Addressing Sleep Apnea Post-Stroke (ASAP)

解决中风后睡眠呼吸暂停问题（尽快）

• 批准号: 10152370
• 负责人: Dawn Marie Bravata
• 金额: --
• 依托单位: VA CONNECTICUT HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-04-01 至 2024-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10152370
• 关键词: Acute; Address; Adherence; Ambulatory Care; Attention; Blood Vessels; Businesses; Caring; Cause of Death; Cerebrovascular Disorders; Chronic Obstructive Airway Disease; Clinical Trials; Congestive Heart Failure; Consolidated Framework for Implementation Research; Continuous Positive Airway Pressure; Cost Savings; Data; Diagnosis; Diagnostic; Early Diagnosis; Early Intervention; Early treatment; Effectiveness of Interventions; Evaluation; Event; Feedback; Guidelines; Home; Hour; Hybrids; Infrastructure; Intervention; Ischemic Stroke; Knowledge; Laboratories; Leadership; Measures; Medical center; Methods; Monitor; Neurologic Symptoms; Obstructive Sleep Apnea; Outcome; Patients; Polysomnography; Prevalence; Prevention; Prevention Guidelines; Protocols documentation; Provider; Randomized; Recommendation; Recording of previous events; Recurrence; Risk Factors; Services; Site; Sleep; Sleep Apnea Syndromes; Stroke; System; Testing; Therapeutic; Time; Titrations; Transient Ischemic Attack; United States Department of Veterans Affairs; Veterans; Veterans Health Administration; acute coronary syndrome; adherence rate; cerebrovascular; design; disability; effectiveness evaluation; effectiveness outcome; functional status; implementation evaluation; implementation intervention; implementation science; implementation strategy; improved; improved outcome; inpatient service; interest; intervention program; mortality; neurological recovery; patient population; post stroke; programs; readmission rates; screening; stroke patient; stroke survivor; uptake; vascular risk factor; virtual

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.

背景：大约 11,000 名退伍军人来到退伍军人事务部医疗中心 (VAMC) 每年发生缺血性中风/短暂性脑缺血发作 (TIA)。有效继发性卒中/TIA 预防包括对血管危险因素进行及时、符合指南的管理。过去的事 十年来，阻塞性睡眠呼吸暂停 (OSA) 已被认为是一种有效的、诊断不足且不充分的疾病。 治疗缺血性中风的危险因素。 OSA 在中风患者中非常常见，患病率 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。未经治疗的 OSA 与脑血管病患者的不良预后相关 疾病。 OSA 可以通过多种方法治疗，但主要治疗方法是持续积极的治疗 气道压力（CPAP）。 CPAP 已被证明可以改善神经症状和功能状态 中风后患有 OSA 的患者，尤其是中风后早期应用时。当前中风/短暂性脑缺血发作 (TIA) 预防 指南建议诊断和治疗中风患者的 OSA；然而，国内很少有患者 退伍军人健康管理局 (VHA) 接受指南一致的评估和管理。 目标：在 6 个不同的 VAMC 中利用混合 I 型、随机、阶梯楔形试验来实施和 评估“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 名入院退伍军人 患有中风但在 14 个月的干预期内没有已知的 OSA 病史，随后进行了 持续期。干预措施的有效性将通过两个主要（设施层面）来衡量 诊断率和 90 天复发性血管事件率）和三个次要领域（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 协作和数据监控；实施战略将包括当地适应、冠军、外部 便利化、审核和反馈。实施研究综合框架（CFIR）将 用于评估干预措施和实施策略在基线、在 一年干预期结束时和可持续期结束时。我们将建立一个企业 设施层面的案例分析，包括与干预相关的财务组成部分。 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 诊断、治疗和 90 天复发性血管事件发生率； (2) 有商业案例 有利于基线复发性血管事件发生率最高的干预部位。 结论和后续步骤：改善退伍军人 OSA 诊断和管理的干预措施 中风/短暂性脑缺血发作 (TIA) 是改善预后所必需的；实施科学策略可以评估吸收情况 以及这种干预措施的可持续性。由于干预和实施策略已 使用现有 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 业务案例分析的结果将与 VAMC 提供商和当地领导层共享 谁可能有兴趣在他们的工厂实施该计划。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），无论是在国内还是国外 维哈。