Dissemination and implementation of DIGEST™ as an evidence-based measurement tool for dysphagia in cancer

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ABSTRACT Dysphagia (difficulty swallowing) is a highly prevalent and impactful condition with significant burden on the healthcare system. Across the lifespan, dysphagia is associated with excess risk of mortality, increased length of stay, aspiration pneumonia, and malnutrition thereby elevating medical costs and resource utilization. Not only a health problem, dysphagia also adversely affects quality of life and daily function with disproportionate impact on cancer survivors. Adoption of evidence-based methods into clinical practice lags decades behind discovery. One such gap is adoption of evidence-based practices (EBP) by speech-language pathologists in dysphagia management. Evidence-based dysphagia care begins with evidence-based swallowing evaluation. Significant progress has been made in the field of dysphagia to develop evidence-based evaluation methods, with particular emphasis on physiologic characterization of swallowing. The relative safety and efficiency of swallowing, that is how well a food or liquid bolus is kept out of the airway and clears fully through the pharynx into the esophagus, is a fundamental driver of clinical decision making – yet, remains inconsistently assessed and reported in clinical practice. To address this gap, the investigators’ developed DIGEST™ (Dynamic Imaging Grade of Swallowing Toxicity). DIGEST is an EBP tool to grade the severity of pharyngeal dysphagia based on results of a radiographic (videofluoroscopic) modified barium swallow (MBS) study. DIGEST uses a basic flowsheet and rubric (available open access via PMC) to summarize the patterns of penetration/aspiration and pharyngeal residue observed on the MBS as markers of swallowing safety and efficiency. DIGEST is a pragmatic yet robust measure validated in the head and neck cancer population, and adopted into routine practice at the PI’s institution with over 11,000 MBS graded in the clinic using the methodology since development in 2016. Peer-reviewed research shows adoption of DIGEST in external academic medical settings and federally funded clinical trials. Despite this promise, several obstacles still limit widespread adoption in routine cancer care. These include scalability to fit diverse clinical contexts outside the PI’s environment and uncertainty about best implementation strategies. The long-term goal of this project is to improve dysphagia care and patient outcomes through reliable adoption of DIGEST into routine clinical practice. Our central hypothesis is that DIGEST scales-up maintaining validity in diverse cancer populations under common clinical practice variations with reliable adoption facilitated by an active implementation strategy. The objective of this application is to use dissemination and implementation (D&I) science to accomplish the following Specific Aims: 1) demonstrate validity of DIGEST in diverse oncology populations and imaging acquisition protocols, 2) examine context and fidelity of natural dissemination of DIGEST in real-world, early adopters, and 3) evaluate active implementation strategies to improve reach and fidelity of DIGEST in clinical practice. With dense multi-site networks and content expertise, the investigators are uniquely equipped to conduct the proposed D&I project. We expect this work to improve care by narrowing the research-to-practice gap in dysphagia diagnostics.