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

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.