Exploring Dysphagia Assessment and Management in Canadian Primary Care: A Clinical Practice Survey

Oropharyngeal dysphagia (OD), or dysphagia, is a common condition involving difficulty in safely forming or moving a bolus of food or liquid from the oral cavity to the esophagus. Dysphagia affects approximately 8% of the world’s population [1], up to 35% of community-dwelling older adults [2–5], and approximately 50% of hospitalized older adults [3, 6, 7]. Dysphagia is recognized as a geriatric syndrome due to its high prevalence in older adults, and its relationship with many comorbidities associated with aging, including progressive neurological diseases, stroke, and cancer [7–9].

As the population in Canada ages, it is anticipated the prevalence of dysphagia will increase [7, 10]. Early identification and management of dysphagia are important to minimize the associated risks of malnutrition, respiratory infections, and aspiration pneumonia [3, 5–7, 11–14].

In Canada, dysphagia assessment and management typically involve registered dietitians (RDs), speech-language pathologists (SLPs), and occupational therapists (OTs) with other disciplines engaged depending on care settings, professional scope of practice, provincial regulations, policies, standards, geographics, professional development, interest, and resource availability [15].

In the primary care setting where patients are living independently, timely dysphagia assessment, diagnosis, and appropriate management are essential to optimize patient outcomes. Currently, there is a paucity of literature describing the dysphagia management practices of RDs, SLPs, and OTs in this setting. The aim of this study was to understand the dysphagia assessment and management practices of these healthcare professionals (HCPs) in primary care and to help identify gaps and opportunities for optimizing care for patients living with dysphagia.

This was a cross-sectional practice survey of RDs, SLPs, and OTs working in primary care. The survey questions, format, and execution were informed by previously published practice-based research [16, 17] and in consultation with a panel of RDs, SLPs, and OTs with experience in practice-based survey research design, primary care clinical practice, and/or dysphagia assessment and management. Study reporting followed the Checklist for Reporting of Survey Studies (CROSS) (Supplementary File 1)¹ [18].

Content validity was confirmed through a survey pilot with 10 RDs, SLPs, and OTs to ensure the survey was comprehensive, relevant, and reflected the Canadian primary care setting and professional practice of clinicians. Minor feedback was incorporated to ensure accuracy of professional roles and work settings. The final survey consisted of 22 questions: 14 nominal, 4 rating, and 4 open-ended questions about respondent and patient demographics, accessibility of dysphagia assessments, frequency of use of various management interventions, available resources, and the challenges in dysphagia assessment and management (Supplementary File 2). Respondents used recall and were not requested to access patient medical records for data.

Primary care RDs, SLPs, and OTs in Canada involved in dysphagia management of adults (>18 years) were eligible to participate. Primary care was defined as Family Physician offices, Family Health Teams (FHT), Community Health Centres (CHC), Family Health Networks (FHN), Patient Care Networks (PCN), Nurse Practitioner Clinics, Homecare, Centre Local de Services Communautaire’s (CLSC), retail settings, programs for seniors/memory clinics, and hospital outpatient clinics.

Potential participants were invited through professional associations, including Dietitians of Canada, Speech-Language & Audiology Canada, Canadian Association of Occupational Therapists, and Ordre des diététistes nutritionnistes du Québec, as well as professional practice networks, listservs, and newsletters. A second invitation was distributed through the same channels to bolster response. No remuneration was provided to participants. The survey was administered in both English and French by DIG Insights, Toronto, Ontario, an independent provider of Canadian market research. The survey was open for 8 weeks from mid-Feb to mid-April 2023. Participation was voluntary, and consent was implied upon completion of survey.

Survey responses were coded to ensure confidentiality and analyzed in aggregate. Descriptive statistics and frequencies were reported, with stratification by profession and province using R statistical software (R Foundation for Statistical Computing. Version 4.3.0.1, Austria, 2023). Data from both partially and fully completed surveys were included in the analyses. This study was reviewed by Canadian SHIELD Ethics Review Board, Burlington, Ontario (2022-12-04).

This study aimed to explore the dysphagia assessment and management practices of RDs, SLPs, and OTs working in primary care in Canada, with the goal of identifying gaps and opportunities for optimizing dysphagia patient care.

Primary care RDs, SLPs, and OTs play an important role in assessing, identifying, and initiating appropriate dysphagia management interventions [15, 19, 20]. Our study found provincial variations in completion of dysphagia assessments, with dietitians primarily assessing in Quebec and Ontario, and SLPs in BC. Provincial dysphagia practice differences by discipline are known in Canada and reflect differences in scope of practice standards and provincial health discipline regulations within professions [15, 20–22].

Regardless of who conducts the swallowing assessment, the primary barriers to completing them were fairly consistent across all HCPs and provinces, with inadequate personnel and limited access to instrumental assessments reported as the most common. Previous Canadian practice-based surveys of RDs and SLPs in 2016 and 2021 also identified limited personnel as a barrier [16, 21]. Unfortunately, this barrier persists and can lead to increased wait times for diagnosis and potential health complications.

Once dysphagia is diagnosed, the primary goals of management are to promote safe oral nutrition, prevent complications, and provide patients with the necessary support for optimal nutrition and hydration [23]. In our study, a range of dysphagia management interventions were reported, with patient education, oral care, and diet modifications being the most common.

Diet modification recommendations varied by profession with fewer SLPs recommending thickened fluids compared to RDs. Increasing fluid viscosity has been shown to reduce penetration and aspiration in individuals with challenges managing thin fluids [24, 25]. A 2015 systematic review supported thickened liquids use in reducing penetration and aspiration and validated there may be an upper level where liquids become too thick, leading to post-swallow residue accumulation in the pharynx and subsequent risk of flow into the airway [24]. This influenced practice towards prescribing thickened fluids at a viscosity necessary for safe swallowing while avoiding fluids that are too thick [24–30]. Our findings aligned with this practice, as no RDs or SLPs recommended extremely thick/pudding consistency, few recommended moderately thick or pureed textured foods, and the majority of SLPs primarily recommended thin fluids. While this is not consistent with a 2023 international study involving 370 SLPs, where the majority of respondents recommended texture-modified fluids [31], it may be a result of a recently published position paper from the Royal College of Speech-Language Therapists in the United Kingdom [32]. The intention of this paper was to challenge clinicians to first explore a personalized approach to dysphagia intervention and consider thickened fluids as one of several dysphagia management tools [32].

To our knowledge, the prevalence of texture-modified diet use in Canada has primarily been studied in long-term care (LTC) settings. In a 2018 observational study of 639 LTC residents, 47.1% received texture-modified foods, ranging from International Dysphagia Diet Standardisation Initiative (IDDSI) level 3–6 (liquidized to soft and bite-sized), with 11% receiving pureed foods [33, 34]. In our study, RDs most often recommend “minced/minced and moist” or “soft and/or bite-sized” textures (IDDSI levels 5 and 6, respectively), while SLPs most often recommend “soft and/or bite-sized” or “regular/easy-to-chew” textures (IDDSI levels 6 and 7 respectively) [34]. It is difficult to tease out whether we are seeing a practice shift towards less texture-modified foods in the past 5 years or if the differences purely reflect the patient populations studied (LTC vs primary care).

The main challenges in dysphagia management reported were inadequate personnel and patient adherence to dysphagia management strategies. Inter-professional clinical care pathways for screening and management as well as patient/caregiver resources were identified as valuable resources in providing dysphagia care. This is consistent with a 2021 RD practice survey where similar needs were identified [16]. However, it would appear little progress has been made in developing these resources to help improve patient care and outcomes.

The healthcare landscape is shifting from an acute-based care to community-based care model and as the population ages in Canada, we continue to be challenged with having adequate healthcare resources in the community to support an increasing dysphagia prevalence [10, 35]. To provide timely services and effective support to those living with dysphagia in the community, staffing, educational resources, and financial investments will need to be increased. Finally, to help improve dysphagia care and patient outcomes, future research should be aimed at better understanding both barriers to adherence to dysphagia interventions from a patient perspective and HCP learning needs.

While our study provides insights into dysphagia assessment and management in Canadian primary care, it is important to consider its limitations. A response rate was not calculated due to the unknown survey distribution extent. Using professional association newsletters/networks to distribute survey invitations may have missed some primary care RDs, SLPs, and OTs with limited networking opportunities. The lack of incentives may have hindered recruitment, and the limited respondents from all three professions limit the generalizability of our findings. Provincial variations in engagement may be due to practice and professional scope differences across Canada.

This study provided valuable insights into the dysphagia assessment and management practices of RDs, SLPs, and OTs in Canadian primary care. Individuals with dysphagia are often older and have multiple comorbidities, and timely assessment and proper management are crucial for minimizing health-related complications. Finding unique and sustainable ways to overcome the barriers for dysphagia assessment and management in primary care will ultimately help improve the identification and care of this vulnerable patient population.

Primary care RDs, SLPs, and OTs play an important role in dysphagia care; however, inadequate personnel, limited access to instrumental assessments, and patient adherence to dysphagia management interventions pose challenges. Initiatives aimed at overcoming these challenges are imperative for improving patient outcomes and enhancing the quality of dysphagia care in Canadian primary care settings. Modifying fluids is evolving towards prescribing minimal thickness for safe swallowing. Practice variations exist between RDs and SLPs and may be influenced by training, resources, and personnel differences in Canada.