RESUMEN
BACKGROUND: Hospitalizations for aspiration pneumonia have doubled among older adults. Using a bedside water swallow test (WST) to screen for swallowing-related aspiration can be efficient and cost-effective for preventing additional comorbidities and mortality. We evaluated screening accuracy of bedside WSTs used to identify patients at risk for dysphagia-associated aspiration. METHODS: Sixteen online databases, Google Scholar, and known content experts through May 2015 were searched. Only prospective studies with patients ≥ 18 years of age given WST screenings validated against nasoendoscopy or videofluoroscopy were included. Data extraction used dual masked extraction and quality assessment following Meta-analysis of Observational Studies in Epidemiology guidelines. RESULTS: Airway response (eg, coughing/choking) with or without voice changes (eg, wet/gurgly voice quality) was used to identify aspiration during three different bedside WSTs. Pooled estimates for single sip volumes (1-5 mL) were 71% sensitive (95% CI, 63%-78%) and 90% specific (95% CI, 86%-93%). Consecutive sips of 90 to 100 mL trials were 91% sensitive (95% CI, 89%-93%) and 53% specific (95% CI, 51%-55%). Trials of progressively increasing volumes of water were 86% sensitive (95% CI, 76%-93%) and 65% specific (95% CI, 57%-73%). Airway response with voice change improved overall accuracy in identifying aspiration. CONCLUSIONS: Currently used bedside WSTs offer sufficient, although not ideal, utility in screening for aspiration. Consecutive sips with large volumes in patients who did not present with overt airway responses or voice changes appropriately ruled out risk of aspiration. Small volumes with single sips appropriately ruled in aspiration when clinical signs were present. Combining these bedside approaches may offer improved screening accuracy, but further research is warranted.
Asunto(s)
Trastornos de Deglución/diagnóstico , Neumonía por Aspiración/prevención & control , Pruebas en el Punto de Atención , Aspiración Respiratoria/diagnóstico , Adulto , Trastornos de Deglución/complicaciones , Endoscopía/métodos , Humanos , Tamizaje Masivo/métodos , Tamizaje Masivo/normas , Fotofluorografía/métodos , Neumonía por Aspiración/etiología , Aspiración Respiratoria/etiología , Sensibilidad y EspecificidadRESUMEN
OBJECTIVE: The present study was performed to determine the clinical effects of the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) on speech and language intervention services and to examine the feasibility of using the federally mandated FIM instrument to establish resource allocation to patients with cognitive, communication, and swallowing disorders. DESIGN: A pre-IRF PPS and post-IRF PPS comparative study was conducted over a 1-yr time interval using data from the American Speech-Language-Hearing Association's National Outcomes Measurement System. Toward this end, the National Outcomes Measurement System's Functional Communication Measures were used to obtain data from 2,631 patients residing in 96 freestanding rehabilitation hospitals or hospitals with rehabilitation units implementing the prospective payment system on or after January 1, 2002. To ensure reliable retrospective and prospective data comparisons, all sites were active participants within the National Outcomes Measurement System program before the introduction of IRF PPS within their facilities. RESULTS: Findings revealed changes in both the utilization of speech-language pathologists and patient outcomes. Under the IRF PPS, there was a clear decline in speech- and language-related lengths of stay. However, clinicians attempted to compensate for these decrements in lengths of stay by increasing the intensity and frequency of their speech and language services. Despite these compensatory efforts, further analyses of the data revealed that under the IRF PPS, fewer patients achieved multiple levels of functional progress in speech and language abilities than before this payment system was implemented. This trend was most noteworthy in the treatment areas of swallowing, motor speech, and memory. In addition, this study revealed that, compared with the National Outcomes Measurement System's Functional Communication Measures, the FIM instrument significantly under-represented and undervalued the extent of a patient's overall progress in recovering from their cognitive, communication, or swallowing disabilities. CONCLUSION: These findings support the notion that the introduction of the IRF PPS has, perhaps unintentionally, caused more patients with cognitive, communication, and swallowing disorders to be discharged from inpatient rehabilitative care with less than adequate functional skill levels. The discouraging results in speech-language pathology utilization and patient outcomes will be useful for clinicians in the future when facing the ongoing challenges of maintaining quality care while streamlining services under the prospective payment system.