Accuracy and clinical utility of comprehensive dysphagia screening assessments in acute stroke: A systematic review and meta-analysis.

Abstract

Nurses and other nonspecialists in dysphagia are often trained to screen swallowing poststroke. There are many basic tools that test water only, they are usually conservative, and patients that fail the test remain nil by mouth until a speech and language therapy assessment. More comprehensive tests also allow nonspecialists to recommend modified oral intake. Little is known about the accuracy, clinical utility and cost-effectiveness of these tests. Following PRISMA guidelines, a systematic review was conducted to describe comprehensive swallowing tests that are available for use in acute stroke by nurses or other nonspecialists in dysphagia. A meta-analysis was performed to evaluate accuracy and the clinical utility of the tests was considered. Searches and analyses, conducted by two reviewers, included MEDLINE, Embase, trial registries and grey literature up to December 2018. Validated studies were assessed for quality and risk of bias using QUADAS-2. Twenty studies were included, describing five different tests, three of which had undergone validation. The tests varied in content, recommendations and use. There was no test superior in accuracy and clinical utility. Three studies validating the Gugging Swallow Screen provided sufficient data for meta-analysis, demonstrating high sensitivity; 96% (95% CI 0.90-0.99), but low specificity, 65% (95% CI 0.47-0.79), in line with many water swallow tests. Results should be interpreted with caution as study quality and applicability to the acute stroke population was poor. There is no comprehensive nurse dysphagia assessment tool that has robustly demonstrated good accuracy, clinical utility and cost-effectiveness in acute stroke. Nurses and other clinicians can develop competencies in screening swallowing and assessing for safe oral intake in those with poststroke dysphagia. It is important to use a validated assessment tool that demonstrates good accuracy, clinical utility and cost-effectiveness.