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Bonilha HS, Reedy EL, Wilmskoetter J, Nietert PJ, Martin-Harris B. Impact of Reducing Fluoroscopy Pulse Rate on Adult Modified Barium Swallow Studies. Dysphagia 2024; 39:632-641. [PMID: 38265506 PMCID: PMC11239744 DOI: 10.1007/s00455-023-10643-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/02/2023] [Indexed: 01/25/2024]
Abstract
Modified Barium Swallow Studies (MBSS) are a critical part of the evaluation, treatment planning, and outcome assessment for persons with swallowing disorders. Since MBSSs use ionizing radiation with associated cancer risks, many clinicians have reduced radiation exposure by reducing the fluoroscopic pulse rate. However, by reducing pulse rate, we also decrease the temporal resolution of MBSSs which has been shown in pilot studies to significantly reduce diagnostic accuracy. Two hundred MBSSs from patients routinely undergoing MBSS as standard of care conducted at 30 pulses per second (pps) using the Modified Barium Swallow Study Impairment Profile (MBSImP™) standardized administration protocol were selected. A stratified sampling method ensured that a full range of swallowing impairments (etiology, type, and severity) was represented. Recordings were down sampled from 30 pps to 15, 7.5, and 4 pps. MBSSs were rated using the MBSImP components and Penetration-Aspiration Scale (PAS) score for each swallow. Percent agreement was calculated across raters for MBSImP and PAS scores by bolus type and volume. The Least-Squares Method was used for hypothesis testing. Statistically significant and clinically meaningful changes in scores of swallowing physiology and penetration/aspiration occurred when reducing pulse rate below 30pps. These changes were evident across bolus types and volumes. Given the impact on diagnostic accuracy and the low radiation risks to adults undergoing MBSSs, reducing pulse rate to 15pps or below is not aligned with the As Low As Reasonably Achievable (ALARA) principle and should not be used as a viable method to reduce radiation exposure from MBSSs.
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Affiliation(s)
- Heather Shaw Bonilha
- Health Sciences and Research, College of Health Professions, Medical University of South Carolina, 77 President Street, MSC 700, Charleston, SC, 29425-2503, USA.
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, MSC 550, Charleston, SC, 29425, USA.
- Department of Communication Sciences and Disorders, University of South Carolina, 915 Greene Street, Room 202B, Columbia, SC, 29208, USA.
| | - Erin L Reedy
- Health Sciences and Research, College of Health Professions, Medical University of South Carolina, 77 President Street, MSC 700, Charleston, SC, 29425-2503, USA
- Roxelyn and Richard Pepper Department of Communication Sciences and Disorders, School of Communication, Northwestern University, 70 Arts Circle Drive, Evanston, IL, 60208, USA
- Edward J. Hines Veteran's Affairs Medical Center, 5000 5th Avenue, Hines, IL, 60141-3030, USA
| | - Janina Wilmskoetter
- Health Sciences and Research, College of Health Professions, Medical University of South Carolina, 77 President Street, MSC 700, Charleston, SC, 29425-2503, USA
- College of Medicine, Department of Neurology, Medical University of South Carolina, 96 Jonathan Lucas Street, MSC 606, Charleston, SC, 29425-2503, USA
| | - Paul J Nietert
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, 135 Cannon Street, MSC 835, Charleston, SC, 29425-2503, USA
| | - Bonnie Martin-Harris
- Roxelyn and Richard Pepper Department of Communication Sciences and Disorders, School of Communication, Northwestern University, 70 Arts Circle Drive, Evanston, IL, 60208, USA
- Feinberg School of Medicine, Otolaryngology - Head & Neck Surgery, Radiation Oncology, Northwestern University, 420 E Superior Street, Chicago, IL, 60611, USA
- Edward J. Hines Veteran's Affairs Medical Center, 5000 5th Avenue, Hines, IL, 60141-3030, USA
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Hutcheson KA, Aldridge EF, Warneke CL, Buoy SN, Tang X, Macdonald C, Alvarez CP, Barringer DA, Barbon CEA, Ebersole BM, McMillan H, Montealegre JR. Clinical Implementation of DIGEST as an Evidence-Based Practice Tool for Videofluoroscopy in Oncology: A Six-Year Single Institution Implementation Evaluation. Dysphagia 2024:10.1007/s00455-024-10721-2. [PMID: 38935170 DOI: 10.1007/s00455-024-10721-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 05/22/2024] [Indexed: 06/28/2024]
Abstract
Clinical implementation of evidence-based practice (EBP) tools is a healthcare priority. The Dynamic Grade of Swallowing Toxicity (DIGEST) is an EBP tool developed in 2016 for videofluoroscopy in head and neck (H&N) oncology with clinical implementation as a goal. We sought to examine: (1) feasibility of clinical implementation of DIGEST in a national comprehensive cancer center, and (2) fidelity of DIGEST adoption in real-world practice. A retrospective implementation evaluation was conducted in accordance with the STARI framework. Electronic health record (EHR) databases were queried for all consecutive modified barium swallow (MBS) studies conducted at MD Anderson Cancer Center from 2016 to 2021. Implementation outcomes included: feasibility as measured by DIGEST reporting in EHR (as a marker of clinical use) and fidelity as measured by accuracy of DIGEST reporting relative to the decision-tree logic (penetration-aspiration scale [PAS], residue, and Safety [S] and Efficiency [E] grades). Contextual factors examined included year, setting, cancer type, MBS indication, and provider. 13,055 MBS were conducted by 29 providers in 7,842 unique patients across the lifespan in diverse oncology populations (69% M; age 1-96 years; 58% H&N cancer; 10% inpatient, 90% outpatient). DIGEST was reported in 12,137/13,088 exams over the 6-year implementation period representing 93% (95% CI: 93-94%) adoption in all exams and 99% (95% CI: 98-99%) of exams excluding the total laryngectomy population (n = 730). DIGEST reporting varied modestly by year, cancer type, and setting/provider (> 91% in all subgroups, p < 0.001). Accuracy of DIGEST reporting was high for overall DIGEST (incorrect SE profile 1.6%, 200/12,137), DIGEST-safety (incorrect PAS 0.4% 51/12,137) and DIGEST-efficiency (incorrect residue 1.2%, 148/12,137). Clinical implementation of DIGEST was feasible with high fidelity in a busy oncology practice across a large number of providers. Adoption of the tool across the lifespan in diverse cancer diagnoses may motivate validation beyond H&N oncology.
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Affiliation(s)
- Katherine A Hutcheson
- Department of Head & Neck Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1445, Houston, Texas, 77030-4009, US.
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Ella F Aldridge
- Department of Head & Neck Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1445, Houston, Texas, 77030-4009, US
| | - Carla L Warneke
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1689, Houston, Texas, 77030, US
| | - Sheila N Buoy
- Department of Head & Neck Surgery - Research, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1445, Houston, Texas, 77030, US
| | - Xiaohui Tang
- Department of Head & Neck Surgery - Research, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Unit 1445, Houston, Texas, 77030, US
| | - Cameron Macdonald
- Qualitative Health Research Center, 111 King St., Suite 23, Madison, WI, 53703, US
| | - Clare P Alvarez
- Department of Head & Neck Center, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 0340, Houston, Texas, 77030, US
| | - Denise A Barringer
- Department of Endoscopy Center, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 0385, Houston, Texas, 77030, US
| | - Carly E A Barbon
- Department of Head & Neck Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1445, Houston, Texas, 77030-4009, US
| | - Barbara M Ebersole
- Department of Head & Neck Center, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. (R10.1810), Houston, Texas, 77030, US
| | - Holly McMillan
- Department of Head & Neck Center, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. (R10.1824), Houston, Texas, 77030, US
| | - Jane R Montealegre
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, 1155 Pressler (CPB3.3253), Houston, Texas, 77030, US
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