Www.research.ed.ac.uk
AHA/ASA ReportEffect of Dysphagia Screening Strategies on Clinical Outcomes After StrokeA Systematic Review for the 2018 AHA/ASA Guidelines for the Early Management of Patients with Acute Ischemic StrokeEric E. Smith MD, MPH, FAHA Chair1; David M. Kent MD, MS, Vice Chair2, Ketan R. Bulsara MD3; Lester Y. Leung MD, MS2; Judith H. Lichtman PhD, MPH, FAHA4; Mathew J. Reeves PhD, DVM5; Amytis Towfighi MD6; William N. Whiteley BM, BCh, MSc, PhD7; Darin Zahuranec MD, FAHA81University of Calgary, Alberta, Canada; 2Tufts Medical Center/Tufts University School of Medicine; 3University of Connecticut; 4Yale School of Public Health; 5Michigan State University; 6University of Southern California; 7University of Edinburgh; 8University of MichiganCorresponding author:Eric E. Smith, MD, MPH, FAHARoom 2941, Health Sciences Building3330 Hospital Drive NWCalgary, Alberta, CanadaT3C 2G7ABSTRACTIntroduction: Dysphagia screening protocols have been recommended to identify patients at risk for aspiration. The American Heart Association convened an Evidence Review Committee to systematically review evidence for the effectiveness of dysphagia screening protocols to reduce the risk of pneumonia, death, or dependency after stroke.Methods: The Medline, Embase, and Cochrane databases were searched on November 1, 2016, to identify randomized controlled trials (RCTs) comparing dysphagia screening protocols or quality interventions to increased dysphagia screening rates, and reporting outcomes of pneumonia, death or dependency. Results: Three RCTs were identified. One RCT found that a combined nursing quality improvement intervention targeting fever and glucose management as well as dysphagia screening reduced death and dependency, but without reducing the pneumonia rate. Another RCT failed to find evidence that pneumonia rates were reduced by adding the cough reflex to routine dysphagia screening. A smaller RCT randomly assigned 2 hospital wards to a stroke care pathway including dysphagia screening or regular care and found that patients on the stroke care pathway were less likely to require intubation and mechanical ventilation; however, the study was small and at risk for bias.Conclusions: There were insufficient RCT data to determine the effect of dysphagia screening protocols on reducing rates of pneumonia, death, or dependency after stroke. Additional trials are needed to compare the validity, feasibility, and clinical effectiveness of different screening methods for dysphagia.Keywords: ischemic stroke, dysphagiaBACKGROUNDDysphagia is a common consequence of stroke and a risk factor for aspiration pneumonia, ADDIN EN.CITE <EndNote><Cite><Author>Martino</Author><Year>2005</Year><RecNum>7672</RecNum><DisplayText><style face="superscript">1</style></DisplayText><record><rec-number>7672</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1450625956">7672</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Martino, R.</author><author>Foley, N.</author><author>Bhogal, S.</author><author>Diamant, N.</author><author>Speechley, M.</author><author>Teasell, R.</author></authors></contributors><auth-address>Graduate Department of Speech Language Pathology, University of Toronto, Ontario, Canada. rosemary.martino@utoronto.ca</auth-address><titles><title>Dysphagia after stroke: incidence, diagnosis, and pulmonary complications</title><secondary-title>Stroke</secondary-title></titles><periodical><full-title>Stroke</full-title></periodical><pages>2756-63</pages><volume>36</volume><number>12</number><keywords><keyword>Adult</keyword><keyword>Comorbidity</keyword><keyword>Deglutition Disorders/*diagnosis/*epidemiology</keyword><keyword>Humans</keyword><keyword>Incidence</keyword><keyword>Pneumonia/*epidemiology</keyword><keyword>Stroke/*epidemiology</keyword></keywords><dates><year>2005</year><pub-dates><date>Dec</date></pub-dates></dates><accession-num>16269630</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>1 which is associated with higher rates of death and disability.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db2hlbjwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 2 Methods for the assessment of aspiration risk include videofluoroscopy, fiberoptic endoscopic evaluation, or comprehensive speech pathology evaluation. However, these assessments require access to technology or specialty expertise with limited availability. Consequently, many hospitals use dysphagia screening protocols to identify patients who are at low risk of aspiration and who can then be safely given food, liquids, and medications.Dysphagia screening protocols have been recommended for stroke patients.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5KYXVjaDwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 6, 7 Furthermore, it is uncertain whether different swallowing assessments reduce the risk of pneumonia, disability, or death after stroke.The Writing Committee for the 2017 AHA Guidelines for Early Management of Acute Ischemic Stroke commissioned an independent Evidence Review Committee (ERC) to review evidence from randomized controlled trials (RCTs) for the effectiveness of dysphagia screening protocols for the prevention of aspiration pneumonia, disability, and death after stroke. The ERC addressed this question: in confirmed stroke patients does dysphagia screening (or a quality improvement intervention including dysphagia screening), compared to no screening or usual care, decrease outcomes of pneumonia, death, or the combined endpoint of death or dependency? The ERC considered RCTs of different screening protocols, RCTs of interventions that included dysphagia screening as 1 element of a multidomain stroke unit intervention, and RCTs of quality improvement interventions designed to increase adherence to local dysphagia screening protocols.METHODSThe ERC systematically reviewed randomized RCTs of dysphagia screening protocols or quality improvement interventions to standardize or increase dysphagia screening rates. Review methods adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards ADDIN EN.CITE <EndNote><Cite><Author>Moher</Author><Year>2009</Year><RecNum>18758</RecNum><DisplayText><style face="superscript">8</style></DisplayText><record><rec-number>18758</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1464368766">18758</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Moher, D.</author><author>Liberati, A.</author><author>Tetzlaff, J.</author><author>Altman, D. G.</author><author>Prisma Group</author></authors></contributors><auth-address>Ottawa Methods Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada. dmoher@ohri.ca</auth-address><titles><title>Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement</title><secondary-title>Ann Intern Med</secondary-title></titles><periodical><full-title>Ann Intern Med</full-title></periodical><pages>264-9, W64</pages><volume>151</volume><number>4</number><keywords><keyword>Evidence-Based Practice/standards</keyword><keyword>Humans</keyword><keyword>*Meta-Analysis as Topic</keyword><keyword>Periodicals as Topic/standards</keyword><keyword>Publication Bias</keyword><keyword>Publishing/*standards</keyword><keyword>Quality Control</keyword><keyword>*Review Literature as Topic</keyword><keyword>*Terminology as Topic</keyword></keywords><dates><year>2009</year><pub-dates><date>Aug 18</date></pub-dates></dates><isbn>1539-3704 (Electronic)
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ADDIN EN.CITE.DATA 9 Studies were considered eligible if they reported a randomized comparison of 2 or more dysphagia screening strategies, including quality improvement interventions designed to improve dysphagia screening rates or methods, and reported outcomes of death, disability, or pneumonia. Full inclusion and exclusion criteria are given in Table 1.Search strategyThe Medline (via PubMed/OVID), Embase (via OVID), and Cochrane Central Database of Controlled Trials (via CENTRAL) were searched on November 1, 2016, using free text, medical subject headings, and synonyms for dysphagia screening in stroke patients. The fully specified search strategy is provided in Table I of the online data supplement. Systematic reviews or meta-analyses of studies meeting the selection criteria were hand-checked and individual studies were included for extraction if they met the selection criteria. References of individual studies were also back-checked for relevant studies. The search strategy was developed by the ERC in consultation with Doctor Evidence (Santa Monica, CA) and carried out by Doctor Evidence medical librarians.Review for eligibilityDoctor Evidence imported the search results into the DOC Library (DOC Library, Santa Monica, CA, Doctor Evidence, LLC), a fully indexed central repository. Screening was performed against the predefined selection criteria (Table 1) developed by the ERC, using the Doctor Evidence Library Management System (Doctor Evidence: Library Management System. Santa Monica, CA: Doctor Evidence, LLC). Library Management System (LMS) is a web-based software platform featuring keyword emphasis (coloring or bolding of keywords), search, and ranking functionalities as well as the ability to assign and manage reasons for rejecting references at all stages of screening.Title and abstract eligibility was performed by a Doctor Evidence medical librarian, with subsequent quality control performed by an independent reviewer. Additional quality control was performed by an independent Doctor Evidence methodologist validating all included abstracts and a random sample of excluded abstracts.Full text eligibility was performed by dual independent review by members of the ERC. Disagreements were resolved by the ERC Chair.Quality AssessmentTwo content ERC members independently assessed the risk of bias and applicability of each study using the Cochrane Risk for Bias tool, ADDIN EN.CITE <EndNote><Cite><Author>Higgins</Author><Year>2011</Year><RecNum>24972</RecNum><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>24972</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1480939213">24972</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Higgins, J. P.</author><author>Altman, D. G.</author><author>Gotzsche, P. C.</author><author>Juni, P.</author><author>Moher, D.</author><author>Oxman, A. D.</author><author>Savovic, J.</author><author>Schulz, K. F.</author><author>Weeks, L.</author><author>Sterne, J. A.</author><author>Cochrane Bias Methods, Group</author><author>Cochrane Statistical Methods, Group</author></authors></contributors><auth-address>MRC Biostatistics Unit, Institute of Public Health, Cambridge CB2 0SR, UK. julian.higgins@mrc-bsu.cam.ac.uk</auth-address><titles><title>The Cochrane Collaboration's tool for assessing risk of bias in randomised trials</title><secondary-title>BMJ</secondary-title></titles><periodical><full-title>BMJ</full-title><abbr-1>Bmj</abbr-1></periodical><pages>d5928</pages><volume>343</volume><keywords><keyword>Bias (Epidemiology)</keyword><keyword>Humans</keyword><keyword>Randomized Controlled Trials as Topic/*standards</keyword><keyword>Research Design</keyword><keyword>Risk Assessment</keyword></keywords><dates><year>2011</year><pub-dates><date>Oct 18</date></pub-dates></dates><isbn>1756-1833 (Electronic)
0959-535X (Linking)</isbn><accession-num>22008217</accession-num><urls><related-urls><url> version 5.1. Discrepancies were resolved by a third reviewer (the ERC Chair). Study quality was not a criterion for eligibility for inclusion in the review.Data AbstractionData points and meta-data were extracted from the articles by Doctor Evidence analysts and entered manually into the DOC Data 2.0 software platform (Doctor Evidence: DOC Data, Version 2.0, Santa Monica, CA: Doctor Evidence, LLC) using a universal electronic extraction form and guided by a data configuration protocol with automated quality control features to prevent incorrect data-type entry. Each collected data point was verified manually against the source article by an independent reviewer (i.e., single extraction with sequential quality control). Ontology management was undertaken to ensure consistency in naming characteristics and outcomes across all studies in a dataset.There were too few studies to perform meta-analysis.RESULTSThe review returned 448 articles, of which 20 were screened by full text review to identify 3 relevant articles (Figure 1). Study quality is shown in Table 2. An overview of the study designs and main findings is shown in Table 3. Full details are provided in Table II in the online-only data supplement.The QASC study was an RCT of a multidomain stroke unit intervention addressing fever, glucose control, and dysphagia management.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaWRkbGV0b248L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA 11 In this cluster randomized trial, 19 stroke units (1,126 patients) were randomized to either receive a Fever, Sugar, and Swallowing (FeSS) intervention designed to improve nursing adherence to evidence-based protocols, or a comparator intervention consisting of an abridged version of existing guidelines. The Acute Screening of Swallow in Stroke or TIA (ASSIST) tool was used as the dysphagia screen. ADDIN EN.CITE <EndNote><Cite><Author>Anonymous</Author><Year>2015</Year><RecNum>30165</RecNum><DisplayText><style face="superscript">12</style></DisplayText><record><rec-number>30165</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1499366339">30165</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Anonymous</author></authors></contributors><titles><title>Quality in Acute Stroke Care (QASC) Trial</title></titles><volume>2017</volume><number>July 3</number><dates><year>2015</year></dates><pub-location>North Sydney, Australia</pub-location><publisher>Australian Catholic University</publisher><urls><related-urls><url>acu.edu.au/qasc</url></related-urls></urls></record></Cite></EndNote>12 This tool uses patient symptoms, signs, and a water swallow test to screen for aspiration risk. Nurses in the intervention stroke units attended an in-service by a speech language pathologist and were required to pass a competency exam, then applied the tool in clinical practice. The study quality was high, with the only risk for bias being that blinding of the intervention was not possible (Table 2). Compared to patients treated in the control stroke units (n=451), those treated at the intervention stroke units (n=558) had a reduction in the composite outcome of death or dependency and better Short Form Health Survey (SF-36) mean scores (see Table 3 for details). However, there were no differences in mortality as a single outcome or the rate of aspiration pneumonia.In another trial, 311 stroke patients referred for swallowing evaluation were randomized to either a standard evaluation or a standard evaluation plus the Cough Reflex Test. ADDIN EN.CITE <EndNote><Cite><Author>Miles</Author><Year>2013</Year><RecNum>26241</RecNum><DisplayText><style face="superscript">13</style></DisplayText><record><rec-number>26241</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485660892">26241</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Miles, A.</author><author>Zeng, I. S.</author><author>McLauchlan, H.</author><author>Huckabee, M. L.</author></authors></contributors><auth-address>Department of Communication Disorders, The University of Canterbury, 66 Stewart St, Christchurch 8011, New Zealand ; Speech Science, School of Psychology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.</auth-address><titles><title>Cough reflex testing in dysphagia following stroke: a randomized controlled trial</title><secondary-title>J Clin Med Res</secondary-title></titles><periodical><full-title>J Clin Med Res</full-title></periodical><pages>222-33</pages><volume>5</volume><number>3</number><keywords><keyword>Cough reflex testing</keyword><keyword>Deglutition</keyword><keyword>Deglutition disorders</keyword><keyword>Dysphagia</keyword><keyword>Pneumonia</keyword><keyword>Silent aspiration</keyword><keyword>Stroke care</keyword></keywords><dates><year>2013</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1918-3003 (Print)
1918-3003 (Linking)</isbn><accession-num>23671548</accession-num><urls><related-urls><url> In the Cough Reflex Test, nebulized citric acid is delivered by face mask, which should normally induce a reflexive cough. If the test was failed, subsequent management was left to the treating physician. The study quality was generally high with low risk of bias (Table 2), with the exceptions that there was no blinding of either the study intervention or the study outcome assessment. Patients randomized to receive the Cough Reflex Test had similar rates of confirmed pneumonia at 90 days compared with those who received standard evaluation (Table 3).Finally, another trial randomly assigned wards in the same hospital to a stroke care pathway (1 ward) or conventional care (1 ward). ADDIN EN.CITE <EndNote><Cite><Author>Rai</Author><Year>2016</Year><RecNum>26242</RecNum><DisplayText><style face="superscript">14</style></DisplayText><record><rec-number>26242</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485660892">26242</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rai, N.</author><author>Prasad, K.</author><author>Bhatia, R.</author><author>Vibha, D.</author><author>Singh, M. B.</author><author>Rai, V. K.</author><author>Kumar, A.</author></authors></contributors><auth-address>Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.</auth-address><titles><title>Development and implementation of acute stroke care pathway in a tertiary care hospital in India: A cluster-randomized study</title><secondary-title>Neurol India</secondary-title></titles><periodical><full-title>Neurol India</full-title><abbr-1>Neurology India</abbr-1></periodical><pages>S39-45</pages><volume>64 Suppl</volume><dates><year>2016</year><pub-dates><date>Mar-Apr</date></pub-dates></dates><isbn>0028-3886 (Print)
0028-3886 (Linking)</isbn><accession-num>26954966</accession-num><urls><related-urls><url> The stroke care pathway included a local institutionally developed swallow screen consisting of assessments of level of consciousness, strength of the patient’s voice and cough, and ability to swallow sips of water and the local soft texture foods khichri, kheer, or payasam (personal communication, Dr. Kameshwar Prasad).. The swallow screen was administered by a resident physician. The study quality was low (Table 2), with many risks for bias including only one ward assigned to each study arm, non-randomized admission of patients to either ward based on unclear criteria, no blinding of the intervention or outcome assessments, inadequate information on the completeness of follow-up, and a baseline imbalance in the number with hemorrhagic stroke in each group. Patients on the unit with the stroke care pathway were less likely to require mechanical ventilation and had lower all-cause mortality at 90 days (Table 3).CONCLUSIONSThis systematic review found insufficient RCT data to show whether implementation of a specific dysphagia screening protocol reduces risk of death or dependency after stroke. Three eligible trials were identified.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaWRkbGV0b248L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA 11, 14 One trial showed no difference in the rates of pneumonia in patients randomized to receive the cough reflex test. ADDIN EN.CITE <EndNote><Cite><Author>Miles</Author><Year>2013</Year><RecNum>26241</RecNum><DisplayText><style face="superscript">13</style></DisplayText><record><rec-number>26241</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485660892">26241</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Miles, A.</author><author>Zeng, I. S.</author><author>McLauchlan, H.</author><author>Huckabee, M. L.</author></authors></contributors><auth-address>Department of Communication Disorders, The University of Canterbury, 66 Stewart St, Christchurch 8011, New Zealand ; Speech Science, School of Psychology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.</auth-address><titles><title>Cough reflex testing in dysphagia following stroke: a randomized controlled trial</title><secondary-title>J Clin Med Res</secondary-title></titles><periodical><full-title>J Clin Med Res</full-title></periodical><pages>222-33</pages><volume>5</volume><number>3</number><keywords><keyword>Cough reflex testing</keyword><keyword>Deglutition</keyword><keyword>Deglutition disorders</keyword><keyword>Dysphagia</keyword><keyword>Pneumonia</keyword><keyword>Silent aspiration</keyword><keyword>Stroke care</keyword></keywords><dates><year>2013</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1918-3003 (Print)
1918-3003 (Linking)</isbn><accession-num>23671548</accession-num><urls><related-urls><url> And 1 trial was small, including only 2 randomized wards, thus limiting the ability to account for baseline differences, and was at high risk for bias according to most criteria of the Cochrane Risk of Bias tool (Table 2).14 Because of the limited data available, no conclusions can be drawn regarding the clinical effectiveness of dysphagia screening protocols.The largest, highest quality study (QASC) showed that a combined quality improvement intervention to implement protocols for fever, glucose, and swallow screening reduced the risk of death or dependency. However, the independent effect of dysphagia screening could not be estimated because it was implemented as only 1 part of a combined multi-domain stroke unit intervention. While the rate of death or dependency in the multi-domain stroke unit quality improvement intervention was lower than in the comparator condition, the rate of aspiration pneumonia did not differ, suggesting that mortality improvements were not due to pneumonia prevention.Managing dysphagia may be a promising avenue to improve stroke outcomes. However, patient selection for future trials of dysphagia screening protocols may benefit from a deeper understanding of the prevalence of aspiration and the association between severity of aspiration and the risk for clinical events such as pneumonia, to allow screening to be targeted to individuals at risk. Furthermore, the clinical effectiveness of a dysphagia screening strategy will depend not only on the accuracy and reliability of the screening method but also on the effectiveness of the dysphagia management interventions that follow. A Cochrane review found evidence that acupuncture and behavioral interventions reduce the prevalence of dysphagia, but there was insufficient evidence to prove a reduction in death or dependency. ADDIN EN.CITE <EndNote><Cite><Author>Geeganage</Author><Year>2012</Year><RecNum>23816</RecNum><DisplayText><style face="superscript">15</style></DisplayText><record><rec-number>23816</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1476719198">23816</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Geeganage, C.</author><author>Beavan, J.</author><author>Ellender, S.</author><author>Bath, P. M.</author></authors></contributors><auth-address>Clinical Pharmacology and Pharmacy, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.</auth-address><titles><title>Interventions for dysphagia and nutritional support in acute and subacute stroke</title><secondary-title>Cochrane Database Syst Rev</secondary-title></titles><periodical><full-title>Cochrane Database Syst Rev</full-title><abbr-1>The Cochrane database of systematic reviews</abbr-1></periodical><pages>CD000323</pages><volume>10</volume><keywords><keyword>Acupuncture Therapy/methods</keyword><keyword>Acute Disease</keyword><keyword>Deglutition</keyword><keyword>Deglutition Disorders/etiology/mortality/*rehabilitation</keyword><keyword>Humans</keyword><keyword>Nutritional Support/*methods</keyword><keyword>Physical Stimulation/*methods</keyword><keyword>Randomized Controlled Trials as Topic</keyword><keyword>Stroke/*complications/rehabilitation</keyword></keywords><dates><year>2012</year><pub-dates><date>Oct 17</date></pub-dates></dates><isbn>1469-493X (Electronic)
1361-6137 (Linking)</isbn><accession-num>23076886</accession-num><urls><related-urls><url> To manage dysphagia, it must first be identified. By design, the ERC did not review evidence for the accuracy and reliability of different nurse-administered dysphagia screening protocols compared to gold standard assessments by a speech language pathologist, videofluoroscopy, or fiberoptic endoscopic evaluation. This has previously been systematically reviewed by Kertcher et al in 2014, who found the best evidence in support of the Volume-Viscosity Swallowing Test, Toronto Bedside Swallowing Screening Test, and the 3 ounce Water Swallowing Test, but without sufficient comparative studies to identify the optimal screening test.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LZXJ0c2NoZXI8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFy
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ADDIN EN.CITE.DATA 4 A consensus group convened by the AHA/ASA in 2013 recommended that an externally validated screening test should be chosen, but that there was insufficient evidence for the superiority of any 1 test.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb25vdmFuPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48
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ADDIN EN.CITE.DATA 16 They also pointed out that the absence of consensus for a single best screening method does not mean that no screening should be performed.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb25vdmFuPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48
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ADDIN EN.CITE.DATA 16 Our review complements this prior work by showing that no recently published RCTs have compared different dysphagia screening methods for their ability to reduce death, dependency, or pneumonia, with the exception of 1 single center RCT ADDIN EN.CITE <EndNote><Cite><Author>Miles</Author><Year>2013</Year><RecNum>26241</RecNum><DisplayText><style face="superscript">13</style></DisplayText><record><rec-number>26241</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485660892">26241</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Miles, A.</author><author>Zeng, I. S.</author><author>McLauchlan, H.</author><author>Huckabee, M. L.</author></authors></contributors><auth-address>Department of Communication Disorders, The University of Canterbury, 66 Stewart St, Christchurch 8011, New Zealand ; Speech Science, School of Psychology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.</auth-address><titles><title>Cough reflex testing in dysphagia following stroke: a randomized controlled trial</title><secondary-title>J Clin Med Res</secondary-title></titles><periodical><full-title>J Clin Med Res</full-title></periodical><pages>222-33</pages><volume>5</volume><number>3</number><keywords><keyword>Cough reflex testing</keyword><keyword>Deglutition</keyword><keyword>Deglutition disorders</keyword><keyword>Dysphagia</keyword><keyword>Pneumonia</keyword><keyword>Silent aspiration</keyword><keyword>Stroke care</keyword></keywords><dates><year>2013</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1918-3003 (Print)
1918-3003 (Linking)</isbn><accession-num>23671548</accession-num><urls><related-urls><url> that failed to find evidence that screening with the Cough Reflex Test reduced rates of pneumonia or death.The ERC identified a need for additional prospective studies to compare the validity, feasibility, and clinical effectiveness of different screening methods for dysphagia. Ideally, these studies would randomly assign patients to different screening methods, potentially using a cluster randomized design, with outcomes including accuracy of dysphagia detection and incidence of pneumonia, stroke-related disability, and death at 90 days. To minimize variation in treatment between randomized groups, the management of patients after screening should be done according to a standardized protocol. The information from such trials would help hospitals to select the most appropriate screening tools for their practice and would help support the validity of dysphagia screening as a performance measure for stroke quality improvement.DISCLOSURESEvidence Review Committee DisclosuresCommittee MemberEmploymentResearch GrantOther Research SupportSpeakers’ Bureau/ HonorariaExpert WitnessOwnership InterestConsultant/ Advisory BoardOtherEric E. Smith (Chair)University of Calgary Clinical Neurosciences, Foothills Medical Centre CANADA NoneNoneNoneNoneNoneNoneNoneDavid M. Kent (Vice Chair)Tufts Medical Center/Tufts University School of Medicine, PACE Center, Institute of Clinical Research and Health Policy StudiesNoneNoneNoneNoneNoneNoneNoneKetan R. BulsaraUniversity of ConnecticutNoneNoneNoneNoneNoneNoneNoneLester Y. LeungTufts Medical CenterNoneNoneNoneNoneNoneNoneNoneJudith H. Lichtman Yale School of Public HealthNoneNoneNoneNoneNoneNoneNoneMathew J. ReevesMichigan State UniversityNoneNoneNoneNoneNoneNoneNoneAmytis TowfighiUniversity of Southern CaliforniaNoneNoneNoneNoneNoneNoneNoneWilliam N. WhiteleyUniversity of Edinburgh UNITED KINGDOMMRC?; Stroke Association?NoneNoneIndependent witness to the court*NoneNoneUniversity of Edinburgh?Darin ZahuranecUniversity of Michigan Cardiovascular CenterNIH?NoneNoneNoneNoneNoneNoneThis table represents the relationships?of writing group members that may be perceived as?actual or reasonably perceived conflicts?of interest?as reported?on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit.?A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.*Modest.?Significant.REFERENCES ADDIN EN.REFLIST 1.Martino R, Foley N, Bhogal S, Diamant N, Speechley M and Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke. 2005;36:2756-63.2.Cohen DL, Roffe C, Beavan J, Blackett B, Fairfield CA, Hamdy S, Havard D, McFarlane M, McLauglin C, Randall M, Robson K, Scutt P, Smith C, Smithard D, Sprigg N, Warusevitane A, Watkins C, Woodhouse L and Bath PM. Post-stroke dysphagia: A review and design considerations for future trials. Int J Stroke. 2016;11:399-411.3.Jauch EC, Saver JL, Adams HP, Jr., Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW, Jr., Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M and Yonas H. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870-947.4.Kertscher B, Speyer R, Palmieri M and Plant C. Bedside screening to detect oropharyngeal dysphagia in patients with neurological disorders: an updated systematic review. Dysphagia. 2014;29:204-12.5.Daniels SK, Anderson JA and Willson PC. Valid items for screening dysphagia risk in patients with stroke: a systematic review. Stroke; a journal of cerebral circulation. 2012;43:892-7.6.Smith EE, Saver JL, Alexander DN, Furie KL, Hopkins LN, Katzan IL, Mackey JS, Miller EL, Schwamm LH and Williams LS. Clinical performance measures for adults hospitalized with acute ischemic stroke: performance measures for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:3472-98.7.Luker JA, Wall K, Bernhardt J, Edwards I and Grimmer-Somers K. Measuring the quality of dysphagia management practices following stroke: a systematic review. Int J Stroke. 2010;5:466-76.8.Moher D, Liberati A, Tetzlaff J, Altman DG and Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151:264-9, W64.9.Jacobs AK, Kushner FG, Ettinger SM, Guyton RA, Anderson JL, Ohman EM, Albert NM, Antman EM, Arnett DK, Bertolet M, Bhatt DL, Brindis RG, Creager MA, DeMets DL, Dickersin K, Fonarow GC, Gibbons RJ, Halperin JL, Hochman JS, Koster MA, Normand SL, Ortiz E, Peterson ED, Roach WH, Jr., Sacco RL, Smith SC, Jr., Stevenson WG, Tomaselli GF, Yancy CW and Zoghbi WA. ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:268-310.10.Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA, Cochrane Bias Methods G and Cochrane Statistical Methods G. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. Bmj. 2011;343:d5928.11.Middleton S, McElduff P, Ward J, Grimshaw JM, Dale S, D'Este C, Drury P, Griffiths R, Cheung NW, Quinn C, Evans M, Cadilhac D and Levi C. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet. 2011;378:1699-706.12.Anonymous. Quality in Acute Stroke Care (QASC) Trial. 2015;2017.13.Miles A, Zeng IS, McLauchlan H and Huckabee ML. Cough reflex testing in dysphagia following stroke: a randomized controlled trial. J Clin Med Res. 2013;5:222-33.14.Rai N, Prasad K, Bhatia R, Vibha D, Singh MB, Rai VK and Kumar A. 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Stroke. 2013;44:e24-31.Table 1: Selection CriteriaSelection Criteria:Hospitalized patients with stroke (either ischemic stroke or intracerebral hemorrhage)Includes adults (≥18 years)Randomized comparisonIntervention was either a dysphagia screen, which could be the only intervention or only one component of a multi-faceted intervention to improve stroke unit care, or a quality improvement intervention to improve screening rates. Screening was defined as “a pass/fail procedure to identify individuals who require a comprehensive assessment of swallowing function or a referral for other professional and/or medical services”PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb25vdmFuPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48
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ADDIN EN.CITE.DATA 16Comparator group was either no screening, an alternative screening method, usual care, or a gold standard diagnostic method for aspiration (either speech language pathologist consultation or videofluoroscopy)Reported one or more of these outcomes: death, dependency, or pneumoniaStudy published in 1975 or later.Table 2. Risk for BiasPotential Causes of BiasLead Author Last NamePublication YearWas the allocation sequence adequately generated?Was allocation adequately concealed?Was knowledge of the allocated interventions adequately prevented during the study? (Blinding)Was knowledge of the allocated interventions adequately prevented during the outcome assessment? (Blinding)Were incomplete outcome data adequately addressed?Are reports of the study free of suggestion of selective outcome reporting?Was the study apparently free of other problems that could put it at a risk of bias?MiddletonPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaWRkbGV0b248L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy
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ADDIN EN.CITE.DATA 112011YES(Low Risk of Bias)YES(Low Risk of Bias)NO(High Risk of Bias)YES(Low Risk of Bias)YES(Low Risk of Bias)YES(Low Risk of Bias)YES(Low Risk of Bias)Miles ADDIN EN.CITE <EndNote><Cite><Author>Miles</Author><Year>2013</Year><RecNum>26241</RecNum><DisplayText><style face="superscript">13</style></DisplayText><record><rec-number>26241</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485660892">26241</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Miles, A.</author><author>Zeng, I. S.</author><author>McLauchlan, H.</author><author>Huckabee, M. L.</author></authors></contributors><auth-address>Department of Communication Disorders, The University of Canterbury, 66 Stewart St, Christchurch 8011, New Zealand ; Speech Science, School of Psychology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.</auth-address><titles><title>Cough reflex testing in dysphagia following stroke: a randomized controlled trial</title><secondary-title>J Clin Med Res</secondary-title></titles><periodical><full-title>J Clin Med Res</full-title></periodical><pages>222-33</pages><volume>5</volume><number>3</number><keywords><keyword>Cough reflex testing</keyword><keyword>Deglutition</keyword><keyword>Deglutition disorders</keyword><keyword>Dysphagia</keyword><keyword>Pneumonia</keyword><keyword>Silent aspiration</keyword><keyword>Stroke care</keyword></keywords><dates><year>2013</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1918-3003 (Print)
1918-3003 (Linking)</isbn><accession-num>23671548</accession-num><urls><related-urls><url>(Low Risk of Bias)YES(Low Risk of Bias)NO(High Risk of Bias)NO(High Risk of Bias)YES(Low Risk of Bias)YES(Low Risk of Bias)YES(Low Risk of Bias)Rai ADDIN EN.CITE <EndNote><Cite><Author>Rai</Author><Year>2016</Year><RecNum>26242</RecNum><DisplayText><style face="superscript">14</style></DisplayText><record><rec-number>26242</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485660892">26242</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rai, N.</author><author>Prasad, K.</author><author>Bhatia, R.</author><author>Vibha, D.</author><author>Singh, M. B.</author><author>Rai, V. K.</author><author>Kumar, A.</author></authors></contributors><auth-address>Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.</auth-address><titles><title>Development and implementation of acute stroke care pathway in a tertiary care hospital in India: A cluster-randomized study</title><secondary-title>Neurol India</secondary-title></titles><periodical><full-title>Neurol India</full-title><abbr-1>Neurology India</abbr-1></periodical><pages>S39-45</pages><volume>64 Suppl</volume><dates><year>2016</year><pub-dates><date>Mar-Apr</date></pub-dates></dates><isbn>0028-3886 (Print)
0028-3886 (Linking)</isbn><accession-num>26954966</accession-num><urls><related-urls><url>(High Risk of Bias)NO(High Risk of Bias)NO(High Risk of Bias)NO(High Risk of Bias)Unclear Risk of Bias (insufficient information)YES(Low Risk of Bias)NOHigh Risk of Bias)*Table 2 Legend: Assessed using the Cochrane Risk of Bias Tool. ADDIN EN.CITE <EndNote><Cite><Author>Higgins</Author><Year>2011</Year><RecNum>24972</RecNum><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>24972</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1480939213">24972</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Higgins, J. P.</author><author>Altman, D. G.</author><author>Gotzsche, P. C.</author><author>Juni, P.</author><author>Moher, D.</author><author>Oxman, A. D.</author><author>Savovic, J.</author><author>Schulz, K. F.</author><author>Weeks, L.</author><author>Sterne, J. A.</author><author>Cochrane Bias Methods, Group</author><author>Cochrane Statistical Methods, Group</author></authors></contributors><auth-address>MRC Biostatistics Unit, Institute of Public Health, Cambridge CB2 0SR, UK. julian.higgins@mrc-bsu.cam.ac.uk</auth-address><titles><title>The Cochrane Collaboration's tool for assessing risk of bias in randomised trials</title><secondary-title>BMJ</secondary-title></titles><periodical><full-title>BMJ</full-title><abbr-1>Bmj</abbr-1></periodical><pages>d5928</pages><volume>343</volume><keywords><keyword>Bias (Epidemiology)</keyword><keyword>Humans</keyword><keyword>Randomized Controlled Trials as Topic/*standards</keyword><keyword>Research Design</keyword><keyword>Risk Assessment</keyword></keywords><dates><year>2011</year><pub-dates><date>Oct 18</date></pub-dates></dates><isbn>1756-1833 (Electronic)
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ADDIN EN.CITE.DATA 11Cluster RCT19 stroke units; 1126 patientsIntervention: Fever, Sugar, Swallowing Intervention consisted of protocols, workshops, site visits, and email/telephone support. Nurses trained to use ASSIST dysphagia screening tool via in-service by speech pathologist, and required to pass competency exam. Comparator:Abridged version of existing guidelinesDeath and dependency (mRS ≥2): 42% (236/558) vs. 58% (259/449) [p=0.002]All-cause mortality: 3.7% (21/558) vs. 5.3% (24/451) [p=0.36]Aspiration pneumonia: 2.1% (13/603) vs. 2.7% (13/483) [p=0.82]Miles ADDIN EN.CITE <EndNote><Cite><Author>Miles</Author><Year>2013</Year><RecNum>26241</RecNum><DisplayText><style face="superscript">13</style></DisplayText><record><rec-number>26241</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485660892">26241</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Miles, A.</author><author>Zeng, I. S.</author><author>McLauchlan, H.</author><author>Huckabee, M. L.</author></authors></contributors><auth-address>Department of Communication Disorders, The University of Canterbury, 66 Stewart St, Christchurch 8011, New Zealand ; Speech Science, School of Psychology, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.</auth-address><titles><title>Cough reflex testing in dysphagia following stroke: a randomized controlled trial</title><secondary-title>J Clin Med Res</secondary-title></titles><periodical><full-title>J Clin Med Res</full-title></periodical><pages>222-33</pages><volume>5</volume><number>3</number><keywords><keyword>Cough reflex testing</keyword><keyword>Deglutition</keyword><keyword>Deglutition disorders</keyword><keyword>Dysphagia</keyword><keyword>Pneumonia</keyword><keyword>Silent aspiration</keyword><keyword>Stroke care</keyword></keywords><dates><year>2013</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1918-3003 (Print)
1918-3003 (Linking)</isbn><accession-num>23671548</accession-num><urls><related-urls><url> patientsIntervention: Clinical Swallowing Evaluation + Cough Reflex TestingComparator: Clinical Swallowing Evaluation Confirmed pneumonia: 26% (38/148) vs. 21% (35/163) [adjusted OR 1.7 [95% CI: 0.9 – 3.0], p = 0.38]All-cause mortality: 14% (20/148) vs. 20% (32/163) [adjusted OR 0.7 [95% CI: 0.4 – 1.3] p = 0.23]Rai ADDIN EN.CITE <EndNote><Cite><Author>Rai</Author><Year>2016</Year><RecNum>26242</RecNum><DisplayText><style face="superscript">14</style></DisplayText><record><rec-number>26242</rec-number><foreign-keys><key app="EN" db-id="9vd92wtd5tawfqetxw4ve5pes5xwr29zr52z" timestamp="1485660892">26242</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rai, N.</author><author>Prasad, K.</author><author>Bhatia, R.</author><author>Vibha, D.</author><author>Singh, M. B.</author><author>Rai, V. K.</author><author>Kumar, A.</author></authors></contributors><auth-address>Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.</auth-address><titles><title>Development and implementation of acute stroke care pathway in a tertiary care hospital in India: A cluster-randomized study</title><secondary-title>Neurol India</secondary-title></titles><periodical><full-title>Neurol India</full-title><abbr-1>Neurology India</abbr-1></periodical><pages>S39-45</pages><volume>64 Suppl</volume><dates><year>2016</year><pub-dates><date>Mar-Apr</date></pub-dates></dates><isbn>0028-3886 (Print)
0028-3886 (Linking)</isbn><accession-num>26954966</accession-num><urls><related-urls><url> RCT2 wards; 162 patientsIntervention: Stroke Care Pathway consisting ofNurse education, care checklist, swallow assessment flow chart, swallow screen, patient and caregiver education. The swallow screen was culturally adapted to local food habits and administered by a resident physician. Comparator: Conventional care based on existing ward practices. Feeding started based on physician judgment.Aspiration pneumonia during hospital stay – 6.5% (5/77) vs.15.3% (13/85) [adjusted OR 0.33 [95% CI 0.09-1.22], p=0.10]Mechanical ventilation during Hospital Stay: 7.8% vs. 17.6% [OR 0.39 [95% CI: 0.14 – 1.07, p=0.05]All-cause mortality at 90 days: 7.8% (6/77) vs 20% (17/85) [p=0.02] [adjusted OR 0.33 [95% CI 0.12 - 0.90], p=0.03]mRS ≤2 at 90 days: 57.1% (44/77) vs. 57.6% (49/85) [p non-significant]Table 3 Legend: RCT, randomized controlled trial; mRS, modified Rankin scale; OR, odds ratio.Figure 1. Flow DiagramCitations identified through PubMed(n = 168)647Full-text articles screened for eligibility (n = 20)Citations screened after duplicates removed: (n = 448)Title/abstracts screened(n = 448)Citations excluded after title/abstract screening (n = 428)Studies Included (n = 3)Full-text articles excluded (n = 17) Reasons for exclusions:1 Wrong intervention2 Duplicate publication3 Wrong outcome (s)10 Not relevant (Does not meet protocol)1 Wrong comparisonCitations identified through Embase(n = 373)???647Citations identified through Cochrane(n = 30)???647Citations identified through PubMed(n = 168)647Full-text articles screened for eligibility (n = 20)Citations screened after duplicates removed: (n = 448)Title/abstracts screened(n = 448)Citations excluded after title/abstract screening (n = 428)Studies Included (n = 3)Full-text articles excluded (n = 17) Reasons for exclusions:1 Wrong intervention2 Duplicate publication3 Wrong outcome (s)10 Not relevant (Does not meet protocol)1 Wrong comparisonCitations identified through Embase(n = 373)???647Citations identified through Cochrane(n = 30)???647 ................
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