Assessment in a Nutshell
After a patient has been screened for dysphagia and identified as being at risk for dysphagia, further assessment is required (Fig.
1). Both ‘gold standard’ assessments VFS and FEES can diagnose aspiration (including silent aspiration) and other physiological problems in the pharyngeal phase. However, access to instrumental assessment may be restricted and no international consensus exists regarding which visuoperceptual or software-based measures to use for analysis of these video recordings. Moreover, there is insufficient psychometric evidence to recommend any individual measure as valid and reliable to interpret VFS and FEES recordings [
29].
Another step after screening is
non-instrumental clinical assessment by a dysphagia expert. In the process of clinical assessment of dysphagia, many different aspects may be distinguished, for example, medical history: conducting a physical examination; the subjective description of the swallowing problem or patients’ complaints [
30]; and the expert’s clinical observations during the interview and examination process. Clinical assessment may have the following purposes, single or in combination: to identify possible causes of the swallowing problems; to estimate the safety of swallowing and risk of aspiration; to support decisions on oral or alternative feeding routes; to identify the need for further assessment (e.g. instrumental assessment); and to establish baseline data for future comparisons after intervention or during the course of a disease [
22]. Clinical assessment may also address patient needs that are specific to certain clinical populations. For example, in patients with head and neck cancer, the effects of radiation and chemotherapy may be important and need to be described in detail.
Clinical assessment may refer to a large variety of assessments, each of which may be describing different aspects of dysphagia. In the absence of systematic reviews, textbooks and current opinion papers provide different overviews. While there is currently no comprehensive overview of clinical assessments, most literature seems to agree on the following four categories: 1) assessment of cognition and communication; 2) evaluation of the oral, laryngeal, and pharyngeal anatomy, physiology, and function (including cranial nerve examination); 3) oral intake and nutritional status; mealtime observations; and 4) intervention trials (e.g. bolus modification, postural adjustments and/or swallow manoeuvers) [
22,
31].
Another form of non-instrumental clinical assessment involves patient self-report measures as part of the multidimensional assessment of dysphagia. Patient self-report measures target two distinct but related concepts:
functional health status (FHS) versus
health-related quality of life (HR-QoL). FHS refers to the influence of a given disease (e.g. dysphagia) on particular functional aspects, whereas HR-QoL is the unique personal perception of someone’s health, taking into account social, functional, and psychological issues [
32].
Patient-Reported Measures
Patient-reported measures play an important role in patient-centred healthcare and can improve communication, patient engagement, and self-efficacy as patients may be more involved in goal setting [
33‐
35]. The use of a patient-reported measure, however, may be limited by patients who experience cognitive and/or language comprehension deficits. Recently, a framework (patient-reported outcome measures or PROM-cycle) was developed to support the selection and implementation of patient-reported measures in individual patient care and for quality improvement [
35]. The PROM-cycle describes eight steps necessary for systematic selection and implementation of PROMs in a cyclic approach and provides links to, for example, relevant tools and existing guidelines, examples from clinical practice and methodological considerations.
Patient self-report measures in dysphagia often combine both FHS and HR-QoL in the same measure, even though both are considered two distinct concepts. Consequently, disease-related functioning cannot be distinguished from disease-related quality of life as subjectively experienced by patients. Further, psychometric reviews on patient self-evaluation (e.g. [
36,
37]) and psychometric evaluations on most commonly used self-report measures in dysphagia (e.g. [
38‐
42]) identified that all existing measures have either poor psychometric properties or lack comprehensive evaluation and reporting of psychometric properties. This flags an urgent need for research. For example, even though the Eating Assessment Tool (EAT-10) is one of the most commonly used FHS measure in dysphagia, recent evidence using contemporary
Item Response Theory1 (IRT; Rasch analyses [
43,
44]) did not support its use in either research or clinical practice [
38,
40‐
42]. Another frequently used FHS questionnaire is the Sydney Swallow Questionnaire (SSQ [
45]), which is yet to be evaluated using IRT.
Among those self-report measures mainly targeting HR-QoL are the Swallowing Quality of Life questionnaire (SWAL-QOL [
46]), the Dysphagia Handicap Index (DHI [
47]), the Deglutition Handicap Index (DHI [
48]), and the MD Anderson Dysphagia Inventory (MDADI [
49]). The SWAL-QoL, like the EAT-10, is one of few measures that has been evaluated using Rasch analyses. As an outcome of the evaluation, it was recommended to further investigate the SWAL-QoL’s underlying structure and psychometric characteristics prior to continued clinical use [
39,
50]. For most self-report measures, however, even though their use is common practice, their psychometric robustness is yet to be established using IRT [
36,
37].
The use of self-report measures for
oral health has gained importance in recent years. Poor oral health and concomitant dysphagia are important risk factors of aspiration pneumonia [
51]. Oropharyngeal colonization by respiratory pathogens has shown to play a key role in the pathophysiology of aspiration pneumonia [
52‐
56]. A recent systematic review reporting on patient-reported measures for oral health in adults identified 20 English-language multiple-item questionnaires summarized into four domains: oral function, orofacial pain, orofacial appearance, and psychosocial impact [
57]. Examples of frequently used self-report measures in oral health include the Oral Health Impact Profile (OHIP [
58]) and the Oral Health Questionnaire for Adults [
59]. Most self-reported measures in oral health, however, need further psychometric evaluation before supporting their implementation in healthcare and research [
57].
Given that
gastroesophageal reflux disease (GERD) is common in populations presenting with dysphagia [
2,
60,
61], self-report on GERD may form part of dysphagia assessment. Many examples can be found in the review by Bolier, Kessing [
62] including, for example, the widely used and validated GERD Impact Scale (GIS [
63]) and the Reflux Disease Questionnaire (RDQ [
64]). Still, in the absence of further psychometric evaluations, many of these measures may not meet psychometric quality criteria [
65].
Assessment of Anatomy and Physiology
Before assessing the anatomy and physiology of the swallowing act, some higher cortical functions that act as precursors to oral feeding need to be evaluated. These include, but are not limited to, the patient’s alertness, responsiveness, cognition and language skills, as well as head and trunk control (i.e. motor control) [
66]. In the absence of standardized formal assessments,
input–output reasoning will inform further clinical assessment of functional anatomy (Table
2–
3) whereby innervation (input) from a muscle or functional groups of muscles (effectors) will, in turn, result in deglutition-related actions (output).
Table 2
Simplified overview of effectors of swallowing: input–output reasoning for clinical assessment of functional anatomy [
111]
V2 (maxillary nerve), V3 (lingual nerve: branch of inferior alveolar nerve of the mandibular nerve) | Lips | VII (Labial sphincter) |
V3 (lingual nerve: branch of mandibular nerve) | Tongue | XII (Oral control of bolus) |
V3 (mandibular nerve) | Jaw | V motor (Mastication) |
V, IX | Soft palate | V, X (Palate function) |
V | Mouth and cheeks | V motor, VII (Oral control of bolus) |
IX | Base of tongue | XII (Propulsion into oropharynx) |
X | Epiglottis (lingual side) | X (Laryngeal sphincter function) |
X (superior laryngeal nerve) | Epiglottis (laryngeal side) | X (Laryngeal sphincter function) |
X (superior laryngeal nerve) | Glottis and supraglottal larynx | X (Laryngeal sphincter function) |
X (inferior laryngeal nerve) | Subglottal larynx | X (Laryngeal sphincter function) |
X | Cervical trachea | X (Cough reflex) |
V, IX, X | Naso-oropharynx | IX, X (Velopharyngeal sphincter function) |
X | Hypopharynx | X (Propulsion, pharyngeal squeeze) |
Table 3
Simplified overview of input, effector, output, and clinical assessment for each functional group involved in deglutition (e.g. [
109‐
111])
Masticatory | CN V | Lateral / Lateral pterygoid Masseter Temporalis | Mastication Closure oral cavity Mandible: raise |
Facial | CN VII | Buccinator Orbicularis oris | Lip/mouth: seal Bolus: push towards teeth |
Intrinsic tongue | CN XII | Inferior / Superior longitudinal Transverse Verticalis | Tongue: shorten – lengthen, narrow – broaden, tip up –down, concave – convex bow tongue Bolus: preparation, formation, positioning, transport |
Extrinsic tongue | CN X | Palatoglossus | Tongue: protrude – retract, lower – raise Bolus: preparation, formation, positioning, transport Seal oral cavity |
CN XII | Genioglossus Hyoglossus Styloglossus |
Suprahyoid | CN V | Anterior belly of digastric Mylohyoid | Hyoid: lower – raise, protract – retract, stabilize Mouth floor: stabilize, elongate Mandible: lower |
CN VII | Posterior belly of digastric Stylohyoid |
C1 [via CN XII] | Geniohyoid |
Infrahyoid | C1 [via CN XII] | Thyrohyoid | Hyoid: lower, stabilize Mouth floor: stabilize, elongate Larynx: raise – lower, stabilize |
C1-C3 [via Ansa cervicalis CN XII] | Omohyoid Sternohyoid Sternothyroid |
Palatal | CN V | Tensor veli palatine | Soft palate: raise – retract, lower, brace, tense Oropharynx entrance: widen Posterior tongue: raise Uvula: raise Seal back of oral cavity from oropharynx Seal nasopharynx |
CN X | Levator veli palatin Palatoglossus |
CN XI [via CN X] | Uvular |
Pharyngeal | CN IX | Stylopharyngeus | Palate: lower Pharynx: raise, shorten Larynx: raise Seal oral cavity Seal nasal cavity Narrow pharyngeal lumen Bolus: transport Oesophageal sphincter: most distal component (of pharyngo-oesophageal segment or PES) |
CN X | Palatopharyngeus Salpingopharyngeus Superior / Middle / Inferior pharyngeal constrictor |
Laryngeal | CN X | Aryepiglottic Lateral / posterior cricoarytenoid Oblique / Transverse arytenoid Thyroarytenoid Thyroepiglottic | Vocal folds: adduct – open Arythenoids cartilages: approximate to epiglottis Epiglottis: lower Aryepiglottic foldsb |
A strict order of events provides clinical markers that guide clinicians during assessment with a functional–anatomic pathway of motor outputs activated by sensory inputs (Table
2) [
67]. Therefore, the anatomy and physiology that underpins the swallowing act need to be understood to allow for the assessment thereof. Swallowing is a highly integrated neuro-sensorimotor function, realized by organs (effectors) affiliated with different systems and inter-linked with other functions, so that swallowing, breathing, and phonoarticulation alternate according to hierarchically correlated pathways [
68]. Swallowing is the result of external (sight and smell) and internal sensory stimuli (touch, temperature, and taste), which converge at the meduallary swallowing centre, from where the motor efferents of the bulbar
cranial nerves (CNs) start: CN V (Trigeminal nerve: motor), CN VII (Facial nerve), CN IX (Glossopharyngeal nerve), CN X (Vagus nerve), CN XII (Hypoglossal nerve), and cervical spinal nerves C1-C3. The CN XI (accessory nerve) carries motor fibres for the sternocleidomastoid muscle and trapezius muscles (spinal root), and parasympathetic preganglionic visceral fibres (cranial root) that join the CN X reaching the soft palate, pharynx, larynx, and oesophagus. The brainstem swallowing centre is widely connected and receives cortical, subcortical, thalamic, limbic and cerebellar descending modulatory afferents, which transform the semi-reflex nature of swallowing into spatiotemporal integrated muscular contractions (muscular patterns) [
5]. The neurological structures (including cortex, extrapyramidal and pyramidal system, and cranial nerves) are contained in the neurocranium (protective shell surrounding the brain and brain stem), while the swallowing effectors are contained in the viscerocranium (skeleton supporting facial structure). At this level, the upper parts of the respiratory and digestive tract are arranged in parallel and conjugate in the pharyngeal cavity, which becomes a common pathway for both air and bolus transport. In this way, the pharynx acts alternately as an organ of the respiratory tract (chamber for air passage) as well as an organ of the digestive tract (peristaltic contracting chamber for bolus passage).
Anatomy of the upper digestive tract allows the organization of functional chambers operating in a concatenated series [
69]. In the oral cavity, the bolus is prepared (minced and mixed with saliva) as a consequence of coordinated actions between facial muscles, cheeks, teeth, jaws, tongue, and oral floor muscles [
70]. When the bolus is transported into the pharyngeal cavity, a reflex reconfiguration of the pharynx occurs; the oropharynx transforms from a respiratory pathway to a swallow pathway [
71]. The pharynx acts as a digestive lumen, generating contractile and peristaltic activities with the aim of transporting the bolus to the oesophagus [
72]. A strict hierarchy between vital primordial reflex activities determines the arrest of respiration (apnea), thus allowing the pharyngeal transportation of the bolus [
73]. The reconfiguration of the pharynx is defined by glossopalatal opening, velopharyngeal closure, upper and anterior hyoid laryngeal excursion, and upper oesophageal sphincter opening.
Articulation and voice quality are checked during speech and sustained vowel production and provide information about vocal fold or glottis closure. Furthermore, facial appearance and expression may indicate concerns about orofacial musculature, presence of surgical scarring, asymmetry, and inadequate labial seal (drooling). Touch, temperature, and taste sensibility can be tested on the lips, mucosa of the oral cavity, tongue (body, base, margins), fauci, soft palate, and posterior wall of the oropharynx using low-tech devices such as a wisp of cotton or tongue blade. The same low-tech devices can be used to test thermal and gustatory sensibility by wetting them in hot or iced water, or in salty, sweet, bitter, sour, or sparkling solutions.
Tone and strength of the tongue can be assessed by eliciting resistance against a tongue blade, while mobility is assessed by administering non-articulatory or articulatory praxis tasks. The opening of the jaws (temporomandibular joint) is closely examined and masticatory muscles are evaluated for its praxis and strength. The pterygoid muscles are tested during lateral mandibular movements with the jaw applying resistance against a hand, while the masseter and temporal muscles can be palpated during contraction. The symmetrical soft palate movement is evaluated using a simple articulatory task (i.e. by sustaining the vowel /a:/) or during the process of testing sensibility. The gag reflex can be elicited by stimulating the back of pharynx with a tongue blade/probe. Finally, the presence of the pharyngeal reflex is elicited by asking patients to perform a dry swallow while the clinician holds three fingers on the external hypo-laryngeal axis; the index finger is placed on the hyoid bone, the middle finger is placed on the thyroid notch, and the ring finger is placed on the cricoid ring. There should be an antero-superior displacement of these structures of about 2 to 2.5 cm during a dry swallow. Table
3 provides additional examples of clinical assessment of functional anatomy and physiology of the swallowing act.
Clinical Swallowing Evaluation
A
clinical swallowing evaluation (CSE) is typically performed after screening for swallowing problems to provide additional information to ascertain the relative risk for aspiration and to direct clinical decision making [
74]. CSE findings are important in determining whether an instrumental assessment may be required (if not already performed) and to decide which compensatory strategies and postural manoeuvres need to be prioritized for trialling to inform dysphagia therapy planning and patient management. At least a tentative diagnosis must be made and a management plan agreed upon following a CSE [
31]. However, aspiration and other physiological problems in the pharyngeal phase of swallowing can only be diagnosed through directly observation using instrumental assessments [
75‐
77].
The initial step in a CSE is to compile a thorough case history with the patient and/or carer. This involves a careful review of the medical history, if available, a history of the present condition (e.g. onset, duration of difficulties, symptoms), current swallowing status (e.g. method of oral intake and current diet, strategies that help swallowing, easiest and most difficult food consistencies to swallow), and factors that might influence management (e.g. comorbidities, cognition, food restrictions and nutritional status, presence of gastroesophageal reflux, and cultural preferences) [
30]. Common examples of the many available measures used while compiling a case history are the Functional Oral Intake Scale (FOIS; [
78]) and the Mini-Mental State Examination (MMSE; [
79]) or Mini-Cog [
80] to screen for cognitive impairment.
After compiling the case history, the clinician forms a preliminary clinical hypothesis that is tested during ensuing assessment. Only a few standardized CSE tests are available across dysphagia populations. The Mann Assessment of Swallowing Ability (MASA [
81]) is an example of a standardized CSE. The MASA was validated on stroke patients and has adaptations for patients with head and neck cancer (MASA -C [
82]). While conducting a CSE, the clinician also completes a clinical observation of the patient noting body posture, head posture at rest, level of alertness, and ability to follow assessment instructions, upper respiratory tract secretions, and the patient’s ability to manage his/her saliva. In addition, an orofacial examination is conducted that includes a cranial nerve examination. Oral health may be assessed using a measure such as the Oral Health Assessment Tool (OHAT [
83]).
Trial feeding is only considered an appropriate management strategy if the patient has an adequate voluntary cough and is able to manage his/her own secretions. If, however, the patient is drowsy, medically unstable, and unable to swallow saliva requiring suctioning, then trial feeding is deemed too high risk and should not be attempted. Self-feeding is preferred over feeding by carers or health care providers, to mimic typical eating and drinking patterns. As mentioned earlier, there are opposing views regarding which consistency to trial first. Some clinicians prefer to begin trials with small 5 ml volumes of water, gradually increasing the volume before moving to thicker consistencies. The rationale is that water, if aspirated, combined with good oral hygiene will be absorbed into the lungs without the immediate risk for the development of pneumonia [
84,
85]. Other clinicians prefer to start with thickened consistencies so as to reduce the risk for aspiration [
15]. Trials with fluids that promote sensation, for example carbonation and sweet and sour bolus, may be included in CSE [
86‐
88]. The temperature of the bolus may also be manipulated with colder boluses used to increase sensation [
89]. Thicker consistencies may be trialled later as they may give rise to residue in the pharynx which, in turn, can lead to aspiration [
18]. When assessing chewing it is important to evaluate the patient’s ability to manage solids and to identify risk of choking also. Assessments such as the Test of Mastication and Swallowing of Solids (TOMASS [
90]) may be useful.
When possible, a CSE should also include mealtime observation. This is particularly useful in patients with cognitive impairments where feeding and swallowing difficulties may be influenced by fluctuating levels of attention, fatigue, or environmental factors (e.g. background noise or other distractors). Observations such as the patient’s ability to self-feed, the need to use adaptive eating utensils, duration of the meal, and the presence of fatigue are noted. Examples of available standardized CSEs based on mealtime observation are the McGill Ingestive Skills Assessment (MISA [
91]) for older persons with feeding difficulties, and the Dysphagia Disorder Survey (DDS; [
92]) developed and validated for persons with developmental disabilities. Both measures have demonstrated promising, robust psychometric properties [
91,
93,
94].
During the CSE, individualized trials are conducted to investigate the effectiveness of compensatory strategies the person may already have put in place or to test new strategies and examine which are most effective for safe and efficient oral intake. Compensatory strategies comprise changing what the person eats (i.e. diet modification) and changing how the person eats (e.g. head posture, alternate liquid/solid swallows, volume control). The efficacy of implementing adaptive equipment (e.g. beakers, modified spoons, straws) in promoting safe oral intake should also be examined.
Ancillary to conducting CSE is evaluation such as pulse oximetry and cervical auscultation. Pulse oximetry measures peripheral capillary oxyhemoglobin saturation and is used to detect a decrease in saturation, which is indicative of aspiration during swallowing [
95]. Cervical auscultation is hypothesized to differentiate between normal and abnormal swallowing by listening to the sound of swallowing and swallowing-related respiration using a stethoscope placed on the neck [
96]. However, there is contention regarding diagnostic accuracy of pulse oximetry in predicting aspiration and current evidence does not support its use [
95]. Cervical auscultation, although commonly used, is equally contentious and there is limited evidence to support its use [
96].
Limitations of the CSE are that protocols vary and that there is variability in practice even within the same clinical settings and between populations [
97‐
99]. However, its key strength is providing low-cost clinical information to the multidisciplinary team in the immediate management of patients with dysphagia, especially if clinical teams do not have access to instrumental assessments.
Challenges and Minimum Requirements for Assessment
A
core outcome set (COS) is an agreed minimum set of outcomes that should be measured and reported in clinical trials of a specific disease or target population [
10]. When selecting outcome measures as part of a COS, four criteria need to be considered [
10]. First, both the construct to be measured (e.g. FHS, HR-QoL) as well as the target population (e.g. age, diagnosis) must be clearly defined. Second, existing measures must be identified by, for example, performing literature searches or using recent systematic reviews. Third, the quality of all measures must be evaluated both in terms of quality of psychometric properties as well as feasibility for administering the measure within particular setting. Fourth, one measure must be selected for each outcome or construct in a COS (Fig.
1).
The COSMIN group established an international consensus-based taxonomy, terminology, and definitions of
measurement properties for health-related patient-reported outcome measures [
25]: guidelines for using the taxonomy, including a standardized appraisal tool for rating methodological quality of psychometric studies [
100],
criteria for evaluating psychometric quality of assessments [
101,
102], and a rating system for synthesizing and grading psychometric evidence [
101,
102]. The taxonomy distinguishes nine psychometric properties across three domains (Table
4): validity (content validity, structural validity, cross-cultural validity, hypothesis testing for construct validity and criterion validity), reliability (internal consistency, reliability and measurement error), and responsiveness. When selecting an assessment, all nine psychometric properties are considered when identifying the assessments with the most robust psychometric properties.
Table 4
Psychometric domains and properties according to the COSMIN taxonomy
Validity | | Degree to which an instrument measures the construct(s) it purports to measure |
| Content validity | Degree to which the content of an instrument is an adequate reflection of the construct to be measured |
| Structural validity | Degree to which the scores of an instrument are an adequate reflection of the dimensionality of the construct to be measured |
| Hypotheses testing for construct validity | Degree to which the scores of an instrument are consistent with hypotheses based on the assumption that an instrument validly measures the construct to be measured |
| Cross-cultural validity | Degree to which the performance of the items on a translated or culturally adapted instrument are an adequate reflection of the performance of the items of the original version of the instrument |
| Criterion validity | Degree to which the scores of an instrument are an adequate reflection of a ‘gold standard’ |
Reliability | | Degree to which the measurement is free from measurement error |
| Internal consistency | Degree of the inter-relatedness among the items |
| Reliability (intra-rater, inter-rater, test–retest) | Proportion of the total variance in the measurements which is because of ‘true’ differences among patients |
| Measurement error (intra-rater, inter-rater, test–retest) | Systematic and random error of a patient’s score that is not attributed to true changes in the construct to be measured |
Responsiveness | | Ability of an instrument to detect change over time in the construct to be measured |
Interpretabilityb | | Degree to which one can assign qualitative meaning to an instrument’s quantitative scores or change in scores |
Assessments that have poor psychometric properties should not be used in either clinical settings or research. Minimum requirements for including an outcome measure in a COS are high-quality evidence for good content validity and good internal consistency [
10]. However, as recent psychometric reviews have identified missing or indeterminate evidence for many psychometric properties of existing assessments in dysphagia (e.g. [
29,
36,
37]), often only preliminary conclusions on the psychometric robustness of the assessments can be drawn based on current available psychometric evidence in the literature.
Content validity, the degree to which the content of an assessment is an adequate reflection of the construct to be measured, is considered the most important psychometric property within the COSMIN taxonomy [
102]. Concerns around content validity are raised when assessments that have been developed and validated for specific target populations are used in different populations. For example, the MD Anderson Dysphagia Inventory (MDADI) is a dysphagia-specific quality of life questionnaire targeting patients with head and neck cancer [
49], whereas the Dysphagia in MUltiple Sclerosis questionnaire (DYMUS) is a FHS self-report assessment for adults with multiple sclerosis [
103]. Assessments like the MDADI and DYMUS that have been developed and validated for a specific clinical population cannot be used in another population without the risk of compromising its content validity [
102]. For an assessment to have good content validity [
102], all items need to be aligned with the construct of interest in a specific population and context of use (relevance), all key concepts of the construct need to be covered (comprehensiveness), and instructions, items and response options need to be understandable to the target population as intended (comprehensibility).
Problems may also occur when using a translated version of an original assessment, without undertaking the required steps to ensure good cultural validity. The proposed framework of translation by Koller, Kantzer [
104] is based on a review of influential translation guidelines and summarizes the reconciliation processes that needs to be undertaken when translating measures. The framework stipulates that through a process of reconciliation, two or more independent forward translations are merged into one single translation using decision criteria on comprehensibility, cultural appropriateness, grammar, and use of relevant and consistent terminology. Next, cross-cultural validity needs to be determined by comparing the performance of items from a translated or culturally adapted assessment with the original assessment version [
24].
Finally, aspects of
feasibility need to be taken into consideration when deciding on which assessments to select for measuring outcomes. Feasibility refers to the practicability of using an assessment in its intended setting, taking into account constraints of time, money, and interpretability [
10]. Other important factors related to feasibility include, for example, patient’s cognitive functioning and physical ability, patient’s and clinician’s ability to comprehend items, ease of administration, duration of administering the assessment, simplicity of score calculation, accessibility of required equipment in different settings, copyright requirements, and associated costs to acquire and administer the assessments [
10]. Another consideration include administering, where appropriate, assessments via telehealth instead of face-to-face to increase accessibility to healthcare in rural and remote areas [
105], to increase service reach, reduce costs [
106], and more recently to continue providing safe health services during the COVID-19 pandemic.