Background: Dysphagia is common among older adults and the physiologic stress of hospitalization can worsen swallowing function. Rehabilitative treatment such as speech language pathology (SLPT), nutrition, and physical therapy (PT) services improve swallowing function, yet little is known about their delivery and impact on dysphagia outcomes after a hospitalization. Here, we describe delivery patterns for rehabilitative treatments among older adults with and without dysphagia discharged to post-acute care in skilled nursing facilities (SNF) and evaluate outcomes of those treatments among patients with dysphagia admitted to SNF.
Methods: Community-dwelling Medicare fee-for-service beneficiaries aged ≥65 years and admitted to SNF after hospitalization in 2019 were retrospectively evaluated using Medicare claims linked to the Minimum Data Set. Patients on hospice, comatose, or on a ventilator were excluded. Dysphagia was measured using diagnoses codes on hospital claims during the 6 months prior to SNF admission. Patients were followed through SNF discharge, 100 days after SNF admission, or death (whichever occurred sooner). Rehabilitative treatments measured were: oral and nutritional nursing care, and speech (SLPT), physical (PT), and occupational therapies (OT). Outcomes assessed were: improvement in self-feeding and oral hygiene, no weight loss on SNF discharge, and successful discharge to community (i.e., no readmission to a facility nor death within 30 days of discharge). First, we used logistic regression to measure the association between dysphagia status and receipt of each treatment. Second, we modeled the outcomes among patients with dysphagia as a function of receipt of each treatment. All models were adjusted for demographics, Elixhauser comorbidities, baseline function and cognition, length of stay, and reason for hospitalization. Standard errors were adjusted for clustering at SNF level.
Results: Among 598,324 patients in our sample, 29,891(5%) had dysphagia. Patients with dysphagia were more likely to be younger, male, non-White race, dually eligible for Medicaid, more cognitively and functionally impaired. Patients hospitalized for medical indications had 2.6 times the odds of dysphagia (95% CI 2.5-2.7; p< 0.001, vs those with surgical indications). Compared to patients without dysphagia, patients with dysphagia were more likely to receive SLPT (aOR=1.7; 95% CI 1.7-1.8; p< 0.001) and assistance with eating (aOR=1.2; 95% 1.2-1.3, p< 0.001), but less likely to receive PT or OT (aOR=0.3; 95% 0.3-0.3, p< 0.001) or oral care (aOR=0.8; 95% 0.8-0.8, p< 0.001). Among patients with dysphagia, those who received (1) SLPT had 1.5 times the odds of improvement in self-feeding and oral hygiene (95% CI 1.4-1.6, p< 0.001 for both, vs those who did not receive SLPT); (2) PT or OT had 1.4 times the odds of maintaining or gaining weight on SNF discharge (95% CI 1.3-1.5, p< 0.001 for both, vs those who did not receive PT or OT); and (3) nursing assistance with eating or oral care had higher odds of successful discharge to community (nutrition: aOR=2.5; 95% 2.4-2.7, p< 0.001; dental care: aOR=1.3; 95% 1.2-1.4, p< 0.001, vs those who did not receive that care).
Conclusions: Patients with dysphagia admitted to SNFs were less likely to receive, yet gain considerable benefit from therapy and nursing interventions aimed to rehabilitate their ability to swallow. Interventions tailoring the use of these treatments available in SNFs to the patients most likely to benefit are urgently needed.