped-wedge cluster randomized trial with 1747 patients at 6 intervention sites and 7454 patients at 30 usual care sites, the 30-day diagnostic testing rate increased from 2.1% (baseline) to 29.1% (21-month active implementation), whereas usual care sites maintained a low rate.

These results suggest that sites seeking to implement acute care sleep services can use quality improvement strategies to provide sleep apnea diagnostic testing to patients with acute cerebrovascular disease.

This cluster randomized trial of patients with ischemic stroke or transient ischemic attacks admitted to Department of Veterans Affairs facilities examines the effectiveness of a quality improvement intervention to increase obstructive sleep apnea diagnostic testing.

Obstructive sleep apnea (OSA) is common among patients with ischemic stroke and transient ischemic attack (TIA) and is associated with poor outcomes. Guidelines favor considering sleep testing among patients with cerebrovascular events.

To evaluate the effectiveness of a quality improvement intervention to increase OSA diagnostic testing after stroke or TIA.

This stepped-wedge cluster randomized trial of patients with ischemic stroke or TIA admitted to Department of Veterans Affairs facilities assessed outcomes during 8 data periods of 7-month duration (May 15, 2019, to January 24, 2024).

The quality improvement intervention was implemented with a virtual kickoff; site teams reviewed their facility’s baseline data, identified improvement opportunities, considered barriers and potential solutions to diagnosing OSA among patients with cerebrovascular disease, and developed a site-specific action plan. Team members attended monthly collaborative conferences. A web-based platform provided quality data, action plans, and a resource library. The research team provided external facilitation.

The primary outcome was 30-day OSA diagnostic testing rate. Secondary outcomes were 30-day positive airway pressure treatment rate, 90-day recurrent vascular event rate, and 90-day readmission rate. Implementation effects were assessed using generalized linear mixed-effects models with binomial distributions and log link fit to patient-level data with site-level random effects.

The study included 1747 patients at 6 intervention sites (mean [SD] age, 68.7 [11.1] years; 1634 [93.5%] male) and 7454 patients at 30 usual care sites (mean [SD] age, 71.8 [10.8] years; 7114 [95.4%] male). The index event was stroke (vs TIA) in 1429 (81.8%) at the intervention sites and 5931 (79.6%) at the usual care sites. The 30-day diagnostic testing rate increased from 2.1% (20 of 952) during baseline to 29.1% (189 of 650) during implementation (odds ratio [OR], 16.13; 95% CI, 8.25-31.53); the 30-day diagnostic testing rate varied from 0.7% to 2.2% among usual care sites across data periods. Thirty-day positive airway pressure treatment increased from 0.3% (3 of 952) during baseline to 2.8% (18 of 650) during implementation (OR, 14.22; 95% CI, 2.40-84.40) at the intervention sites, while varying from 0.0% (0 of 876) to 0.4% (4 of 1158) at the usual care sites. No statistically significant changes were observed in 90-day readmission or recurrent vascular event rates.

In this cluster randomized trial of patients with acute cerebrovascular events, quality improvement approaches increased OSA testing. These results suggest that health care systems can improve the delivery of guideline-concordant care for patients with acute ischemic stroke and TIA by delivering inpatient sleep medicine services.

ClinicalTrials.gov Identifier: NCT04322162