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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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Successful implementation, defined by a GO score of \u2265\u20096, 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration<\/jats:title>\n                    <jats:p>ClinicalTrials.gov NCT04322162.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s43058-026-00944-9","type":"journal-article","created":{"date-parts":[[2026,4,17]],"date-time":"2026-04-17T04:54:38Z","timestamp":1776401678000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Difference-making factors in implementing a quality improvement program for sleep apnea in stroke\/TIA patients"],"prefix":"10.1186","volume":"7","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9683-889X","authenticated-orcid":false,"given":"Nicholas A.","family":"Rattray","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Edward J.","family":"Miech","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dawn M.","family":"Bravata","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"K. 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