Addressing Sleep Apnea Post-Stroke (ASAP)

解决中风后睡眠呼吸暂停问题（尽快）

• 批准号: 10395931
• 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 2024-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10395931
• 关键词: Acute; Address; Adherence; Ambulatory Care; Attention; Blood Vessels; Businesses; Caring; Cause of Death; Cerebrovascular Disorders; Chronic Obstructive Pulmonary 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; diagnostic strategy; 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名退伍军人在退伍军人事务部医疗中心 （VAMC）每年使用缺血性中风/短暂性缺血性发作（TIA）。有效的次级中风/TIA 预防包括对血管风险因素进行及时的指导协同管理。过去 十年，阻塞性睡眠呼吸暂停（OSA）已被认为是有效的，未诊断的，并且不充分 缺血性中风的治疗危险因素。 OSA在中风患者中非常普遍 60-70％。尽管高度普遍，但多达70-80％的OSA患者既未被诊断，也不是 治疗。未经治疗的OSA与脑血管患者的结局差有关 疾病。 OSA可以通过多种方法进行治疗，但治疗的主要阶段是持续的阳性 气道压力（CPAP）。 CPAP已显示可改善神经系统症状和功能状态 在中风后患有OSA的患者中，尤其是在中风早期应用时。当前中风/TIA预防 指南建议在中风患者中诊断和治疗OSA；但是，很少有患者 退伍军人卫生管理局（VHA）获得指南一致的评估和管理。 目的：利用I型混合动力车，在6种不同的VAMC中随机，踩踏的审判，实施和实施 评估用于解决睡眠的实施策略的有效性和可持续性 呼吸暂停后（ASAP）计划，旨在改善OSA的诊断和管理。 方法：我们将在6个VAMC上启动ASAP程序，每年至少关心50名退伍军人 有中风，但在十四个月的干预期间没有OSA的已知历史，然后是 可持续性时期。干预措施的有效性将在两个主要（设施级别）上进行测量 诊断率和90天复发性血管事件率）和三个次要结构域（治疗率，PAP 依从性和90天全因再入院率）。 ASAP协议将包括一个系统重新设计虚拟 协作和数据监控；实施策略将包括本地改编，冠军，外部 便利，审计和反馈。实施研究的合并框架（CFIR）将是 用于评估基线时的干预和实施策略的实施 一年的干预期结束，并在可持续性期结束时。我们将建立一家业务 设施级别的案例分析，包括与干预有关的财务组件。 假设：我们认为我们可以在不同的VAMC上实施可持续的ASAP计划：（1） 改善OSA诊断，治疗和90天复发性血管事件率，并且； （2）有业务案例 有利于基线复发性血管事件率的干预地点。 结论和下一步：改善退伍军人诊断和管理的干预措施 用中风/TIA改善预后是必要的；实施科学策略可以评估吸收 和这种干预的可持续性。由于干预和实施策略已经 使用现有的VHA基础架构设计，如果有效，该程序将准备范围内缩放系统。 ASAP业务分析的结果将与VAMC提供商和本地领导人共享 谁可能有兴趣在其设施中实施此计划。此外，急性睡眠服务可能 适应其他患者人群（例如，慢性阻塞性肺疾病） vha。