- Email: [email protected]
Response to Steele et al
To obtain evidence of SLPs’ practices in swallowing disorders, knowledge base, perceptions of their own lack of training and expertise, questions posed, and other relevant data, the reader can visit the archives of a worldwide public mail list.6 It is gratifying to learn that there is a development within ASHA that one must infer is intended to have improvement as its goal, although this is not explicitly stated. Far from denigrating an entire profession, I believe that SLPs have an essential role to play. I would suggest that ASHA give more attention to adults and children who need the services of SLPs in the treatment of communication disorders in which there is a long history of more efficacy. As Enderby and Petheram7 have identified, the requirements of those who are impaired by communication disorders are being overlooked because of the increasing time spent on swallowing disorders. It is unfortunate that the professional association of SLPs in the United States is at such pains not only to deny serious deficiencies in knowledge and training but to encourage continued participation in an area of medicine for which most are ill prepared. Irene Campbell-Taylor, MB, ChB, PhD Cape Breton Injured Workers’ Association New Waterford, Nova Scotia, Canada (I.C.-T.) REFERENCES 1. Gottfred C. Oropharyngeal dysphagia in long-term care: Response from ASHA. J Am Med Dir Assoc 2009;10:78. 2. Campbell-Taylor I. Oropharyngeal dysphagia in long-term care: Misperceptions of treatment efficacy: J Am Med Dir Assoc 2008;9:523–531. 3. Steele CM, Coyle JL, Davis LA, et al. Oropharyngeal dysphagia assessment and treatment efficacy: Setting the record straight. J Am Med Dir Assoc 2009;10:62-66. 4. Ashford JR. Water: Understanding a necessity of life. The ASHA Leader 2009;13:10 –12. 5. Mills RH. Dysphagia management: Using thickened liquids. The ASHA Leader 2008;13:12–13. 6. Dysphagia Resource Center. Dysphagia Mail List Archive. Available at: http://dysphagia.com/mlist/. Accessed October 24, 2008. 7. Enderby P, Petheram B. Has aphasia therapy been swallowed up? Clin Rehabil 2002;16:604 – 608.
DOI: 10.1016/j.jamda.2008.10.012
Response to Steele et al To the Editor: Dr J. Rosenbek has written of the demise of aphasia treatment that started in 1969 and, in turn, brought about the development of efficacy research in aphasiology. He compares this event with intervention in swallowing disorders and states, “No such alarm has yet sounded in dysphagia . . . Somewhere, someone has toyed with the idea of shattering the glass that covers the alarm bell. Dysphagia programs are simply too visible and too prosperous to be . . . allowed to continue proclaiming their efficacy without more convincingly demonstrating it.”1(p263) Campbell-Taylor
THE USE OF VIDEOFLUOROSCOPIC SWALLOWING STUDY (VFSS) IN LONG-TERM CARE The authors of the article offered in rebuttal2 have either overlooked or misinterpreted several points. A careful reading of the original article3 will show that I was quoting the Agency for Health Care Policy and Research report on the failure of VFSS as a gold standard and the potential sensitivity of the clinical examination.4 I was quite clear that identification of aspiration was not the primary objective of either clinical or instrumental examination. The VFSS reveals abnormalities of the swallow but cannot identify what consistencies can be consumed, nor what happens during a meal,5 as is admitted in the American Speech-Language-Hearing Association’s (ASHA) own documentation,6 yet the authors2 state, “This reality (some interventions may be harmful) further underscores the importance of . . . (testing) . . . interventions with instrumentation prior to recommending them for patients.” It is difficult to find a response to this position. ASHA acknowledges a lack of correspondence between VFSS boluses and “meal-time food and liquid,” as is shown in multiple studies, yet we are to be persuaded that VFSS is essential for decisions about meal contents for patients.7 To clarify the qualifications of speech language pathologists (SLPs) with respect to the videofluoroscopic examination of swallowing, so clearly criticized by Dr Sonies,8 it should be realized that radiologists must complete, during their residency, 700 examinations related to the anatomical areas that include deglutition.9 These examinations are conducted under the close supervision of qualified, board-certified radiologists. In contrast, most SLPs obtain their experience either from books or from other SLPs similarly lacking expert instruction and supervision, yet the ASHA Guidelines7 do not require the presence of a radiologist during VFSS. A letter from Dr S. Peer10 in response to Gates et al11 points out that VFSS has become a seldom-taught procedure, practiced by few radiologists. The response from Gates and colleagues states that “Videofluoroscopy is fast becoming a dying art for radiologists in the United States; all too often, speech pathologists work independently or may ‘benefit’ from the company of a technologist who is present only to ‘stand on the pedal.’” Given the inadequate training and lack of standards described by Dr Sonies,8 this is an alarming situation. Regardless of whether or not one believes that VFSS is essential in the assessment of swallowing, the expertise with which it is conducted should be a first principle. Feinberg and Ekberg12 have shown that “the efficacy of swallowing studies has not been established. No large, well-controlled clinical trials have been done that indicate a significant reduction in morbidity or mortality for any age group or specific condition.” That would appear to still be the case. THICKENED LIQUIDS The study known as Protocol 201 appears in several versions. It was not “completed” as the authors assert. It was terminated for reasons of futility. Stopping for futility means that the independent review committee elects to stop a trial early because the likelihood of finding a treatment effect is LETTERS TO THE EDITOR 79
low or the risk of adverse effects is high. It was decided that adding subjects would not achieve the intended result. Also, the final line of Table 2, “Adverse Experiences, Hospitalizations, or Death, by Intervention,”14 reads as follows: Chin Down
Both Liquids
Nectar
Honey
Serious adverse 71 (27%) 66 (26%) 34 (26%) 32 (26%) event† † Life-threatening adverse experience, hospitalization, or death.
In the version of the study published in the Annals of Internal Medicine,13 the editor makes the point that the confidence intervals in the results were too wide and, in the section entitled “Summaries for Patients”14 states the following: “The study does not prove which liquid or head position best prevents aspiration pneumonia; however, it suggests that drinking very thick liquids (those with the consistency of honey) may be harmful for older adults with swallowing problems, and that patients drinking thickened liquids more often had dehydration (6% vs. 2%), fever (4% vs. 2%), and urinary tract infections (6% vs. 3%).” The authors themselves state that “Long-term results show that despite differential effect of interventions on immediate elimination of aspiration in videofluoroscopic suite, the 3-month incidence of pneumonia was similar for chin down posture compared to liquids.” This would seem to imply that the results under VFSS bore little or no relationship to the eventual outcome. They also pay scant attention to the statistically significant finding that patients on thickened liquids became dehydrated, a devastatingly adverse effect for the elderly. In this version, they describe the study as a “randomized, controlled, parallel-design trial,” an unusual designation as they had no control group. They go on to state that “Part II of the study proceeded as a true randomized control trial, with videofluoroscopic evidence that the 515 participants had truly equal chances of responding favorably (or unfavorably) to the experimental interventions. As such, this study stands as a stellar example of impeccable design; few randomized controlled trials . . . demonstrate such equality in opportunity for either positive or negative response . . . . However, it must also be recognized that 2/3 of the participants in this phase . . . continued to aspirate in part I, despite any of the tested interventions.” This is a puzzling proposition given that no one was blinded to interventions, and a true, unrelated control group was not used. One can only infer that the authors are proposing that each subject, by some means, served as his or her own control. The difficulty with an approach in which it is planned that each serve as his or her own control is that there may be effects of a treatment that carry over from one period of intervention to the next, thereby confounding the picture. The authors specifically explain their lack of a control group as being “unethical.” “Our study has limitations. We did not include a no-treatment group because ‘no treatment’ is unethical. . . . The nature of the interventions did not allow blinding of direct care providers.” I believe a “no-treatment” group is also known as a control group. 80 LETTERS TO THE EDITOR
A letter in response to this article from Dr Dimitri Drekonja of the Minneapolis VA Medical Center15 takes issue with the lack of a control group and identifies this oversight as the “fatal flaw” of the study since the interventions used are previously untested with a lack of efficacy data. The claim that a control group would be unethical, presumably because of denying intervention, could easily be overcome by selecting subjects from locations in which intervention by speech therapists is not available. The other alternative is a waitlist group. Dr Drekonja goes on to posit that “one could argue that expending large amounts of energy, time, and funding, in order to produce a result that is severely limited by the lack of a control arm, is ethically questionable in its own right.” The authors state: “It is emphasized that this study looked only at the short-term, immediate effects of these three interventions.” I understand this to imply that, while there may be an effect on aspiration during the VFSS, it does not necessarily carry over to mealtime. This important point may have become clear to Medicaid/ Medicare. As of September 1, 2008, surveyors are instructed as follows: “Dietary restrictions, therapeutic (e.g., low fat or sodium restricted) diets, and mechanically altered diets may help in select situations. At other times, they may impair adequate nutrition and lead to further decline in nutritional status, especially in already undernourished or at-risk individuals.”16 They also reference the use of hypodermoclysis as an acceptable form of hydration.17 Certification Board Recognition in Swallowing is in no way equivalent to the board certification required of physicians. Their standard-setting organization is the American Board of Medical Specialties (ABMS),18 which is composed of 24 primary medical specialty boards and 6 associate members. Board certification for physicians guarantees extensive training and examination. There are, certainly, incompetent professionals of all types, but there are important differences between “qualified” and “competent”; the former resulting from standardized examination and the latter a consequence of adequate training plus personal ability. Board “recognition” is essentially meaningless. “Recognition” certificates are generally awarded as a token of gratitude by an organization. In addition, the board in this case is not the board of ASHA, but that of a special interest group. At the moment, ASHA provides, after graduate education and examination, a Certificate of Clinical Competence. To the average, reasonable individual, this indicates that the association is certifying that those who hold this document are competent to practice within the clinical fields they claim to have within their scope of practice and has been so certifying for many years. It is, however, denied by the association that this certification means that the clinician is competent in the area of swallowing disorders.19 There are no data currently available regarding the effectiveness of the education and training suggested in any curriculum for SLPs and swallowing disorders. JAMDA – January 2009
OVERVIEW COMMENTS The authors contend that I have fallen prey to the fallacy of the “call to perfection.” Are they implying that it is impossible for SLPs to be given correct and up-to-date information superimposed on a basic understanding of the medical sciences? That was my proposition and, if this is impossible to achieve, it would seem to follow, logically, that SLPs have no place in dysphagia intervention. The authors throughout their argument fall prey to the argument from ignorance that says that something (the efficacy of dysphagia intervention) must be true because it has not been proven to be false. Absolute proof may still be lacking but the signs are everywhere. They state that “Other undesirable health status outcomes (dehydration, urinary tract infection, and fever) were also relatively rare in the Protocol 201 Part II population (none of these conditions occurred at rates higher than 6%).” They may have been “rare” but dehydration was significant at P less than .05, and quite possibly related to urinary tract infections and fever. The authors examined a specific population, that, by definition, tends to be frail and to have multiple comorbidities including gastrointestinal dysmotility, hyperglycemia, polypharmacy , undernutrition, dehydration, poor oral hygiene, dependency for care, and other factors reducing the ability to withstand infection or other physiological attack. Robbins et al13 refer to this as an “efficacy” trial. Efficacy is improvement resulting from treatment applied in a rigidly controlled design when treatment and no-treatment conditions are compared. A comparison of 2 treatments of unproven efficacy is not an efficacy study. In the account of the study contained in the Journal of Speech, Hearing, and Language Research20 now identified as 3, not 2 interventions, the authors state that “This study was designed to identify which of 3 treatments for aspiration on thin liquids . . . results in the most successful immediate elimination of aspiration on thin liquids during the videofluorographic swallow study . . . . The longer-term impact of short-term prevention of aspiration requires further study.” The version in the Annals of Internal Medicine would appear to be about the longer-term impact13 with the first part designed only to select subjects. ASPIRATION The authors apparently missed my reference to the Baine et al21 article on aspiration pneumonia and its conclusions about the apparent increase in diagnoses of aspiration pneumonia possibly being financially driven. They appear to believe that pneumonia results only from aspiration of food mixed with saliva. They do not address the destination of the copious amounts of bacteria-filled saliva produced daily by most people. They apparently are unaware of the extensive literature on causes of both aspiration pneumonitis and aspiration pneumonia. There are too many references to cite on the basic facts: aspiration of what, how much, how often, and, most importantly, the patient’s resistance to infection.22 After an extensive search, I can find no instance of speech pathologists being taught the process of vomiting/regurgitation, which may explain the lack of understanding of the risk of aspiration of stomach contents in persons with oropharynCampbell-Taylor
geal dysphagia (OPD) associated with vomiting, gastroesophageal reflux disease (GERD), sedation, reduced consciousness, supine positioning, and other factors.23 It is unfortunate that the authors chose the Pikus et al24 study as proof of the relationship between OPD and pneumonia. Apart from the limitations that Dr Pikus and colleagues admit, these authors have confused, as is all too common, aspiration pneumonia and aspiration pneumonitis, giving as their evidence of the hazards of aspiration, 2 articles on the results of aspiration of gastric contents.25,26 Pikus and colleagues included 91 patients (24%) with other conditions “known to predispose individuals to aspiration, including gastroesophageal reflux disease in 32 (8%).” As is pointed out, pneumonia is the most frequent cause of death by infectious disease in the United States but it is unclear why it would be assumed that it is always, or even frequently, due to aspiration of oropharyngeal contents. Feinberg and colleagues27 showed that there was no simple relationship between prandial liquid aspiration and pneumonia in long-term care patients followed for 3 years. The authors have misidentified the DePippo et al28 article. The latter investigators found that limited patient and family instruction regarding diet modification and compensatory swallowing techniques during inpatient rehabilitation is as effective as therapist intervention for the prevention of medical complications associated with dysphagia following stroke. The authors propose that, “It is also important to remember that dysphagia therapy is designed to reduce adverse sequelae, but complete elimination of sequelae is not possible in any disease/disorder treatment.” I believe a surgeon might take offense at that statement after a successful appendectomy. Of course many diseases/disorders can be completely cured but with respect to OPD, however, we are dealing with a symptom of disease, a fact that seems to be repeatedly overlooked. “Sequelae of a symptom” is a confusing concept. PUBLISHED OPINIONS OF AUTHORS Articles such as this response2 are usually presented as rebuttal of the original. It is surprising to find that so many of the authors are on record as agreeing with the major points of the original article.3 Dr Rosenbek et al29: “We all know that not all aspirators get sick.” Dr Steele: “Diet texture modification is by far the most commonly applied intervention for dysphagia. It has been called a ‘cornerstone’ of our practice yet recent articles continue to show that . . . practices . . . challenge our conventional assumptions regarding the benefits of these products. So, even if they aren’t always effective in preventing aspiration or improving swallowing, can we at least argue that thickened liquids don’t hurt our patients? Unfortunately, this may not be the case. There is some evidence that patients who are prescribed . . . thickened liquids, are at greater risk for malnutrition and dehydration.”30 Dr Langmore et al31: “. . . Dysphagia was concluded to be an important risk for aspiration pneumonia, but generally not sufficient to cause pneumonia unless other risk factors are LETTERS TO THE EDITOR 81
present as well. A dependency upon others for feeding emerged as the dominant risk factor.” Dr Langmore32: “Unfortunately, efficacy has not been demonstrated in any of the studies where large groups of patients have been enrolled in dysphagia programs.” There also appears to be agreement as to the inadequate training of SLPs. Dr Coyle: “A ‘review article’ has just been published in an obscure journal, that is going to create some shock waves through our profession as well as with the physicians that read it, if it receives any exposure . . . . It discusses the fact (and I agree with this one point) that the lack of adequate education in the medical sciences and the until-recently absent formal specialization in dysphagia in our profession is responsible for the poor evidence base we have in our specialty, and has created much doubt regarding the value of our work (anonymous personal communication).” Dr Langmore33(p3): “Speech-language pathologists are not alone in being inadequately trained in dysphagia. Physicians, including otolaryngologists, generally do not get adequate training in medical school or in their residencies to be proficient in assessing and treating oropharyngeal dysphagia.” Dr Martin-Harris et al34(p137): “Misguided tendency to refer to the modified barium study only as a tool for identifying aspiration . . . . A seasoned clinician can gain a fairly good clinical impression regarding the presence of or potential for aspiration from bedside observations.” Drs Crawford and Leslie35: “Risks associated with dysphagia intervention: Reduced nutrition, reduced hydration, reduced social contact, reduced overall quality of life and reduced patient choice.” Dr Leslie et al36(p433): “Increasing evidence shows that radiologically defined aspiration does not necessarily indicate clinical complications or potentially poor long-term outcome.” Dr Robbins et al37: “Thickening liquids has been and continues to be one of the most frequently used compensatory interventions in hospitals and long-term care facilities . . . . Nonetheless, there are little (sic) extant data that convincingly demonstrate that drinking thickened liquids has a significant positive effect on health outcomes such as pneumonia, hydration, nutrition, or quality of life.” This article might have been an interesting response were it not so clearly a rush to judgment. Irene Campbell-Taylor, MB, ChB, PhD Cape Breton Injured Workers’ Association New Waterford, NS, Canada (I.C.-T.) REFERENCES 1. Rosenbek JC. Efficacy in dysphagia. Dysphagia 1995;10:263–267. 2. Steele CM, Coyle JL, Davis LA, et al. Oropharyngeal dysphagia assessment and treatment efficacy: Setting the record straight. J Am Med Dir Assoc 2009;10:62– 66. 3. Campbell-Taylor I. Oropharyngeal dysphagia in long-term care: Misperceptions of treatment efficacy. J Am Med Dir Assoc 2008;9:523–553. 82 LETTERS TO THE EDITOR
4. Evidence Report/Technology Assessment Number 8. Diagnosis and Treatment of Swallowing Disorders (Dysphagia) in Acute-Care Stroke Patients. Rockville, MD: Agency for Health Care Policy and Research, US Dept of Health and Human Services, 1999. AHCPR publication 99-E024. 5. Dua J, Ren E, Bardan P, Shaker R. Coordination of deglutitive glottal function and pharyngeal bolus transit during normal eating. Gastroenterology 1995;112:73– 83. 6. American Speech-Language-Hearing Association. Clinical Indicators for Instrumental Assessment of Dysphagia [Guidelines]. 2000. Available at: www.asha.org/policy. Accessed November 18, 2007. 7. American Speech-Language-Hearing Association. Guidelines for SpeechLanguage Pathologists Performing Videofluoroscopic Swallowing Studies [Guidelines]. 2004. Available at: www.asha.org/policy. Accessed October 21, 2008. 8. Sonies BC. Meet the masters symposium. ASHA Annual Convention, November 2003. Available at: http://dysphagassist.com/vfss. Accessed February 1, 2008. 9. American Board of Radiology. Available at: http://theabr.org/. Accessed October 21, 2008. 10. Peer S. Letter Gates et al. Available at: http://radiographics.rsnajnls.org/ cgi/eletters/26/1/e22#80073. Accessed October 21, 2008. 11. Gates J, Hartnell GG, Gramigna GD. Videofluoroscopy and swallowing studies for neurologic disease: a primer. RadioGraphics 2006;26:e22. 12. Feinberg MJ, Ekberg O. Videofluoroscopy in elderly patients with aspiration [letter]. AJR Am J Roentgenol 1991;157:647. 13. Robbins J, Gensler G, Hind J, et al. Comparison of 2 interventions for liquid aspiration on pneumonia incidence: A randomized trial. Ann Intern Med 2008;148:509 –518. 14. Summaries for patients. Can thickened liquids or chin-down posture prevent aspiration? Ann Intern Med. 2008;148:I–39. 15. Drekonja D. Ethics of a control arm [letter]. Ann Intern Med 2008;148: 509 –518. 16. CMS Manual System Department of Health & Human Services (DHHS) Pub. 100-07 State Operations Provider Certification. Centers for Medicare & Medicaid Services (CMS). Available at: http://www. aahsa.org/WorkArea/showcontent.aspx?id⫽518. Accessed November 21, 2008. 17. Dasgupta M, Binns MA, Rochon PA. Subcutaneous fluid infusion in a long-term care setting. J Am Geriatr Soc 2000;48:795–799. 18. American Board of Medical Specialties. Available at: http://www.abms. org/About_Board_Certification/. Accessed October 21, 2008. 19. Manning RK. The relationship of knowledge of the physiology of normal and abnormal swallowing to accuracy interpreting instrumental observation of swallowing: A Dissertation presented to the faculty of the College of Health and Human Services of Ohio University in partial fulfillment of the requirements for the degree Doctor of Philosophy, March 2002. Available at: http://www.ohiolink.edu/etd/multiview.cgi/ohiou1015595609/ ohiou1015595609.pdf. Accessed October 21, 2008. 20. Logemann J, Gensler G, Robbins J, et al. A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson’s disease. J Speech Lang Hear Res 2008;51:173–183. 21. Baine WB, Yu W, Summe JP. Epidemiologic trends in the hospitalization of elderly Medicare patients for pneumonia; 1991–1998. Am J Public Health 2001;91:1121–1123. 22. Cassiere HA. Aspiration pneumonia: Current concepts and approach to management. Medscape General Medicine 1999;1(3): Available at: http://bcbsma.medscape.com/viewarticle/408725_print. Accessed October 21, 2008. 23. Lang IM, Sarna SK, Dodds WJ. Pharyngeal, esophageal, and proximal gastric responses associated with vomiting. Am J Physiol 1993;265: G963–G972. 24. Pikus L, Levine MS, Yang YX, et al. Videofluoroscopic studies of swallowing dysfunction and the relative risk of pneumonia. AJR Am J Roentgenol 2003;180:1613–1616. 25. Scheld WM, Mandell GL. Nosocomial pneumonia: Pathogenesis and recent advances in diagnosis and therapy. Rev Infect Dis 1991;13:S743– 751. JAMDA – January 2009
26. Cameron JL, Mitchell WH, Zuidema GD. Aspiration pneumonia: Clinical outcome following documented aspiration. Arch Surg 1973;106: 49 –52. 27. Feinberg MJ, Knebl J, Tully J. Prandial aspiration and pneumonia in an elderly population followed over 3 years. Dysphagia 1996;11:104 –109. 28. DePippo KL, Holas MA, Reding MJ, et al. Dysphagia therapy following stroke: A controlled trial. Neurology 1994;44:1655–1660. 29. Rosenbek JC, Power M, Lefton-Greif M, Arvedson J, et al. Translation to treatment: The clinical implications of penetration/aspiration. Short Course SC15. ASHA 2006 Convention, Miami Beach, Florida. Available at: http://convention.asha.org/2006/handouts.cfm. Accessed November 21, 2008. 30. Steele CM. Food for thought: Primum non nocere: The potential for harm in dysphagia intervention. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 2006:15:19 –23. Available at: http:// div13perspectives.asha.org/cgi/issue_pdf/toc_pdf/15/4.pdf. Accessed November 21, 2008. 31. Langmore SE, Terpenning MS, Schork A, et al. Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia 1998;13:69 – 81. 32. Langmore SE. Efficacy of behavioral treatment for oropharyngeal dysphagia. Dysphagia 1995;10:259 –262. 33. Langmore SE. Endoscopic Evaluation and Treatment of Swallowing Disorders. Thieme Medical Publishers, New York, 2001. Chapter 1. 34. Martin-Harris B, Logemann JA, McMahon S, et al. Clinical utility of the modified barium swallow. Dysphagia 2000;15:136 –141. 35. Crawford H, Leslie P. Managing complex risk in ethical dysphagia management. ASHA Convention 2007, Boston, MA. Available at: http:// convention.asha.org/2007/handouts/1137_1621Leslie_Paula_106267_ Nov19_2007_Time_011112PM.pdf. Accessed October 21, 2008. 36. Leslie P, Carding PN, Wilson JA. Investigation and management of chronic dysphagia. BMJ 2003;326:433– 436. 37. Robbins J, Nicosia M, Hind JA, et al. Defining physical properties of fluids for dysphagia evaluation and treatment. American Speech-LanguageHearing Association Special Interest Division 13 Newsletter 2002;11:16– 19. Available at: http://div13perspectives.asha.org/cgi/reprint/11/2/16. Members only.
DOI: 10.1016/j.jamda.2008.10.011
Hospitalization in Veterans Residing in Veterans Health Administration Nursing Homes To the Editor: I greatly enjoyed the in-depth article by Dr. French et al.1 However, I don’t agree with their conclusion that reduced hospitalization in veterans residing in Veterans Health Administration (VHA) nursing homes is only attributable to lack of financial incentives. We need to realize that nursing homes in Veterans Affairs medical centers differ widely from nursing homes in the community. Most VHA nursing homes are within the main medical center or in close proximity to it. By virtue of this, most nursing homes in the VHA have 24-hour in-house physician coverage as well as ancillary services like imaging and laboratory services. In addition, a vast majority of nursing homes in the VHA provide intravenous fluids and intravenous antibiotics in relatively stable patients. Some even provide blood transfusions for chronic anemia, ie, not for acute blood loss but for chronic anemia. Nursing homes in the community (non-VHA nursing homes) are usually unable to provide intravenous fluids and antibiotics, and 24-hour in-house physician services. It is not clear whether the nursing home residents described in the study1 resided in those nursing homes where intravenous fluids, intravenous antibiotics, 24-hour in-house physician Iraqi
coverage, and 24-hour laboratory services were available or not. If these services were available, like at our facility, then the decrease in hospitalization rate may not be attributable to financial incentives but rather because the care these patients required was able to be provided in the nursing homes where these patients were residing. Abid Iraqi, MD, CMD, FACP, AGSF Syracuse VA Medical Center Syracuse, New York REFERENCE 1. French DD, Campbell RR, Rubenstein LZ. Long stay nursing home residents’ hospitalizations in the VHA: The potential impact of aligning financial incentives on hospitalizations. J Am Med Dir Assoc 2008;9:499 – 503.
DOI: 10.1016/j.jamda.2008.10.005
Hospitalization in Veterans Residing in Veterans Health Administration Nursing Homes: Response to the Letter to the Editor by Dr. Abid Iraqi To the Editor: The points raised by Dr. Iraqi concerning hospitalization in the Veterans Health Administration (VHA) and community nursing homes are well taken and deserve further comment. First, we did not mean to suggest that VHA nursing homes and community nursing homes are one in the same. As Dr. Iraqi notes, the VHA provides services that most nursing homes (NHs) in the community are unable to provide. This is because the VHA funds its nursing homes in a totally different way and is not dependent on the Medicare skilled nursing facility (SNF) prospective payment system’s Resource Utilization Group (RUG) methodology to determine what services will be provided. Second, the VHA is essentially at full financial risk for all services in all settings of care for its patients as opposed to different payer mixes of Medicaid for long-term care services and Medicare for hospitalization (ie, dually eligible). While our analysis did not compare the variation in hospitalizations among VHA facilities, it demonstrated the potential economic savings within our own system, let alone community NHs outside the VHA. Again because the VHA is 1 payer (ie, the VHA) as opposed to 2 payers (Medicaid for NH stays and Medicare for inpatient hospitalization), one can further evaluate and build a business case (eg, cost-benefit analysis) for restorative care and other clinical services provided in VHA nursing homes aimed at reducing acute care hospitalizations. The conundrum of 2 potential payers in the non-VHA NH setting may create a misalignment of financial incentives. Community NHs do not have the financial incentives under the SNF prospective payment system’s RUG reimbursement system to provide certain types of advanced restorative care and other clinical services that could prevent certain types of hospital admissions. As Dr. Iraqi notes, “Nursing homes in the commuLETTERS TO THE EDITOR 83
DOI: 10.1016/j.jamda.2008.10.012
Response to Steele et al To the Editor: Dr J. Rosenbek has written of the demise of aphasia treatment that started in 1969 and, in turn, brought about the development of efficacy research in aphasiology. He compares this event with intervention in swallowing disorders and states, “No such alarm has yet sounded in dysphagia . . . Somewhere, someone has toyed with the idea of shattering the glass that covers the alarm bell. Dysphagia programs are simply too visible and too prosperous to be . . . allowed to continue proclaiming their efficacy without more convincingly demonstrating it.”1(p263) Campbell-Taylor
THE USE OF VIDEOFLUOROSCOPIC SWALLOWING STUDY (VFSS) IN LONG-TERM CARE The authors of the article offered in rebuttal2 have either overlooked or misinterpreted several points. A careful reading of the original article3 will show that I was quoting the Agency for Health Care Policy and Research report on the failure of VFSS as a gold standard and the potential sensitivity of the clinical examination.4 I was quite clear that identification of aspiration was not the primary objective of either clinical or instrumental examination. The VFSS reveals abnormalities of the swallow but cannot identify what consistencies can be consumed, nor what happens during a meal,5 as is admitted in the American Speech-Language-Hearing Association’s (ASHA) own documentation,6 yet the authors2 state, “This reality (some interventions may be harmful) further underscores the importance of . . . (testing) . . . interventions with instrumentation prior to recommending them for patients.” It is difficult to find a response to this position. ASHA acknowledges a lack of correspondence between VFSS boluses and “meal-time food and liquid,” as is shown in multiple studies, yet we are to be persuaded that VFSS is essential for decisions about meal contents for patients.7 To clarify the qualifications of speech language pathologists (SLPs) with respect to the videofluoroscopic examination of swallowing, so clearly criticized by Dr Sonies,8 it should be realized that radiologists must complete, during their residency, 700 examinations related to the anatomical areas that include deglutition.9 These examinations are conducted under the close supervision of qualified, board-certified radiologists. In contrast, most SLPs obtain their experience either from books or from other SLPs similarly lacking expert instruction and supervision, yet the ASHA Guidelines7 do not require the presence of a radiologist during VFSS. A letter from Dr S. Peer10 in response to Gates et al11 points out that VFSS has become a seldom-taught procedure, practiced by few radiologists. The response from Gates and colleagues states that “Videofluoroscopy is fast becoming a dying art for radiologists in the United States; all too often, speech pathologists work independently or may ‘benefit’ from the company of a technologist who is present only to ‘stand on the pedal.’” Given the inadequate training and lack of standards described by Dr Sonies,8 this is an alarming situation. Regardless of whether or not one believes that VFSS is essential in the assessment of swallowing, the expertise with which it is conducted should be a first principle. Feinberg and Ekberg12 have shown that “the efficacy of swallowing studies has not been established. No large, well-controlled clinical trials have been done that indicate a significant reduction in morbidity or mortality for any age group or specific condition.” That would appear to still be the case. THICKENED LIQUIDS The study known as Protocol 201 appears in several versions. It was not “completed” as the authors assert. It was terminated for reasons of futility. Stopping for futility means that the independent review committee elects to stop a trial early because the likelihood of finding a treatment effect is LETTERS TO THE EDITOR 79
low or the risk of adverse effects is high. It was decided that adding subjects would not achieve the intended result. Also, the final line of Table 2, “Adverse Experiences, Hospitalizations, or Death, by Intervention,”14 reads as follows: Chin Down
Both Liquids
Nectar
Honey
Serious adverse 71 (27%) 66 (26%) 34 (26%) 32 (26%) event† † Life-threatening adverse experience, hospitalization, or death.
In the version of the study published in the Annals of Internal Medicine,13 the editor makes the point that the confidence intervals in the results were too wide and, in the section entitled “Summaries for Patients”14 states the following: “The study does not prove which liquid or head position best prevents aspiration pneumonia; however, it suggests that drinking very thick liquids (those with the consistency of honey) may be harmful for older adults with swallowing problems, and that patients drinking thickened liquids more often had dehydration (6% vs. 2%), fever (4% vs. 2%), and urinary tract infections (6% vs. 3%).” The authors themselves state that “Long-term results show that despite differential effect of interventions on immediate elimination of aspiration in videofluoroscopic suite, the 3-month incidence of pneumonia was similar for chin down posture compared to liquids.” This would seem to imply that the results under VFSS bore little or no relationship to the eventual outcome. They also pay scant attention to the statistically significant finding that patients on thickened liquids became dehydrated, a devastatingly adverse effect for the elderly. In this version, they describe the study as a “randomized, controlled, parallel-design trial,” an unusual designation as they had no control group. They go on to state that “Part II of the study proceeded as a true randomized control trial, with videofluoroscopic evidence that the 515 participants had truly equal chances of responding favorably (or unfavorably) to the experimental interventions. As such, this study stands as a stellar example of impeccable design; few randomized controlled trials . . . demonstrate such equality in opportunity for either positive or negative response . . . . However, it must also be recognized that 2/3 of the participants in this phase . . . continued to aspirate in part I, despite any of the tested interventions.” This is a puzzling proposition given that no one was blinded to interventions, and a true, unrelated control group was not used. One can only infer that the authors are proposing that each subject, by some means, served as his or her own control. The difficulty with an approach in which it is planned that each serve as his or her own control is that there may be effects of a treatment that carry over from one period of intervention to the next, thereby confounding the picture. The authors specifically explain their lack of a control group as being “unethical.” “Our study has limitations. We did not include a no-treatment group because ‘no treatment’ is unethical. . . . The nature of the interventions did not allow blinding of direct care providers.” I believe a “no-treatment” group is also known as a control group. 80 LETTERS TO THE EDITOR
A letter in response to this article from Dr Dimitri Drekonja of the Minneapolis VA Medical Center15 takes issue with the lack of a control group and identifies this oversight as the “fatal flaw” of the study since the interventions used are previously untested with a lack of efficacy data. The claim that a control group would be unethical, presumably because of denying intervention, could easily be overcome by selecting subjects from locations in which intervention by speech therapists is not available. The other alternative is a waitlist group. Dr Drekonja goes on to posit that “one could argue that expending large amounts of energy, time, and funding, in order to produce a result that is severely limited by the lack of a control arm, is ethically questionable in its own right.” The authors state: “It is emphasized that this study looked only at the short-term, immediate effects of these three interventions.” I understand this to imply that, while there may be an effect on aspiration during the VFSS, it does not necessarily carry over to mealtime. This important point may have become clear to Medicaid/ Medicare. As of September 1, 2008, surveyors are instructed as follows: “Dietary restrictions, therapeutic (e.g., low fat or sodium restricted) diets, and mechanically altered diets may help in select situations. At other times, they may impair adequate nutrition and lead to further decline in nutritional status, especially in already undernourished or at-risk individuals.”16 They also reference the use of hypodermoclysis as an acceptable form of hydration.17 Certification Board Recognition in Swallowing is in no way equivalent to the board certification required of physicians. Their standard-setting organization is the American Board of Medical Specialties (ABMS),18 which is composed of 24 primary medical specialty boards and 6 associate members. Board certification for physicians guarantees extensive training and examination. There are, certainly, incompetent professionals of all types, but there are important differences between “qualified” and “competent”; the former resulting from standardized examination and the latter a consequence of adequate training plus personal ability. Board “recognition” is essentially meaningless. “Recognition” certificates are generally awarded as a token of gratitude by an organization. In addition, the board in this case is not the board of ASHA, but that of a special interest group. At the moment, ASHA provides, after graduate education and examination, a Certificate of Clinical Competence. To the average, reasonable individual, this indicates that the association is certifying that those who hold this document are competent to practice within the clinical fields they claim to have within their scope of practice and has been so certifying for many years. It is, however, denied by the association that this certification means that the clinician is competent in the area of swallowing disorders.19 There are no data currently available regarding the effectiveness of the education and training suggested in any curriculum for SLPs and swallowing disorders. JAMDA – January 2009
OVERVIEW COMMENTS The authors contend that I have fallen prey to the fallacy of the “call to perfection.” Are they implying that it is impossible for SLPs to be given correct and up-to-date information superimposed on a basic understanding of the medical sciences? That was my proposition and, if this is impossible to achieve, it would seem to follow, logically, that SLPs have no place in dysphagia intervention. The authors throughout their argument fall prey to the argument from ignorance that says that something (the efficacy of dysphagia intervention) must be true because it has not been proven to be false. Absolute proof may still be lacking but the signs are everywhere. They state that “Other undesirable health status outcomes (dehydration, urinary tract infection, and fever) were also relatively rare in the Protocol 201 Part II population (none of these conditions occurred at rates higher than 6%).” They may have been “rare” but dehydration was significant at P less than .05, and quite possibly related to urinary tract infections and fever. The authors examined a specific population, that, by definition, tends to be frail and to have multiple comorbidities including gastrointestinal dysmotility, hyperglycemia, polypharmacy , undernutrition, dehydration, poor oral hygiene, dependency for care, and other factors reducing the ability to withstand infection or other physiological attack. Robbins et al13 refer to this as an “efficacy” trial. Efficacy is improvement resulting from treatment applied in a rigidly controlled design when treatment and no-treatment conditions are compared. A comparison of 2 treatments of unproven efficacy is not an efficacy study. In the account of the study contained in the Journal of Speech, Hearing, and Language Research20 now identified as 3, not 2 interventions, the authors state that “This study was designed to identify which of 3 treatments for aspiration on thin liquids . . . results in the most successful immediate elimination of aspiration on thin liquids during the videofluorographic swallow study . . . . The longer-term impact of short-term prevention of aspiration requires further study.” The version in the Annals of Internal Medicine would appear to be about the longer-term impact13 with the first part designed only to select subjects. ASPIRATION The authors apparently missed my reference to the Baine et al21 article on aspiration pneumonia and its conclusions about the apparent increase in diagnoses of aspiration pneumonia possibly being financially driven. They appear to believe that pneumonia results only from aspiration of food mixed with saliva. They do not address the destination of the copious amounts of bacteria-filled saliva produced daily by most people. They apparently are unaware of the extensive literature on causes of both aspiration pneumonitis and aspiration pneumonia. There are too many references to cite on the basic facts: aspiration of what, how much, how often, and, most importantly, the patient’s resistance to infection.22 After an extensive search, I can find no instance of speech pathologists being taught the process of vomiting/regurgitation, which may explain the lack of understanding of the risk of aspiration of stomach contents in persons with oropharynCampbell-Taylor
geal dysphagia (OPD) associated with vomiting, gastroesophageal reflux disease (GERD), sedation, reduced consciousness, supine positioning, and other factors.23 It is unfortunate that the authors chose the Pikus et al24 study as proof of the relationship between OPD and pneumonia. Apart from the limitations that Dr Pikus and colleagues admit, these authors have confused, as is all too common, aspiration pneumonia and aspiration pneumonitis, giving as their evidence of the hazards of aspiration, 2 articles on the results of aspiration of gastric contents.25,26 Pikus and colleagues included 91 patients (24%) with other conditions “known to predispose individuals to aspiration, including gastroesophageal reflux disease in 32 (8%).” As is pointed out, pneumonia is the most frequent cause of death by infectious disease in the United States but it is unclear why it would be assumed that it is always, or even frequently, due to aspiration of oropharyngeal contents. Feinberg and colleagues27 showed that there was no simple relationship between prandial liquid aspiration and pneumonia in long-term care patients followed for 3 years. The authors have misidentified the DePippo et al28 article. The latter investigators found that limited patient and family instruction regarding diet modification and compensatory swallowing techniques during inpatient rehabilitation is as effective as therapist intervention for the prevention of medical complications associated with dysphagia following stroke. The authors propose that, “It is also important to remember that dysphagia therapy is designed to reduce adverse sequelae, but complete elimination of sequelae is not possible in any disease/disorder treatment.” I believe a surgeon might take offense at that statement after a successful appendectomy. Of course many diseases/disorders can be completely cured but with respect to OPD, however, we are dealing with a symptom of disease, a fact that seems to be repeatedly overlooked. “Sequelae of a symptom” is a confusing concept. PUBLISHED OPINIONS OF AUTHORS Articles such as this response2 are usually presented as rebuttal of the original. It is surprising to find that so many of the authors are on record as agreeing with the major points of the original article.3 Dr Rosenbek et al29: “We all know that not all aspirators get sick.” Dr Steele: “Diet texture modification is by far the most commonly applied intervention for dysphagia. It has been called a ‘cornerstone’ of our practice yet recent articles continue to show that . . . practices . . . challenge our conventional assumptions regarding the benefits of these products. So, even if they aren’t always effective in preventing aspiration or improving swallowing, can we at least argue that thickened liquids don’t hurt our patients? Unfortunately, this may not be the case. There is some evidence that patients who are prescribed . . . thickened liquids, are at greater risk for malnutrition and dehydration.”30 Dr Langmore et al31: “. . . Dysphagia was concluded to be an important risk for aspiration pneumonia, but generally not sufficient to cause pneumonia unless other risk factors are LETTERS TO THE EDITOR 81
present as well. A dependency upon others for feeding emerged as the dominant risk factor.” Dr Langmore32: “Unfortunately, efficacy has not been demonstrated in any of the studies where large groups of patients have been enrolled in dysphagia programs.” There also appears to be agreement as to the inadequate training of SLPs. Dr Coyle: “A ‘review article’ has just been published in an obscure journal, that is going to create some shock waves through our profession as well as with the physicians that read it, if it receives any exposure . . . . It discusses the fact (and I agree with this one point) that the lack of adequate education in the medical sciences and the until-recently absent formal specialization in dysphagia in our profession is responsible for the poor evidence base we have in our specialty, and has created much doubt regarding the value of our work (anonymous personal communication).” Dr Langmore33(p3): “Speech-language pathologists are not alone in being inadequately trained in dysphagia. Physicians, including otolaryngologists, generally do not get adequate training in medical school or in their residencies to be proficient in assessing and treating oropharyngeal dysphagia.” Dr Martin-Harris et al34(p137): “Misguided tendency to refer to the modified barium study only as a tool for identifying aspiration . . . . A seasoned clinician can gain a fairly good clinical impression regarding the presence of or potential for aspiration from bedside observations.” Drs Crawford and Leslie35: “Risks associated with dysphagia intervention: Reduced nutrition, reduced hydration, reduced social contact, reduced overall quality of life and reduced patient choice.” Dr Leslie et al36(p433): “Increasing evidence shows that radiologically defined aspiration does not necessarily indicate clinical complications or potentially poor long-term outcome.” Dr Robbins et al37: “Thickening liquids has been and continues to be one of the most frequently used compensatory interventions in hospitals and long-term care facilities . . . . Nonetheless, there are little (sic) extant data that convincingly demonstrate that drinking thickened liquids has a significant positive effect on health outcomes such as pneumonia, hydration, nutrition, or quality of life.” This article might have been an interesting response were it not so clearly a rush to judgment. Irene Campbell-Taylor, MB, ChB, PhD Cape Breton Injured Workers’ Association New Waterford, NS, Canada (I.C.-T.) REFERENCES 1. Rosenbek JC. Efficacy in dysphagia. Dysphagia 1995;10:263–267. 2. Steele CM, Coyle JL, Davis LA, et al. Oropharyngeal dysphagia assessment and treatment efficacy: Setting the record straight. J Am Med Dir Assoc 2009;10:62– 66. 3. Campbell-Taylor I. Oropharyngeal dysphagia in long-term care: Misperceptions of treatment efficacy. J Am Med Dir Assoc 2008;9:523–553. 82 LETTERS TO THE EDITOR
4. Evidence Report/Technology Assessment Number 8. Diagnosis and Treatment of Swallowing Disorders (Dysphagia) in Acute-Care Stroke Patients. Rockville, MD: Agency for Health Care Policy and Research, US Dept of Health and Human Services, 1999. AHCPR publication 99-E024. 5. Dua J, Ren E, Bardan P, Shaker R. Coordination of deglutitive glottal function and pharyngeal bolus transit during normal eating. Gastroenterology 1995;112:73– 83. 6. American Speech-Language-Hearing Association. Clinical Indicators for Instrumental Assessment of Dysphagia [Guidelines]. 2000. Available at: www.asha.org/policy. Accessed November 18, 2007. 7. American Speech-Language-Hearing Association. Guidelines for SpeechLanguage Pathologists Performing Videofluoroscopic Swallowing Studies [Guidelines]. 2004. Available at: www.asha.org/policy. Accessed October 21, 2008. 8. Sonies BC. Meet the masters symposium. ASHA Annual Convention, November 2003. Available at: http://dysphagassist.com/vfss. Accessed February 1, 2008. 9. American Board of Radiology. Available at: http://theabr.org/. Accessed October 21, 2008. 10. Peer S. Letter Gates et al. Available at: http://radiographics.rsnajnls.org/ cgi/eletters/26/1/e22#80073. Accessed October 21, 2008. 11. Gates J, Hartnell GG, Gramigna GD. Videofluoroscopy and swallowing studies for neurologic disease: a primer. RadioGraphics 2006;26:e22. 12. Feinberg MJ, Ekberg O. Videofluoroscopy in elderly patients with aspiration [letter]. AJR Am J Roentgenol 1991;157:647. 13. Robbins J, Gensler G, Hind J, et al. Comparison of 2 interventions for liquid aspiration on pneumonia incidence: A randomized trial. Ann Intern Med 2008;148:509 –518. 14. Summaries for patients. Can thickened liquids or chin-down posture prevent aspiration? Ann Intern Med. 2008;148:I–39. 15. Drekonja D. Ethics of a control arm [letter]. Ann Intern Med 2008;148: 509 –518. 16. CMS Manual System Department of Health & Human Services (DHHS) Pub. 100-07 State Operations Provider Certification. Centers for Medicare & Medicaid Services (CMS). Available at: http://www. aahsa.org/WorkArea/showcontent.aspx?id⫽518. Accessed November 21, 2008. 17. Dasgupta M, Binns MA, Rochon PA. Subcutaneous fluid infusion in a long-term care setting. J Am Geriatr Soc 2000;48:795–799. 18. American Board of Medical Specialties. Available at: http://www.abms. org/About_Board_Certification/. Accessed October 21, 2008. 19. Manning RK. The relationship of knowledge of the physiology of normal and abnormal swallowing to accuracy interpreting instrumental observation of swallowing: A Dissertation presented to the faculty of the College of Health and Human Services of Ohio University in partial fulfillment of the requirements for the degree Doctor of Philosophy, March 2002. Available at: http://www.ohiolink.edu/etd/multiview.cgi/ohiou1015595609/ ohiou1015595609.pdf. Accessed October 21, 2008. 20. Logemann J, Gensler G, Robbins J, et al. A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson’s disease. J Speech Lang Hear Res 2008;51:173–183. 21. Baine WB, Yu W, Summe JP. Epidemiologic trends in the hospitalization of elderly Medicare patients for pneumonia; 1991–1998. Am J Public Health 2001;91:1121–1123. 22. Cassiere HA. Aspiration pneumonia: Current concepts and approach to management. Medscape General Medicine 1999;1(3): Available at: http://bcbsma.medscape.com/viewarticle/408725_print. Accessed October 21, 2008. 23. Lang IM, Sarna SK, Dodds WJ. Pharyngeal, esophageal, and proximal gastric responses associated with vomiting. Am J Physiol 1993;265: G963–G972. 24. Pikus L, Levine MS, Yang YX, et al. Videofluoroscopic studies of swallowing dysfunction and the relative risk of pneumonia. AJR Am J Roentgenol 2003;180:1613–1616. 25. Scheld WM, Mandell GL. Nosocomial pneumonia: Pathogenesis and recent advances in diagnosis and therapy. Rev Infect Dis 1991;13:S743– 751. JAMDA – January 2009
26. Cameron JL, Mitchell WH, Zuidema GD. Aspiration pneumonia: Clinical outcome following documented aspiration. Arch Surg 1973;106: 49 –52. 27. Feinberg MJ, Knebl J, Tully J. Prandial aspiration and pneumonia in an elderly population followed over 3 years. Dysphagia 1996;11:104 –109. 28. DePippo KL, Holas MA, Reding MJ, et al. Dysphagia therapy following stroke: A controlled trial. Neurology 1994;44:1655–1660. 29. Rosenbek JC, Power M, Lefton-Greif M, Arvedson J, et al. Translation to treatment: The clinical implications of penetration/aspiration. Short Course SC15. ASHA 2006 Convention, Miami Beach, Florida. Available at: http://convention.asha.org/2006/handouts.cfm. Accessed November 21, 2008. 30. Steele CM. Food for thought: Primum non nocere: The potential for harm in dysphagia intervention. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 2006:15:19 –23. Available at: http:// div13perspectives.asha.org/cgi/issue_pdf/toc_pdf/15/4.pdf. Accessed November 21, 2008. 31. Langmore SE, Terpenning MS, Schork A, et al. Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia 1998;13:69 – 81. 32. Langmore SE. Efficacy of behavioral treatment for oropharyngeal dysphagia. Dysphagia 1995;10:259 –262. 33. Langmore SE. Endoscopic Evaluation and Treatment of Swallowing Disorders. Thieme Medical Publishers, New York, 2001. Chapter 1. 34. Martin-Harris B, Logemann JA, McMahon S, et al. Clinical utility of the modified barium swallow. Dysphagia 2000;15:136 –141. 35. Crawford H, Leslie P. Managing complex risk in ethical dysphagia management. ASHA Convention 2007, Boston, MA. Available at: http:// convention.asha.org/2007/handouts/1137_1621Leslie_Paula_106267_ Nov19_2007_Time_011112PM.pdf. Accessed October 21, 2008. 36. Leslie P, Carding PN, Wilson JA. Investigation and management of chronic dysphagia. BMJ 2003;326:433– 436. 37. Robbins J, Nicosia M, Hind JA, et al. Defining physical properties of fluids for dysphagia evaluation and treatment. American Speech-LanguageHearing Association Special Interest Division 13 Newsletter 2002;11:16– 19. Available at: http://div13perspectives.asha.org/cgi/reprint/11/2/16. Members only.
DOI: 10.1016/j.jamda.2008.10.011
Hospitalization in Veterans Residing in Veterans Health Administration Nursing Homes To the Editor: I greatly enjoyed the in-depth article by Dr. French et al.1 However, I don’t agree with their conclusion that reduced hospitalization in veterans residing in Veterans Health Administration (VHA) nursing homes is only attributable to lack of financial incentives. We need to realize that nursing homes in Veterans Affairs medical centers differ widely from nursing homes in the community. Most VHA nursing homes are within the main medical center or in close proximity to it. By virtue of this, most nursing homes in the VHA have 24-hour in-house physician coverage as well as ancillary services like imaging and laboratory services. In addition, a vast majority of nursing homes in the VHA provide intravenous fluids and intravenous antibiotics in relatively stable patients. Some even provide blood transfusions for chronic anemia, ie, not for acute blood loss but for chronic anemia. Nursing homes in the community (non-VHA nursing homes) are usually unable to provide intravenous fluids and antibiotics, and 24-hour in-house physician services. It is not clear whether the nursing home residents described in the study1 resided in those nursing homes where intravenous fluids, intravenous antibiotics, 24-hour in-house physician Iraqi
coverage, and 24-hour laboratory services were available or not. If these services were available, like at our facility, then the decrease in hospitalization rate may not be attributable to financial incentives but rather because the care these patients required was able to be provided in the nursing homes where these patients were residing. Abid Iraqi, MD, CMD, FACP, AGSF Syracuse VA Medical Center Syracuse, New York REFERENCE 1. French DD, Campbell RR, Rubenstein LZ. Long stay nursing home residents’ hospitalizations in the VHA: The potential impact of aligning financial incentives on hospitalizations. J Am Med Dir Assoc 2008;9:499 – 503.
DOI: 10.1016/j.jamda.2008.10.005
Hospitalization in Veterans Residing in Veterans Health Administration Nursing Homes: Response to the Letter to the Editor by Dr. Abid Iraqi To the Editor: The points raised by Dr. Iraqi concerning hospitalization in the Veterans Health Administration (VHA) and community nursing homes are well taken and deserve further comment. First, we did not mean to suggest that VHA nursing homes and community nursing homes are one in the same. As Dr. Iraqi notes, the VHA provides services that most nursing homes (NHs) in the community are unable to provide. This is because the VHA funds its nursing homes in a totally different way and is not dependent on the Medicare skilled nursing facility (SNF) prospective payment system’s Resource Utilization Group (RUG) methodology to determine what services will be provided. Second, the VHA is essentially at full financial risk for all services in all settings of care for its patients as opposed to different payer mixes of Medicaid for long-term care services and Medicare for hospitalization (ie, dually eligible). While our analysis did not compare the variation in hospitalizations among VHA facilities, it demonstrated the potential economic savings within our own system, let alone community NHs outside the VHA. Again because the VHA is 1 payer (ie, the VHA) as opposed to 2 payers (Medicaid for NH stays and Medicare for inpatient hospitalization), one can further evaluate and build a business case (eg, cost-benefit analysis) for restorative care and other clinical services provided in VHA nursing homes aimed at reducing acute care hospitalizations. The conundrum of 2 potential payers in the non-VHA NH setting may create a misalignment of financial incentives. Community NHs do not have the financial incentives under the SNF prospective payment system’s RUG reimbursement system to provide certain types of advanced restorative care and other clinical services that could prevent certain types of hospital admissions. As Dr. Iraqi notes, “Nursing homes in the commuLETTERS TO THE EDITOR 83