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Press Release Date: March 30, 1999
Current research on swallowing problems (dysphagia) suggests that hospital stroke management plans that include programs to diagnose and treat dysphagia may yield dramatic reductions in pneumonia rates, according to a new evidence report produced by ECRI, an Evidence-based Practice Center (EPC) under contract to the Agency for Health Care Policy and Research (AHCPR). The report also found that use of comprehensive examinations conducted at the patient's bedside detected most serious swallowing problems, and could improve quality of care and may help reduce costs.
About 6.2 million Americans over age 60 have dysphagia, a condition that can result in
"aspiration"—when food or fluids enter a person's lungs—and lead to pneumonia. The topic for this report was nominated by the Health Care Financing Administration, which sought an evidence-based assessment of methods for diagnosing and treating dysphagia in elderly individuals with neurologic diseases, specifically those methods associated with services provided by speech-language pathologists.
"While many older Americans have swallowing problems as a result of neurologic disorders, the majority of the research conducted has focused on people who have had strokes," said Jeffrey C. Lerner, Ph.D., ECRI's Vice President for Strategic Planning and director of ECRI's EPC activities. "This area has been the focus of study because most of the approximately 300,000 to 600,000 new cases of dysphagia each year occur in stroke patients, and dysphagia can cause potentially life-threatening complications in these patients."
In addition to showing that patients benefit from acute stroke management programs that include specific efforts to diagnose and treat swallowing problems, an analysis of the available literature demonstrates the value of full bedside examinations in providing a solid core of information that health professionals and others can use in deciding on a course of treatment. A full bedside examination includes taking a detailed history, performing a physical examination of the mouth and throat, and observing the patient attempting to swallow various consistencies and sizes of foods and liquids.
"The findings of this analysis will go a long way in helping those people on the front line of care to determine the most effective ways to treat dysphagia resulting from stroke and other neurologic diseases," said John M. Eisenberg, M.D., AHCPR Administrator. "In particular, use of information from the report could help to improve the quality of care for Medicare beneficiaries if the reductions in pneumonia rates the report describes can be achieved."
Other findings in the report include:
- Use of full bedside examinations in dysphagia management programs are capable of identifying up to 80% of cases of aspiration, which is often difficult to detect because about half of patients with dysphagia who aspirate do so silently (without a cough).
- The limitations of available evidence do not allow one to determine the extent to which invasive procedures like videofluoroscopy or fiberoptic endoscopy reduce pneumonia rates more than full bedside examinations. Although these procedures may provide additional information, existing studies are insufficient to determine this information's usefulness.
- The evidence is inconclusive about how the frequency of swallow therapy sessions affects patient outcomes.
- The only controlled trial that compared a soft diet (some solids) to a traditional pureed diet (liquids only) found that a soft diet resulted in lower pneumonia rates among stroke patients with a history of aspiration pneumonia.
According to Charles M. Turkelson, Ph.D., ECRI's Chief Research Analyst and the Manager of ECRI's EPC projects, another important finding is the great need for more extensive and better designed research in the area of dysphagia. "For diagnosis of dysphagia there is no clearly demonstrated 'gold standard.' What would be most useful in terms of continuing research in this field would be a well-designed trial comparing dysphagia management programs using different diagnostic modalities." ECRI's report provides a detailed description of the design and analysis of a trial that would address several major unanswered questions and would also overcome some of the limitations of current research, such as sample sizes that are too small and the pooling of outcomes data on patients with dysphagia resulting from different causes.
A summary of Diagnosis and Treatment of Swallowing Disorders (Dysphagia) in Acute-Care Stroke Patients (AHCPR 99-E023) is available from AHCPR's Web site at http://www.ahrq.gov/clinic/epcsums/dysphsum.htm. Print copies are available from AHCPR's Publications Clearinghouse (P.O. Box 8547, Silver Spring, MD 20907; telephone within the U.S.: 1-800-358-9295, and 410-381-3150 from outside the United States).
The full report will be posted on the National Library of Medicine's HSTAT full text retrieval system. Hard copies will be available from the AHCPR Publications Clearinghouse by mid-1999.
For additional information, please contact AHCPR Public Affairs: Karen Migdail (301) 427-1855 (KMigdail@ahrq.gov). For further details about the study, contact Dr. Charles Turkelson, ECRI, at (610) 825-6000, ext. 5528.