Addressing Sleep Apnea Post-Stroke (ASAP)

背景：大约11,000名退伍军人参加了退伍军人事务部医学中心 (VAMC)每年有缺血性中风/短暂性脑缺血发作(TIA)。有效继发性卒中/短暂性脑缺血发作 预防包括及时提供与指南一致的血管风险因素管理。在过去的时间里 十年来，阻塞性睡眠呼吸暂停(OSA)一直被认为是一种严重的、被低估的、不充分的 治疗缺血性中风的危险因素。OSA在中风患者中非常常见，其患病率为 60%-70%。尽管OSA非常普遍，但多达70%-80%的OSA患者既没有被诊断出来，也没有被诊断出来 治疗过了。未经治疗的阻塞性睡眠呼吸暂停与脑血管疾病患者的不良预后有关 疾病。阻塞性睡眠呼吸暂停综合征的治疗方法多种多样，但主要的治疗方法是持续积极的。 呼吸道压力(CPAP)。CPAP已被证明可以改善神经症状和功能状态 在中风后阻塞性睡眠呼吸暂停综合征患者中，尤其是在中风后早期应用时。目前预防中风/短暂性脑缺血发作 指南建议在中风患者中诊断和治疗阻塞性睡眠呼吸暂停；然而，在 退伍军人健康管理局(VHA)接受指南一致性评估和管理。 目的：在6个不同的VAMC中，利用I型混合、随机、阶梯楔形试验，实施和 评估用于解决睡眠问题的实施策略的有效性和可持续性 卒中后呼吸暂停(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名入院的退伍军人 中风，但在14个月的干预期内没有已知的阻塞性睡眠呼吸暂停病史 可持续发展期。干预的有效性将在两个主要(设施级别)上进行衡量 诊断率和90天血管复发事件发生率)和三个次级领域(治疗率、PAP 依从性和90天全原因再住院率)。ASAP协议将包括虚拟系统重新设计 协作和数据监测；实施战略将包括本地适应、领头羊、外部 促进、审计和反馈。实施研究综合框架(CFIR)将是 用于评估干预措施的执行情况和基线的执行战略 在为期一年的干预期结束时，在可持续发展期结束时。我们将建立一家企业 设施一级的案例分析，包括与干预有关的财务部分。 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：(1) 提高OSA的诊断、治疗和90天的血管复发事件发生率；以及；(2)拥有业务案例 倾向于基线血管再发事件发生率最高的介入部位。 结论和下一步：改善退伍军人阻塞性睡眠呼吸暂停的诊断和治疗的干预措施 卒中/短暂性脑缺血发作是改善预后所必需的；实施科学战略可以评估吸收情况 以及这种干预的可持续性。自干预以来，实施战略一直是 使用现有的VHA基础设施设计，如果有效，该计划将准备好在系统范围内扩展。 ASAP的业务案例分析结果将与VAMC提供商和当地领导层共享 他们可能有兴趣在他们的设施中实施这一计划。此外，急性睡眠服务可以 适应其他患者群体(例如慢性阻塞性肺病)，无论是在 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.