Addressing Sleep Apnea Post-Stroke (ASAP)

背景：大约有11，000名退伍军人来到退伍军人事务部医疗中心 （VAMC）每年与缺血性卒中/短暂性脑缺血发作（TIA）。有效继发性卒中/TIA 预防包括提供及时的、与指南一致的血管风险因素管理。过去 十年来，阻塞性睡眠呼吸暂停（OSA）被认为是一种有效的，诊断不足， 缺血性卒中的治疗风险因素。阻塞性睡眠呼吸暂停在中风患者中非常常见， 六七成尽管非常普遍，但多达70-80%的OSA患者既未被诊断， 治疗。在脑血管疾病患者中，未治疗的OSA与不良结局相关。 疾病阻塞性睡眠呼吸暂停综合征可以用多种方法治疗，但主要的治疗方法是持续积极治疗 气道压力（CPAP）。CPAP已被证明可以改善神经症状和功能状态 在中风后OSA患者中，尤其是在中风后早期应用时。当前卒中/TIA预防 指南建议在中风患者中诊断和治疗OSA;然而， 退伍军人健康管理局（VHA）接受指导方针一致的评估和管理。 目的：在6种不同的VAMC中使用混合I型、随机、步进楔形试验， 评估在解决睡眠问题中使用的实施策略的有效性和可持续性 中风后呼吸暂停（ASAP）计划旨在改善OSA的诊断和管理。 方法：我们将在6个VAMC启动ASAP计划，每年至少照顾50名退伍军人入院 有中风但没有已知的OSA病史的患者进行为期14个月的干预， 可持续期。干预措施的有效性将在两个主要（设施一级） 诊断率和90天血管事件复发率）和三个次级领域（治疗率、PAP 依从性和90天全因再入院率）。ASAP协议将包括系统重新设计虚拟 合作和数据监测;实施战略将包括当地适应、倡导者、外部 促进、审计和反馈。实施研究综合框架将 用于评价基线时干预措施和实施战略的实施情况， 一年干预期结束时，以及可持续期结束时。我们将建立一个企业 设施一级的案例分析，包括与干预措施有关的财政部分。 假设：我们相信我们可以在不同的VAMC中实施可持续的ASAP计划，其中：（1） 改善OSA的诊断、治疗和90天复发血管事件率;（2）具有商业案例 有利于基线血管事件复发率最高的介入部位。 结论和下一步：改善退伍军人OSA诊断和管理的干预措施 对于改善结果是必要的;实施科学策略可以评估 以及这种干预的可持续性。自干预和实施策略以来， 该计划使用现有的VHA基础设施设计，如果有效，该计划将准备在系统范围内扩展。 ASAP业务案例分析的结果将与VAMC供应商和当地领导层分享 他们可能有兴趣在他们的工厂实施这个项目。此外，急性睡眠服务可以 适应于其他患者群体（例如，慢性阻塞性肺疾病），无论是内部和外部的 VHA。

Background: Approximately 11,000 Veterans present to a Department of Veterans Affairs Medical Center (VAMC) annually with ischemic stroke/transient ischemic attack (TIA). Effective secondary stroke/TIA prevention includes delivering timely, guideline-concordant management of vascular risk factors. Over the past decade, obstructive sleep apnea (OSA) has been recognized as a potent, underdiagnosed, and inadequately treated risk factor for ischemic stroke. OSA is very common among patients with stroke with a prevalence of 60-70%. Despite being highly prevalent, as many as 70-80% of patients with OSA are neither diagnosed nor treated. Untreated OSA has been associated with poor outcomes among patients with cerebrovascular disease. OSA can be treated with a variety of approaches but the mainstay of therapy is continuous positive airway pressure (CPAP). CPAP has been shown to improve neurological symptoms and functional status among post-stroke patients with OSA, especially when applied early post-stroke. Current stroke/TIA prevention guidelines recommend diagnosing and treating OSA among stroke patients; however, few patients within the Veterans Health Administration (VHA) receive guideline concordant evaluation and management. Objective: Utilizing a Hybrid Type I, randomized, stepped-wedge trial at 6 diverse VAMCs, to implement and evaluate the effectiveness and sustainability of implementation strategies utilized in an Addressing Sleep Apnea Post-stroke (ASAP) program designed to improve diagnosis and management of OSA. Methods: We will initiate the ASAP program at 6 VAMCs that annually care for at least 50 Veterans admitted with a stroke but without a known history of OSA for a fourteen-month intervention period followed by a sustainability period. Effectiveness of the intervention will be measured across two primary (facility-level diagnostic rate and 90-day recurrent vascular event rate) and three secondary domains (treatment rate, PAP adherence, and 90-day all-cause readmission rate). ASAP protocol will include a systems redesign virtual collaborative and data monitoring; implementation strategies will include local adaptation, champions, external facilitation, and audit and feedback. The Consolidated Framework for Implementation Research (CFIR) will be used to evaluate the implementation of the intervention and of the implementation strategies at baseline, at the end of the one-year intervention period, and at the end of the sustainability period. We will construct a business case analysis at the facility-level, including financial components related to the intervention. Hypothesis: We believe that we can implement a sustainable ASAP program across diverse VAMCs which: (1) improves OSA diagnosis, treatment, and 90-day recurrent vascular event rate, and; (2) has a business case favoring intervention sites with the highest baseline recurrent vascular event rate. Conclusion and next steps: Interventions that improve diagnosis and management of OSA among Veterans with stroke/TIA are necessary to improve outcomes; implementation science strategies can assess the uptake and sustainability of this intervention. Since the intervention and implementation strategies have been designed using existing VHA infrastructure, if effective, the program would be ready for scaling system-wide. Results from the business-case analysis for ASAP will be shared with VAMC providers and local leadership who may be interested in implementing this program at their facility. Additionally, an acute sleep service could be adapted other patient populations (e.g., chronic obstructive pulmonary disease), both within and outside of VHA.