Quality Improvement Program Greatly Expands Sleep Apnea Testing After Stroke in VA Hospitals

A structured quality improvement (QI) program signficantly increased diagnostic testing for obstructive sleep apnea (OSA) among adults hospitalized with acute ischemic stroke or transient ischemic attack (TIA), according to findings from a large Veterans Health Administration trial published in JAMA Network Open.

The stepped-wedge cluster randomized study, which included more than 9,000 participants, demonstrated a more than 10-fold rise in post-stroke sleep apnea testing at intervention sites compared with usual care. The findings highlight the feasibility of incorporating sleep assessment into inpatient stroke pathways and offer a model for improving guideline-concordant care, the authors wrote.

Prevalence of OSA

OSA is highly prevalent among individuals who have acute cerebrovascular events. The study authors cite data estimating that up to 70% of adults with ischemic stroke or TIA meet diagnostic criteria for sleep-disordered breathing.² Despite guideline support for evaluation, inpatient OSA testing remains uncommon in routine practice: the authors note that baseline testing rates across the VA system were very low, typically between 1% and 2%.

Given OSA’s association with recurrent vascular events, poorer functional recovery, prolonged hospitalization, and increased readmissions, the research team sought to determine whether an operationally focused QI strategy could meaningfully expand access to diagnostic testing during or shortly after acute stroke hospitalization. As the authors explained, inpatient pathways often lack defined processes for sleep assessment, and a structured, support-focused model might overcome workflow, resource, and staffing barriers.

QI Program and Evaluation

The trial included 6 intervention sites and 30 usual-care sites across the VHA. Researchers evaluated a total of 1,747 participants at intervention sites and 7,454 at usual-care sites between May 2019 and January 2024. The cohort was predominantly older and male, according to the study, which refelcts the VA population. Approximately 80% of individuals in both groups were hospitalized for ischemic stroke.

The QI program began with a virtual kickoff, during which site teams reviewed their baseline performance, identified barriers to OSA testing, and developed customized action plans. The intervention emphasized collaborative learning, monthly meetings, a web-based platform for real-time performance feedback, and external facilitation to guide troubleshooting and workflow redesign. Sites were encouraged to integrate testing directly into acute hospitalization, often using limited-channel home sleep apnea tests such as Nox T3 or WatchPAT, which could be administered at bedside.

Testing Rates Increase by Sixteen-Fold

There was a steep rise in OSA testing within 30 says of stroke or TIA across intervention sites, according to the study. From baseline rates of 2.1%, rates increased to 29.1% during the 21-month active implementation phase—representing a 16-fold increase in odds of testing (adjusted OR, 16.90; 95% CI, 9.49–30.10).

Although testing rates varied by facility, there was improvement across all participating intervention sites. Study authors reporrted that in some periods, pooled testing exceeded 35%. Even after active facilitation ended, testing remained substantially higher than at baseline (11.7%), suggesting that practice change could be at least partially sustainable.

In contrast, usual-care sites showed no increase, with testing rates consistently between 0.7% and 2.2%.

Among the 159 sleep studies completed at intervention sites, approximately 70% identified sleep-disordered breathing. Notably, 112 tests (70%) were completed during hospitalization, supporting the feasibility of performing sleep studies in the inpatient setting—an approach that may reduce missed diagnostic opportunities.

Positive airway pressure initiation also increased, though at lower absolute levels, rising from 0.3% at baseline to 2.8% during implementation (adjusted OR, 14.22; 95% CI, 2.40–84.40) .

Impact on Clinical Outcomes

The study was not powered to detect differences in recurrent vascular events or readmissions, and no statistically significant differences were observed in 90-day outcomes between intervention and usual-care sites. The authors emphasize that these analyses were exploratory and not intended to establish treatment effect—a limitation the authors acknowledged. They also pointed to the predominantly male VA population and the possibility of variation in testing access across sites as factors limiting the ability to generalize the findings outside of the study parameters. Additionally, incomplete sustainability following the end of active facilitation suggests that ongoing support may be needed to maintain improvements.

Implications for Practice

The findings suggest that hospitals can substantially increase OSA testing during stroke care when barriers are made visible and teams are supported through structured QI processes. The authors note that the intervention was designed for scalability, with components ssuch as virtual facilitation, peer-learning sessions, and performance dashboards—readily adaptable to other health systems.

Clinically, the authors emphasized, identifying OSA supports earlier PAP intervention, which has been shown to improve blood pressure, daytime sleepiness, and functional recovery after stroke.

Clinicians may therefore view inpatient or early post-discharge testing as an opportunity to address a common and treatable contributor to adverse cerebrovascular outcomes.

1. Bravata DM, Perkins AJ, Myers LJ, 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. doi:10.1001/jamanetworkopen.2025.43385
2. Seiler A, Camilo M, Korostovtseva L, et al. Prevalence of sleep-disordered breathing after stroke and TIA: a meta-analysis. Neurology. 2019;92(7):e648-e654. doi:10.1212/WNL.0000000000006904