Acute Dysphagia Following Reperfusion Therapies: A Prospective Pilot Cohort Study.

Dysphagia is a well-documented sequela of stroke. Recent advancements in medical treatments for stroke include reperfusion therapies (endovascular thrombectomy (EVT) and thrombolysis). As outcomes following reperfusion therapies are typically measured via general functional scales, the pattern and progression of acute dysphagia following reperfusion therapies is less known. To determine the progression of acute dysphagia (0-72 h) following reperfusion therapies and relationships between various stroke parameters and dysphagia, twenty-six patients were prospectively recruited across two EVT and thrombolysis centres in Brisbane, Australia. Dysphagia was screened via the Gugging Swallowing Screen (GUSS) at the bedside at three timepoints: 0-24 h, 24-48 h, and 48-72 h post-reperfusion therapies. Across three groups (EVT only, thrombolysis only, or both), the incidence of any dysphagia within the first 24 h of reperfusion therapy was 92.31% (n = 24/26), 91.30% (n = 21/23) by 48 h, and 90.91% (n = 20/22) by 72 h. Fifteen patients presented with severe dysphagia at 0-24 h, 10 at 24-48 h, and 10 at 48-72 h. Whilst dysphagia was not significantly correlated to infarct penumbra/core size, dysphagia severity was significantly related to the number of passes required during EVT (p = 0.009).Dysphagia continues to persist in the acute stroke population despite recent advancements in technology aimed to reduce morbidity and mortality post-stroke. Further research is required to establish protocols for management of dysphagia post-reperfusion therapies.

Evaluating telehealth for the education and monitoring of lymphoedema and shoulder dysfunction after breast cancer surgery.

PURPOSE: The primary aim of this study was to compare the attendance rates at a group lymphoedema education and same-day individual surveillance appointment between telehealth (TH) and in-person (IP) care for participants following breast cancer (BC) surgery. Secondary aims included evaluating participant satisfaction and costs between the two service models, while also determining the extent of technical issues and clinician satisfaction towards TH. METHODS: Participants following axillary lymph node dissection surgery attended a group lymphoedema education and same-day 1:1 monitoring session via their preferred mode (TH or IP). Attendance rates, satisfaction and costs were recorded for both cohorts, and technical disruption and clinician satisfaction for the TH cohort. RESULTS: Fifty-five individuals participated. All 28 participants who nominated the IP intervention attended, while 22/27 who nominated the TH intervention attended an appointment. Overall reported participant experience was positive with no significant differences between cohorts. All TH appointments were successfully completed. Clinicians reported high satisfaction for delivery of education (median = 4[IQR 4-5]) and individual assessment (median = 4[IQR 3-4]) via TH. Median attendance costs per participant were Australian $39.68 (Q1-Q3 $28.52-$68.64) for TH and Australian $154.26 (Q1-Q3 $81.89-$251.48) for the IP cohort. CONCLUSION: Telehealth-delivered lymphoedema education and assessment for individuals following BC surgery was associated with favourable satisfaction, cost savings and minimal technical issues despite lower attendance than IP care. This study contributes to the growing evidence for TH and its potential applicability to other populations where risk for cancer-related lymphoedema exists.

Identifying prioritised actions for improving dysphagia services in Singapore: Insights from concept mapping with patients and caregivers.

BACKGROUND: Person-centred services are inherently related to patients/caregivers' needs. However, the extent to which dysphagia services within Singapore meet consumer needs is largely unknown. Involving patients/caregivers in service evaluation/redesign deepens the understanding of consumer needs. This process also increases the success of implementing service enhancements through relevant and meaningful change. AIM: This study aimed to identify aspects of dysphagia services, within acute and subacute settings in Singapore, perceived as highly important and easy to change by patients/caregivers. METHODS & PROCEDURES: Using concept mapping methodology, 5 patients and 11 caregivers reflected on their experiences of receiving dysphagia care and proposed 59 unique suggestions to improve dysphagia services within Singapore. Then, each individual sorted the suggestions into groups based on similarity and rated each statement for its perceived importance and changeability for service enhancement. Data were analysed using multidimensional scaling, hierarchical cluster analysis, and bivariate analysis to generate clusters of conceptually similar suggestions and a prioritised list of suggestions for service enhancement. RESULTS: Twelve clusters were identified, with most rated as more important than changeable for service improvement. Participants prioritised 23 (39%) of the suggestions as highly important and easy to change, and these focused on ensuring effective communication among consumers and healthcare team, enhancing patients and carers' access to support at home, increasing patients and carers' access to educational resources, and improving service quality and access through technology. CONCLUSION: These findings provide future directions on how to develop and implement dysphagia services in Singapore to better meet the needs of patients/caregivers. WHAT THIS PAPER ADDS: What is already known on this subject Little is known about patients and caregivers' experiences and expectations of receiving dysphagia services in Singapore. Consulting them in service review and improvement deepens understanding of their needs and increases the success of implementing meaningful service enhancements. What this study adds to existing knowledge This study shows that patients and caregivers in Singapore identified a wide range of dysphagia service issues and prioritised a list of suggestions for service improvement. They prioritised four key areas for service optimisation: ensuring effective communication among consumers and healthcare team, enhancing patients and carers' access to support at home, increasing patients and carers' access to educational resources, and improving service quality and access through technology. What are the clinical implications of this work? This research highlights the importance of considering the consumers' perspectives in service review and redesign. Patients and caregivers in Singapore identified four prioritised areas for service enhancements. These findings provide future directions on how to develop and implement dysphagia services in Singapore to better meet the needs of patients and caregivers.

Exploring the impact of remoteness on people with head and neck cancer: Utilisation of a state-wide dataset.

OBJECTIVE: Living in regional/rural areas can impact outcomes for people with head and neck cancer (HNC). Using a comprehensive state-wide dataset, the impact of remoteness on key service parameters and outcomes for people with HNC was examined. METHODS: Retrospective quantitative analysis of routinely collected data held within the Queensland Oncology Repository. DESIGN: Quantitative methods (descriptive statistics, multivariable logistic regression and geospatial analysis). SETTING: All people diagnosed with HNC in Queensland, Australia. PARTICIPANTS: The impact of remoteness was examined in 1991 people (1171 metropolitan, 485 inner-regional, 335 rural) with HNC cancer diagnosed between 2013 and 2015. MAIN OUTCOME MEASURES: This paper reports key demographics and tumour characteristics (age, gender, socioeconomic status, First Nations status, co-morbidities, primary tumour site and staging), service use/uptake (treatment rates, attendance at multidisciplinary team review and timing to treatment) and post-acute outcomes (readmission rates, causes of readmission and 2-year survival). In addition to this, the distribution of people with HNC across QLD, distances travelled and patterns of readmission were also analysed. RESULTS: Regression analysis revealed remoteness significantly (p < 0.001) impacted access to MDT review, receiving treatment, and time to treatment commencement, but not readmission or 2-year survival. Reasons for readmission did not differ by remoteness, with dysphagia, nutritional inadequacies, gastrointestinal disorders and fluid imbalance indicated in the majority of readmissions. Rural people were significantly (p < 0.0001) more likely to travel to care and to readmit to a different facility than provided primary treatment. CONCLUSIONS: This study provides new insights into the health care disparities for people with HNC residing in regional/rural areas.

Telepractice and Dysphagia Management: The Era of COVID-19 and Beyond.

The COVID-19 pandemic drove rapid and widespread uptake of telepractice across all aspects of healthcare. The delivery of dysphagia care was no exception, with telepractice recognized as a service modality that could support social distancing/infection control, overcome service delivery challenges created by lockdowns/service closures, and address consumer concerns about attending in-person appointments. Now, almost two years since most services first rapidly deployed telepractice, it is time to reflect on the big picture, and consider how telepractice will continue as a service option that is sustained and integrated into mainstream dysphagia care. It is also timely to consider the research agenda needed to support this goal. To this end, in this paper we present 4 discussion topics, which raise key considerations for the current and future use of telepractice within adult and pediatric dysphagia services. These are (1) Dysphagia services must meet consumer and service needs; (2) Aspects of dysphagia services can be safely and reliably provided via telepractice; (3) Telepractice can be used in flexible ways to support the delivery of dysphagia services; and (4) Providing quality dysphagia services via telepractice requires planned implementation and evaluation. Then directions for future research are discussed. These considerations are presented to help shift perspectives away from viewing telepractice as simply a COVID-19 "interim-care solution". Rather, we encourage clinicians, services, and researchers to embrace a future of "integrated care", where traditional dysphagia services are combined with telepractice models, to enhance the quality of care provided to our clients.

Implementation of a speech and language therapy-led referring model for videofluoroscopic swallow studies: An evaluation of service outcomes.

BACKGROUND: Videofluoroscopic swallow studies (VFSS) are integral to diagnosing and supporting dysphagia management. However, in many countries, only doctors are authorized to complete medical imaging request forms, in accordance with radiation safety regulations. This can impact workflow and timely access to VFSS. Enhanced scope of practice (ESP) models of care exist, where speech and language therapists (SLTs) are authorized to complete VFSS request forms. However, formal evaluations of these ESP models are currently lacking. AIMS: The primary aim of this study was to examine service outcomes regarding the safety and efficiency of SLTs completing VFSS request forms compared with the medical referring model (standard care). The secondary aim was to ascertain the impacts on SLTs' daily workflow and the utility of training for SLTs to complete VFSS requests. METHODS & PROCEDURES: The study involved a mixed-method design. First, referrals completed using standard care versus those completed under the new SLT-led VFSS referring model were compared for efficiency (days to request completion, number of contacts between staff to complete requests and delay to VFSS appointments) and safety (compliance with radiation safety standards for requests, adverse events and change to dysphagia management to justify radiation exposure). Semi-structured interviews were then conducted with SLT referrers (n = 7) exploring the impacts of the model on daily workflow and the utility of training. OUTCOMES & RESULTS: VFSS inpatient requests were examined across a 3-month period (n = 61 requests) using the standard model, and for 6 months (n = 109 requests) following the introduction of SLT-led VFSS referring. Regarding efficiency, there was no significant difference between the two models, with most request forms taking less than or equal to 1 day to be completed. Adherence to radiation safety requirements was significantly greater in the SLT-led VFSS referring model compared with the standard model (p < 0.001) in relation to the overall requisite clinical information being documented on the request forms. No adverse events occurred and 100% of VFSSs led to changed dysphagia management. Interviews of VFSS referring SLTs revealed that completing requests was not complex or onerous, and that the training equipped them well to undertake the role. CONCLUSIONS & IMPLICATIONS: The SLT-led VFSS referring model was feasible for SLTs and resulted in satisfactory efficiency and greater adherence to radiation safety requirements for VFSS request forms than the standard model. Improved information on VFSS request forms provides clearer justification for the radiation procedure and helps optimize the diagnostic yield of VFSS. The evidence supports further widespread adoption of this model. WHAT THIS PAPER ADDS: What is already known on the subject Models of care permitting selected allied health professionals to refer patients for diagnostic radiology procedures have been established to achieve healthcare efficiencies. Evidence supports the safety and efficiency of physiotherapists referring to radiology. However, limited published outcome data exist regarding models of SLTs referring for radiology procedures, such as VFSS. What this paper adds to existing knowledge This study describes the implementation of a SLT-led VFSS inpatient referring model in a quaternary hospital and examines service outcomes. The findings reveal that VFSS request forms completed in the SLT-led referring model had greater adherence to radiation safety standards compared with the standard referring model. Efficiency was similar across both models and there were no adverse events. Completing VFSS requests did not disrupt daily workflow for SLTs and training was effective preparation for the role. What are the potential or actual clinical implications of this work? Results demonstrate that the SLT-led VFSS referral model can be safely and appropriately implemented in the inpatient setting. Improved quality of information documented on request forms by SLTs increases adherence with radiation safety standards, providing clearer justification for radiation assessments and potentially eliciting more targeted diagnostic information to inform dysphagia treatment planning. These findings may support other hospital services to establish this type of referring model.

Evaluation of the implementation of a speech and language therapist-led referring model for VFSS using the Consolidated Framework for Implementation Research (CFIR).

BACKGROUND: Speech and language therapists (SLTs) use videofluoroscopic swallow study (VFSS) results to manage dysphagia. Yet, in some services only doctors can directly request a VFSS, potentially creating workflow inefficiencies and delaying patient access to VFSS. An alternative model, where SLTs directly refer patients for VFSS, is used in many services in the UK and Australia. However, processes for implementing and sustaining this model have not been reported. AIMS: To evaluate the implementation of an SLT-led inpatient VFSS referring model using the Consolidated Framework for Implementation Research (CFIR) to ascertain implementation barriers, facilitators and critical sustainability factors. METHODS & PROCEDURES: This implementation evaluation examined stakeholder perceptions of implementing the SLT-led VFSS referring model via interviews of (1) SLTs who treat and refer inpatients for VFSS; (2) doctors who manage and refer inpatients for VFSS; (3) radiologists; and (4) trained VFSS referring SLTs. The CFIR was used to prospectively guide implementation planning, evaluation and outcome reporting, regarding barriers, facilitators and sustainability factors. OUTCOMES & RESULTS: Implementation facilitators were (1) the advantage of SLT-led VFSS referring over the standard model (doctors referring), in promoting high-quality VFSS referrals; (2) compatibility of the model with the SLT skill set; (3) supportive communication networks between staff groups; and (4) engaging stakeholders throughout implementation. Adequate availability of trained VFSS referring SLTs was both a barrier and a facilitator of implementation. It was also a critical sustainability factor, along with ongoing staff education and outcome monitoring. CONCLUSIONS & IMPLICATIONS: The CFIR supported systematic evaluation of implementation facilitators and barriers, and adjustment of factors critical for implementing and sustaining the new model. Findings may assist other organizations to establish the SLT-led VFSS referring model. WHAT THIS PAPER ADDS: What is already known on the subject Models where SLTs directly refer patients for VFSS have been described in the literature, with evidence of appropriate referrals and adherence to radiation safety standards. However, the process for establishing and sustaining this referring model has not been published. What this paper adds to existing knowledge This study describes the process and outcomes of implementing an SLT-led VFSS referring model, using the CFIR. A key advantage of the new model that facilitated implementation was the improved quality of VFSS referrals compared with the standard referring model. Important facilitating factors in the environment were the compatibility of the model with SLTs' skillset and supportive communication network between doctors and SLTs. Initially, an implementation barrier was the inadequate availability of trained SLT referrers. Using proactive implementation strategies, more referrers were trained (which was a facilitating factor for implementing and sustaining the model). What are the potential or actual clinical implications of this work? This study highlights that successful implementation requires more than just an effective model. Features of the environment require consideration to minimize barriers and optimize facilitating factors, supported by proactive implementation strategies. Planning and evaluating implementation processes and outcomes using a standardized implementation framework such as CFIR aided understanding of barriers and facilitators for introducing the SLT-led VFSS referring model. This process may assist other services to implement the model.

Clinician and consumer perceptions of head and neck cancer services in rural areas: Implications for speech pathology service delivery.

OBJECTIVE: Individuals with head and neck cancer residing in rural areas face numerous challenges accessing post-acute rehabilitation services, including speech pathology services. In order to inform future service enhancements, the key issues impacting access to, and the provision of, speech pathology head and neck cancer services in rural areas was explored through the perspectives of patients, carers, speech pathology clinicians and service managers. SETTING: A rural health referral network in Queensland consisting of tertiary, regional and remote hospitals. PARTICIPANTS: Twenty-eight participants, including 12 speech pathology staff/managers and 16 consumers (people with head and neck cancer/carers). DESIGN: Qualitative methodology using semi-structured interviews was analysed using content analysis. RESULTS: Two themes were identified from the consumer group including (a) navigating health services for head and neck cancer management and (b) burden of accessing head and neck cancer care. Speech pathology staff/managers interviews raised 3 themes: (a) transfer of care and access to local services, (b) workforce and workload and (c) travelling impacts the service our patients can receive. An integrative theme across both groups highlighted the perceived disparity in health care access that existed for people with head and neck cancer in rural areas. CONCLUSIONS: In rural areas, consumers face multiple barriers navigating the head and neck cancer treatment pathway, while health services encounter specific challenges ensuring access and equity in care. Despite the complexities, possible avenues for service change and service enhancement are proposed. Speech pathology services in rural areas need to proactively evaluate services and address existing disparities in order to enact positive change for people with head and neck cancer living outside metropolitan locations.

Speech-language therapists' perceptions of an eLearning program to support training in videofluoroscopic swallow studies.

BACKGROUND: Speech-language therapists (SLTs) seek a range of educational opportunities for training in adult videofluoroscopic swallow studies (VFSS). However, variable training methods and/or unequal access to training can influence VFSS practice. AIMS: To document current SLT needs and barriers to VFSS training and to determine if a new beginner-level VFSS eLearning program would assist to meet their training needs. The program incorporated multimedia modules on preparing, conducting, interpreting and reporting VFSS. METHODS & PROCEDURES: SLTs with limited experience in adult VFSS completed surveys relating to VFSS training experience and barriers, and perceived changes in knowledge, skills and confidence on core VFSS module topics pre- (n = 36) and post- (n = 32) eLearning training. OUTCOMES & RESULTS: Inconsistent access to VFSS training opportunities and time-related work pressures were reported as the greatest training barriers. SLTs viewed the eLearning program as a suitable option for VFSS training. Post-training, participants perceived they gained confidence, as well as improved knowledge and skills in all VFSS aspects along with generalised benefits for dysphagia management. SLTs indicated that key benefits of the eLearning program were its comprehensive content and self-directed learning with multimedia tools, which afforded theoretical and practical learning opportunities. CONCLUSIONS & IMPLICATIONS: The eLearning program offered SLTs free access to beginner-level adult VFSS training, meeting many identified training needs and providing a foundation from which to develop further practical knowledge and skills within a VFSS clinic setting. What this paper adds What is already known on the subject SLTs demonstrate variable knowledge and skill in conducting and interpreting VFSS, which can impact dysphagia diagnosis and management. While access to VFSS training can be challenging, the barriers to training for SLTs have not been clearly documented. Research has confirmed that eLearning can be used effectively in healthcare education, and in some aspects of VFSS training; however, it is yet to be applied to address the broad range of VFSS training needs. What this paper adds to existing knowledge This study describes the SLT reported barriers to VFSS training which include limited access to formal and practical training, workload-related time pressures and the complexity of learning the VFSS skill set. The findings highlight that an eLearning program, was an accepted mode of learning for VFSS training. SLTs reported the online program met their learning needs by improving access to training, the multimedia program features supported their understanding of complex anatomical and physiological concepts, and training frameworks assisted their clinical reasoning and VFSS interpretation. What are the potential or actual clinical implications of this work? eLearning can assist in overcoming many VFSS training barriers identified by SLTs and the multimedia aspects of eLearning can effectively support VFSS beginner-level education to complement and expedite in-clinic practical training. Given that VFSS results inform decisions regarding commencement and progression of oral intake and swallow rehabilitation, enhanced VFSS training has the potential to positively influence dysphagia outcomes and quality of life.

Evaluation of a speech pathology service delivery model for patients at low dysphagia risk during radiotherapy for HNC.

PURPOSE: There are no evidence-based guidelines informing which patients with head and neck cancer (HNC) require regular speech pathology (SP) support during radiation treatment (RT). Hence, some services use a "one-size-fits-all" model, potentially over-servicing those patients at low risk for dysphagia. This study evaluated the clinical safety and efficiency of an interdisciplinary service model for patients identified prospectively as "low risk" for dysphagia during RT. METHODS: A prospective cohort of 65 patients with HNCs of the skin, thyroid, parotid, nose, and salivary glands, receiving curative RT, were managed on a low-risk pathway. Patients with baseline dysphagia (functional oral intake score ≤ 5) were excluded. The model involved dietitians conducting dysphagia screening at weeks 3, 5, and 6/7 within scheduled appointments. Patients at risk of dysphagia were referred to SP for assessment, then management if required. To validate the model, SP assessed swallow status/toxicities at week 5/6/7 during RT and confirmed dysphagia status at weeks 2 and 6 post RT. RESULTS: Most (89.3%) patients did not require dysphagia support from SP services. Of the 18 patients identified on screening, only 7 (10.7%) had sufficient issues to return to SP care. Week 5/6/7 SP review confirmed low levels of toxicity. No post-treatment dysphagia was observed. There was an incremental benefit of A$15.02 for SP staff costs and a recovery of 5.31 appointments per patient. CONCLUSION: The pathway is a safe and effective service model to manage patients with HNC at low risk for dysphagia during RT, avoiding unnecessary SP appointments for the patient and service.

Radiotherapy for cutaneous head and neck cancer and parotid tumours: a prospective investigation of treatment-related acute swallowing and toxicity patterns.

PURPOSE: Reports of acute treatment-related dysphagia and toxicities for patients with parotid tumours or cutaneous head and neck cancer (HNC) are limited. This study aimed to describe the severity and timing of dysphagia and related toxicities experienced during radiotherapy for cutaneous HNC and parotid tumours, to inform the nature of future speech pathology (SP) service models required during treatment. METHODS: Prospective study of 32 patients with parotid tumours and 36 with cutaneous HNC undergoing curative non-surgical management. Dysphagia and acute toxicity data was collected weekly during treatment and at 2, 4 and 12 weeks post-treatment using the Functional Oral Intake Scale, diet descriptors and CTCAE v4.0. RESULTS: In both groups, minimal treatment toxicities (grades 0-1) were observed. Xerostomia and dysgeusia were the most frequently reported grade 2 toxicities. Only 3% of parotid patients and 6% with cutaneous HNC experienced grade 3 dysphagia. Full or soft texture diets were maintained by > 70% of patients in both groups. Symptoms peaked in the final week of treatment and rapidly improved thereafter. Apart from xerostomia < 10% of patients had any grade 2 toxicity at 12 weeks post-treatment. CONCLUSION: Patients in these subgroups of HNC experienced minimal treatment-related toxicity during radiotherapy. As such, the need for supportive symptom management by SP is low. Models that involve interdisciplinary surveillance of symptoms with referral to SP only when required may be best suited for these individuals to ensure issues are identified whilst minimising patient burden created by unnecessary routine SP appointments.

Conducting Real-Time Videofluoroscopic Swallow Study via Telepractice: A Preliminary Feasibility and Reliability Study.

A small number of studies have examined the feasibility of conducting videofluoroscopic swallow studies (VFSS) via telepractice. While the results have confirmed this potential, the systems tested to date have either reported issues that impacted the ability to analyze/interpret the VFSS recordings in real time, or they were not designed to enable real-time interpretation. Further system design is needed to establish a telepractice model that enables the VFSS assessment to be both guided and interpreted live in real time. The aim of this study was to test the feasibility and reliability of using a telepractice system to enable live VFSS assessment. Twenty adult patients underwent a VFSS assessment directed by a telepractice SLP with competency in VFSS located in another room of the hospital. The telepractice clinician led the sessions using a C20 Cisco TelePresence System. This was linked in real time via a secure telehealth network (at 4 megabits per second (Mbit/s)) to a C60 Cisco TelePresence System located in a fluoroscopy suite, connected to the digital fluoroscopy system. Levels of agreement were calculated between the telepractice clinician and a face-to-face clinician who simultaneously rated the VFSS in real time. High levels of agreement for swallowing parameters (range = 75-100 %; k = -0.34 to 1.0) and management decisions (range = 70-100 %, k = 0.64-1.0) were found. A post-session questionnaire revealed clinicians agreed that the telepractice system enabled successful remote assessment of VFSS. The findings support the potential to conduct live VFSS assessment via a telepractice model.

A Dynamic Image Quality Evaluation of Videofluoroscopy Images: Considerations for Telepractice Applications.

High-quality fluoroscopy images are required for accurate interpretation of videofluoroscopic swallow studies (VFSS) by speech pathologists and radiologists. Consequently, integral to developing any system to conduct VFSS remotely via telepractice is ensuring that the quality of the VFSS images transferred via the telepractice system is optimized. This study evaluates the extent of change observed in image quality when videofluoroscopic images are transmitted from a digital fluoroscopy system to (a) current clinical equipment (KayPentax Digital Swallowing Workstation, and b) four different telepractice system configurations. The telepractice system configurations consisted of either a local C20 or C60 Cisco TelePresence System (codec unit) connected to the digital fluoroscopy system and linked to a second remote C20 or C60 Cisco TelePresence System via a network running at speeds of either 2, 4 or 6 megabits per second (Mbit/s). Image quality was tested using the NEMA XR 21 Phantom, and results demonstrated some loss in spatial resolution, low contrast detectability and temporal resolution for all transferred images when compared to the fluoroscopy source. When using higher capacity codec units and/or the highest bandwidths to support data transmission, image quality transmitted through the telepractice system was found to be comparable if not better than the current clinical system. This study confirms that telepractice systems can be designed to support fluoroscopy image transfer and highlights important considerations when developing telepractice systems for VFSS analysis to ensure high-quality radiological image reproduction.

Impact of dysphagia severity on clinical decision making via telerehabilitation.

OBJECTIVE: Recent research supports the proposal that valid and reliable clinical swallow examinations (CSEs) can be conducted via telerehabilitation. However, no studies have explored whether dysphagia severity has an impact on the success of the session or its outcomes. The current study examined how dysphagia severity impacted on either (a) clinical decision making for safety of oral intake or (b) clinician perceptions of CSEs conducted via telerehabilitation. SUBJECTS AND METHODS: One hundred patients (25 nondysphagics and 25 mild, 25 moderate, and 25 severe dysphagics) were assessed using a telehealth system and methodology reported in prior research. For each assessment, the online and face-to-face (FTF) clinicians simultaneously completed a structured CSE. On session completion, the online clinician indicated level of agreement with two statements regarding the level of rapport and ability to competently assess the patient. RESULTS: In each of the four groups, acceptable levels of agreement were observed between raters for the three primary outcomes (decisions regarding oral/nonoral intake and safe food and fluids) as well as over 90% of the CSE items. Clinicians agreed they could develop good rapport with the majority of patients in all groups. However, for a small but significant (p<0.5) proportion of patents in the severe dysphagic group, clinicians disagreed they were able to satisfactorily and competently assess to the best of their abilities using the telerehabilitation system. CONCLUSIONS: Clinical decisions made during and as an outcome of the total CSE were found to be comparable to those made in the FTF environment regardless of dysphagia severity. Clinicians noted some difficulty assessing patients with greater complexity, which occurred in greater numbers in the group with severe dysphagia.

Using concept mapping to guide dysphagia service enhancements in Singapore: Recommendations from the speech-language pathology workforce.

PURPOSE: Optimising dysphagia service delivery is crucial to minimise personal and service impacts associated with dysphagia. However, limited data exist on how to achieve this in Singapore. This study aimed to develop prioritised enhancements that the speech-language pathology workforce perceived as needed to improve dysphagia services in Singapore. METHOD: Using a concept mapping approach, 19 speech-language pathologists (SLPs) and 10 managers listed suggestions for dysphagia service optimisation. Within their groups, the collated suggestions were sorted based on similarity, and individually rated on a 5-point scale based on importance and changeability. Using cluster and bivariate analysis, clusters of similar suggestions and prioritised suggestions for service optimisation were identified. RESULT: The SLPs and managers proposed 73 and 51 unique suggestions respectively. Six clusters were identified for each group, with similar themes suggesting agreement of service improvements. All clusters were rated as more important than changeable. The managers perceived services as easier to change. The SLPs and managers rated 37% (27/73) and 43% (22/51) of suggestions, respectively, as high priority, with similarities relating to workforce capacity and capability, support and services access, care transitions, and telehealth services. CONCLUSION: Prioritised enhancements identified by SLPs and managers provide direction for dysphagia service optimisation in Singapore.

Comprehensive quality assessment for aphasia rehabilitation after stroke: protocol for a multicentre, mixed-methods study.

INTRODUCTION: People with aphasia following stroke experience disproportionally poor outcomes, yet there is no comprehensive approach to measuring the quality of aphasia services. The Meaningful Evaluation of Aphasia SeRvicES (MEASuRES) minimum dataset was developed in partnership with people with lived experience of aphasia, clinicians and researchers to address this gap. It comprises sociodemographic characteristics, quality indicators, treatment descriptors and outcome measurement instruments. We present a protocol to pilot the MEASuRES minimum dataset in clinical practice, describe the factors that hinder or support implementation and determine meaningful thresholds of clinical change for core outcome measurement instruments. METHODS AND ANALYSIS: This research aims to deliver a comprehensive quality assessment toolkit for poststroke aphasia services in four studies. A multicentre pilot study (study 1) will test the administration of the MEASuRES minimum dataset within five Australian health services. An embedded mixed-methods process evaluation (study 2) will evaluate the performance of the minimum dataset and explore its clinical applicability. A consensus study (study 3) will establish consumer-informed thresholds of meaningful change on core aphasia outcome constructs, which will then be used to establish minimal important change values for corresponding core outcome measurement instruments (study 4). ETHICS AND DISSEMINATION: Studies 1 and 2 have been registered with the Australian and New Zealand Clinical Trial Registry (ACTRN12623001313628). Ethics approval has been obtained from the Royal Brisbane and Women's Hospital (HREC/2023/MNHB/95293) and The University of Queensland (2022/HE001946 and 2023/HE001175). Study findings will be disseminated through peer-reviewed publications, conference presentations and engagement with relevant stakeholders including healthcare providers, policy-makers, stroke and rehabilitation audit and clinical quality registry custodians, consumer support organisations, and individuals with aphasia and their families.

A time and cost analysis of speech pathology paediatric feeding services delivered in-person versus via telepractice.

INTRODUCTION: Telepractice models of care have the potential to reduce the time and financial burdens that consumers may experience accessing healthcare services. The current study aimed to conduct a time and financial cost analysis of paediatric feeding appointments accessed via telepractice (using videoconferencing) compared to an in-person model. METHODS: Parents of 44 children with paediatric feeding disorders (PFDs) residing in a metropolitan area completed three questionnaires relating to (a) demographics, (b) time and cost for in-person care and (c) time and cost for telepractice. Both cost questionnaires collected data required for direct and indirect costs comparisons (e.g. out-of-pocket costs associated with the appointment (direct), time away from usual duties (indirect)). Average number of services accessed by each participant, and PFD appointments conducted annually by the service, were collected from service statistics. Analysis involved cost minimisation and cost modelling from a societal perspective. RESULTS: The telepractice appointment resulted in significant time (p = 0.007) and cost (AUD$95.09 per appointment, SD = AUD$64.47, p = < 0.0001) savings per family. The health service cost was equivalent for both models (AUD$58.25). Cost modelling identified cost savings of up to AUD$475.45 per family if 50% of appointments in a 10-session block were converted to telepractice. Potential cost savings of AUD$68,750.07 per annum to society could be realised if 50% of feeding appointments within the service were provided via telepractice. DISCUSSION: The telepractice model offered both time and cost benefits. Future service re-design incorporating hybrid services (in-person and telepractice) will help optimise benefits and minimise burden for families accessing services for PFDs.

Post-laryngectomy pulmonary and related symptom changes following adoption of an optimal day-and-night heat and moisture exchanger (HME) regimen.

BACKGROUND: This study examined post-laryngectomy pulmonary and related symptom changes following establishment of an optimal day/night regimen (all day/night wear of devices with improved humidification) using a new generation range of heat and moisture exchanger (HME) devices. METHODS: In Phase 1 (6 weeks), 42 post-laryngectomy HME users transitioned from their usual HME regime to equivalent new device/s (i.e., "like-for-like"). In Phase 2 (6 weeks) participants used the full range of HMEs to achieve an optimal day/night regimen. Pulmonary symptoms, device use, sleep, skin integrity, quality of life and satisfaction were examined at baseline, and weeks 2 and 6 of each Phase. RESULTS: From baseline to end of Phase 2, cough symptoms and impact significantly improved, as did sputum symptoms, sputum impact, duration and types of HMEs used, reasons for HME replacement, involuntary coughs, and sleep. CONCLUSION: The new HME range supported improved HME use, with pulmonary and related symptom benefits.

Digital divide or digital exclusion? Do allied health professionals' assumptions drive use of telehealth?

INTRODUCTION: Telehealth use within allied health services currently lacks structure and consistency, ultimately affecting who can, and cannot, access services. This study aimed to investigate the factors influencing allied health professionals' (AHP) selection of consumers and appointments for telehealth. METHODS: This study was conducted across 16 allied health departments from four Australian hospitals. Semi-structured focus groups were conducted with 58 AHPs. Analysis was underpinned by Qualitative Description methodology with inductive coding guided by Braun and Clarke's thematic analysis approach. RESULTS: Six themes were identified that influenced AHPs' evaluation of telehealth suitability and selection of consumers. These included the following: (1) ease, efficiency and comfort of telehealth for clinicians; (2) clear benefits of telehealth for the consumer, yet the consumers were not always given the choice; (3) consumers' technology access and ability; (4) establishing and maintaining effective therapeutic relationships via telehealth; (5) delivering clinically appropriate and effective care via telehealth; and (6) external influences on telehealth service provision. A further theme of 'assumption versus reality' was noted to pervade all six themes. DISCUSSION: Clinicians remain the key decision makers for whether telehealth is offered within allied health services. Ease and efficiency of use is a major driver in AHP's willingness to use telehealth. Assumptions and pre-conceived frames-of-reference often underpin decisions to not offer telehealth and present major barriers to telehealth adoption. The development of evidence-based, decision-support frameworks that engage the consumer and clinician in determining when telehealth is used is required. Services need to actively pursue joint decision-making between the clinician and consumer about service delivery preferences.

Enhancing speech-language pathology head and neck cancer service provision in rural Australia: Using a plan, do, study, act approach.

PURPOSE: People with head and neck cancer (HNC) require ongoing speech-language pathology (SLP) services into the post-acute recovery phase of care. However, there are recognised service inequities/barriers for people from rural areas who are unable to access SLP services locally, necessitating travel to metropolitan centres. This study implemented strategies to assist rural speech-language pathologists to work to full scope of practice and support post-acute rehabilitation services for people with HNC. METHOD: The study involved five SLP departments within a rural health referral network (one tertiary cancer centre, four rural sites). It involved a Plan-Do-Study-Act (PDSA) method, across two six month cycles, to achieve implementation of a model to support local SLP delivery of HNC care. Data collected included service activity, consumer feedback from people accessing local care, staff perceptions of the model and changes to local SLP service capabilities. RESULT: Staff identified four objectives for change across the two PDSA cycles including resource development, upskilling/training and improving communication, and handover processes. In cycle 1, multiple resources were developed such as an eLearning program for training and skill development. In cycle 2, a pilot trial of a shared-care model was implemented, which successfully supported a transfer of care to local services for eight people with HNC. The majority of consumers accessing HNC care locally were satisfied with the service and would recommend future people with HNC receive similar care. CONCLUSION: The PDSA process supported development and implementation of a model enabling local speech-language pathologists to offer post-acute care for people with HNC. This model helps rural people with HNC to access care closer to home by supporting rural clinicians to work to full scope of practice.