Background: Early dysphagia screening and appropriate management are recommended by current guidelines to reduce complications and case fatality in acute stroke. However, data on the potential benefit of changes in dysphagia care on patient outcome are limited. Our objective was to assess the degree of implementation of dysphagia guidelines and determine the impact of modifications in dysphagia screening and treatment practices on disease complications and outcome in stroke patients over time. Methods: In this prospective register-based study (“Stroke Register of Northwestern Germany”), all adult stroke patients admitted to 157 participating hospitals between January, 2008 and December, 2015 were included (n = 674,423). Dysphagia incidence upon admission, the proportion of patients receiving a standardized swallowing screening, and the percentage of dysphagic patients being referred to a speech language therapist (SLT) for treatment were obtained per year. Pneumonia rate, modified Rankin Scale (mRS) at discharge, and in-hospital mortality were compared between groups of dysphagic vs. non-dysphagic patients over time. Results: Screening proportions continuously increased from 47.2% in 2008 to 86.6% in 2015. But the proportion diagnosed with dysphagia remained stable with about 19%. The number of dysphagic patients receiving SLT treatment grew from 81.6 up to 87.0%. Pneumonia incidence was higher in dysphagic stroke cases (adjusted OR 5.4 [5.2–5.5], p < 0.001), accompanied by a worse mRS at discharge (adjusted OR for mRS ≥3: 3.1 [3.0–3.1], p < 0.001) and higher mortality (adjusted OR 3.1 [3.0–3.2], p < 0.001). The order of magnitude of these end points did not change over time. Conclusion: Although advances have been made in dysphagia care, prevalent screening and treatment practices remain insufficient to reduce pneumonia rate, improve functional outcome, and decrease case fatality in dysphagic stroke patients. More research is urgently needed to develop more effective swallowing therapies.

Arnold M, Liesirova K, Broeg-Morvay A, Meisterernst J, Schlager M, Mono ML, El-Koussy M, Kagi G, Jung S, Sarikaya H: Dysphagia in acute stroke: incidence, burden and impact on clinical outcome. PLoS One 2016; 11:e0148424.
Meng NH, Wang TG, Lien IN: Dysphagia in patients with brainstem stroke: incidence and outcome. Am J Phys Med Rehabil 2000; 79: 170–175.
Smithard DG, O’Neill PA, Parks C, Morris J: Complications and outcome after acute stroke. Does dysphagia matter? Stroke 1996; 27: 1200–1204.
Prvu Bettger J, McCoy L, Smith EE, Fonarow GC, Schwamm LH, Peterson ED: Contemporary trends and predictors of postacute service use and routine discharge home after stroke. J Am Heart Assoc 2015; 4:pii:e001038.
Smithard DG, Smeeton NC, Wolfe CD: Long-term outcome after stroke: does dysphagia matter? Age Ageing 2007; 36: 90–94.
Bonilha HS, Simpson AN, Ellis C, Mauldin P, Martin-Harris B, Simpson K: The one-year attributable cost of post-stroke dysphagia. Dysphagia 2014; 29: 545–552.
Carnaby G, Hankey GJ, Pizzi J: Behavioural intervention for dysphagia in acute stroke: a randomised controlled trial. Lancet Neurol 2006; 5: 31–37.
Gandolfi M, Smania N, Bisoffi G, Squaquara T, Zuccher P, Mazzucco S: Improving post-stroke dysphagia outcomes through a standardized and multidisciplinary protocol: an exploratory cohort study. Dysphagia 2014; 29: 704–712.
Al-Khaled M, Matthis C, Binder A, Mudter J, Schattschneider J, Pulkowski U, Strohmaier T, Niehoff T, Zybur R, Eggers J, Valdueza JM, Royl G; for QugSS II Group: Dysphagia in patients with acute ischemic stroke: early dysphagia screening may reduce stroke-related pneumonia and improve stroke outcomes. Cerebrovasc Dis 2016; 42: 81–89.
Hines S, Kynoch K, Munday J: Nursing interventions for identifying and managing acute dysphagia are effective for improving patient outcomes: a systematic review update. J Neurosci Nurs 2016; 48: 215–223.
Bray BD, Smith CJ, Cloud GC, Enderby P, James M, Paley L, Tyrrell PJ, Wolfe CD, Rudd AG; SSNAP Collaboration: The association between delays in screening for and assessing dysphagia after acute stroke, and the risk of stroke-associated pneumonia. J Neurol Neurosurg Psychiatry 2017; 88: 25–30.
Prosiegel M, Riecker A, Weinert M, Dziewas R, Lindner-Pfleghar B, Stanschus S, Warnecke T: Management of dysphagic patients with acute stroke. Nervenarzt 2012; 83: 1590–1599.
Prosiegel M (federführend): Neurogene Dysphagien; in: Diener HC, Weimar C (eds): Leitlinien für Diagnostik und Therapie in der Neurologie. (ed 5). Stuttgart, Thieme, 2012, pp 1078–1086.
Schmidt WP, Heuschmann P, Taeger D, Henningsen H, Buecker-Nott HJ, Berger K: Determinants of IV heparin treatment in patients with ischemic stroke. Neurology 2004; 63: 2407–2409.
Minnerup J, Wersching H, Ringelstein EB, Schilling M, Schabitz WR, Wellmann J, Berger K: Impact of the extended thrombolysis time window on the proportion of recombinant tissue-type plasminogen activator-treated stroke patients and on door-to-needle time. Stroke 2011; 42: 2838–2843.
Unrath M, Kalic M, Berger K: Who receives rehabilitation after stroke?: Data from the quality assurance project “Stroke Register Northwest Germany”. Dtsch Arztebl Int 2013; 110: 101–107.
Nabavi DG, Ringelstein EB, Faiss J, Kessler C, Rother J, Busse O: Regional and national stroke units in Germany: amended certification criteria. Nervenarzt 2012; 83: 1039–1052.
Nabavi DG, Ossenbrink M, Schinkel M, Koennecke HC, Hamann G, Busse O: Revised certification criteria for regional and national stroke units in Germany. Nervenarzt 2015; 86: 978–988.
Kampman MT, Eltoft A, Karaliute M, Borvik MT, Nilssen H, Rasmussen I, Johnsen SH: Full implementation of screening for nutritional risk and dysphagia in an acute stroke unit: a clinical audit. Neurohospitalist 2015; 5: 205–211.
Barer DH: The natural history and functional consequences of dysphagia after hemispheric stroke. J Neurol Neurosurg Psychiatry 1989; 52: 236–241.
Falsetti P, Acciai C, Palilla R, Bosi M, Carpinteri F, Zingarelli A, Pedace C, Lenzi L: Oropharyngeal dysphagia after stroke: incidence, diagnosis, and clinical predictors in patients admitted to a neurorehabilitation unit. J Stroke Cerebrovasc Dis 2009; 18: 329–335.
Jeyaseelan RD, Vargo MM, Chae J: National Institutes of Health Stroke Scale (NIHSS) as an early predictor of poststroke dysphagia. PM R 2015; 7: 593–598.
Baroni AF, Fabio SR, Dantas RO: Risk factors for swallowing dysfunction in stroke patients. Arq Gastroenterol 2012; 49: 118–124.
Muhle P, Wirth R, Glahn J, Dziewas R: Age-related changes in swallowing. Physiology and pathophysiology. Nervenarzt 2015; 86: 440–451.
Maeda K, Akagi J: Sarcopenia is an independent risk factor of dysphagia in hospitalized older people. Geriatr Gerontol Int 2016; 16: 515–521.
Sorensen RT, Rasmussen RS, Overgaard K, Lerche A, Johansen AM, Lindhardt T: Dysphagia screening and intensified oral hygiene reduce pneumonia after stroke. J Neurosci Nurs 2013; 45: 139–146.
Hoffmann S, Malzahn U, Harms H, Koennecke HC, Berger K, Kalic M, Walter G, Meisel A, Heuschmann PU; Berlin Stroke Register and the Stroke Register of Northwest Germany: Development of a clinical score (A2DS2) to predict pneumonia in acute ischemic stroke. Stroke 2012; 43: 2617–2623.
Hoffmann S, Harms H, Ulm L, Nabavi DG, Mackert BM, Schmehl I, Jungehulsing GJ, Montaner J, Bustamante A, Hermans M, Hamilton F, Gohler J, Malzahn U, Malsch C, Heuschmann PU, Meisel C, Meisel A; PREDICT Investigators: Stroke-induced immunodepression and dysphagia independently predict stroke-associated pneumonia – The PREDICT study. J Cereb Blood Flow Metab 2017; 37: 3671–3682.
Cohen DL, Roffe C, Beavan J, Blackett B, Fairfield CA, Hamdy S, Havard D, McFarlane M, McLauglin C, Randall M, Robson K, Scutt P, Smith C, Smithard D, Sprigg N, Warusevitane A, Watkins C, Woodhouse L, Bath PM: Post-stroke dysphagia: a review and design considerations for future trials. Int J Stroke 2016; 11: 399–411.
Nguyen VQ, PrvuBettger J, Guerrier T, Hirsch MA, Thomas JG, Pugh TM, Rhoads CF 3rd: Factors associated with discharge to home versus discharge to institutional care after inpatient stroke rehabilitation. Arch Phys Med Rehabil 2015; 96: 1297–1303.
Gadodia G, Rizk N, Camp D, Bryant K, Zimmerman S, Brasher C, Connelly K, Dunn J, Frankel M, Ido MS, Lugtu J, Nahab F: Presenting symptoms and dysphagia screen predict outcome in mild and rapidly improving acute ischemic stroke patients. J Stroke Cerebrovasc Dis 2016; 25: 2876–2881.
Tong X, Kuklina EV, Gillespie C, George MG: Medical complications among hospitalizations for ischemic stroke in the United States from 1998 to 2007. Stroke 2010; 41: 980–986.
Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S; Stroke Practice Improvement Network Investigators: Formal dysphagia screening protocols prevent pneumonia. Stroke 2005; 36: 1972–1976.
Suntrup S, Meisel A, Dziewas R, Ende F, Reichmann H, Heuschmann P, Ickenstein GW: Dysphagia diagnostics and therapy of acute stroke: Federal survey of certified stroke units. Nervenarzt 2012; 83: 1619–1624.
Speyer R, Baijens L, Heijnen M, Zwijnenberg I: Effects of therapy in oropharyngeal dysphagia by speech and language therapists: a systematic review. Dysphagia 2010; 25: 40–65.
Geeganage C, Beavan J, Ellender S, Bath PM: Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev 2012; 10:CD000323.
Leder SB, Sasaki CT, Burrell MI: Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia 1998; 13: 19–21.
Flader CM, Rosendahl C, Günther T: Guideline conform diagnostics for dysphagia: a representative survey of speech therapists at certified stroke units in Germany. Nervenarzt 2017; 88: 1168–1176.
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