Towards development of guidelines for virtual administration of paediatric standardized language and literacy assessments: Considerations for clinicians and researchers

OBJECTIVES

Previous virtual care literature within the field of speech-language pathology has primarily focused on validating the virtual use of intervention programmes. There are fewer articles addressing the validity of conducting virtual assessments, particularly standardized assessment of oral language and literacy abilities in children. In addition, there is a lack of practical, useful recommendations available to support clinicians and researchers on how to conduct these assessment measures virtually. Given the recent rapid rise in virtual care and research as a result of the Coronavirus-19 pandemic, clinicians and researchers require guidance on best practices for virtual administration of these tools imminently. This article seeks to fill this gap in the literature by providing such recommendations.

METHODS

We (a) completed a narrative review of the extant literature, and (b) conducted semi-structured interviews with a group of 12 clinicians, students and researchers who had administered standardized language and literacy assessments with a variety of monolingual and multilingual school-aged children, with and without speech and language difficulties, in clinical and research settings. Six themes: candidacy for virtual assessment, communication and collaboration with caregivers, technology and equipment, virtual administration, ethics, consent and confidentiality, and considerations for bilingual populations were identified as a result of these two processes and were used to develop a set of recommendations to guide the use of standardized assessments in a virtual setting. In line with the Guidelines International Network, these recommendations were rated by group members, and reviewed by external stakeholders. A quasi-Delphi consensus procedure was used to reach agreement on ratings for recommendations.

RESULTS

We have developed and outlined several recommendations for clinicians and researchers to guide their use of standardized language and literacy assessments in virtual care, across six key themes.

CONCLUSIONS

This article is one of the first to share practical recommendations for virtual assessment in the domain of oral language and literacy assessment for clinicians and researchers. We hope the current recommendations will facilitate future clinical research in this area, and as the body of research in this field grows, this article will act as a basis for the development of formal Clinical Practice Guidelines.

Development of a Remote Examination of Deglutition Based on Consensus Surveys of Clinicians (Part I): Selection of Examination Items

In order to ensure appropriateness and feasibility of examination items for remote evaluation for deglutition disorders, a questionnaire based on the Delphi method was administered to 122 speech–language–hearing therapists (STs), and a set of examination items was selected. The participants were instructed to view a video recording of a remote assessment situation and answer a 30-item questionnaire. Of 19 items ensuring the appropriateness for deglutition disorders detection, 13 items ultimately met the consensus criteria for remote feasibility. Factor analysis extracted three factors: ‘oral observation,’ ‘overall evaluation,’ and ‘perceptual voice judgment.’ In free-text responses, “quality and stability of the voice that may be heard through the device” were the most common concerns, followed by “the need to correct of the camera angle, magnification, and targets that should be projected,” “concerns about the technical aspects of the assistants and their role in relation with the examiner/ST,” and “the need for palpation as well as visual confirmation.” The proposed 13-item examination is considered to capture the characteristics of deglutition disorders, while items that appeared difficult to implement remotely were excluded. The fact that some items could be influenced by the video calling experience when judging the feasibility of remote implementation, the acceptability of such items, is likely to increase in the future.

Swallowing and Communication Management of Tracheostomy and Laryngectomy in the Context of COVID-19: A Review

IMPORTANCE

The care of patients with a surgically modified airway, such as tracheostomy or laryngectomy, represents a challenge for speech-language pathologists (SLPs) in the context of the coronavirus disease 2019 (COVID-19) pandemic. The objective was to review available publications and practice guidelines on management of tracheostomy and laryngectomy in the context of COVID-19. This study performed a review and synthesis of information available in the PubMed database and from national SLP organizations across 6 countries.

OBSERVATIONS

From the search, 22 publications on tracheostomy and 3 referring to laryngectomy were identified. After analysis of titles and abstracts followed by full-text review, 4 publications were identified as presenting guidelines for specific approaches to tracheostomy and were selected; all 3 publications on laryngectomy were selected. The main guidelines on tracheostomy described considerations during management (eg, cuff manipulation, suctioning, valve placement) owing to the increased risk of aerosol generation and transmission during swallowing and communication interventions in this population. Regarding laryngectomy, the guidelines focused on the care and protection of both the professional and the patient, offering recommendations on the management of adverse events and leakage of the tracheoesophageal prosthesis.

CONCLUSIONS AND RELEVANCE

Frequent guideline updates for SLPs are necessary to inform best practice and ensure patient and health care worker protection and safety while providing high-quality care and rehabilitation.

Prophylactic swallowing therapy for patients with head and neck cancer: A three-arm randomized parallel-group trial

BACKGROUND

Intensive prophylactic swallowing therapy can mitigate dysphagia in patients with oropharyngeal (OP) SCC, however, presents service challenges. This trial investigated the clinical efficacy of three service models delivering prophylactic swallowing therapy during (chemo)radiotherapy ([C]RT).

METHODS

Patients (n = 79) with OPSCC receiving (C)RT were were randomized to: (a) clinician-directed face-to-face therapy (n = 26); (b) telepractice therapy via "SwallowIT" (n = 26); or (c) patient self-directed therapy (n = 27). Swallowing, nutritional, and functional status were compared at baseline, 6-weeks, and 3-months post-(C)RT. Patients' perceptions/preferences for service-delivery were collated posttreatment.

RESULTS

Service-delivery mode did not affect clinical outcomes, with no significant (P > .05) between-group differences or group-by-time interactions observed for swallowing, nutrition, or functional measures. Therapy adherence declined during (C)RT in all groups. SwallowIT and clinician-directed models were preferred by significantly (P = .002) more patients than patient-directed.

CONCLUSIONS

SwallowIT provided clinically equivalent outcomes to traditional service models. SwallowIT and clinician-directed therapy were preferred by patients, likely due to higher levels of therapy support.

Home-based telehealth service for swallowing and nutrition management following head and neck cancer treatment

Introduction

Following (chemo)radiotherapy (C/RT) for head and neck cancer (HNC), patients return to hospital for regular outpatient reviews with speech pathology (SP) and nutrition and dietetics (ND) for acute symptom monitoring, nutritional management, and swallowing and communication rehabilitation. The aim of the current study was to determine the feasibility of a home-based telehealth model for delivering SP and ND reviews, to provide patients with more convenient access to these appointments.

Methods

Service outcomes, costs, and consumer satisfaction were examined across 30 matched participants: 15 supported via the standard model of care (SMOC), and 15 via the home-based telehealth model of care (TMOC).

Results

All patients were successfully managed via telehealth. The TMOC was more efficient, with a reduced number ( p < 0.003) and duration ( p < 0.01) of appointments required until discharge. Significant patient cost savings ( p = 0.002) were reported for the TMOC due to decreased travel requirements. While staff costs were reduced, additional telehealth equipment levies resulted in a lower but non-significant overall cost difference to the health service when using the TMOC. High satisfaction was reported by all participants attending the TMOC.

Discussion

The findings support the feasibility of a home-based telehealth model for conducting SP and ND reviews post C/RT for HNC.

Randomized controlled trial of a multisite speech pathology telepractice service providing swallowing and communication intervention to patients with head and neck cancer: Evaluation of service outcomes

BACKGROUND

The purpose of this study was to present our evaluation of a new speech pathology telepractice service supporting the swallowing and communication management of patients with head and neck cancer.

METHODS

A multicenter randomized controlled trial was conducted within a large public cancer service. Referrals from speech pathologists at 3 regional sites (spoke sites) were managed by a specialist clinician from a cancer center (hub site) either via standard care (phone/email support/appointments at the hub site) or a newly established telepractice service (online consultation between the hub site and spoke site).

RESULTS

Eighty-two referrals (39 for standard care and 43 for telepractice care) were managed. Service efficiency favoring the telepractice model was reported with a significant reduction in the number (p = .004) and duration (p = .024) of contact events required to manage the referrals. Higher consumer and clinician satisfaction was also reported for the telepractice service.

CONCLUSION

A speech pathology telepractice service benefits both the patient and health provider through higher service efficiency and treatment satisfaction. © 2017 Wiley Periodicals, Inc. Head Neck 39: 932-939, 2017.

Telehealth for Dysphagia Rehabilitation: The Present and the Future

Dysphagia affects about nine million adults and half a million children annually in the United States alone, and its prevalence is only projected to increase as the baby boomer generation grows older. For many individuals who live in rural or underserved areas, accessing a speech-language pathologist (SLP) with expertise in dysphagia can be challenging. Telehealth appears to be a viable solution to address the needs of individuals living in these areas, and for patients and clinicians with mobility/access limitations. This article provides an overview of the current research evidence in dysphagia telehealth and identifies research and clinical practice gaps as well as potential solutions. Our aim is to provide foundational knowledge for dysphagia clinicians who are interested in entering the telehealth arena.

A scoping review of Australian allied health research in ehealth

Background

Uptake of e-health, the use of information communication technologies (ICT) for health service delivery, in allied health appears to be lagging behind other health care areas, despite offering the potential to address problems with service access by rural and remote Australians. The aim of the study was to conduct a scoping review of studies into the application of or attitudes towards ehealth amongst allied health professionals conducted in Australia.

Methods

Studies meeting inclusion criteria published from January 2004 to June 2015 were reviewed. Professions included were audiology, dietetics, exercise physiology, occupational therapy, physiotherapy, podiatry, social work, and speech pathology. Terms for these professions and forms of ehealth were combined in databases of CINAHL (EBSCO), Cochrane Library, PsycINFO (1806 – Ovid), MEDLINE (Ovid) and AMED (Ovid).

Results

Forty-four studies meeting inclusion criteria were summarised. They were either trials of aspects of ehealth service delivery, or clinician and/or client use of and attitudes towards ehealth. Trials of ehealth were largely from two research groups located at the Universities of Sydney and Queensland; most involved speech pathology and physiotherapy. Assessments through ehealth and intervention outcomes through ehealth were comparable with face-to-face delivery. Clinicians used ICT mostly for managing their work and for professional development, but were reticent about its use in service delivery, which contrasted with the more positive attitudes and experiences of clients.

Conclusion

The potential of ehealth to address allied health needs of Australians living in rural and remote Australia appears unrealised. Clinicians may need to embrace ehealth as a means to radicalise practice, rather than replicate existing practices through a different mode of delivery.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1791-x) contains supplementary material, which is available to authorized users.

A telehealth approach to conducting clinical swallowing evaluations in children with cerebral palsy

BACKGROUND

Accurate and timely evaluation of dysphagia in children with cerebral palsy (CP) is critical. For children with limited access to quality healthcare, telehealth is an option; however, its reliability needs to be investigated.

AIM

To test the reliability of an asynchronous telehealth model for evaluating dysphagia in children with CP using a standardized clinical assessment.

METHODS AND PROCEDURES

Nineteen children (age range 6.9-17.5) were assessed at three mealtimes via the Dysphagia Disorder Survey (DDS) by three clinicians (face-to-face evaluations). Mealtimes were video-recorded to allow asynchronous evaluations by a remote clinician who also completed approximately 1/3 of face-to-face evaluations. Agreement was tested on DDS variables and dysphagia severity.

OUTCOMES AND RESULTS

Results revealed substantial to excellent agreement between face-to-face and remote assessments by the same rater (78-100%, KW=0.64-1) on all, but two variables (oral transport and oral pharyngeal swallow) and by different raters (69-89%, KW=0.6-0.86) on all but one variable (orienting). For dysphagia severity, intrarater agreement was excellent (100%, KW=1); interrater agreement was substantial (85%; KW=0.76).

CONCLUSIONS AND IMPLICATIONS

Asynchronous clinical swallowing evaluations using standardized tools have acceptable levels of agreement with face-to-face evaluations, and can be an alternative for children with limited access to expert swallowing care.

A systematic review of the use of telehealth in speech, language and hearing sciences

Introduction

We conducted a systematic literature review to investigate the domain of speech-language and hearing sciences (SLHS) in telehealth.

Methods

The databases used for the literature search were Web of Knowledge, Pubmed, Scopus, Embase and Scielo. The inclusion criteria consisted of papers published up to August 2014. Papers without peer-review evaluation, and those without abstracts or available full texts were excluded.

Results

A total of 103 papers were selected. The selected studies have focused primarily on hearing (32.1%), followed by speech (19.4%), language (16.5%), voice (8.7%), swallowing (5.8%), multiple areas (13.6%) and others (3.9%). The majority of the studies focused on assessment (36.9%) or intervention (36.9%). The use of telehealth in SLHS has been increasing in many countries, especially in the last 5 years. The country with the largest number of published studies was the United States of America (32.03%), followed by Australia (29.12%). The remaining studies were distributed in lower numbers among other countries.

Discussion

The advancement of information and communication technologies provides more favourable conditions for providing distance care in several areas. Most of studies concluded that the telehealth procedure had advantages over the non-telehealth alternative approach (85.5%); however, 13.6% reported that it was unclear whether the telehealth procedure had advantages. Some barriers still need to be overcome, such as technology, training, regulation, acceptance and recognition of the benefits of this practice by the public and professionals. The need for speech-language pathologists and audiologists to adapt to this new health care modality is evident.

A review of the efficacy and effectiveness of using telehealth for paediatric speech and language assessment

We reviewed the literature relating to the use of telehealth for paediatric speech and language assessment. Four databases, and relevant reference lists, were searched for articles published between January 2004 and July 2014. A total of 180 articles were identified, of which only five were relevant. All studies assessed efficacy using method comparison techniques; no studies assessed effectiveness. The method comparison studies investigated the validity and/or reliability of speech and language assessment via telehealth, when compared with face-to-face assessment. Studies varied in terms of participant group, assessment tools, statistical analysis and telehealth equipment. The papers reviewed presented some evidence that telehealth can be used to make valid assessments of oromotor function, speech intelligibility and language. Articulation screening via telehealth was found to be valid, but there was conflicting evidence about full articulation assessment. Intra- and inter-rater reliability was good for all speech and language tasks, with the exception of oromotor assessment, which also had reduced reliability when assessed face-to-face. There were discrepancies between the two modalities for individual oromotor tasks, judgement of individual speech sounds, detection of pluralisation, and discriminating between similar sounding words; these have the potential to be clinically important. Evidence regarding satisfaction was extremely limited, with only one study reporting parental satisfaction, and no studies reporting child or clinician satisfaction. Although there is limited evidence to support the validity and reliability of speech and language assessment via telehealth, it is probably not yet sufficient to influence clinical practice or policy development.

Evaluation of a Clinical Service Model for Dysphagia Assessment via Telerehabilitation

Emerging research supports the feasibility and viability of conducting clinical swallow examinations (CSE) for patients with dysphagia via telerehabilitation. However, minimal data has been reported to date regarding the implementation of such services within the clinical setting or the user perceptions of this type of clinical service. A mixed methods study design was employed to examine the outcomes of a weekly dysphagia assessment clinic conducted via telerehabilitation and examine issues relating to service delivery and user perceptions. Data was collected across a total of 100 patient assessments. Information relating to primary patient outcomes, session statistics, patient perceptions, and clinician perceptions was examined. Results revealed that session durations averaged 45 minutes, there was minimal technical difficulty experienced, and clinical decisions made regarding primary patient outcomes were comparable between the online and face to face clinicians. Patient satisfaction was high and clinicians felt that they developed good rapport, found the system easy to use, and were satisfied with the service in over 90% of the assessments conducted. Key factors relating to screening patient suitability, having good general organization, and skilled staff were identified as facilitators for the service. This trial has highlighted important issues for consideration when planning or implementing a telerehabilitation service for dysphagia management.

Voice Therapy Telepractice; Voice Care For The 21 st Century

“America’s high schools are obsolete […] designed 50 years ago to meet the needs of another age.” – Bill Gates, National Governors’ Conference, 2005.

Obsolete and designed for another time—the same could be said for our existing health care system, treatment approaches, and service delivery models. The emergence of outcome-based payment by Accountable Care Organizations, severe restrictions in funding, and limited or absent insurance coverage for voice treatment are powerful drivers for more effective voice therapy treatment. Findings reported from the Voice and Swallowing Center of Maine support significant cost reductions to payers when telepractice is used in voice treatment (Towey, 2012a). This article describes three distinct applications of voice telepractice that expands conventional thinking about voice therapy and voice therapy telepractice. It is believed these presented cases are the first published examples that demonstrate the efficacy of voice telepractice to: (1) assess and fit a device for a laryngectomee; (2) complete virtual musculoskeletal assessment of a voice patient; and (3) provide virtual simultaneous co-treatment in voice therapy.

A pilot trial of a speech pathology telehealth service for head and neck cancer patients

We explored the feasibility of providing access to specialist speech pathology services via telehealth for patients with head and neck cancer. A weekly telehealth clinic was conducted between the speech pathology departments of a tertiary hospital and a regional hospital in Queensland. Over a 5-month period, 50 telehealth sessions were conducted for 18 patients. There were 38 patient consultations, nine case discussions between clinicians and three clinical training sessions relating to the skills needed for specific client management (e.g. voice prosthesis selection). Eight sessions had multidisciplinary involvement. All cases were successfully managed via telehealth. All patients agreed that they were comfortable using telehealth and would be happy to use it again in future. Both clinicians agreed that they could competently assess patients using the telehealth system. There appeared to be financial benefits for the patient, because by receiving specialist intervention at a local facility their travel expenses were lower. There was also the opportunity for workforce training and development through online case discussion and clinical consultation.

The Use of Telepractice Technology To Provide Speech and Language Services to Persons Aging With Communication Disorders

Telepractice, providing speech and language services at a distance from clients, is becoming another tool clinicians can use to provide services. Relieving the burden of travel may help those aging with a communication disability to access beneficial services. I will present evidence from several studies using telepractice for assessment and treatment of communication disorders. Although researchers have published promising results, future researchers should determine which populations will receive the most benefit from telepractice.

A new era in speech-language pathology practice: innovation and diversification

A new era in speech-language pathology practice is pending, and one that impels us to innovate and diversify as we move forward into the 21(st) century. The impetus for this transformation will include the increasing cost and demand for healthcare services as the population ages, changes in Australian society, rapid developments in technology, and major advances in neuroscience. New models of service delivery will need to be considered in line with evidence-based treatment protocols, the concept of a continuum of care for chronic disorders, and the need to engage clients in self-management. Innovations in technology will provide the means by which these new models of service delivery might be achieved. The exponential increase in electronic therapy resources and devices will transform the therapeutic process and provide clinicians with engaging and flexible therapy options. Clinicians will be challenged by this paradigm shift in service delivery, and their long-held perceptions of their clients' capacity to respond to these changes. Other challenges will include the preparation of future speech-language pathologists, reimbursement for services, availability of appropriate technology, and widespread connectivity. The future of the profession is an exciting one as we move forward into an era of unprecedented change.

Telepractice in Speech-Language Pathology: The Evidence, the Challenges, and the Future

This article provides a review of the evidence base for telepractice in speech-language pathology, the challenges that exist, and the future directions for this field. It describes the benefits of telepractice for clients and their families and outlines the evidence currently available to support the validity and reliability of this mode of delivery in the management of adult neurogenic communication disorders (aphasia, dysarthria, apraxia of speech); voice disorders; stuttering; dysphagia; laryngectomy; and articulation, language, and literacy disorders in children. The challenges facing telepractice in speech-language pathology and the future directions for this field are discussed.

Telepractice is an emerging area of service delivery in speech-language pathology that is likely to become an integral part of mainstream practice in the future. In order to achieve this, it is imperative that the profession accelerates its program of research and clinical endeavor in this area.

Internet-Based Telehealth Assessment of Language Using the CELF–4

Purpose

Telehealth has the potential to improve children’s access to speech-language pathology services. Validation of telehealth applications, including the assessment of childhood language disorders, is necessary for telehealth to become an accepted alternative mode of service provision. The aim of this study was to validate an Internet-based telehealth system for assessing childhood language disorders.

Method

Twenty-five children ages 5 to 9 years were assessed using the core language subtests of the Clinical Evaluation of Language Fundamentals—4th Edition (CELF–4; Semel, Wiig, & Secord, 2003). Each participant was simultaneously assessed online and face-to-face (FTF). Assessments were administered by either an online or an FTF speech-language pathologist (SLP), but were simultaneously rated by both SLPs.

Results

No significant difference was found between the online and FTF total raw scores and scaled scores for each subtest. Weighted kappas revealed very good agreement on the individual items, total raw scores, scaled scores, core language score, and severity level. Intra- and interrater reliability were determined for a sample of online ratings, with intraclass correlation analysis revealing very good agreement on all measures.

Conclusion

The results of this study support the validity and reliability of scoring the core language subtests of the CELF–4 via telehealth.

Assessment of communication and swallowing post-laryngectomy: a telerehabilitation trial

Ten laryngectomy patients were assessed using a purpose-designed, multimedia videoconferencing system incorporating a freestanding, self-focusing camera. Swallowing, stoma and communication status were assessed simultaneously by a remote clinician and face-to-face, by a second clinician at the patient's site. The remote trial took place over a distance of approximately 1700 km using a commercial 3G phone network. A satisfaction questionnaire was also completed. There was excellent agreement between the two assessing clinicians. Image quality obtained via the freestanding camera was rated as lower than direct observation, but it was sufficient to assess the stoma and status of the voice prosthesis. During the trial, occasional difficulties with audio delays and image distortion were experienced, although these were manageable. Both patient and clinician satisfaction with remote assessment was high. The results provide further evidence to support the use of telerehabilitation for evaluating the speech and swallowing status of laryngectomy patients following discharge from acute care.

Telerehabilitation for service delivery in speech-language pathology

Communication disorders in adults and children can have a significant effect on their quality of life and on that of their families. Speech-language pathologists face several challenges in providing assessment and treatment services to such people. Challenges include facilitating equitable access to services and providing appropriate management within a changing social and economic context. Telerehabilitation has the potential to deliver services in the home or local community via videoconferencing and through interactive computer-based therapy activities. This form of service delivery has the capacity to optimize functional outcomes by facilitating generalization of treatment effects within the person's everyday environment, and enable monitoring of communication and swallowing behaviours on a long-term basis. A number of image-based telerehabilitation applications have been used in the management of adult neurogenic speech and language disorders, stuttering, voice disorders, speech and language disorders in children, laryngectomy and swallowing dysfunction. Further development of such applications and other computer-based therapies, cost-benefit and cost-effectiveness analyses, and professional education are needed if telerehabilitation is to become an integral part of speech-language pathology practice.