A STRUCTURED quality improvement program significantly increased sleep apnea testing after ischemic stroke and transient ischemic attack in a large Veterans Affairs cohort.
Quality Improvement Intervention Boosts Sleep Apnea Testing
Obstructive sleep apnea is frequent after stroke and transient ischemic attack and is linked with poorer outcomes, yet sleep apnea testing after stroke remains underused. In this stepped wedge cluster randomized trial across Veterans Affairs facilities, investigators evaluated whether a multi component quality improvement program could close this gap.
Six intervention sites and thirty usual care sites contributed data from 2019 to 2024 across eight sequential periods. The intervention began with a virtual launch in which local teams reviewed baseline sleep testing rates, identified barriers, and built site specific action plans. Teams then joined monthly collaborative calls and used a web-based platform showing quality data, action plans, and practical resources, supported by external facilitation.
Among 1,747 patients at intervention sites and 7454 at usual care sites, the primary outcome was the 30-day sleep apnea diagnostic testing rate after the index cerebrovascular event. At intervention sites, testing increased from 2.1% at baseline to 29.1% during implementation. In contrast, testing at usual care sites remained low, varying between 0.7-2.2% across data periods.
Treatment Uptake and Clinical Outcomes
The quality program also increased initiation of positive airway pressure treatment within 30 days. Treatment rose from 0.3% at baseline to 2.8% during implementation at intervention sites, while usual care sites remained near zero.
Despite these gains in sleep apnea testing after stroke and TIA and higher early treatment rates, there were no statistically significant differences in 90-day hospital readmissions or recurrent vascular events between intervention and usual care sites. This suggests the intervention improved diagnostic and treatment processes without an early safety signal.
Implications for Inpatient Stroke Pathways
These findings indicate that health systems can meaningfully increase sleep apnea testing after stroke using structured quality improvement strategies embedded in inpatient pathways. The results support delivering sleep medicine services within acute stroke care to better align with guideline recommended assessment for obstructive sleep apnea in patients with ischemic stroke and transient ischemic attack. For clinicians, integrating systematic screening, streamlined referral, and rapid diagnostic testing may help move sleep apnea assessment from an optional add on to a routine component of post stroke care.
Reference: Bravata DM et al. Quality Improvement Intervention to Increase Sleep Apnea Diagnostic Testing After Stroke and Transient Ischemic Attack: A Cluster Randomized Trial. JAMA Netw Open. 2025;8(11):e2543385.
