BackgroundHealthcare systems internationally are under an ever-increasing demand for services that must be delivered in an efficient, effective and affordable manner. Several patient-related and organisational factors influence health-care expenditure and utilisation, including oropharyngeal dysphagia. Here, we present a systematic review of the literature and meta-analyses investigating how oropharyngeal dysphagia influences healthcare utilisation through length of stay (LOS) and cost.MethodsUsing a standardised approach, eight databases were systematically searched for relevant articles reporting on oropharyngeal dysphagia attributable inpatient LOS and healthcare costs through June 2016. Study methodologies were critically appraised and where appropriate, extracted LOS data were analysed in an overall summary statistic.ResultsEleven studies reported on cost data, and 23 studies were included reporting on LOS data. Descriptively, the presence of dysphagia added 40.36% to health care costs across studies. Meta-analysis of all-cause admission data from 13 cohort studies revealed an increased LOS of 2.99 days (95% CI, 2.7, 3.3). A subgroup analysis revealed that admission for stroke resulted in higher and more variable LOS of 4.73 days (95% CI, 2.7, 7.2). Presence of dysphagia across all causes was also statistically significantly different regardless of geographical location: Europe (8.42 days; 95% CI, 4.3; 12.5), North America (3.91 days; 95% CI, 3.3, 4.5). No studies included in meta-analysis were conducted in Asia.ConclusionsThis systematic review demonstrated that the presence of oropharyngeal dysphagia significantly increases healthcare utilisation and cost, highlighting the need to recognise oropharyngeal dysphagia as an important contributor to pressure on healthcare systems.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3376-3) contains supplementary material, which is available to authorized users.

The objective: To determine whether a simple oral hygiene protocol improves the oral health of inpatients in stroke rehabilitation.The background data discussing the present status of the field: Poor oral health can lead to serious complications, such as pneumonia. The comorbidities associated with stroke, such as dysphagia, hemiparesis and cognitive impairment, can further impede independent oral care. International stroke guidelines recommend routine oral care but stop short of detailing specific regimes. Materials and methods:The oral health assessment tool (OHAT) was conducted by speech-language pathologists with 100 patients with and without dysphagia in three metropolitan inpatient stroke rehabilitation facilities. A simple nurse-led oral hygiene regime was then implemented with all participants, which included twice daily tooth brushing and mouth rinsing after lunch, and oral health was measured again one week later.Results: Initially, dysphagia was negatively associated with OHAT scores, and independence for oral hygiene was positively associated with oral health. After one week of a simple oral hygiene regime, the OHAT scores available for 89 participants indicated an improvement on average for all participants. In particular, 59% of participants with dysphagia had an improvement of 1 or more points. None of the participants developed pneumonia. Conclusion:A simple, inexpensive oral hygiene regime resulted in positive outcomes for patients with and without dysphagia in inpatient stroke rehabilitation settings. Oral health assessments and oral hygiene regimes that are simple to implement by the interdisciplinary team can be incorporated into standard stroke care with positive effect. K E Y W O R D Sclinical protocols, deglutition disorders, dysphagia, nursing, oral health, oral hygiene, rehabilitation, stroke

The benefit of water protocols for individuals with thin-liquid aspiration remains controversial, with mixed findings from a small number of randomized controlled trials (RCTs). This study aimed to contribute to the evidence of the effectiveness of water protocols with a particular emphasis on health outcomes, especiallyhydration. An RCT was conducted with patients with known thin-liquid aspiration post-stroke randomized to receiving thickened liquids only or a water protocol. For the 14 participants in rehabilitation facilities whose data proceeded to analysis, there was no difference in the total amount of beverages consumed between the water protocol group (mean=1103ml per day, SD=215ml) and the thickened liquids only group (mean=1103ml, SD=247ml). Participants in the water protocol group drank on average 299ml (SD 274) of water but offset this by drinking less of the thickened liquids. Their hydration improved over time compared with participants in the thickened liquids only group, but differences between groups were not significant. Twenty-one percent of the total sample was diagnosed with dehydration and no participants in either group were diagnosed with pneumonia. There were significantly more diagnoses of urinary tract infection in the thickened liquids only group compared to the water protocol group (χ 2 =5.091, p=0.024), but no differences between groups with regard to diagnoses of dehydration (χ 2 = 0.884, p=0.347) or constipation (χ 2 =0.117, p=0.733). The findings reinforce evidence about the relative safety of water protocols for patients in rehabilitation post-stroke and provide impetus for future research into the potential benefits for hydration status and minimizing adverse health outcomes.Drinking, deglutition, deglutition disorders, stroke, water, water-electrolyte imbalance [6]. The premise is that thickening a liquid makes it more cohesive and dense, reducing its flow rate. This enables many patients to better control the bolus intra-orally, thereby reducing aspiration risk before and during swallowing [7,8].There has been growing concern, however, about the blanket prescription of thickened liquids for a number of [14,18,19]. By far the greatest concern about thickened liquid prescription is that individuals with dysphagia do not consume enough fluids. Researchers have demonstrated that the bioavailability of water from a quantity of thickened liquids is equivalent to that from the same quantity of thin liquid [20][21][22] confirming that thickened liquids themselves are not the cause of dehydration. Furthermore, it is recognised that, in addition to beverages, food contributes to approximately 20% of overall fluid intake with an even greater percentage if individuals are on pureed food [23,24]. Notably, food was found to be the greatest contributor to oral fluid intake in a cohort of patients with dysphagia in acute settings [25]. However, total fluid intake has consistently been found to be inadequate for individuals with dysphagia on modified diet and liquids, especially if reliant o...

There is widespread concern that individuals with dysphagia as a result of stroke do not drink enough fluids when they are prescribed thickened liquids. This paper details a retrospective audit of thickened liquid consumption of 69 individuals with dysphagia following stroke in acute and rehabilitation hospitals in Adelaide, South Australia. Hospitalized individuals with dysphagia following stroke drank a mean of 781ml (SD = 507ml) of prescribed thickened liquids per day, significantly less in the acute setting (M = 519ml, SD = 305ml) than in the rehabilitation setting (M = 1274ml, SD = 442ml) (t (67)= -8.34, p <0.001). This daily intake of thickened liquids was lower than recommended standards of fluid intake for hospitalized adults. Fluid intake could be increased with definitive protocols for the provision and 2 monitoring of consumption of thickened liquids, by offering more fluid via food or free water protocols or by routine use of non-oral supplementary routes. Future research into the effectiveness of such recommendations needs to evaluate not only the impact on fluid intake but also on health outcomes.

Dysphagia has been strongly associated with poor hydration in acute stroke settings. However, in sub-acute settings, the contribution to dehydration of dysphagia in combination with other common stroke comorbidities has not been explored. The aim of this study was to investigate which demographic and stroke comorbidities, including dysphagia, contribute most significantly to oral fluid intake, hydration status and specific adverse health outcomes for patients in sub-acute rehabilitation following stroke. Data from 100 inpatients from three Australian rehabilitation facilities (14 with confirmed dysphagia and 86 without dysphagia) were analysed. Hierarchical multiple regressions were conducted to determine which demographic or stroke comorbidities were most predictive of each outcome: average daily fluid intake; Blood urea nitrogen/creatinine (BUN/Cr) ratio as an index of hydration and medically diagnosed adverse events of pneumonia, dehydration, urinary tract infection or constipation. Average daily beverage intake (M = 1448 ml, SD 369 ml) was significantly and independently predicted by Functional Independence Measure (FIM) at admission (F change = 9.212, p = 0.004). BUN/Cr ratio (M = 20, SD 5.16) was predicted only by age (F change = 4.026, p = 0.049). Adverse health events, diagnosed for 20% of participants, were significantly predicted by Admission FIM (OR 1.040, 95% CI 1.001, 1.081, p = 0.047). Dysphagia was not a significant predictor of any of the outcomes measured. Rather, overall functional dependency was the most significant predictor of poor oral fluid intake and fluid-related adverse health outcomes in sub-acute stroke. Clinical Trial number: Data for the post hoc analysis presented in this article came from the registered trial ACTRN12610000752066.