Build a Case For Instrumental Swallowing Assessments in Long-Term Care
Armed with facts and evidence, SLPs can help change policies that deny instrumental swallowing evaluations to patients with dysphagia in long-term care facilities. Rinki Varindani Desai , MS, CCC-SLP https://doi.org/10.1044/leader.OTP.24032019.38
Without access to instrumental swallowing assessments, how can speech-language pathologists treat patients with dysphagia effectively and ethically?
Many medical settings, particularly long-term care and skilled nursing facilities, do not allow their SLPs to order instrumental swallowing assessments: VFSS (videofluoroscopic swallow study), also known as MBSS (modified barium swallow study), and FEES (fiberoptic endoscopic evaluation of swallowing). No state or federal law or regulation compels MBSS or FEES assessments, and ASHA cannot dictate facility policies. Without access to these tools to help evaluate swallow function, providing evidence-based best practices is extremely challenging.
But there is hope. Many of us around the country have successfully advocated for instrumental assessments at our facilities. Using facts and evidence, you too can “sell” the need for and benefits of instrumental swallowing exams to administrators, as well as showcase your expertise.
Armor up, fellow SLPs. The time for change is now. Here’s what you need to know.
The cost conundrum
SLPs report the most common barrier is cost. Let’s put our frustration aside and think about this from a business perspective. Isn’t it reasonable for an administrator to question the cost and reimbursement of sending someone for a diagnostic study they possibly know very little about?
Part of our role in advocating for the needs of patients with dysphagia is providing education to the interdisciplinary team for optimal patient care. If your facility has no access to instrumental evaluations, take the initiative to prepare a solid case. Present it to administrators and physicians at your facility to help them understand our role in dysphagia management and how they can, in the long term, save money with instrumental exams.
Here are some facts:
- The monthly cost for thickened liquids ranges from $174 to $289 per patient.
- Keeping a patient on a feeding tube with no oral intake costs about $35,000 annually.
- Hospital re-admissions due to consequences of dysphagia cost about $30,000 each.
- Dysphagia is associated with longer hospital stays, higher inpatient costs, higher likelihood of discharge to post-acute care facilities, and increased mortality rates.
Make an effective case for instrumentation by comparing those costs to that of a FEES or MBS study (anywhere from $500 to $1,500), which can help prevent these dysphagia-related consequences, minimize costs and significantly improve quality of life.
Here are some tips for advocacy success:
- Do the groundwork—craft and practice your argument.
- Tailor your argument for each stakeholder—focus on value and cost savings.
- Be prepared to explain the limitations of the clinical swallowing examination and how that affects treatment.
- Share success stories and case studies in which instrumental exams made a positive difference in treatment outcomes.
- Identify local mobile FEES/MBSS companies that could provide assessments and help minimize costs.
- Reach out to other SLPs who have had success with advocacy.
- Use current research and data to support your needs.
Remember: Don’t raise your voice—improve your argument. And be persistent!
No X-ray vision
Administrators and physicians might ask whether the clinical swallowing examination (CSE) is enough. This “bedside swallow exam” does have value. It provides important information to formulate a hypothesis about the probable nature of the patient’s swallowing impairments and helps develop trial interventions, especially when instrumental testing is not feasible, warranted or available.
However, is the CSE enough? Let’s review what research literature tells us (see sources):
- Although quick and informative, the CSE cannot diagnose swallowing pathophysiology or allow objective decisions about bolus flow.
- 40 percent of the variables typically used in a CSE are not evidence-based.
- Less than 50 percent of the measures clinicians typically use in a CSE exhibit adequate intra- and inter-judge reliability.
- Detecting aspiration using a CSE is usually less than 70-percent accurate, while ruling it out is even less precise. Even if a swallowing problem is “guessed” correctly about 70 percent of the time by SLPs, results provide no information on its etiology or severity.
- Silent aspiration, which occurs without any overt signs of dysphagia, can be detected only with VFSS or FEES.
SLPs are frequently taught to use digital palpation of the thyroid notch to gauge laryngeal elevation and excursion during the swallow. However, current evidence tell us this is not accurate (see sources). Some SLPs may be diagnosing a patient with perceived reduced hyolaryngeal elevation as having dysphagia when, in fact, this elevation may be the patient’s norm. Even if we can feel laryngeal elevation in a CSE and suspect dysphagia, we have no other information about any other pharyngeal swallow events that could affect a patient’s ability to consume a meal safely.
Without VFSS and/or FEES, SLPs cannot make physiology-based treatment decisions. We end up treating the symptom—and not the cause—of the disease, analogous to a neurologist diagnosing and treating a stroke based on the patient’s self-identified signs and symptoms, rather than using appropriate imaging techniques (CT or MRI) to make a definitive diagnosis.
Instrumental evaluations allow assessment and viewing of critical physiologic elements of the oropharyngeal swallow and their temporal and biomechanical relationships. With these procedures, you can also do a “treatment efficacy trial,” systematically assessing the effects of various treatment and compensatory strategies on the patient’s swallow safety and efficiency.
Without an instrumental exam, we simply don’t know what to treat. We may also end up recommending ineffective, or even contraindicated, techniques.
Many SLPs realize the limitations of the CSE, but may not have other options. I have been in this position, too. My advice to those SLPs would be: Don’t be afraid to question or challenge your superiors and explain the strengths and limitations of the CSE. Let’s stop perpetuating practice patterns that don’t support evidence-based decision-making.
There is only so much we can see at bedside. We don’t have X-ray vision.
Use instrumentals wisely
It helps to demonstrate that you will be judicious in recommending and using instrumental swallow assessments. Not every patient needs VFSS or FEES.
If you routinely perform instrumental examinations, use your time wisely. Data show us that SLPs tend to focus more on identification of bolus flow outcomes (aspiration, penetration and residue) than on physiologic impairments. Dysphagia management that focuses merely on diet modifications and compensations, rather than on restoring physiologic function, may fail to capitalize on neuroplasticity and limits the possibility of functional improvement for impaired pathophysiology. We need to look beyond aspiration.
For those completing MBS studies, the quality of videofluoroscopy is also critical. You need a minimum temporal resolution of 30 frames per second to properly evaluate swallow events and function. Recording at reduced frame rates may be inadequate for capturing essential swallowing events (see sources).
Complete documentation is also critical to a successful study. An instrumental examination captures a very short period of time when compared to the entire mealtime experience. The treating clinician needs all the information necessary to make appropriate clinical decisions, which can be achieved only through communication and collaboration between the evaluating and treating SLPs.
Documentation should focus on detailed descriptions of the pathophysiology, strategies tried and rationale for recommendations, rather than recommending a diet and discussing the presence or absence of aspiration.
Under-use and misuse of any of these techniques is a significant barrier to SLPs’ ability to accurately diagnose and treat dysphagia and is a disservice to our patients. Let’s harness the power of the instrumental exam wisely.