Decision-making for starting direct therapy for dysphagia

Abstract

In an attempt to establish clinical criteria for starting direct therapy for dysphagia，we retrospectively detected significant factors that influenced decision-making of the therapy initiation．We included 21 patients with stroke transferred to our hospital for multidisciplinary rehabilitation with prohibited oral intake in acute hospitals because of dysphagia．Direct therapy was subsequently started in 14 patients (oral intake group) but not in 7 patients （non-oral intake group） after a few weeks of intensive swallowing therapy． Factors we hypothesized to influence the starting of direct therapy included 1．alertness，2．gross motor function，3．cognitive function，4．history of pneumonia，5．oral motor function，6．saliva swallowing，7．findings of repetitive saliva swallowing test，8．findings of revised water swallowing test (3 ml)，and 9．VF/VE findings．Significantly different factors between two groups were 1．Alertness (p＜0.05)，4．history of pneumonia (p＜0.01)，5．oral motor function (p＜0.05)，6．saliva swallowing (p＜0.01)，and 9．VF/VE findings (p＜0.05)． Discrimination of two groups by a single factor appeared to be insufficient since concordance rate of each factor was not high enough (CR ＝ 0.71～0.81，mean 0.76)．Thus we set 26 compound factor sets that consisted of some of the 5 significant factors．Using compound factors，We tried to discriminate two groups．To increase number of factors included in the sets improved concordance rate (ANOVA：df ＝ 3，F ＝ 16.001，p＜0.0001)．This finding is in accordance with our clinical impression that decision-making of starting direct therapy should be based on comprehensive perspective regarding multiple factors． Compound factor sets that were effective for the discrimination were set V (factor 1，4，5，9，cut-off point 13-14，sensitivity 1.00，specificity 0.92，CR 0.95)，set W (1，4，6，9，cut-off point 13-14，sensitivity 1.00，specificity 0.92，CR 0.95) and set Z (1，4，5，6，9，cut-off point 13-14，sensitivity 1.00，specificity 0.92，CR 0.95) To optimize the decision-making in an environment where VF and VE are unavailable， we investigated relevant compound factor sets that consisted of factors other than VF/VE findings．Relatively satisfactory levels were obtained from the set of 6 factors (CR greater than 0.90)．Those factors might be helpful in making a decision to start direct therapy in the situation．