A Survey of Clinician Decision Making When Identifying Swallowing Impairments and Determining Treatment

Abstract

Purpose Speech-language pathologists (SLPs) are the primary providers of dysphagia management; however, this role has been criticized with assertions that SLPs are inadequately trained in swallowing physiology (Campbell-Taylor, 2008). To date, diagnostic acuity and treatment planning for swallowing impairments by practicing SLPs have not been examined. We conducted a survey to examine how clinician demographics and swallowing complexity influence decision making for swallowing impairments in videofluoroscopic images. Our goal was to determine whether SLPs' judgments of swallowing timing impairments align with impairment thresholds available in the research literature and whether or not there is agreement among SLPs regarding therapeutic recommendations. Method The survey included 3 videofluoroscopic swallows ranging in complexity (easy, moderate, and complex). Three hundred three practicing SLPs in dysphagia management participated in the survey in a web-based format (Qualtrics, 2005) with frame-by-frame viewing capabilities. SLPs' judgments of impairment were compared against impairment thresholds for swallowing timing measures based on 95% confidence intervals from healthy swallows reported in the literature. Results The primary impairment in swallowing physiology was identified 67% of the time for the easy swallow, 6% for the moderate swallow, and 6% for the complex swallow. On average, practicing clinicians mislabeled 8 or more swallowing events as impaired that were within the normal physiologic range compared with healthy normative data available in the literature. Agreement was higher among clinicians who report using frame-by-frame analysis 80% of the time. A range of 19–21 different treatments was recommended for each video, regardless of complexity. Conclusions Poor to modest agreement in swallowing impairment identification, frequent false positives, and wide variability in treatment planning recommendations suggest that additional research and training in healthy and disordered swallowing are needed to increase accurate dysphagia diagnosis and treatment among clinicians.

Dysphagia services in the era of COVID-19: Are speech-language therapists essential?

“…What makes SLTs clinicians rather than merely technicians is this ability to critically evaluate and make immediate diagnostic decisions at the bedside. This process is multifaceted and based on a variety of factors such as patient and environmental factors, clinical experience and exposure, and theoretical understanding (Croskerry, 2009 ; Plowman & Humbert, 2018 ; Vose, Kesneck, Sunday, Plowman, & Humbert, 2018 ). This is another suggested area of focus for SA SLTs, especially now that we are in this era of limited access to instrumental measures.…”

Speech–language therapists’ perceptions of an eLearning program to support training in videofluoroscopic swallow studies

“…Participants reported the most significant barrier to completing VFSS training was limited access to learning opportunities such as professional development activities, expert mentoring and VFSS clinic attendance. It is acknowledged that decreased exposure to VFSS clinics, alongside inconsistent information and training methods, can significantly impact the development of skill and accuracy in conducting and interpreting VFSS (Murray 2009, Power et al 2006, Vose et al 2018. The eLearning program has addressed some of these barriers through providing free and convenient ac-cess to VFSS education for all SLTs within a state-wide public health service.…”

“…2006, Vose et al . 2018). The eLearning program has addressed some of these barriers through providing free and convenient access to VFSS education for all SLTs within a state‐wide public health service.…”

“…Practicing SLTs demonstrate variable skills in accurately diagnosing dysphagia and planning treatment from VFSS images (Vose et al . 2018). While this highlights the need to improve VFSS education, the optimum content and method of training remains unclear.…”

“Hidden in Plain Sight”: A Descriptive Review of Laryngeal Vestibule Closure

“…We believe that access to and frequent use of appropriate imaging techniques for clinicians should be standard care. Underutilization of these techniques is a barrier to clinicians' ability to accurately diagnose and treat LVC [42]. Another limitation is that proper evaluation of swallowing events during videofluoroscopy requires a minimum temporal resolution of 30 frames per second.…”