Adult dysphagia services in acute and subacute settings in Singapore

ABSTRACT

International studies examining dysphagia management have identified that a degree of practice variability exists globally, with multiple factors within the local health service context influencing the nature of services. Understanding current practices and service inefficiencies is a foundational step for service optimization. Thus, this study aimed to understand service characteristics and issues associated with adult dysphagia service provision within acute and subacute settings in Singapore. Two online anonymous surveys were conducted with: (a) managers to explore practice documents used to guide dysphagia services, and (b) speech-language pathologists (SLPs) to understand dysphagia practices and service issues. Data were analyzed using descriptive statistics and content analysis. Responses from 12 managers and 68 SLPs working in acute and subacute settings were analyzed. There was a lack of national practice documents to guide dysphagia clinical training and service provision, and services were generally guided by internal documents. Despite this, dysphagia services were similar across acute and subacute settings. However, differences between settings were identified in screening and instrumental assessments services, perceived rehabilitation intensity, perceived rehabilitation adherence among patients, and extent of challenges with onward referrals. Whilst Singapore’s dysphagia services were largely aligned with other countries, challenges unique to the Singapore context was found relating to enteral feeding management, language barrier, financing framework, and care transitions. These findings build on the knowledge of dysphagia practices internationally, and provide direction for service optimization in Singapore.

KEYWORDS:

• Dysphagia
• acute
• subacute
• speech-language pathology
• service delivery
• survey
• practice documents

Introduction

Dysphagia is recognized as a prevalent condition within the acute care setting (Leder & Suiter, 2009; Leder, Suiter, Agogo, & Cooney, 2016), and can have considerable implications for patients, families, and healthcare systems. Studies have reported that dysphagia is associated with higher risk of medical complications such as pneumonia and malnutrition (Martino et al., 2005; Patel et al., 2018; van der Maarel-Wierink, Vanobbergen, Bronkhorst, Schols, & de Baat, 2011), and significantly impacts quality of life (Alali, Ballard, & Bogaardt, 2018; da Costa Franceschini & Mourao, 2015; Nund et al., 2014a, 2014b). Furthermore, managing patients with dysphagia has been documented to result in higher healthcare expenses and utilization (Attrill, White, Murray, Hammond, & Doeltgen, 2018; Paranji, Paranji, Wright, & Chandra, 2017; Patel et al., 2018), therefore, early diagnosis and timely management is paramount in mitigating these consequences (Bray et al., 2017; Panebianco, Marchese-Ragona, Masiero, & Restivo, 2020; Patel et al., 2018).

While delivery of consistent, high quality dysphagia services is ideal, current evidence indicates that this is not yet the reality globally. To date, several studies have described variable dysphagia practices across countries and clinical services (e.g., acute care, community) (Blackwell & Littlejohns, 2010; Engh & Speyer, 2022; Howells, Cornwell, Ward, & Kuipers, 2019; Kamal, Ward, & Cornwell, 2012; Lal et al., 2020; Rangarathnam & Desai, 2020; Rumbach, Coombes, & Doeltgen, 2018; Steele et al., 2007; Sugiyama et al., 2014). For example, depending on the country and setting, the utilization rates for a clinical swallow examination (CSE) are reported to range from 90.5 to 99.3%, while the utilization rates for instrumental assessments are lower, with higher variability, with reported use of videofluoroscopic swallowing study (VFSS) being <5 to 88.3%, and fiberoptic endoscopic evaluation of swallowing (FEES) being <5 to 46.8% (Blackwell & Littlejohns, 2010; Howells et al., 2019; Kamal et al., 2012; Lal et al., 2020; Miller, Deane, Jones, Noble, & Gibb, 2011; Rangarathnam & Desai, 2020; Roe et al., 2012; Rumbach et al., 2018; Steele et al., 2007; Sugiyama et al., 2014; van Snippenburg et al., 2019). Extensive variability in assessment practices was also found in studies that utilized standardized clinical scenarios to examine speech-language pathologist (SLP) assessment recommendations (Mathers-Schmidt & Kurlinski, 2003; Pettigrew & O’Toole, 2007).

Additionally, variability exists in SLPs’ management of dysphagia (Archer, Wellwood, Smith, & Newham, 2013; Carnaby & Harenberg, 2013; Jones, Cartwright, Whitworth, & Cocks, 2018; McCurtin & Healy, 2017). For instance, Jones et al. (2018) found that only one therapy, supervised swallow trials with bolus, was used by more than 75% of SLPs working in acute and subacute setting, and no other rehabilitation technique was consistently used by SLPs across acute, subacute, and community settings. Similarly, in another study that examined swallow rehabilitation using a hypothetical clinical scenario, 254 SLPs recommended 47 different therapy techniques and 96 different therapy combinations, with no clinician proposing an identical management plan (Carnaby & Harenberg, 2013). These findings support that substantial variability in dysphagia assessment and management exists.

Many reasons account for variability in clinical practices, including availability and accessibility of resources (Bennett, Cartwright, & Young, 2019; Rangarathnam & Desai, 2020; Rumbach et al., 2018), cost of services (Rangarathnam & Desai, 2020; Rumbach et al., 2018; Walshe, Ryan, & Regan, 2018), and cultural beliefs (Nordin, Kamaruzzaman, Chin, Poi, & Tan, 2015). Therefore, variability in practices is to be expected, and different healthcare systems will have aspects of care that are both similar and distinct from one another. However, it is important to identify aspects of services that are not aligned with evidence-based practices to inform future service redesign and improve quality of care.

To date, little is known about adult dysphagia service characteristics in Singapore, their level of variability, or how dysphagia practices align with other countries. It is reasonable to expect differences and unique challenges within Singapore, considering the relatively recent maturation of the speech-language pathology profession (Allied Health Professions Council, 2022; Lee & Satku, 2015), the nature of its health services (Tan, Lam, Matchar, Zee, & Wong, 2021), and its societal challenges, such as the ageing population (Tan et al., 2021). Indeed, in a study of aphasia services in Singapore, variability was found in assessment practices, the intensity of rehabilitation provided, and the types of intervention models used (Guo, Togher, & Power, 2014). Service challenges unique to Singapore, such as the nature of the healthcare funding system, lack of family engagement during SLP intervention, and the impact of cultural and linguistic diversity on service delivery were also identified (Guo et al., 2014), and these issues may also impact dysphagia services.

Optimization of dysphagia services is crucial to minimize negative personal and service impacts associated with dysphagia, and understanding the way dysphagia services are being delivered is the first step in improving the care pathway. Through an evaluation of current practices, greater understanding of SLP dysphagia practices can be achieved, and service inefficiencies can be identified. Therefore, the aim of this study was to understand service characteristics and issues associated with adult dysphagia service provision within acute and subacute settings in Singapore. The objective of this research was to identify current service characteristics, extent of variability between services, and challenges impacting the delivery of adult dysphagia services in Singapore to inform future service redesign.

Materials and methods

This study is reported in accordance with the checklist for reporting of survey studies (Sharma et al., 2021). Cross-sectional survey methodology was used to examine current dysphagia practices, and explore practice documents used within services related to dysphagia care. Ethical approvals were obtained from the National Healthcare Group Domain Specific Review Board (Singapore) and The University of Queensland (Australia). This study is part of a broader programme of research examining dysphagia services across the healthcare continuum in Singapore.

Surveys

Two sets of surveys, one for managers and one for SLPs, were co-developed by the study authors who have clinical and research experience in dysphagia care. The manager survey was designed to explore the nature and extent of policy and/or practice documents currently being used within services to guide dysphagia care. A systematic search of dysphagia-related practice documents was first conducted on government (Ministry of Health and Allied Health Professions Council) and professional organization (Speech and Language Therapy Singapore) websites, and five documents were retrieved (see Supplementary Material A). In addition, the principal investigator reviewed internal dysphagia-related documents used within own workplace. These documents were then used to inform the development of the manager survey, comprising of three sections: (1) documents at national level (Ministry of Health and Allied Health Professions Council), (2) documents at professional organization level (Speech and Language Therapy Singapore), and (3) documents at institution level (see Supplementary Material B for the manager survey). The survey had seven questions, and took five minutes to complete.

The SLP survey aimed to explore dysphagia practices and service issues, and a master version was first created and informed by previous international studies (Howells et al., 2019; Kamal et al., 2012; Rumbach et al., 2018; Steele et al., 2007). Using the master survey, four versions of the survey were developed, with slight wording variations to reflect four clinical settings in Singapore: (1) acute inpatient services, (2) outpatient services, (3) community hospital inpatient services, and (4) inpatient rehabilitation centres. The SLP survey comprised of nine sections incorporating demographic information, referrals, screening, assessment, management, education and adherence to recommendations, collaborative practices, care continuity, and service facilitators and barriers (see Supplementary Material C for the SLP master survey). The final SLP survey had 48 questions, and took 15 min to complete.

Both manager and SLPs surveys questions included binary choice, multiple choice, and open-ended responses. Skip logic was employed, and all questions were optional, except for the initial questions which confirmed eligibility and consent. Prior to dissemination, the surveys were piloted with one manager and three SLPs with dysphagia experience in acute and subacute settings. They provided feedback on the content, structure, and time needed to complete the surveys.

Procedure

Eligibility criteria for the manager survey required all respondents to be managers of a speech-language pathology department in either an acute or subacute setting within Singapore that provides dysphagia services for adults. For the SLP survey, eligibility criteria included registered SLPs who were: (a) working in any of the four clinical settings within Singapore, and (b) providing dysphagia care to adults (18 years old and above). Both manager and SLP surveys were hosted on a government website. The survey links were distributed via invitation emails and text messages to managers and SLPs on a distribution list, created from Singapore’s acute hospitals’ email directory, integrated community care agency’s contacts, and a public SLP registry. Snowball sampling was encouraged to optimize responses, and reminder emails and text messages were re-distributed one month (manager group) and two months (SLP group) after the surveys opened. The manager survey was open from January to February 2023 (1 ½ months), and the SLP survey was accessible between February and June 2021 (3 ½ months).

Analysis

Survey data were downloaded into a Microsoft Excel file for analysis. As all questions (excluding the consent questions) were optional, the count for ‘non-response’ was included in the analysis of each question. Questions containing 5-level responses (i.e., ‘never’, ‘rarely’, ‘sometimes’, ‘often’, and ‘always’) were collapsed into three groups – ‘never/rarely’, ‘sometimes’, and ‘often/always’. Demographic information, service patterns, and practice document utilization were analyzed using descriptive statistics. For the SLP survey, an additional step of statistical comparative analysis was performed between acute and subacute groups, using SPSS 28. Depending on the nature of the data, comparisons between settings were conducted using either the Fisher’s Exact test (for nominal data) or Mann–Whitney U test (for ordinal data). Significance was set at p < .05. Open-ended responses were analyzed using content analysis (Graneheim & Lundman, 2004) where the responses were read multiple times by the lead investigator to derive meaningful units and themes, and these themes were subsequently discussed and confirmed by other study authors.

Results

Manager survey

The survey was sent to 14 managers who met eligibility criteria. There were 12 responses received (acute n = 1, subacute n = 2, mixed acute/subacute service n = 9), representing a response rate of 85.7%. All managers completed all survey questions, thus all 12 responses were included in the analysis.

Documents at national level

Almost all managers indicated that their departments used Ministry of Health (MOH) and Allied Health Professions Council (AHPC) documents and frameworks to guide staff training in dysphagia care (used 83.3%, n = 10/12; did not use 16.7%, n = 2/12). The most common document used was the AHPC supervised practice guidelines for occupational therapists, physiotherapists, and speech-language pathologists (90%, n = 9/10), followed by AHPC guidelines for competence required for independently working with clients with dysphagia and feeding issues (80%, n = 8/10), AHPC guidelines on supervision and delegation of tasks to therapy support staff (70%, n = 7/10), and skills framework for healthcare (20%, n = 2/10). A review of these documents found that they are guidelines for clinical supervision and expected competencies of SLPs and therapy assistants. However, of these four documents, only one document, the AHPC guidelines for competence required for independently working with clients with dysphagia and feeding issues, is specific to dysphagia care, and it stipulates the expected hours of dysphagia clinical training, knowledge, and competencies to achieve entry-level competency for managing dysphagia caseload.

Similarly, almost all managers reported that their departments used MOH and AHPC documents to guide dysphagia service delivery (used 75%, n = 9/12; did not use 25%, n = 3/12), and the national one-rehabilitation framework (77.8%, n = 7/9) and AHPC guidelines on supervision and delegation of tasks to therapy support staff (77.8%, n = 7/9) were used equally. A review of the one-rehabilitation framework revealed that its purpose is to guide clinicians in facilitating patients’ care transition across healthcare settings using harmonized rehabilitation pathways for selected medical conditions, whereas the AHPC guidelines on supervision and delegation of tasks to therapy support staff indicate the generic roles and responsibilities of SLPs and therapy assistants during service provision. Both documents are not specific to dysphagia service delivery.

Documents at professional organization level

All managers indicated that their departments did not use any Speech and Language Therapy Singapore documents to guide staff training and dysphagia service delivery.

Documents at institution level

All managers reported that their departments used internally developed documents and frameworks to guide staff training in dysphagia care, such as clinical swallow examination (91.7%, n = 11/12), tracheostomy management (75%, n = 9/12), training of therapy assistants (75%, n = 9/12), VFSS (66.7%, n = 8/12), FEES (58.3%, n = 7/12), critical care (41.7%, n = 5/12), training of other healthcare professionals outside of speech-language pathology department (41.7%, n = 5/12), and other areas (8.3%, n = 1/12). Additionally, nearly all managers indicated that their departments used internal documents to guide dysphagia service delivery (used 91.7%, n = 11/12; did not use 8.3%, n = 1/12). Specifically, these included written practice documents relating to referral prioritization (63.6%, n = 7/11), screening (54.5%, n = 6/11), clinical swallow examination (81.8%, n = 9/11), VFSS (72.7%, n = 8/11), FEES (72.7%, n = 8/11), recommendations and management (63.6%, n = 7/11), patient and family education (63.6%, n = 7/11), and care transitions (72.7%, n = 8/11). Very few reported having specific documents relating to home dysphagia services (27.3%, n = 3/11), or dysphagia telehealth services (36.4%, n = 4/11).

Speech-language pathologist survey

A total of 68 responses were received, and all were included in analysis as each survey had >50% of the questions answered. The number of responses across the four clinical settings was: acute inpatient services (n = 46), outpatient services (n = 5), community hospital inpatient services (n = 14), and inpatient rehabilitation centres (n = 3). Due to small numbers in some groups, responses were collapsed into two main groups: (a) acute inpatient services and outpatient services were combined into the ‘acute setting’ (n = 51) as both services were typically situated within acute hospitals; and (b) community hospital inpatient services and inpatient rehabilitation centres were combined as the ‘subacute setting’ (n = 17). While the exact response rate could not be determined, a recent report by the Allied Health Professions Council (2022) indicated that 288 SLPs worked in acute and subacute settings, therefore the response rate is estimated at approximately a quarter (23.6%) of the eligible speech-language pathology profession.

Demographics and clinical load

Demographics and clinical caseload characteristics were similar for SLPs working in acute and subacute settings (Table 1). Most SLPs worked full-time, had less than five years of clinical experience in dysphagia, and had dysphagia management as their primary caseload, comprising of patients with a range of aetiologies. Clinicians working in the acute setting typically practiced at two or more sites, whereas most SLPS working in the subacute setting practiced at one site.

Table 1. Demographics and clinical load of speech-language pathologists.

Demographic and clinical load	Acute (n = 51)		Subacute (n = 17)		All (n = 68)
	%	(n)	%	(n)	%	(n)
Employment status
Full-time	86.3	(44)	88.2	(15)	86.8	(59)
Part-time	13.7	(7)	5.9	(1)	11.8	(8)
No response	0	(0)	5.9	(1)	1.5	(1)
Experience working in dysphagia services
0–5 years	52.9	(27)	64.7	(11)	55.9	(38)
More than 5 years	47.1	(24)	35.3	(6)	44.1	(30)
Percentage of caseload dedicated to dysphagia
1–50%	7.8	(4)	0	(0)	5.9	(4)
51–75%	33.3	(17)	29.4	(5)	32.3	(22)
76–100%	56.9	(29)	70.6	(12)	60.3	(41)
No response	2	(1)	0	(0)	1.5	(1)
Clinical caseloads managed^a
General and/or geriatric medicine	88.2	(45)	88.2	(15)	88.2	(60)
Neurology and/or neurosurgery	82.4	(42)	94.1	(16)	85.3	(58)
Respiratory medicine	72.5	(37)	82.4	(14)	75	(51)
Cancer	54.9	(28)	41.2	(7)	51.5	(35)
Cardiac medicine	43.1	(22)	58.8	(10)	47.1	(32)
General surgery	47.1	(24)	5.9	(1)	36.8	(25)
Critical care	41.2	(21)	–	–	30.9	(21)
Emergency department	7.8	(4)	–	–	5.9	(4)
Other	7.8	(4)	17.6	(3)	10.3	(7)
No. of practice setting
1	31.4	(16)	52.9	(9)	36.8	(25)
2	41.2	(21)	17.6	(3)	35.3	(24)
3 or more	27.4	(14)	29.4	(5)	27.9	(19)

Note: Bold indicates highest frequency responses; ^aTotal percentages >100% as multiple choices could be selected.

Referrals

There was no significant difference between the settings for main dysphagia referral sources or methods of prioritization (Table 2). Medical doctors were the main referral source, and new referrals were prioritized based on clinical characteristics and urgency. However, the wait time for new referrals was significantly different between the settings (Table 2), and this was skewed by five responses from outpatient services who reported longer waiting time (3–6 days n = 2, more than 2 weeks n = 3). When these five responses were removed from analysis, no significant difference was found (U = 285, p = .09), with a typical wait time of less than 1-day in both settings.

Table 2. Dysphagia referral practices reported by speech-language pathologists.

Referral practices	Acute (n = 51)		Subacute (n = 17)		All (n = 68)
	%	(n)	%	(n)	%	(n)
Main referral source*
Medical doctors	90.2	(46)	100	17	92.6	(63)
Allied health professionals	5.9	(3)	0	(0)	4.4	(3)
Nurses	2	(1)	0	(0)	1.5	(1)
No response	2	(1)	0	(0)	1.5	(1)
Prioritization of referrals*
No prioritization	19.6	(10)	29.4	(5)	22.1	(15)
Based on clinical characteristics and urgency	66.7	(34)	58.8	(10)	64.7	(44)
Based on a formal prioritization framework	13.7	(7)	5.9	(1)	11.8	(8)
No response	0	(0)	5.9	(1)	1.5	(1)
Waiting time for initial assessments^#
Less than a day	58.8	(30)	82.4	(14)	64.7	(44)
1–2 days	29.4	(15)	11.8	(2)	25	(17)
3–6 days	5.9	(3)	0	(0)	4.4	(3)
A week or more	5.9	(3)	0	(0)	4.4	(3)
No response	0	(0)	5.9	(1)	1.5	(1)

Note: Bold indicates highest frequency responses; *p > .05; ^#U = 285, p = .031.

Screening

Across both settings, a significant difference (p < .001) was found in dysphagia screening utilization, with screening services more commonly employed in the acute (screening 86.3%, n = 44/51; no screening 3.9%, n = 2/51; no response 9.8%, n = 5/51) than the subacute settings (screening 29.4%, n = 5/17; no screening 70.6%, n = 12/17). Clinicians who had screening services in their clinical settings (acute n = 44, subacute n = 5) answered another three questions (see Table 3) which revealed significant differences in screening practices between the two settings. Screening in the acute setting was typically conducted for patients who fulfilled a specific criterion, while no specific pattern was identified in the subacute setting. Additionally, screening in the acute setting was mainly conducted by nurses, whereas screening in the subacute setting was typically administered by medical doctors. Lastly, most screening tools in the acute setting were developed by the speech-language pathology departments, but in the subacute setting, it was common to use ad-hoc and informal screening tools. Majority of the SLPs who had screening services felt they were beneficial (acute 93.2%, n = 41/44; subacute 40%, n = 2/5; total 87.8%, n = 43/49), and those who felt that the tools were not useful (acute 6.8%, n = 3/44; subacute 20%, n = 1/5; total 8.2%, n = 4/49) cited reasons for this being the use of non-standardized screening tools and practices.

Table 3. Nature of dysphagia screening practices reported by speech-language pathologists.

Screening practices	Acute (n = 44)		Subacute (n = 5)
	%	(n)	%	(n)
Screening criteria^#
All new admissions	4.5	(2)	20	(1)
Patients who fulfil specific criterions (e.g., clinical pathways)	81.8	(36)	40	(2)
No standard criteria	4.5	(2)	40	(2)
Other (e.g., dependent on medical team’s concerns)	6.8	(3)	0	(0)
No response	2.3	(1)	0	(0)
Professionals who conducted screening^a
Medical doctor	61.4	(27)	80	(4)
Nurse	90.9	(40)	40	(2)
Speech and language pathology assistant	2.3	(1)	0	(0)
Screening tools^a
Published screening tool	18.2	(8)	20	(1)
Screening tool developed by speech pathology department	68.2	(30)	40	(2)
Informal screening tools, not developed by speech pathology department	25	(11)	60	(3)
Other	13.6	(6)	20	(1)

Note: Bold indicates highest frequency responses; ^#p = .039; ^aTotal percentages >100% as multiple choices could be selected.

Most SLPs who indicated that they did not have dysphagia screening services in their clinical settings (acute n = 2, subacute n = 12, total n = 14) felt that screening would be useful (acute 50%, n = 1/2; subacute 66.7%, n = 8/12; total 64.3%, n = 9/14). They stated that screening would help to identify and prioritize patients with dysphagia, increase dysphagia awareness, and provide additional information about a patient’s swallowing difficulties. Conversely, a smaller group of SLPs shared that screening would not be beneficial (acute 50%, n = 1/2; subacute 33.3%, n = 4/12; total 35.7%, n = 5/14), citing reasons such as (1) screening did not provide information on safe food texture, (2) patients were being appropriately identified and referred without screening, (3) screening was not needed in the subacute setting as patients had been reviewed by a SLP prior to admission, and (4) screening and SLP assessment in quick succession resulted in communication issues regarding dietary recommendations.

Assessment

When asked about clinical assessment, apart from 1:1 in-person assessment, SLPs from both settings listed telehealth (n = 26) and group assessments (n = 8) as alternative modes of delivery. Almost all SLPs reported regular (‘often/always’) CSE usage in both settings (acute 98%, n = 50/51; subacute 94.1%, n = 16/17; total 97%, n = 66/68; p = .928). However, significant differences were reported when comparing VFSS and FEES assessments (VFSS p < .001; FEES p < .001), with better availability and accessibility for both assessments in the acute setting (Table 4). Similarly, both assessments were used more regularly in the acute than subacute setting (VFSS U = 162.5, p < .001; FEES U = 164.5, p = .002) (Table 4). No significant difference in VFSS wait time between both settings was found (U = 507.5, p = .255), with a typical wait time of 3–6 days, whereas a significant difference in FEES wait time was reported (U = 363, p = .041), with a shorter waiting time in the acute setting (Table 4).

Table 4. Instrumental assessments services reported by speech-language pathologists (SLPs).

Instrumental assessment services	Acute				Subacute
	VFSS		FEES		VFSS		FEES
	%	(n)	%	(n)	%	(n)	%	(n)
All respondents from the acute (n = 51) and subacute (n = 17) settings
Local availability and accessibility (including access at other sites)
Available and accessible	86.3	(44)	72.5	(37)	35.3	(6)	35.3	(6)
Available, but difficult to access	9.8	(5)	19.6	(10)	5.9	(1)	5.9	(1)
Not available, but easy to access	3.9	(2)	2	(1)	29.4	(5)	5.9	(1)
Not available, difficult to access	0	(0)	0	(0)	29.4	(5)	35.3	(6)
Not available, not accessible	0	(0)	2	(1)	0	(0)	17.6	(3)
No response	0	(0)	3.9	(2)	0	(0)	0	(0)
Respondents who had at least some availability and accessibility to instrumental assessments.
Acute setting (VFSS n = 51; FEES n = 48); subacute setting (VFSS n = 17; FEES n = 14)
Utilization frequency
Never/rarely	3.9	(2)	22.9	(11)	29.4	(5)	64.3	(9)
Sometimes	31.4	(16)	50	(24)	52.9	(9)	35.7	(5)
Often/always	64.7	(33)	27.1	(13)	17.6	(3)	0	(0)
Waiting time for assessment
1–2 days	11.8	(6)	39.6	(19)	11.8	(2)	14.3	(2)
3–6 days	52.9	(27)	39.6	(19)	41.2	(7)	28.6	(4)
1–2 weeks	31.4	(16)	20.8	(10)	23.5	(4)	14.3	(2)
2 weeks to a month	3.9	(2)	0	(0)	17.6	(3)	14.3	(2)
More than a month	0	(0)	0	(0)	5.9	(1)	7.1	(1)
No response	0	(0)	0	(0)	0	(0)	21.4	(3)
Reasons preventing utilization^a
Patient declined due to safety concerns	29.4	(15)	56.3	(27)	23.5	(4)	50	(7)
Patient declined due to cost	56.9	(29)	25	(12)	58.8	(10)	28.6	(4)
Medical team did not give approval	31.4	(16)	18.8	(9)	11.8	(2)	14.3	(2)
Patient support not available	5.9	(3)	12.5	(6)	5.9	(1)	7.1	(1)
SLPs not trained in procedure	–	–	22.9	(11)	–	–	35.7	(5)
Other	41.2	(21)	41.7	(20)	29.4	(5)	7.1	(1)

Note: Bold indicates highest frequency responses; VFSS = Videofluoroscopic swallowing study; FEES = Fiberoptic endoscopic evaluation of swallowing; ^aTotal percentages >100% as multiple choices could be selected.

Both groups of SLPs reported similar reasons for why instrumental assessments were not routinely used (Table 4). Main issues impacting VFSS utilization were patients’ concern regarding assessment cost, followed by safety concerns (e.g., radiation exposure), whereas for FEES, the primary reasons impacting utilization were patients’ concerns regarding safety and assessment cost. The common themes for ‘other’ reasons preventing utilization of VFSS included clinic availability, patient factors (e.g., behaviour), and the complex referral and scheduling processes, particularly for patients from other facilities. Whereas for FEES, the common themes for ‘other’ reasons impacting utilization were patient factors (e.g., behaviour) and patients’ concerns regarding discomfort with the procedure.

Recommendations and management

Apart from delivering in-person individual therapy sessions, SLPs listed telehealth (acute n = 22; subacute n = 1; total n = 23) and group intervention (acute n = 3) as alternative modes of delivering therapy. Across both settings, no significant difference was reported in the primary provider of therapy (p = .178), with this predominantly being SLPs (acute 56.9%, n = 29/51; subacute 70.6%, n = 12/17; total 60.3%, n = 41/68), followed by SLP assistants (acute 19.6%, n = 10/51; subacute 29.4%, n = 5/17; total 22.1%, n = 15/68), then caregivers (acute 15.7%, n = 8/51; subacute 0%, n = 0; total 11.8%, n = 8/68). Similarly, no significant difference was found between settings in the utilization of compensatory strategies (U = 426.5, p = .877) and traditional swallowing exercises (U = 395, p = .525), and both management practices were regularly prescribed by SLPs (Table 5). In terms of device assisted therapy, more than 90% of the acute SLPs and 70% of the subacute SLPs reported that they had access to devices, however, both groups indicated infrequent usage, with no significant difference between settings (U = 258, p = .615).

Table 5. Dysphagia recommendations and perceived adherence reported by speech-language pathologists.

Utilization and perceived adherence	Acute (n = 51)		Subacute (n = 17)		All (n = 68)
	%	(n)	%	(n)	%	(n)
Utilization of management strategies
Compensatory strategies
Never/rarely	2	(1)	0	(0)	1.5	(1)
Sometimes	13.7	(7)	17.6	(3)	14.7	(10)
Often/always	84.3	(43)	82.4	(14)	83.8	(57)
Traditional rehabilitation
Never/rarely	0	(0)	17.6	(3)	4.4	(3)
Sometimes	39.2	(20)	23.5	(4)	35.3	(24)
Often/always	60.8	(31)	58.8	(10)	60.3	(41)
Device assisted therapy
Not available	7.8	(4)	29.4	(5)	13.2	(9)
Never/rarely	43.1	(22)	35.3	(6)	41.2	(28)
Sometimes	39.2	(20)	35.3	(6)	38.2	(26)
Often/always	9.8	(5)	0	(0)	7.4	(5)
Perceived adherence and agreement
Dietary modifications
Never/rarely	0	(0)	0	(0)	0	(0)
Sometimes	25.5	(13)	17.6	(3)	23.5	(16)
Often/always	72.5	(37)	82.4	(14)	75	(51)
No response	2	(1)	0	(0)	1.5	(1)
Swallowing strategies
Never/rarely	13.7	(7)	23.5	(4)	16.2	(11)
Sometimes	68.6	(35)	29.4	(5)	58.8	(40)
Often/always	13.7	(7)	41.2	(7)	20.6	(14)
No response	3.9	(2)	5.9	(1)	4.4	(3)
Rehabilitation
Never/rarely	17.6	(9)	11.8	(2)	16.2	(11)
Sometimes	62.7	(32)	35.3	(6)	55.9	(38)
Often/always	13.7	(7)	52.9	(9)	23.5	(16)
No response	5.9	(3)	0	(0)	4.4	(3)
Continue dysphagia care
Never/rarely	0	(0)	0	(0)	0	(0)
Sometimes	21.6	(11)	0	(0)	16.2	(11)
Often/always	78.4	(40)	100	(17)	83.8	(57)

Note: Bold indicates highest frequency responses.

Despite similarities in dysphagia management practices, differences were reported across settings regarding the ideal frequency of therapy. Significantly more SLPs (p = .002) from the subacute setting (64.7%, n = 11/17) felt that patients received the ideal therapy frequency in their setting compared to the SLPs working in the acute setting (23.5%, n = 12/51). Both groups reported reasons for suboptimal therapy frequency as high caseload demands, workforce constraints, and lack of access to resources. Clinicians working in the acute setting also described the de-prioritization of rehabilitation over other tasks (e.g., new referrals) and the cost of services for patients as barriers.

Regarding enteral feeding recommendations, no significant difference was found between both groups (p = .581), with more than half of the SLPs reported experiencing challenges recommending enteral feeding (acute 54.9%, n = 28/51; subacute 47.1%, n = 8; total 52.9%, n = 36/68). When asked to elaborate on these challenges, SLPs shared (1) strong resistance and poor acceptance of enteral feeding from medical staff and patients/families, (2) inadequate knowledge of enteral feeding among staff and patients/families, and (3) negative perceptions of enteral feeding by patient/families (e.g., reduced quality of life and burden of tube care). Even greater challenges were reported when recommending percutaneous endoscopic gastrostomy (PEG) due to (1) the perception that SLPs should not initiate a PEG discussion with patients/families, (2) difficulties in referring and accessing PEG services, and (3) lack of subsidies for PEG services resulting in additional costs for patients, especially in the subacute setting.

Education and adherence

Both groups of SLPs reported similar methods for conducting dysphagia education with patients/families, and they regularly used verbal explanation (acute 96.1%, n = 49/51; subacute 94.1%, n = 16/17; total 95.6%, n = 65/68), demonstration (acute 92.2%, n = 47/51; subacute 100%, n = 17/17; total 94.1%, n = 64/68), visual resources (e.g., diagrams) (acute 90.2%, n = 46/51; subacute 82.4%, n = 14/71; total 88.2%, n = 60/68), and written information (acute 90.2%, n = 46/51; subacute 70.6%, n = 12/17; total 85.3%, n = 58/68), whereas the sharing of FEES/VFSS recordings (acute 29.4%, n = 15/51; subacute 11.8%, n = 2/17; total 25%, n = 17/68) was uncommon. Both groups of SLPs reported challenges in dysphagia education (acute 60.8%, n = 31/51; subacute 41.2%, n = 7/17; total 55.8%, n = 38/68; p = .163). Four key issues were shared: (1) language barrier of caregivers, due to the linguistic diversity of migrant domestic workers; (2) lack of understanding and acceptance of a dysphagia diagnosis by patients/families; (3) patients/families’ preference to discontinue dysphagia recommendations; and (4) difficulties in providing dysphagia education pre-discharge, particularly on short notice when family members were uncontactable or unavailable (e.g., at work).

Across both settings, no significant difference in adherence to dietary recommendations was reported (U = 460.5, p = .489), with high perceived adherence rate (Table 5). Similarly, there was no significant difference in perceived patient adherence to swallowing strategies (U = 455, p = .269), with SLPs reporting most patients ‘sometimes’ performed swallowing strategies (Table 5). However, a significant difference was observed between both settings for perceived rehabilitation adherence (U = 559.5, p = .010), with SLPs from the subacute setting indicating higher patient adherence to swallowing exercise programmes (Table 5). In both settings, SLPs perceived that most patients agreed to continue dysphagia care (U = 527, p = .38) (Table 5), and reasons for patients discontinuing dysphagia services were cost of services, lack of understanding or acceptance of a dysphagia diagnosis, a perceived lack of value in continuing care, and service access issues (e.g., transport to appointments).

Collaborative practices

Across both settings, a multi-disciplinary care model was most common (acute 78.4%, n = 40/51; subacute 82.4%, n = 14/17; total 79.4%, n = 54/68), with only 10 SLPs reported delivering dysphagia services independently (acute 15.7%, n = 8/51; subacute 11.8%, n = 2/17; total 14.7%, n = 10/68). Similarly, both groups cited extensive stakeholder involvement, with the five most common being dietitians (98.5%, n = 67/68), medical doctors (86.8%, n = 59/68), caregivers (86.8%, n = 59/68), nurses (82.4%, n = 56/68), and kitchen staff (48.5%, n = 33/68).

Care continuity across services

Both groups of SLPs reported similar extent of challenges when accepting referrals from another dysphagia service provider (acute 76.5%, n = 39/51; subacute 82.4%, n = 14/17; total 77.9%, n = 53/68; p = .745). The reported issues were: (1) breakdown in information transfer, especially across different healthcare clusters, resulting in conflicting information and confusion among healthcare colleagues; (2) late referrals and resource constraints impacting timely delivery of dysphagia services; and (3) variable clinical practices among referring and receiving SLPs causing conflicting clinical decisions and confusion among patients regarding management plans.

Regarding making onward referrals to other dysphagia services, SLPs in the subacute setting reported significantly more difficulties with onward referrals (p = .039) than their acute counterparts (acute 45.1%, n = 23/51; subacute 70.6%, n = 12/17; total 51.5%, n = 35/68). Both groups of SLPs reported five similar issues which challenged the onward referral process including: (1) breakdown in information transfer; (2) complex referral process; (3) difficulties navigating the funding system when referring subsidized patients to other providers; (4) poor awareness of available services, resulting in time spent searching for services and referral processes; and (5) lengthy waiting lists and resource constraints preventing the receiving service from continuing timely dysphagia care.

Service barriers

Content analysis of barriers to optimal dysphagia service delivery revealed similar themes reported by SLPs in both settings (Table 6). The first theme was staffing constraints and high workload, where increased clinical demand on SLPs along with the lack of SLPs and therapy assistants, resulted in insufficient time to plan and provide optimum dysphagia services. The second theme was having limited resource access, such as access to instrumental assessments and therapy devices, which hindered SLPs’ abilities to provide ideal dysphagia care. The third theme was a breakdown in communication across services, where SLPs described difficulties in accessing patients’ medical records across healthcare clusters, which prevented comprehensive understanding of patient issues and continuation of dysphagia care. The fourth theme was the lack of dysphagia knowledge and support from healthcare professionals (e.g., doctors, nurses etc.), such as poor understanding of dysphagia and SLP role, making inappropriate referrals, and limited collaborative practices. The fifth theme was suboptimal professional and organization culture, where SLPs expressed the need to advocate for service enhancements to improve dysphagia care. The sixth theme was limited opportunities for professional development, and this was partially attributed to clinical demands and time constraints which limited opportunities to keep up with latest research and practices. The final theme pertained to patient and family factors, with SLPs describing financial constraints and reluctance to follow recommendations impacting the delivery of optimal dysphagia care.

Table 6. Service barriers described by speech-language pathologists.

Theme	Example responses
Staffing constraints and high workload	‘Lack of manpower. Lack of time. Too much pressure on delivering stats of patients seen instead.’ [SLP 48]
	‘High caseloads and admin portfolios, leaving insufficient time to think deeply about patient management or remain abreast of latest research to improve patient care’ [SLP 2]
Limited accessible resources	‘Lack of resources’ [SLP 32] ‘Lack of access to instrumentals and devices’ [SLP 51]
Breakdown in communication across services	‘Communication is not always streamlined/clear across different healthcare clusters.’ [SLP 36]
	‘Incomplete information, difficult process of getting information from other institutions’ [SLP 4]
Lack of dysphagia knowledge and support among other healthcare professionals	‘Lack of awareness of speech therapy services, lack of support from team to support dysphagia rehabilitation.’ [SLP 7]
	‘Lack of multidisciplinary collaborations/understanding between the medical doctors and the therapists.’ [SLP 41]
Suboptimal professional and organizational culture	‘Reduced visibility to higher management, having to fight for things like VFSS frame rate.’ [SLP 13]
	‘Resistance towards change.’ [SLP 52]
Limited professional development opportunities	‘Lack of further training opportunities for staff.’ [SLP 66] ‘Lack of manpower to provide quality service and also have time for training, projects etc.’ [SLP 13]
Patients and family factors	‘Patients have to pay for whatever service we provide – may be a financial burden’ [SLP 59]
	‘Patient refusal’ [SLP 11]

Note: VFSS = Videofluoroscopic swallowing study; SLP = speech-language pathologist.

Discussion

This is the first known study to describe dysphagia service characteristics and challenges within acute and subacute settings in Singapore. The survey findings from the managers revealed that there is a lack of national practice documents to guide dysphagia clinical training and service provision in Singapore. At present, most services used their own internal policy documents to guide dysphagia service delivery. From the SLP surveys it was revealed that current dysphagia service provision is mostly similar across acute and subacute settings. However, differences were found to exist across key areas, such as screening and instrumental assessments services, perceived rehabilitation intensity, perceived rehabilitation adherence among patients, and extent of challenges when referring patients to other dysphagia services. Additionally, while dysphagia services within Singapore are largely aligned with international literature, there are challenges identified that were unique to the Singapore community. These findings provide insights to guide service improvement and future research.

‘Practice documents’ encompass a broad range of documents including clinical practice guidelines, preferred practice patterns, and position statements, and their purpose is to provide guidance on evidence-based practices and professional issues (American Speech-Language-Hearing Association, 2023; Speech Pathology Australia, 2023). They are an important component of any service as they help to reduce variability in practices (Boaden, Nightingale, Bradbury, Hives, & Georgiou, 2020) and improve care and clinical outcomes (Hubbard et al., 2012). The current study has identified that there is a lack of national practice documents on dysphagia care in Singapore. This is in contrast to other international settings where speech-language pathology professional bodies, such as the American Speech-Language-Hearing Association (2023), the Royal College of Speech and Language Therapists (2023), and the Speech Pathology Australia (2023), provide clear guidelines to inform national practice in dysphagia care. However, despite the lack of national documents, most managers indicated using their own internal policies. This confirms that services have recognized the lack of national documents and have addressed this by creating their own internal documents. Whilst this is a positive step toward ensuring delivery of quality and consistent local services, there remains potential for these internal documents to differ between services, and contribute to ongoing variation in practices across services within Singapore.

Review of the SLP survey data from both the acute and subacute settings revealed a number of key differences relating to use of screening and instrumental assessments services, with higher utilization of screening and instrumental assessments reported in acute settings. Several factors may account for these findings. Firstly, high rates of screening in acute settings are consistent with international recommendations for early identification of dysphagia in key at-risk conditions at time of initial diagnosis, such as stroke (National Institute for Health and Care Excellence, 2019; Stroke Foundation, 2022). It is also by nature that dysphagia is first observed and assessed within the acute setting, before patients are transitioned to subacute settings. Hence, higher reliance on both screening and instrumental assessment in the acute setting is to be expected. Furthermore, the lower reported use of instrumental assessments in subacute settings may also be related to the resource constraints and complicated cross-institution referral and scheduling process raised by the survey respondents. Such challenges accessing instrumental assessments within non-acute settings have been highlighted previously in other international research (Howells et al., 2019; Steele et al., 2007).

Differences in dysphagia management practices between acute and subacute settings were also identified. Clinicians from the subacute setting perceived higher rehabilitation intensity and better adherence to rehabilitation among patients, and this is expected as subacute settings have a stronger focus on rehabilitation (Tan et al., 2021). Interestingly, the SLPs within the subacute setting were able to provide higher rehabilitation intensity despite recent reports suggesting fewer SLPs to hospital bed ratio within subacute settings, with an estimated ratio of SLPs to hospital beds being 1:71 in subacute settings compared with 1:47 in acute settings (Allied Health Professions Council, 2022; Ministry of Health Singapore, 2022a). The reasons for differences in manpower and their impact on rehabilitation services could be explored in future studies.

Comparison of dysphagia service patterns between Singapore and international literature has revealed several similarities. Screening practices within Singapore mirror findings of a survey conducted in Australia, where 47 SLPs working in acute settings reported access to screening services, compared to only 10 SLPs from subacute settings (Rumbach et al., 2018). Similarly, Singapore has a high CSE utilization of 97%, which is comparable to the usage rate of 89–99% reported internationally (Howells et al., 2019; Lal et al., 2020; Miller et al., 2011; Roe et al., 2012; Rumbach et al., 2018; Steele et al., 2007). Furthermore, instrumental assessment practices within Singapore are consistent with studies conducted in Australia (Howells et al., 2019; Rumbach et al., 2018), Canada (Steele et al., 2007), and the United Kingdom (Miller et al., 2011; Roe et al., 2012). For example, a survey with 154 SLPs within Australia has found that 88.3% used VFSS as the predominant instrumental assessment, compared to 46.7% who used FEES (Rumbach et al., 2018).

Additionally, the dominant use of compensatory strategies in Singapore reflects international practices (Jones et al., 2018; Lal et al., 2020; McCurtin & Healy, 2017; Rangarathnam & Desai, 2020; Rumbach et al., 2018). Specifically, the utilization rates for compensatory strategies (83.8%) and rehabilitation (60.3%) within Singapore are comparable to the international reports of 80–92% for compensatory strategies and 34–71% for rehabilitation (Lal et al., 2020; Rangarathnam & Desai, 2020). Also, most of the 154 SLPs surveyed within Australia have reported prescribing dysphagia management plans comprising mainly of compensatory strategies, and only 10–30% rehabilitation exercises (Rumbach et al., 2018).

Conversely, service issues unique to the Singapore community were also found. Firstly, SLPs within Singapore have reported significant challenges with PEG management, and while difficulties in recommending enteral feeding can be common in Asia (Lin, Li, & Watson, 2011; Zaherah Mohamed Shah et al., 2012), the issues raised by SLPs in this study pertain to the local referral process, healthcare subsidy, and service access. Such challenges appear prevalent in Singapore as other healthcare professionals have shared similar issues, including unclear referral guidelines, poor communication among professionals, and the lack of community support (Ang et al., 2019). To address these challenges, initial steps could be the development of standardized referral protocols and increased community access, which is aligned with the ministry’s direction of moving from hospital-centric healthcare to the community (Tan et al., 2021).

In addition, language barrier was identified as a key service challenge by SLPs in Singapore, and this has not been extensively documented in international dysphagia literature. In Singapore, there is a large community of migrant domestic caregivers, with a survey reporting 49% of 1190 families had employed a migrant domestic worker for caregiving of an elderly (Ministry of Social and Family Development Singapore, 2013). These caregivers may not speak the local languages, which presents as a challenge during healthcare interactions as reported by several local studies (Guo et al., 2014; Ha, Chong, Choo, Tam, & Yap, 2018; Heng, Fan, & Chan, 2019; Mehta & Leng, 2017; Xu et al., 2019). Language barriers may affect a caregiver’s ability to understand and carry out dysphagia care, leading to safety concerns. For this reason, it is essential that more resources are available to support communication and education with linguistically diverse caregivers providing dysphagia care within Singapore health services.

The SLPs in Singapore have also described several unique challenges associated with the healthcare finance framework, resulting in service access issues and disruptions in care continuation. Singapore utilizes a multi-layered financing model comprising of government subsidies, national insurance schemes, and patients’ out-of-pocket payment (Tan et al., 2021). Even though public healthcare services are heavily subsidized, patients may need to co-pay a portion of healthcare costs due to eligibility and limits of subsidy and insurance schemes (Lee & Satku, 2015; Tan et al., 2021), which can lead to service access issues. This has been previously documented by a local survey with 36 SLPs, where 13.9% of them cited aphasia therapy cost as a service barrier.

Furthermore, to qualify for subsidized services, a dysphagia referral must be made by a medical practitioner within public healthcare institutions, thus, SLPs may need to navigate multiple referral points for a cross-institution subsidized referral. This is particularly challenging for SLPs in subacute settings who have restricted resources and often need to access services in acute settings, such as VFSS and FEES. Similar access challenges for community-based patients have also been reported by nurses who described an inability to make direct referrals to outpatient SLP services (Lim et al., 2018). To address these challenges, there may be a need to review and reform finance policies. Recently, the health ministry has announced a shift in healthcare funding model from workload-based to capitation-based, where each healthcare cluster receives a budget based on the number of residents within the assigned geographical region (Ministry of Health Singapore, 2022b). However, as these initiatives are newly implemented, their impact on dysphagia services is unknown, and should be explored in the future.

Limitations

There are acknowledged limitations to this study. Survey data is by nature limited in detail and specificity, therefore can only provide insights into general practice patterns. Also, the functionality of the survey platform could not prevent repeated participation, but this is unlikely to have occurred given the number and diverse nature of responses. The sample size of 68 SLPs is also relatively small for a national survey, but this is estimated to represent 23.6% of the eligible workforce based on the Allied Health Professions Council (2022) report. In fact, the actual response rate is likely higher as the report included SLPs who were not eligible to participate in the survey (e.g., paediatric and non-dysphagia services), making the findings a realistic representation of dysphagia practices in Singapore. Additionally, this study only acknowledges the insights of SLPs working in acute and subacute settings, and future studies should explore the perspectives of SLPs working in other settings (e.g., community services). Lastly, the bias associated with any survey that involves self-selection and self-reporting is acknowledged, thus results can only represent those who responded, and not all clinical practices in Singapore.

Conclusion

In conclusion, despite the lack of national practice documents to guide dysphagia clinical training and service provision, clinicians’ reports of dysphagia practices in Singapore revealed largely similar practices across acute and subacute settings, except for a few key areas. Although dysphagia services in Singapore are largely aligned with international literature, there were challenges unique to the Singapore community identified by this research relating to enteral feeding management, language barrier, and the financing model. The current findings build on the knowledge of dysphagia practices internationally, and provide direction for optimization of dysphagia services in Singapore. To inform service enhancement, a holistic understanding of service delivery, gaps, and improvements is required not only from SLPs, but also from the perspectives of other key stakeholders (e.g., patients, caregivers, and speech-language pathology managers), and this should be explored in future studies.

Disclosure of interest

The authors report no conflict of interest.

Acknowledgements

The authors would like to thank the managers and SLPs involved with the pilot surveys, surveys dissemination, and surveys participation for their valuable feedback and contribution.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.