Abstract
RationaleAspiration is a common sequela post stroke as a result of oropharyngeal dysphagia. It is primarily managed using the poorly empirically supported intervention of thickened liquids. Where evidence is limited, clinicians may rely on clinical practice guidelines to support decision making. The purpose of this systematic review and narrative synthesis was to evaluate the evidentiary bases of recommendations made by stroke clinical practice guidelines regarding the thickened liquids intervention.MethodsA systematic review was conducted on stroke clinical guidelines retrieved via searches conducted across a range of databases including Academic Search Complete, CINAHL, MEDLINE, and the Cochrane Library as well as through association websites. Guidelines were eligible for inclusion if they focused on adult stroke populations, made recommendations relating to the thickened liquid intervention and were published between January 2010 and December 2018. Four independent reviewers rated methodological quality using the AGREE‐II instrument. Intervention recommendations were extracted and analysed using the Criteria for Levels of Evidence Reported from the Canadian Stroke Best Practice Recommendations and a novel framework examining the appropriateness of the supporting evidence.ResultsThirteen clinical guidelines were included in the review. Methodological quality was variable with seven rating as good‐excellent overall. Thirty recommendations regarding the intervention were extracted. Of these, 16 recommendations were classed as a recommendation to use the treatment and all guidelines made this recommendation. Much of the evidence used to scaffold recommendations did not directly support the intervention.ConclusionsDespite the limited evidence base for the thickened liquid intervention, there was consensus among stroke guidelines in recommending it. This is despite limited empirical support. Furthermore, much of the evidence used to support recommendations was not appropriate, suggesting less than satisfactory evidence‐based practices in formulating recommendations. In this case, clinical guidelines may not be reliable decision‐support tools for facilitating clinical decision making.
Highlights
IntroductionAbbreviations: AGREE-II, The Appraisal of Guidelines for Research and Evaluation Second Edition; Australia 2017, The Stroke Foundation of Australia CPG; Cameroon 2013, SEEPD Program of the Cameroon Baptist Convention Health Board, the Bamenda Coordinating Centre for Studies in Disability and Rehabilitation (BCCSDR), and ICDR-Cameroon of the University of Toronto CPG; Canada 2015, Heart and Stroke Foundation (HSF-C)/Canadian Stroke Best Practices Advisory Committee CPG; Canada 2018, Heart and Stroke Foundation (HSF-C)/Canadian Stroke Best Practices Advisory Committee CPG; CPGs, clinical practice guidelines; Germany 2013, German Nutrition Society (DGEM) German Society for Neurology, German Geriatric Society CPG; Ireland 2010, Irish Heart Foundation CPG; Philippines 2010, The Stroke Society of the Philippines CPG; PRISMA, Preferred Reporting of Items for Systematic Reviews; PWD, people with dysphagia; TL, thickened liquids; Scotland 2010 #118, Scottish Intercollegiate Network (SIGN) CPG #118; Scotland 2010 #119, Scottish Intercollegiate Network (SIGN) CPG #119; UK 2013, National Institute for Clinical Excellence (NICE) CPG; UK 2016, Royal College of Physicians (RCP) Intercollegiate Stroke Working Party CPG; USA 2010, Veterans Association/Department of Defence (VA/DOD) CPG; USA 2016, American Heart Association (AHA)/American Stroke Association (ASA) CPG
This study examined the evidentiary bases of recommendations for the intervention of thickened liquids (TL) for people with dysphagia (PWD) post-stroke
The quality of the 13 stroke clinical practice guidelines (CPGs) included in this study was generally good, based on tools examining the development of those guidelines
Summary
Abbreviations: AGREE-II, The Appraisal of Guidelines for Research and Evaluation Second Edition; Australia 2017, The Stroke Foundation of Australia CPG; Cameroon 2013, SEEPD Program of the Cameroon Baptist Convention Health Board, the Bamenda Coordinating Centre for Studies in Disability and Rehabilitation (BCCSDR), and ICDR-Cameroon of the University of Toronto CPG; Canada 2015, Heart and Stroke Foundation (HSF-C)/Canadian Stroke Best Practices Advisory Committee CPG; Canada 2018, Heart and Stroke Foundation (HSF-C)/Canadian Stroke Best Practices Advisory Committee CPG; CPGs, clinical practice guidelines; Germany 2013, German Nutrition Society (DGEM) German Society for Neurology, German Geriatric Society CPG; Ireland 2010, Irish Heart Foundation CPG; Philippines 2010, The Stroke Society of the Philippines CPG; PRISMA, Preferred Reporting of Items for Systematic Reviews; PWD, people with dysphagia; TL, thickened liquids; Scotland 2010 #118, Scottish Intercollegiate Network (SIGN) CPG #118; Scotland 2010 #119, Scottish Intercollegiate Network (SIGN) CPG #119; UK 2013, National Institute for Clinical Excellence (NICE) CPG; UK 2016, Royal College of Physicians (RCP) Intercollegiate Stroke Working Party CPG; USA 2010, Veterans Association/Department of Defence (VA/DOD) CPG; USA 2016, American Heart Association (AHA)/American Stroke Association (ASA) CPG.
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