Compensatory Swallowing Strategies Recommended in Oncology Practice: Practice Patterns and Relationship to Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) Grades

Compensatory swallow strategies are recommended to improve swallow safety and efficiency; however, there is limited evidence on use in specific populations or their relationship to swallow study results. We sought to describe/explore strategy recommendations in an oncology practice and their relationship to Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) grades as a marker of clinical utility of the tool. This is a sub-study of a STARI-guided retrospective implementation evaluation at a single comprehensive cancer center. Electronic health record databases were queried to sample all modified barium swallow studies (MBS) for all adult oncology patients from 2016 to 2021, excluding total laryngectomy, leak studies and those with missing DIGEST grades. For patients with multiple MBS studies across the study period, one MBS was randomly selected to be included in the analytic sample. DIGEST grade, diet recommendation, oncologic details, and swallow strategy details were chart abstracted. Strategies and oral intake recommendations were classified from least to most restrictive. This study included 4570 patients representing diverse oncology populations (46% head and neck). DIGEST grades indicating at least mild dysphagia (grades >= 1) were reported in 2486 of MBS (54%). Strategies were recommended in 2028 MBS (44%). As DIGEST grade increased so did strategy utilization and complexity (Spearman's r (r(S)) = 0.76, p < 0.0001). This pattern was consistent for Safety (r(S) = 0.68) and Efficiency (r(S) = 0.73) grades (both p < 0.0001). Swallow strategies are frequently recommended in oncology populations. This is the first study to show a systematic link between DIGEST grade and MBS compensatory strategy recommendations, supporting clinical effectiveness of DIGEST as an evidence-based practice tool.