Background
Methods
Objectives
Definitions
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Cost: reference to financial cost or economic impact in any care setting.
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Length of stay (LOS): mean or median number of patient days between a formal admission to, and a formal separation from a hospital care environment [22].
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Dysphagia: reference to a patient group with impaired oral and/or pharyngeal swallowing (oropharyngeal dysphagia).
Inclusion criteria
Types of participants
Type of outcomes
Types of studies
Search strategy
Method of the review
Study selection
Critical appraisal and data extraction
Cohort studies | |||||||||||
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Authors, date | Design | Sampling - Cohort selection | Presence of dysphagia | Confounders | Outcomes | Statistics | Overall quality rating | ||||
Retrospective or Prospective | Recruited from similar population | Cohorts similar at baseline | Measure used valid and reliable | Measured similarly for correct allocation | Groups free of dysphagia at start | Identified | Approp strategies to deal with | Measure used valid and reliable | Approp stats used | ||
Altman et al., 2010 [11] | Retro | + | ˜ | x | + | ˜ | + | + | + | + | Moderate |
Arnold et al., 2016 [27] | Retro | + | + | + | + | ˜ | + | + | + | + | Moderate |
Bonilha, et al., 2014 [15] | Retro | + | ˜ | x | + | ˜ | + | ˜ | + | + | Moderate |
Bradley et al., 2011 [28] | Retro | + | + | + | + | + | + | x | + | + | Low |
Chaw et al., 2012 [35] | Pro | + | + | + | + | + | + | ˜ | + | ˜ | Low |
Chen & Ke, 2016 [36] | Retro | + | ˜ | + | + | ˜ | + | + | + | + | Moderate |
Falsetti et al., 2009 [37] | Pro | + | ˜ | + | + | ˜ | + | x | + | + | Low |
Ferraris et al., (2001) [38] | Pro | + | ˜ | + | + | ˜ | + | ˜ | + | + | Low |
Genther & Gourin, 2015 [16] | Retro | + | ˜ | x | + | ˜ | + | + | + | + | Moderate |
Gourin et al., 2015 [17] | Retro | + | ˜ | x | + | ˜ | + | + | + | + | Moderate |
Guyomard et al., 2009 [39] | Retro | + | ˜ | + | + | + | + | + | + | + | Moderate |
Hogue et al., 1995 [29] | Retro | + | + | + | + | ˜ | + | + | + | + | Moderate |
Holmes et al., 2016 [32] | Retro | + | ˜ | + | + | + | ˜ | x | + | + | Low |
Macht et al., 2013 [40] | Retro | + | ˜ | + | + | ˜ | ˜ | ˜ | + | + | Low |
Macht et al., 2011 [41] | Retro | + | ˜ | + | + | ˜ | + | + | + | + | Moderate |
Nilsson et al., 1998 [31] | Pro | + | + | x | + | ˜ | x | x | + | + | Low |
Odderson et al., 1995 [42] | Pro | + | + | x | + | ˜ | x | x | + | + | Low |
Rao et al., 2005 [26] | ˜ | ˜ | ˜ | ˜ | ˜ | ˜ | x | x | + | ˜ | Very low |
Smithard et al., 1996 [12] | Pro | + | + | + | + | ˜ | + | ˜ | + | + | Moderate |
Teasell et al., 2002 [43] | Retro | + | + | + | + | ˜ | x | x | + | + | Low |
Tian et al., 2013 [44] | Retro | + | + | x | + | ˜ | + | + | + | + | Moderate |
Westergren et al., 1999 [33] | Pro | + | + | + | + | ˜ | + | x | + | + | Low |
Young et al., 1990 [30] | Retro | + | + | x | + | ˜ | + | x | + | x | Low |
Data analysis
Authors, date | Total sample size (dysphagia) | Primary clinical diagnosis | Data source (years) | Costs inclusive of | Mean US$ difference = attributable cost of dysphagia | % difference | P value | Statistical test used |
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Cohort studies | ||||||||
Bonilha, et al., 2014 [15] | 2883 (317) | Ischaemic stroke | US Medicare billing records (2004–2005) | Cost over and above general care (dysphagia attributable cost) | 4510 | 25.4 | < 0.0001 | Gamma distributed generalised linear model |
Chen & Ke, 2016 [36] | 237 (118) | Haemorrhagic stroke | National health insurance billing, Taiwan (2002–2012) | Total medical cost (insurer and co-payments by individual) | 1393.7 | 23.5 | < 0.001 | Multivariate linear regression |
Ferraris et al., (2001) [38] | 1042 (31) | Post-cardiac surgery | Hospital surgical data (1998–1999) | Hospital related costs per admission | 33,323 | 92.1 | < 0.0001 | Mann-Whitney test of inference |
Genther & Gourin, 2015 [16] | 61,740 (4461) | Head and Neck cancer | Nation-wide inpatient sample, Health care cost and utilisation project, Agency for Healthcare, Research and Quality (AHRQ) (2001–2010) | Total cost per admission | 3976 | 16.4 | < 0.001 | Generalised linear regression |
Gourin et al., 2015 [17] | 2370 (616)a | Head and Neck cancer | National surveillance, Epidemiology and End Results (SEER)- Medicare linked database (2004–2007) | Total Medicare paid amounts | 65,766b | 102 | Not reported | Multivariate linear regression |
Rao et al., 2005 [26] | 4551 (908) | Stroke | Not reported | Actual cost of care | 5107 | 28.5 | < 0.001 | Not reported |
Tian et al., 2013 [44] | 8977 (485) | Alzheimer’s disease | Medicare and Marketscan Commercial databases (2006–2010) | Total health care cost (hospitalisation, outpatient, ER, pharmacy) | 3620 | 35.2 | Not reported | Multivariate linear regression |
Cross-sectional | ||||||||
Chan et al., 2013 [45] | 7791 (467) | Head and Neck cancer | AHRQ (2001–2008) | Hospital related costs only per admission | 8201 | 52 | < 0.001 | Generalised linear regression |
Semenov et al., 2012 [46] | 93,663 (5245) | Head and Neck cancer | AHRQ (2003–2008) | Hospital related costs only per admission | 2609 | 12 | < 0.001 | Generalised linear regression |
Starmer et al., 2014 [47] | 1,649,871 (32,922) | Anterior cervical disc surgery | AHRQ (2001–2010) | Hospital related costs only per admission | 4692 | 28.6 | < 0.001 | Generalised linear regression |
Ward et al., 2012 [48] | 17,281 (443) | Head and Neck cancer | AHRQ (2003–2008) | Hospital related costs only per admission | 6663 | 28.3 | < 0.001 | Generalised linear regression |
Study type | Citation | Primary clinical diagnosis | Size of population that LOS is based on | Reported LOS Dysphagia (mean unless otherwise stated) | Reported LOS No-dysphagia OR Total sample (mean unless otherwise stated) | Reported significance |
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cohort | Altman, K. W., Yu, G. P., & Schaefer, S. D. (2010) USA [11] | Acute hospitalisations (conditions detailed in Table 4) | Admissions = 77,540,204 Dysphagia = 271,983 | median 4.04 days (4.0–5.0; 95%CI) | median 2.4 days, (3.0–3.0; 95%CI) (data error?) | not reported |
cohort | Arnold, M., Liesirova, K., Broeg-Morvay, A., Meisterernst, J., Schlager, M., Mono, M. L.,. Sarikaya, H. (2016) Switerland [27] | Ischaemic stroke | No dysphagia n = 452; mean age 64.9 years (SD = 14); Dysphagia n = 118 (20.7%); mean age 65.6 years (SD 14.5). | Total hospital LOS = 7.9 (SD = 4.8 days); Stroke unit LOS = 4.4 (SD = 2.8) | Total hospital LOS 7.2 (SD = 4.4); Stroke unit LOS 2.7 (SD = 2.4) | Total hospital LOS, p < 0.145; Stroke unit LOS p < 0.001 |
cohort | Bradley, J. F., 3rd, Jones, M. A., Farmer, E. A., Fann, S. A., & Bynoe, R. (2011) USA [28] | Cervical spine injury (blunt trauma) | No dysphagia n = 19, mean age 36.9y; Dysphagia n = 37, mean age 42.2y | Total LOS = 10.162 days (SD = 7.13); ICU LOS = 5.486 days (SD = 6.06). | Total LOS 6 days (SD 4.28); ICU LOS 4 days (SD 8.1) | Total LOS p = 0.083; ICU LOS p = 0.019 |
cohort | Chaw, E., Shem, K., Castillo, K., Wong, S. L., & Chang, J. (2012) USA [35] | Tetraplegia | Admissions n = 63; mean age 43 years (SD = 17.2); Dysphagia n = 21 (30.9%); mean age 48.6y (SD = 18.4) | 47.9 (+/−20.8) days | 38.7 (+/−17.0) days | p = 0.87 |
cohort | Falsetti, P., Acciai, C., Palilla, R., Bosi, M., Carpinteri, F., Zingarelli, A.,. .Lenzi, L. (2009) Italy [37] | neurorehab (non acute) ischaemic or haemorrhagic stroke | No dysphagia n = 89 (58.9%); mean age 78.6y (SD = 6.6); Dysphagia n = 62 (41%); mean age 80.7y (SD = 5.4) | 35 days (range = 13–93, SD = 16.7) | 26.6 days (range = 6–60, SD = 12.3) | p = 0.0012 |
cohort | Ferraris, V. A., Ferraris, S. P., Moritz, D. M., & Welch, S. (2001) USA [38] | post cardiac surgery | No dysphagia n = 1011 (97%), mean age = 62.8 (SD = 11.8); Dysphagia n = 31 (3%), mean age 71.9y (SD = 8.3) | 16.1 days (SD = 11.7) | 5.7 days (SD = 3.1) | p < 0.0001 |
cohort | Genther, D. J., & Gourin, C. G. (2015) USA [16] | Head and neck cancer patients who underwent ablative surgery. | 61,740 patients, median age 73y (range 66–104); Dysphagia n = 4461 (7.2%) | 10 days. Intercept + 0.2242 (0.1419–0.3065 95%CI) | 8 days, intercept 0.8448 (0.7211–0.9684 95%CI) | p < 0.001 |
cohort | Guyomard, V., Fulcher, R. A., Redmayne, O., Metcalf, A. K., Potter, J. F., & Myint, P. K. (2009) UK [39] | Stroke (ischaemic or haemorrhagic) | No dysphagia n = 1477, mean age 75y (SD = 12.1); Dysphagia n = 1506, Mean age 79y (SD = 9.7). | 16.0 days (SD = 9.9) | 10.5 days (SD = 6.3) | < 0.001 |
cohort | Hogue, C. W., Jr., Lappas, G. D., Creswell, L. L., Ferguson, T. B., Jr., Sample, M., Pugh, D., Lappas, D. G. (1995) USA [29] | acute hospitalisation with cardiopulomoary bypass | No dysphagia n = 835, mean age 63 y (+/− 0.4), Dysphagia n = 34, 71y (+/−2) | ICU = 15.1 days (+/− 3.1), Post operative LOS = 33.4 days (+/− 4.4) | ICU = 4.4 days (+/− 0.2); Post operative LOS = 12.3 days (+/− 0.4) | p = 0.0001 |
cohort | Holmes, S. R. M., Sabel, A. L., Gaudiani, J. L., Gudridge, T., Brinton, J. T., & Mehler, P. S. (2016) USA [32] | Anorexia nervosa | No dysphagia n = 164, 27 y (22–35); Dysphagia n = 42, 32 years (23–47) | median = 21 days (IQR = 14–27) | Median = 14 days (IQR = 9–20) | p < 0.001 |
cohort | Nilsson, H., Ekberg, O., Olsson, R., & Hindfelt, B. (1998). Sweden [31] | Stroke | No Dysphagia n = 58; Dysphagia n = 14. | median = 14 days (IQR = 8–47) | median = 10 days (IQR = 6–22) | Not significant |
cohort | Odderson, I. R., Keaton, J. C., & McKenna, B. S. (1995) USA [42] | Acute non-haemorrhagic stroke | No-Dysphagia n = 76, age = 75.3y (+/− 1.4); Dysphagia n = 48; age = 75.2y (+/− 1.5) | 8.4 days (+/− 0.9) | 6.4 days (+/− 0.6) | p = 0.05 |
cohort | Rao, N., Brady, S., Chaudhuri, G., Ruroede, K., & Caldwell, R. 2005 [26] | Stroke | No dysphagia n = 380 (42%); Dysphagia n = 527 (58%) | 22.08 days | 16.18 days | p < 0.001 |
cohort | Smithard, D. G., O’Neill, P. A., Parks, C., & Morris, J. 1996, UK [12] | Stroke | No dysphagia n = 61; Dysphagia n = 60 patients | 44.8 days (32–62; 95%CI) | 24.5 days (18–33; CI = 95%) | p < 0.001 |
cohort | Teasell, R., Foley, N., Fisher, J., & Finestone, H, 2002 Canada [43] | Medullary stroke | No Dysphagia n = 9, mean age = 55y (+/− 16); Dysphagia n = 11 (mean; age: 57 +/− 16) | Total hospital: 66 days (+/− 17); Rehabilitation: 48 days (+/− 14) | Total hospital: 44 days (+/− 22). Rehabilitation: 24 days (+/− 17) | Total hospital p = 0.023, Rehabilitation p = 0.002 |
cohort | Westergren, A., Hallberg, I. R., & Ohlsson, O. (1999). Sweden [33] | Stroke | Total n = 96, mean age 74.3y (SD = 9.6), Dysphagia n = 35, mean age 74.6y (SD = 7.6) | 53.9 days (+/− 35.9) | 25.2 days (+/− 24.6) | p < 0.001 |
cohort | Young, E. C., & Durant-Jones, L. (1990). USA [30] | Stroke | No Dysphagia n = 35, mean age 61 yrs.; Dysphagia n = 65, mean age 75 yrs | mean LOS = 53.06; median LOS = 32 | mean LOS = 22.10 days; median LOS = 15 days | p < 0.0002 (calculated from median) |
cross section | Chan, J. Y., Li, R. J., & Gourin, C. G. (2013) USA [45] | Head and neck cancer patients who underwent ablative surgery. | Total n = 7791, mean age 53.4 years (range 18–89); Dysphagia = 6.6% of total | Add 2.5 days compared with whole sample (95% CI .5307–.8021, estimate .6664, p < 0.001). | Whole sample = 3.7 days (95% CI 0.0205–0.9909) | p < 0.001 |
cross section | Semenov, Y. R., Starmer, H. M., & Gourin, C. G. (2012). USA [46] | Head and neck cancer patients who underwent ablative surgery. | Total n = 93,636, Dysphagia = 5.6% of total | Add 2.8 days to total sample | 7.3 days (estimate: 0.1998, 95%CI 0.1364–0.2632) | p < 0.001 |
cross section | Starmer, H. M., Riley, L. H., 3rd, Hillel, A. T., Akst, L. M., Best, S. R., & Gourin, C. G. 2004, USA [47] | Anterior Cervical Disc surgery | Total n = 1,659,871; Dysphagia n = 32,922 (2%). | Add 1.2 days to total sample, estimate: 0.558 (0.05173–0.7908) | 2.2 days (estimate 0.4742 (0.4523–0.4961) | p < 0.001 |
cross section | Ward, B. K., Francis, H. W., Best, S. R., Starmer, H. M., Akst, L. M., & Gourin, C. G. (2012) USA [48] | Vagus nerve injury due to vestibular schwannoma. | Total n = 17,281, mean age 50.4 yrs. (range 18–97); Dysphagia n = 443 | Add 1.72 days to total sample (0.23–0.49, 95%CI) | intercept 4.73 days | p = 0.001 |
case series | Chen, C. J., Saulle, D., Fu, K. M., Smith, J. S., & Shaffrey, C. I. (2013) USA [49] | Combined anterior-posterior cervical spine surgery | Total n = 30, mean age = 59.1 y (range 36–80); Dysphagia n = 13 (43.3%), mean age 60.7 years (SD = 7.2). | 10.8 days (SD 4.9) | 5.9 days (SD 2.6) | p = 0.004; After adjustment for age, LOS remained significantly p = 0.021 |
case series | Field, L. H., & Weiss, C. J. (1989) USA [50] | Traumatic Brain Injury | Total n = 30, Dysphagia n = 9 (30%) | 126.7 days | 52.3 days | None; descriptive only. No indication of variance or CIs |
Citation | Primary clinical diagnosis | Reported LOS Dysphagia. Mean +/− SD days | Reported LOS No-dysphagia.Mean +/− SD days | Mean difference (days) | Varience Standard Error (SE) | t-statistic and significance level | ||
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n = | n = | |||||||
Arnold, M., et al. (2016) Switerland [27] | Ischaemic stroke | 118 | Total hospitalisation: 7.9 +/− 4.8 | 452 | Total hospitalisation: 7.2 +/− 4.4 | 0.7 | SE: 0.464, 95% CI - 1.6107 to 0.2107 | t-statistic −1.510, DF 568, Significance level P = 0.1317 |
Stroke unit LOS: 4.4 +/− 2.8 | Stroke unit LOS: 2.7 +/− 2.4 | 1.7 | SE 0.257, 95% CI - 2.2051 to −1.1949 | t-statistic −6.610, DF 568, Significance level P < 0.0001 | ||||
Falsetti, P., et al. (2009) Italy [37] | neurorehab (non acute) ischaemic or haemorrhagic stroke | 62 | 35 +/− 16.7 | 89 | 26.6 +/− 12.3 | 8.4 | SE 2.360, 95% CI -13.0634 to −3.7366 | t-statistic −3.559, DF 149, Significance level P = 0.0005 |
Guyomard, V., et al. (2009) UK [39] | Stroke (ischaemic or haemorrhagic) | 1506 | 16.0+/− 9.9 | 1477 | 10.5+/− 6.3 | 5.5 | SE 0.304, 95% CI - 6.0970 to −4.9030 | t-statistic −18.063, DF 2981, Significance level P < 0.0001 |
Odderson, I. R., et al. (1995) USA [42] | Acute non-haem CVA | 48 | 8.4 +/− 0.9 | 76 | n = 76, 6.4 (+/− 0.6) | 2 | SE 1.039, 95% CI - 4.0571 to 0.0571 | t-statistic −1.925, DF 122, Significance level P = 0.0566 |
Teasell, R., et al. 2002 Canada [43] | medullary CVA pts. with and without dysphagia | 527 | mean total hospital: 66 +/−17 days | 380 | total hospital: 44 +/−22 days | Difference 22.0 | SE 8.712, 95% CI - 40.3024 to −3.6976 | t-statistic − 2.525, DF 18, Significance level P = 0.0212 |
Rehab: 48+/−14 days | Rehab 24+/−17 days | Rehab: Difference 24.0 | SEr 6.924, 95% CI - 38.5474 to −9.4526 | t-statistic −3.466, DF 18, Significance level P = 0.002 | ||||
Westergren, A., et al. (1999). Sweden [33] | stroke | 60 | 53.9 +/−35.9 | 61 | 25.2 +/−24.6 | −28.7 | SE 5.533, 95% CI - 39.6481 to −17.7519 | t-statistic −5.187, DF 129, Significance level P < 0.0001 |