Disparities in the prevalence of self-reported dysphagia and treatment among U.S. adults

Racial and Ethnic Disparities in Speech-Language Pathology Utilization for Patients With Oropharyngeal Dysphagia in Acute Care

PURPOSE

Disparities in health care utilization are modifiable drivers of disparities in health outcomes but have not been explored regarding speech-language pathology utilization for patients with dysphagia. This study explores racial and ethnic disparities in the utilization of speech-language pathology services among adult patients diagnosed with oropharyngeal dysphagia during acute care hospitalizations.

METHOD

We analyzed New York State Inpatient Data on acute care hospitalizations in 2019. We identified adults with a diagnosis of oropharyngeal dysphagia and determined whether they received speech-language pathology services via revenue center codes, which indicate receipt of a speech-language pathology evaluation or treatment. Using generalized estimating equations, we estimated the effect of race/ethnicity (White, Black, Hispanic, and Other race) on speech-language pathology utilization (yes, no) during the acute care hospitalization, controlling for patient clinical characteristics (e.g., acute diagnoses and clinical comorbidities), demographic characteristics (e.g., insurance status, rural-urban status), and health system factors (e.g., hospital size). Subgroup analyses were conducted for select primary diagnoses (i.e., stroke, sepsis, and aspiration pneumonia).

RESULTS

We identified 56,198 individuals with a diagnosis of oropharyngeal dysphagia; 60.7% received speech-language pathology services. In the full sample analysis, the adjusted odds of speech-language pathology utilization were lower in Black relative to White individuals (odds ratio [OR] = 0.87 [0.76, 0.98], p = .026). Racial and ethnic disparities were present in the subgroup analyses, most notably for sepsis, where speech-language pathology utilization was significantly lower for Black, Hispanic, and Other race individuals (ORs from 0.61 to 0.77) relative to White individuals.

CONCLUSIONS

We found evidence of racial and ethnic disparities in the utilization of speech-language pathology services for patients with oropharyngeal dysphagia in the acute care setting that varied by primary diagnosis. Further research is needed to replicate these findings and to begin to understand the reasons behind these disparities.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.26791741.

Conceptualizing Adult Dysphagia in the United States Within the International Classification of Functioning, Disability and Health (ICF)

Despite the well-documented safety concerns and effect on quality of life, there does not yet exist a wide-reaching framework that links the etiologies of swallowing disorders to the potential short- and long-term outcomes in the context of International Classification of Functioning, Disability and Health (ICF). This paper introduces an expert-reviewed conceptual framework to highlight common etiologies of dysphagia as well as integrate immediate outcomes of dysphagia with long-term outcomes of dysphagia in terms of medical problems, health-related quality of life, functional effect, and psychosocial features. It also outlines the potential cyclical nature of long-term dysphagia outcomes perpetuating the original dysphagia. This framework serves to inform clinicians of important dysphagic outcomes and to bring awareness to long-term outcomes that should be monitored by health care professionals, caregivers, or people with dysphagia.

Prevalence of Self-Reported Swallowing Difficulties and Swallowing-Related Quality of Life Among Community-Dwelling Older Adults in India

Self-reported swallowing difficulties are highly prevalent but underreported among older adults. The aging population in India is increasing, yet there is a lack of empirical data on self-reported swallowing difficulties in older adults. In the present study, we aimed to estimate the prevalence of self-reported swallowing difficulties and assess the swallowing-related quality of life (QOL) among community-dwelling older adults in India. We recruited 361 older adults (60-91 years) from the community. Participants completed the Eating Assessment Tool-10 (EAT-10) to assess self-reported swallowing difficulties and the Dysphagia Handicap Index (DHI) to assess swallowing-related QOL. Participants rated the EAT-10 from 0 for 'no problem' to 4 for 'severe problem'. The DHI rating included 0 for 'never', 2 for 'sometimes', and 4 for 'always'. The total scores of EAT-10 and DHI were summarised using descriptive statistics. Statistically significant differences between pass-fail groups of EAT-10 and DHI were evaluated using an independent t-test and multivariate analysis of variance test, respectively. The overall mean score for EAT-10 was 3.34, and 7.56 for DHI, with higher scores observed among females. 36.6% of older adults self-reported experiencing swallowing difficulties, while 47.4% self-reported having poor swallowing-related QOL at p < 0.05. A strong positive correlation (r = 0.86) was found between EAT-10 and total DHI scores at p < 0.001. The present study sheds light on the widespread yet underreported issue of self-reported swallowing difficulties and the impact on swallowing-related QOL among older adults in India. These findings emphasize the urgent need for early swallowing screening programs among older adults.

A Psychometric Evaluation of the Dysphagia Handicap Index Using Rasch Analysis

Background/Objectives: The Dysphagia Handicap Index (DHI) is commonly used in oropharyngeal dysphagia (OD) research as a self-report measure of functional health status and health-related quality of life. The DHI was developed and validated using classic test theory. The aim of this study was to use item response theory (Rasch analysis) to evaluate the psychometric properties of the DHI. Methods: Prospective, consecutive patient data were collected at dysphagia or otorhinolaryngology clinics. The sample included 256 adults (53.1% male; mean age 65.2) at risk of OD. The measure's response scale, person and item fit characteristics, differential item functioning, and dimensionality were evaluated. Results: The rating scale was ordered but showed a potential gap in the rating category labels for the overall measure. The overall person (0.91) and item (0.97) reliability was excellent. The overall measure reliably separated persons into at least three distinct groups (person separation index = 3.23) based on swallowing abilities, but the subscales showed inadequate separation. All infit mean squares were in the acceptable range except for the underfitting for item 22 (F). More misfitting was evident in the Z-Standard statistics. Differential item functioning results indicated good performance at an item level for the overall measure; however, contrary to expectation, an OD diagnosis presented only with marginal DIF. The dimensionality of the DHI showed two dimensions in contrast to the three dimensions suggested by the original authors. Conclusions: The DHI failed to reproduce the original three subscales. Caution is needed using the DHI subscales; only the DHI total score should be used. A redevelopment of the DHI is needed; however, given the complexities involved in addressing these issues, the development of a new measure that ensures good content validity may be preferred.

Evaluation of Social Determinants of Health on Dysphagia Care Pathways at a Tertiary Care Facility

OBJECTIVES

Limited research exists evaluating the impact of social determinants of health in influencing care pathways for patients with dysphagia. A better understanding of whether these determinants correlate to altered care and resource utilization is essential as it relates to patient outcomes.

STUDY DESIGN

Retrospective chart review.

METHODS

All adult patients seen at a tertiary midwestern hospital were screened for ICD codes of dysphagia diagnoses from 2009 to 2019. Demographic information was collected from these patients with dysphagia including sex, race, ethnicity, and insurance status. Subgroup analysis was performed to assess referral pattern rates and types of diagnostic interventions ordered (none, videofluoroscopic swallow study, esophagram, and esophagogastroduodenoscopy).

RESULTS

A total of 31,858 patients with dysphagia were seen at our institution during the study period, with a majority being female (56.36%), Caucasian (79.83%), and publicly insured (63.16%), at a median age of 60.35 years. There were no significant care delivery pattern differences based on geography/zip code analyses. African American patients were significantly more likely to have imaging or interventions performed (odds ratio [OR] 1.463, p = 0.005). Patients with public insurance also had higher rates of diagnostic study utilization (OR 1.53, p = 0.01). Only 3% of all patients with dysphagia were seen by laryngologists.

CONCLUSION

No significant differences were seen in dysphagia evaluation modalities based on zip code analyses surrounding this tertiary care facility. African American patients and those with public insurance had significantly higher utilization of subsequent testing and intervention for dysphagia care. Further studies are necessary to delineate causes and outcome differences for these measurable differences in dysphagia care pathways.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1139-1146, 2024.