Abstract
This review discusses the impact of the evidence-based report on dysphagia diagnosis and treatment in stroke patients prepared in 1999 by ECRI under contract with the Agency for Healthcare Research and Quality (AHRQ). Subsequent research findings are highlighted and research design and reporting problems in the field are discussed. Progress has been made toward standardizing training and rating of videofluoroscopic studies of swallowing (VFSS); however, a consensus does not yet exist. A randomized, controlled trial demonstrated that treatment directed by fiber-optic endoscopic evaluation of swallowing with sensory testing (FEESST) or VFSS resulted in approximately equivalent pneumonia rates. These two different methods provide both overlapping and complementary information. There is discussion of the research design problems of mixed patients versus homogeneous populations, case-control diagnostic studies, inappropriate calculations of diagnostic sensitivity/specificity using imperfect “gold standards,” the lack of concurrent control groups in treatment studies, and the misuse of statistical significance tests and P values in examining matching of patient characteristics in comparative studies and in identifying important variables in regression analysis.
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References and Recommended Reading
Agency for Healthcare Research and Quality (AHRQ): Diagnosis and treatment of swallowing disorders (dysphagia) in acute-care stroke patients. Rockville, MD: AHRQ; 1999.
Agency for Healthcare Research and Quality (AHRQ): Clinical Information. Evidence-based Practice. Accessible at: http://www.ahrq.gov/clinic/epcix.htm. Accessed March 18, 2002.
Nilsson H, Ekberg O, Olsson R, et al.: Dysphagia in stroke: a prospective study of quantitative aspects of swallowing in dysphagic patients. Dysphagia 1998, 13:32–38.
Odderson IR, Keaton JC, McKenna BS: Swallow management in patients on an acute stroke pathway: quality is cost effective. Arch Phys Med Rehabil 1995, 76:1130–1133.
Daniels SK, Brailey K, Priestly DH, et al.: Aspiration in patients with acute stroke. Arch Phys Med Rehabil 1998, 79:14–19.
Spiegel JR, Creed J, Selber JC, et al.: Evaluation of a protocol for dysphagia management using VESS in nursing homes. Submitted for publication.
Medicare program: revisions to payment policies and five-year review of and adjustments to the relative value units under the physician fee schedule for calendar year 2002: final rule.Fed Regist 2001, 66:55246–55503.
The 2002 Medicare Physician Fee Schedule for Speech-language Pathologists and Audiologists. Rockville, MD: American Speech Language Hearing Association (ASHA); 2002.
Englert J, Davis KM, Koch KE: Using clinical practice analysis to improve care. J Comm J Qual Improv 2001, 27:291–301.
Newell SD Jr, Englert J, Box-Taylor A, et al.: Clinical efficiency tools improve stroke management in a rural southern health system. Stroke 1998, 29:1092–1098.
Perry L, McLaren S: An evaluation of implementation of evidence-based guidelines for dysphagia screening and assessment following acute stroke: phase 2 of an evidence-based practice project. J Clin Excel 2000, 2:147–156.
Hinds NP, Wiles CM: Assessment of swallowing and referral to speech and language therapists in acute stroke. QJM 1998, 91:829–835.
Low J, Wyles C, Wilkinson T, et al.: The effect of compliance on clinical outcomes for patients with dysphagia on videofluoroscopy. Dysphagia 2001, 16:123–127.
Davies S, Taylor H, MacDonald A, et al.: An inter-disciplinary approach to swallowing problems in acute stroke. Int J Lang Commun Disord 2001, 36(suppl):357–362.
Logemann JA, Veis S, Colangelo L: A screening procedure for oropharyngeal dysphagia. Dysphagia 1999, 14:44–51.
Daniels SK, Ballo LA, Mahoney MC, et al.: Clinical predictors of dysphagia and aspiration risk: outcome measures in acute stroke patients. Arch Phys Med Rehabil 2000, 81:1030–1033.
Sellars C, Dunnet C, Carter R: A preliminary comparison of videofluoroscopy of swallow and pulse oximetry in the identification of aspiration in dysphagic patients. Dysphagia 1998, 13:82–86.
Leder SB: Use of arterial oxygen saturation, heart rate, and blood pressure as indirect objective physiologic markers to predict aspiration. Dysphagia 2000, 15:201–205.
Sherman B, Nisenboum JM, Jesberger BL, et al.: Assessment of dysphagia with the use of pulse oximetry. Dysphagia 1999, 14:152–156.
Smith HA, Lee SH, O’Neill PA, et al.: The combination of bedside swallowing assessment and oxygen saturation monitoring of swallowing in acute stroke: a safe and humane screening tool. Age Ageing 2000, 29:495–499.
Lim SH, Lieu PK, Phua SY, et al.: Accuracy of bedside clinical methods compared with fiberoptic endoscopic examination of swallowing (FEES) in determining the risk of aspiration in acute stroke patients. Dysphagia 2001, 16:1–6.
Addington WR, Stephens RE, Gilliland K, et al.: Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke. Arch Phys Med Rehabil 1999, 80:150–154.
Addington WR, Stephens RE, Gilliland KA: Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke: an interhospital comparison. Stroke 1999, 30:1203–1207.
McCullough GM, Wertz RT, Rosenbek JC, et al.: Clinicians’ preferences and practices in conducting clinical/bedside and videofluoroscopic examinations of swallowing. Am J Speech Lang Pathol 1999, 8:149–163.
McCullough GH, Wertz RT, Rosenbek JC, et al.: Inter-and intrajudge reliability of a clinical examination of swallowing in adults. Dysphagia 2000, 15:58–67.
McCullough GH, Wertz RT, Rosenbek JC: Sensitivity and specificity of clinical/bedside examination signs for detecting aspiration in adults subsequent to stroke. J Commun Disord 2001, 34:55–72.
Kuhlemeier KV, Yates P, Palmer JB: Intra- and interrater variation in the evaluation of videofluorographic swallowing studies. Dysphagia 1998, 13:142–147.
Scott A, Perry A, Bench J: A study of interrater reliability when using videofluoroscopy as an assessment of swallowing. Dysphagia 1998, 13:223–227.
McCullough GH, Wertz RT, Rosenbek JC, et al.: Inter-and intrajudge reliability for videofluoroscopic swallowing evaluation measures. Dysphagia 2001, 16:110–118.
Robbins J, Coyle J, Rosenbek J, et al.: Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale. Dysphagia 1999, 14:228–232.
O’Neil KH, Purdy M, Falk J, et al.: The dysphagia outcome and severity scale. Dysphagia 1999, 14:139–145.
Logemann JA, Lazarus CL, Keeley SP, et al.: Effectiveness of four hours of education in interpretation of radiographic studies. Dysphagia 2000, 15:180–183.
Han TR, Paik NJ, Park JW: Quantifying swallowing function after stroke: a functional dysphagia scale based on videofluoroscopic studies. Arch Phys Med Rehabil 2001, 82:677–682.
Teasell RW, McRae M, Heitzner J, et al.: Frequency of videofluoroscopic modified barium swallow studies and pneumonia in stroke rehabilitation patients: a comparative study. Arch Phys Med Rehabil 1999, 80:294–298.
Martin-Harris B, Logemann JA, McMahon S, et al.: Clinical utility of the modified barium swallow. Dysphagia 2000, 15:136–141.
Leder SB: Serial fiberoptic endoscopic swallowing evaluations in the management of patients with dysphagia. Arch Phys Med Rehabil 1998, 79:1264–1269.
Schroter-Morasch H, Bartolome G, Troppmann N, et al.: Values and limitations of pharyngolaryngoscopy (transnasal, transoral) in patients with dysphagia. Folia Phoniatr Logop 1999, 51:172–182.
Aviv JE: Prospective, randomized outcome study of endoscopy versus modified barium swallow in patients with dysphagia. Laryngoscope 2000, 110:563–574.
Aviv JE, Sacco RL, Mohr JP, et al.: Laryngopharyngeal sensory testing with modified barium swallow as predictors of aspiration pneumonia after stroke. Laryngoscope 1997, 107:1254–1260.
Cichero JA, Jackson O, Halley PJ, et al.: How thick is thick? Multicenter study of the rheological and material property characteristics of mealtime fluids and videofluoroscopy fluids. Dysphagia 2000, 15:188–200.
Goulding R, Bakheit AM: Evaluation of the benefits of monitoring fluid thickness in the dietary management of dysphagic stroke patients. Clin Rehabil 2000, 14:119–124.
Whelan K: Inadequate fluid intakes in dysphagic acute stroke. Clin Nutr 2001, 20:423–428.
Finestone HM, Foley NC, Woodbury MG, et al.: Quantifying fluid intake in dysphagic stroke patients: a preliminary comparison of oral and nonoral strategies. Arch Phys Med Rehabil 2001, 82:1744–1746.
Gariballa SE, Parker SG, Taub N, et al.: A randomized, controlled, single-blind trial of nutritional supplementation after acute stroke. J Parenter Enteral Nutr 1998, 22:315–319.
Freed ML, Freed L, Chatburn RL, et al.: Electrical stimulation for swallowing disorders caused by stroke. Respir Care 2001, 46:466–474.
Huckabee ML, Cannito MP: Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: a retrospective evaluation. Dysphagia 1999, 14:93–109.
Rudberg MA, Egleston BL, Grant MD, et al.: Effectiveness of feeding tubes in nursing home residents with swallowing disorders. J Parenter Enteral Nutr 2000, 24:97–102.
Mitchell SL, Tetroe J, O’Connor AM: A decision aid for long-term tube feeding in cognitively impaired older persons. J Am Geriatr Soc 2001, 49:313–316.
Tube feeding and advanced progressive dementia.Hastings Cent Rep 2001, 31:36–42.
Finucane TE, Christmas C, Travis K: Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 1999, 282:1365–1370.
Yamaya M, Yanai M, Ohrui T, et al.: Interventions to prevent pneumonia among older adults. J Am Geriatr Soc 2001, 49:85–90.
McHorney CA, Bricker DE, Kramer AE, et al.: The SWAL-QOL outcomes tool for oropharyngeal dysphagia in adults: I. Conceptual foundation and item development. Dysphagia 2000, 15:115–121.
Pan M, Suarez de Lezo J, Sancho M, et al.: Significance of the dynamics of enzyme release in patients with acute myocardial infarction re-perfused early [Spanish]. Rev Esp Cardiol 1986, 39:338–343.
American Gastroenterological Association: American Gastroenterological Association medical position statement on management of oropharyngeal dysphagia. Gastroenterology 1999, 116:452–454.
Martino R, Pron G, Diamant N: Screening for oropharyngeal dysphagia in stroke: insufficient evidence for guidelines. Dysphagia 2000, 15:19–30.
Perry L, Love CP: Screening for dysphagia and aspiration in acute stroke: a systematic review. Dysphagia 2001, 16:7–18.
Bath PM, Bath FJ, Smithard DG: Interventions for dysphagia in acute stroke. In The Cochrane Library. Oxford: Update Software; 2001:Issue 4.
Ioannidis JP, Lau J: The impact of high-risk patients on the results of clinical trials. J Clin Epidemiol 1997, 50:1089–1098.
Teramoto S, Fukuchi Y: Detection of aspiration and swallowing disorder in older stroke patients: simple swallowing provocation test versus water swallowing test. Arch Phys Med Rehabil 2000, 81:1517–1519.
Ransohoff DF, Feinstein AR: Problems of spectrum and bias in evaluating the efficacy of diagnostic tests. N Engl J Med 1978, 299:926–930.
Gann PH: Prostate-specific antigen screening for prostate cancer: issues involving test validity. Endocr Related Cancer 1996, 3:179–189.
Lijmer JG, Mol BW, Heisterkamp S, et al.: Empirical evidence of design-related bias in studies of diagnostic tests. JAMA 1999, 282:1061–1066.
Fletcher RH, Fletcher SW, Wagner EH: Clinical epidemiology: The Essentials. Baltimore: Williams & Wilkins; 1988.
Ding R, Logemann JA: Pneumonia in stroke patients: a retrospective study. Dysphagia 2000, 15:51–57.
Armitage P, Berry G: Statistical methods in medical research. Oxford: Blackwell Scientific; 1994.
Elmstahl S, Bulow M, Ekberg O, et al.: Treatment of dysphagia improves nutritional conditions in stroke patients. Dysphagia 1999, 14:61–66.
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Doggett, D.L., Turkelson, C.M. & Coates, V. Recent developments in diagnosis and intervention for aspiration and dysphagia in stroke and other neuromuscular disorders. Curr Atheroscler Rep 4, 304–311 (2002). https://doi.org/10.1007/s11883-002-0010-x
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DOI: https://doi.org/10.1007/s11883-002-0010-x