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

摘要 吞咽困难（吞咽困难）是一种非常普遍和有影响的疾病，对患者造成重大负担。 医疗保健系统。在整个生命周期中，吞咽困难与死亡率的过度风险， 住院时间延长、吸入性肺炎和营养不良，从而提高了医疗费用和资源利用率。不仅 作为一种健康问题，吞咽困难也对生活质量和日常功能产生不利影响， 癌症幸存者身上。循证医学方法在临床实践中的应用落后于发现数十年。 一个这样的差距是采用循证实践（EBP）的言语语言病理学家在吞咽困难 管理循证吞咽障碍护理始于循证吞咽评估。显著 在吞咽困难领域已经取得了进展，以开发基于证据的评估方法，特别是 强调吞咽的生理特征。吞咽的相对安全性和效率，即 食物或液体团被保持在气道外并完全通过咽进入食道的程度， 是临床决策的基本驱动力-但在临床评估和报告中仍然不一致 实践为了解决这一差距，研究人员开发了DIGEST™（吞咽动态成像分级）， 毒性）。DIGEST是一种EBP工具，用于根据咽部吞咽困难的结果对咽部吞咽困难的严重程度进行分级。 X线摄影（视频荧光镜）改良吞钡（MBS）研究。DIGEST使用基本流程图， 标题（可通过PMC开放入路），以总结穿透/抽吸和咽部 MBS上观察到的残留物作为吞咽安全性和效率的标志。DIGEST是一个务实而强大的 在头颈部癌症人群中验证的措施，并在PI机构的常规实践中采用 自2016年开发以来，已有超过11，000例MBS在临床上使用该方法进行分级。同行评审 研究表明，在外部学术医疗环境和联邦资助的临床试验中采用DIGEST。 尽管有这样的希望，但仍有一些障碍限制了常规癌症护理的广泛采用。这些包括 可扩展性，以适应PI环境之外的各种临床背景，以及最佳实施的不确定性 战略布局该项目的长期目标是通过可靠的方法改善吞咽困难护理和患者结局。 将DIGEST纳入常规临床实践。我们的中心假设是，DIGEST规模扩大， 在常见临床实践差异下对不同癌症人群的有效性，并促进可靠的采用 积极的实施战略。该应用程序的目标是利用传播和 实施（D&I）科学，以实现以下具体目标：1）证明DIGEST在 不同的肿瘤学人群和成像采集协议，2）检查自然的背景和保真度 DIGEST在现实世界中的传播，早期采用者，和3）评估积极的实施战略， 提高了DIGEST在临床应用中的可达性和准确性。凭借密集的多站点网络和内容专业知识， 调查人员具备进行拟议D&I项目的独特条件。我们期待这项工作得到改进 通过缩小吞咽困难诊断中的研究与实践差距，

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.