Untreated dysphagia, or impaired swallowing, can have significant consequences including weight loss, malnutrition and aspiration – often a pivotal factor in a patient’s decline. In the 2012 National Health Interview Survey, 1 in 25 adults reported trouble swallowing. Only 22 percent who reported this difficulty, however, had seen a healthcare professional for the condition. Of those who had seen a doctor, just one-third were given a dysphagia diagnosis.

“While there have been a number of studies focused on dysphagia and stroke,” said Dhyanesh (Dan) Patel, M.D., assistant professor of gastroenterology, hepatology and nutrition at Vanderbilt University Medical Center, “surprisingly few have evaluated the overall impact of dysphagia among U.S. inpatients regardless of their primary admission diagnoses. We suspected there was a correlation between dysphagia and hospital outcomes.”

To test this hypothesis, Patel collaborated with ENT specialists and the Vanderbilt Department of Outcomes Research to conduct the first cross-sectional study evaluating economic and survival burden of dysphagia among inpatients in the U.S. Their study was published in Diseases of the Esophagus.

The investigators used 2009-2013 hospital discharge data from the National Inpatient Sample (NIS) to determine the prevalence of dysphagia in adult patients and its effect on length of stay (LOS), in-hospital mortality, discharge disposition, in-hospital costs and total charges. The NIS is a nationally representative sample of more than 94 percent of U.S. discharges.

Growing Incidence of Inpatient Dysphagia

The investigators analyzed patients aged 45 years or older with ≤ 180-day hospital stays, comparing those with an ICD-9 code of dysphagia to those without a dysphagia diagnosis. Variables with a potential or expected relationship to outcomes were extracted including patient characteristics (sex, race, age), type of admission to the hospital (elective, nonelective), payer status (Medicare, Medicaid, private insurance, self-pay, no charge, other), comorbidities and hospital characteristics such as census region and bed size. Statistical analyses were used to match comorbidities.

The analysis found that approximately 3 percent of 88 million adult U.S. inpatients 45 years of age or older had a dysphagia diagnosis. During the study period, this prevalence increased – from 2.5 percent of admissions in 2009 to 3.3 percent in 2013. For the patients with dysphagia, hospital LOS was 3.8 days or 43 percent longer. Inpatient charges were more than $6,000 higher, with total charges per patient increasing approximately $22,000 over the study period. More significant, there were an additional 11,833 to 19,043 deaths per year among patients with dysphagia.

“Looking at these trends,” Patel said, “you wonder if we’ve really made a difference. You’d expect that as you get better in health care delivery, length of stay and costs would improve. But when you extrapolate these data, the total cost of dysphagia is $17 billion over the course of the study. And when you look at the true impact on patients, those with dysphagia are nearly twice as likely to die in the hospital.”

Mitigating DYSPHAGIA Impact

Patel thinks it’s important to increase dysphagia awareness so hospitals can do a better job of delivering interventions that reduce mortality. “Often when people have difficulty swallowing,” he said, “it’s associated with something else and the symptom gets thrown to the bottom of the list. We have to recognize that this is an important symptom.”

The key, he said, is screening.

“When you ask a patient if they’re having difficulty swallowing, a lot of times they’ve just come to accept it as the norm. We need to do a better job of screening them when they come in.”

“We also need to do a better job of monitoring dysphagia,” Patel said. “Many patients in the ICU require intubation and develop myopathy; their esophagus gets weaker. This can play a huge role in outcomes.”

The next phase, Patel said, is a randomized study of patients entering the hospital. “Screening questionnaires, wireless endoscopic evaluation and other tests can help us reduce the impact of dysphagia in inpatients. If we know someone’s having difficulty swallowing, we can provide earlier behavioral modification with speech therapy or esophageal dilation and help them return to their normal swallowing patterns quickly.”

About the Expert

Dhyanesh Patel, M.D.

Dyanesh Patel, M.D. is an assistant professor of medicine at Vanderbilt University Medical Center. He is also a provider within the Vanderbilt Digestive Diseases Center, specializing in esophageal diseases, gastroenterology, hepatology and nutrition.