Dysphagia FEES Professional Issues Research

October Research Tuesday

Ode to the Bean Counter: The Price of Dysphagia
In every medical facility there is always a bean counter, and in most, more than one.  They are the people who deny your ten thousandth request for a new Hausted chair for modified barium swallow studies because the old one “works just fine,” even when it doesn’t.  They are the folks who won’t purchase prethickened liquids because dietary can mix it up from powder, even though cups of glue keep showing up on patient trays.  And they are the ones who don’t understand why you need an instrumental exam to determine a patient’s diet status – no one has ever needed one before you came along.  So we, the ever faithful army of passionate dysphagia professionals, start collecting our own special data – we document the delayed or impossible studies, present facts about our patient’s hydration status and outline how the changes we are begging for will improve the quality of care we provide.  I’m not sure about you, but this kind of research was not covered in my graduate program…
Having been the one addressing the bean counters on many of occasions, I get waaay too excited when I find an article like this – one that speaks the bean counter’s language.  Dollars and cents!  Complex statistical analyses!  Facts and figures!  Historically speech pathologists haven’t spent a lot of time researching cost/benefit analyses and the impact on our services to hospitals, but in the last few months I have seen some promising studies coming out on this very topic (here’s looking at you, London Health Sciences Center in Ontario, Canada and the University of South Carolina).  With the changing landscape of healthcare and insurance, justification of our services will become even more crucial.  This article, which comes from our ENT colleagues at Mount Sinai School of Medicine and New York Eye & Ear, is just a small snapshot of the incidence and financial impact of dysphagia, but the information it provides could be invaluable to you the next time you have to email your bean counter.  Enjoy!
Altman KW, Yu GP, Schaefer SD. 2010. Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Archives of Otolaryngology Head Neck Surgery 136(8):784-9. Full Text Here
This study looked at the National Hospital Discharge Survey (NHDS) data from 2005-2006 to identify the incidence of dysphagia and its most common comorbid medical diagnoses as well as to further quantify the length of stay, morbidity and mortality of dysphagia.
To obtain their data, the investigators searched for the dysphagia ICD-9 code (ICD-9-CM 787.2) in the first 7 diagnosis codes of each patient abstract from the 2005-2006 NHDS data (the NHDS lists the most important diagnoses first).  They then searched for dysphagia symptoms and other major accompanying disorders listed in the first 7 diagnoses.  There were 20 major diseases identified as most frequently occurring with dysphagia.  Using some very fancy software and complex statistical analysis, the authors found the mortality rates as well as the standard errors, confidence intervals and rate ratios of the disease and mortality rates among patients with and without dysphagia.
During the years 2005-2006, there were over 77 million estimated hospital admissions and 271,983 of these were associated with dysphagia (.35% of all hospital admissions).  See the chart below for further details regarding rate of dysphagia by sex, age and race.

oct data

The authors note that the most significant findings from the demographic section of the investigation were that the percent of hospitalizations increase with age and that those with dysphagia older than 75 had twice the national average of hospital admissions than the average of all other groups.
When the authors looked at major diseases and symptoms associated with dysphagia, they noted that half of the admissions had at least one comorbid diagnosis of fluid & electrolyte disorder, disease of the esophagus, ischemic stroke, or aspiration pneumonia.  Those patients who had a diagnosis of dysphagia had an increased number of diagnoses at discharge compared to those without dysphagia – 88.9% vs 57.7% with 5 or more comorbid diagnoses, respectively.
The mortality rate of patients with dysphagia undergoing rehabilitation and those with coronary atherosclerosis was significantly elevated compared to those who did not have dysphagia.
The most notable (and bean-counter important) part of the study looked at the median number of hospital days for diseases associated with dysphagia compared to those not associated with dysphagia.  They found that the median number of hospitalization days for patients without dysphagia was 2.4 days compared to 4.04 days for those with dysphagia – that’s a 40.6% increase!!!!  Hospital stay was increased by 30% or more for patients with congestive heart failure, Parkinson disease and ischemic stroke and for patients with hemorrhagic stroke, the median hospital stay increased to 10.55 days.
To summarize their findings the author noted these three important take-aways:
  1. age older than 75 years was associated with double the risk of dysphagia associated with hospitalization
  2. the presence of dysphagia was associated with a 40% increase in length of hospital stay in all age groups
  3. patients undergoing rehabilitation had a greater than 13-fold increased risk of mortality during their hospitalization when they had dysphagia.
The aim of the study was to find statistically significant associations of variables.  The authors concede that cause and effect relationships cannot be determined from this type of data, but that important conclusions can be made.
The investigators then presented more data supporting the additional costs and the likely underestimated number of patients diagnosed with dysphagia. One of the figures was an established formula that was created to determine the actual increased cost for a one-day stay with community-acquired pneumonia.  The total daily cost was found to be $2,454 which they believe is less than the actual daily cost of a patient with dysphagia/aspiration pneumonia (alternative means of nutrition/hydration, additional diagnostic testing and more care from more providers would raise the price). They extrapolate the additional number of hospitalization days per year and the estimated additional cost per year of the extra days of hospitalization to yield an economic burden of approximately $547,307,964.
Whew.  That was a lot of math, but it is important math that helps us help the bean counters understand why we are fighting so hard to help people with dysphagia.
As a speech pathologist I most often enjoy looking at the little picture – helping the individual patient get better and eat.  While that is my mission and the joy of my heart, I must remember that the bean counter’s mission is to look at the big picture – to make sure that the hospital has enough money to stay open.  The authors conclude that the best ways to save money in dysphagia care are to identify the dysphagia early, especially in those patients with high-risk comorbid conditions such as old age, stroke, neurodegenerative disease, and pneumonia, and to provide proper intervention including evaluation, treatment and diet modification.  So, armed with all of your data, documentation, and published research, let’s work with those bean counters to get patients properly (and objectively) evaluated and treated to help improve both the big and little picture.

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out or connect with Kelley on Twitter or LinkedIn.

Photo credit flikr for creative commons

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