Oesophageal screening in videofluoroscopic swallow studies: Perspectives from the multidisciplinary dysphagia team to refine the clinical pathway

Kellie McCarthy; Emma Finch; Anna Miles

doi:10.1111/1460-6984.70006

. 2025 Feb 20;60(2):e70006. doi: 10.1111/1460-6984.70006

Oesophageal screening in videofluoroscopic swallow studies: Perspectives from the multidisciplinary dysphagia team to refine the clinical pathway

Kellie McCarthy ^1,^2,^✉, Emma Finch ^1,^2,³, Anna Miles ⁴

PMCID: PMC11842011 PMID: 39977716

Abstract

Background

Videofluoroscopic swallow studies (VFSS) are multidisciplinary swallowing assessments led by speech‐language therapists (SLTs). The purpose of oesophageal screening in VFSS is to guide further diagnostic assessment and treatment of possible oesophageal abnormalities. Yet, internationally standard protocols and clinical pathways for oesophageal screening in VFSS have not been established.

Aim(s)

The aim of this study was to refine and optimise oesophageal screening in VFSS at one Australian metropolitan hospital by incorporating expertise of the multidisciplinary dysphagia team.

Methods and Procedures

Focus groups/semi‐structured interviews were conducted with SLTs, radiologists (RADs), gastroenterologists (GEs), referring medical officers (MEDs) and medical radiation technicians (MRTs, also known as radiographers) working in VFSS. Interview questions explored oesophageal screening approaches, interpretation and reporting practices, GE referral criteria and clinical recommendations. Data were analysed via qualitative content analysis to determine meaning units, sub‐categories, and categories.

Outcomes and Results

Twenty‐six health professionals were interviewed (n = 8 SLTs, n = 6 RADs, n = 5 MEDs, n = 4 MRTs, n = 3 GEs). Four categories were identified: (1) oesophageal screening in VFSS adds clinical information but has limitations; (2) specific knowledge, skills and organisational factors are needed to optimise oesophageal screening, including in procedure, interpretation, reporting, GE referral pathway and intervention selection; (3) multidisciplinary consensus is needed regarding normal versus abnormal oesophageal transit and GE referral criteria; and (4) patient context, preferences and reported symptoms should primarily guide dysphagia decision‐making. Each category had several component subcategories. The local clinical pathway (also known as care pathway or care map) for oesophageal screening in VFSS was refined by incorporating multidisciplinary dysphagia team expertise.

Conclusions and Implications

There was a willingness from the multidisciplinary dysphagia team to refine the local clinical pathway for oesophageal screening in VFSS. Detailed clinical pathways that guide workflow and decision‐making should be considered when introducing oesophageal screening into VFSS protocols.

WHAT THIS PAPER ADDS

What is already known on the subject

Despite the recognised benefits of including oesophageal screening in VFSS, there has been limited uptake of oesophageal screening protocols internationally. Implementation research is needed that supports clinicians to embed oesophageal screening into routine VFSS practice.

What this study adds

This is the first published study that explores in‐depth the perspectives of the multidisciplinary dysphagia team regarding oesophageal screening in VFSS.

What are the clinical implications of this work?

This study proposes a clinical pathway refined by the multidisciplinary dysphagia team to support clinicians in embedding oesophageal screening and its findings into routine dysphagia practice.

Keywords: clinical pathway, dysphagia, multidisciplinary, oesophageal screening, VFSS

INTRODUCTION

Dysphagia refers to a difficulty and/or disorder in swallowing (Groher, 2021). Dysphagia can occur in any part of the swallowing mechanism, from the mouth to the stomach (Logemann, 1998). Typically, speech‐language therapists (SLTs) lead oropharyngeal dysphagia management, whilst gastroenterologists (GEs) lead oesophageal dysphagia management (Logemann, 1998). Other key disciplines involved in dysphagia management include ear, nose and throat specialists (also known as otolaryngologists) and radiologists (RADs) (Starmer et al., 2020). Each member of the multidisciplinary dysphagia team provides a unique but valuable perspective (Starmer et al., 2020), influenced by discipline‐specific training and clinical guidelines (Bonilha et al., 2023). Therefore, close collaboration between multidisciplinary dysphagia clinicians is needed for optimal patient care (Levine & Rubesin, 2017).

Videofluoroscopic swallow studies (VFSS, also known as modified barium swallow studies) are detailed radiological assessments of oropharyngeal swallowing via fluoroscopy (Crary, 2021; Dhar et al., 2023). Ideally, VFSS are completed as a multidisciplinary swallowing assessment (Azpeitia Armán et al., 2019; Martin‐Harris et al., 2020). Typically, VFSS referrals are generated by treating medical officers (MEDs) in discussion with treating SLTs, the study is led by SLTs and conducted in collaboration with RADs and/or medical radiation technicians (MRTs, also known as radiographers) (Dhar et al., 2023; Martin‐Harris et al., 2020). Teamwork between SLTs and RADs is considered best practice in VFSS (Martin‐Harris et al., 2020). However, in many settings internationally, RADs are no longer present during VFSS due to billing structures, competing clinical priorities and limited available training (Benfield et al., 2021; Bonilha et al., 2023; Coman et al., 2022).

Oesophageal screening in VFSS (also known as an oesophageal sweep) refers to the brief visualisation of the speed and extent of bolus clearance through the oesophagus (Crary, 2021; Martin‐Harris et al., 2020). The purpose of oesophageal screening in VFSS is to identify possible anatomical and/or transit abnormalities to guide further diagnostic assessment (Allen, 2019; Dhar et al., 2023) and treatment planning (Miles et al., 2019; Reedy et al., 2021). It is well‐known that pharyngeal and oesophageal swallowing disorders can co‐occur (Jones et al., 1985; Smith et al., 1998) and up to two‐thirds of patients referred for SLT‐led VFSS have an oesophageal component to their dysphagia (Gullung et al., 2012; Miles et al., 2015). Therefore, the inclusion of oesophageal screening in VFSS, in addition to oropharyngeal imaging, optimises the multidisciplinary dysphagia team's understanding of the patient's overall swallowing function (Allen et al., 2012; Gregor & Watts, 2023; Miles et al., 2015; Miles et al., 2019).

However, routine standardised oesophageal screening in VFSS is not widely occurring in clinical practice (McCarthy et al., 2023a; Regan et al., 2020). Reported barriers to the broad implementation of oesophageal screening in VFSS include contrasting published protocols (Dhar et al., 2023; Miles et al., 2016; Watts et al., 2020), lack of specific training and variable support from multidisciplinary colleagues (McCarthy et al., 2023a; Regan et al., 2020). Published oesophageal screening protocols to date vary regarding imaging views, length of imaging periods, textures and volumes used and interpretation methods. Furthermore, published oesophageal screening protocols have not yet extended beyond procedural and interpretation components to include the clinical application of oesophageal screening findings. McCarthy et al. (2023b) found that the introduction of an oesophageal screening protocol in VFSS increased the number of patients being identified with possible oesophageal abnormality but made no overall difference in follow‐up dysphagia assessment and treatment when compared to a pre‐protocol group. Therefore, further engagement is needed with the multidisciplinary dysphagia team to refine clinical pathways (also known as care pathways or care maps) for oesophageal screening in VFSS to optimise patient outcomes.

Study aims

This study was part of a broader research project applying action research methodology to refine and optimise oesophageal screening in VFSS at the research site (McCarthy et al., 2023b). Action research is a participatory research approach where teams engage in cycles of planning, action, observation and reflection to improve specific areas of practice (Cordeiro & Soares, 2018).

The aims of this study were:

to explore in‐depth the perspectives of the multidisciplinary dysphagia team at one Australian metropolitan hospital following the trial of an oesophageal screening protocol.
to enhance the oesophageal screening clinical pathway by developing strategies to manage the limitations of oesophageal screening, by refining GE referral criteria when possible oesophageal abnormality is identified, and by developing strategies to optimise the clinical application of oesophageal screening findings.

METHODS AND PROCEDURES

This study used a qualitative focus group/semi‐structured interview design with purposive sampling. Ethical clearance for this study was awarded by the relevant hospital and university Human Research Ethics Committees (HREC/2022/QMS/83709; 2022/HE002058). The Consolidated Criteria for Reporting Qualitative Research checklist for interviews and focus groups (Tong et al., 2007) was used to report this study.

Context

This research was conducted at a large tertiary hospital in an Australian city that has a weekly VFSS clinic for patients with mixed aetiology dysphagia from across the acute to rehabilitation continuum of care. Two SLTs, one RAD registrar (i.e., RAD in‐training, known as resident in the United States) and one MRT are present for all VFSS at the research site. Separate VFSS reports are generated by SLTs and RADs. A supervising RAD consultant (i.e., RAD specialist, known as attending physician in the United States) is on site during all VFSS, reviewing images post‐VFSS and endorsing RAD registrar VFSS reports.

Historically at the research site oesophageal screening was not routinely included in VFSS, with oesophageal assessment led by RADs in consultation with SLTs. Decision‐making regarding the oesophageal images obtained, their interpretation, and recommendation for onward specialist referral occurred on a case‐by‐case basis. In the 3 years prior to this study, an oesophageal screening protocol was introduced at the research site. Following a review of published oesophageal screening protocols, which vary regarding imaging specifics, number of textures used and bolus volumes, a brief binary screener was selected involving a timed 20 mL bolus of International Dysphagia Diet Standardisation Initiative (IDDSI) Level 0 (thin fluids) followed from mouth to stomach in seated anterior‐posterior view (McCarthy et al., 2023b). The existing clinical pathway for oesophageal screening in VFSS is summarised in Figure 1. Oesophageal screening was not conducted if a 20 mL bolus of thin fluids was considered an aspiration risk. Oesophageal transit time was recorded for each patient and compared to age‐matched norms (Miles et al., 2016). SLTs and RADs discussed and reported any possible oesophageal transit and/or anatomical abnormalities. Patients met the criteria for GE referral if oesophageal transit time was outside norms for age, or if possible oesophageal transit and/or anatomical abnormalities were identified. Initiation of the GE referral was at the discretion of the patient's treating medical team.

Existing local clinical pathway for oesophageal screening in videofluoroscopic swallow studies. Abbreviations: GE, gastroenterologist; IDDSI, International Dysphagia Diet Standardisation Initiative; VFSS, videofluoroscopic swallow studies.

The introduction of a protocol for oesophageal screening at the research site led to a significant increase in rates of oesophageal screening and an increase in the number of patients being identified with possible oesophageal abnormalities (McCarthy et al., 2023b). However, there was no difference in dysphagia‐related admission rates, dysphagia‐related procedure rates or overall GE consult rates following the oesophageal screening protocol introduction (McCarthy et al., 2023b). Therefore, the current study was conducted to refine the local oesophageal screening protocol and clinical pathway to further meet the needs of patients and the multidisciplinary dysphagia team.

Participants

Participants in this study were members of the multidisciplinary dysphagia team working at the research site. The inclusion criterion was health professionals who work in or refer patients to VFSS, including SLTs, MRTs, RADs (registrars and/or consultants), GEs (registrars, fellows and/or consultants) and MEDs (registrars, fellows and/or consultants). The exclusion criteria for this study were health professionals who did not work in or refer patients to VFSS at the research site and patients. The target sample size was for representation across all included health professional groups and until data saturation was reached (Hennick & Kaiser, 2022). Data saturation was determined by the repetition of information from multiple participants.

Procedure

Flyers advertising the study were emailed to the key stakeholders and displayed in relevant clinical areas. Interested potential participants contacted the research team and were screened to ensure they met the study inclusion criterion. After participants provided written consent, demographic information was collected including their profession (including specialty or dual specialty for MEDs), years of experience in their profession, and years of experience with VFSS. Participants were allocated a study identification code which represented their profession and participant number (e.g., SLT1).

Participants attended either a single focus group or semi‐structured interview based on their preference and availability. The focus groups/interviews had a maximum duration of 60 min, and the same questions were used in both formats. The focus groups and interviews were conducted at a location that was convenient for participants, either in‐person or virtually via Microsoft Office TEAMS. Focus groups aimed to have a maximum of six participants; however, the size of each focus group was also dependent upon participant availability. Focus group composition was considered, aiming to minimise any power imbalances and to maximise group interaction. Focus groups were kept discipline‐specific to avoid bias and/or coercion from one profession's point of view to another.

Focus group/interview questions and prompts were developed by the research team (all authors) via consensus decision‐making. The questions were not pilot tested but were guided by a literature review and previous research in the area. Prior to the focus group/interview, questions were emailed to participants to allow time for reflection. All focus groups/interviews were facilitated by the lead author (K.M.) who was an experienced female SLT and PhD candidate working in the VFSS clinic at the research site. One coauthor (E.F.) was also present for the first two focus groups to supervise the lead author (K.M.) and to enhance the rigour of the study. Each focus group/interview opened with a short presentation comparing data from two different oesophageal screening approaches recently trialled at the research site (i.e., clinician‐led vs. following a protocol; McCarthy et al., 2023b). Interview questions explored the benefits and challenges of oesophageal screening approaches, barriers and facilitators to the protocol trial, interpretation and reporting methods for oesophageal screening, referral criteria for diagnostic assessment and clinical recommendations (Supporting Information 1). Each focus group/interview was recorded, and a transcript generated via Microsoft Office TEAMS. A backup audio recording was also made. Notes were also taken by the facilitator (lead author K.M.), and coauthor (E.F.). The lead author (K.M.) reviewed the accuracy of the Microsoft Office TEAMS generated transcripts with the recordings for each focus group/interview, and corrections were made as required.

Data analysis

Qualitative content analysis (Graneheim & Lundman, 2004) was selected for this study because it is systematic and objective, allows for both qualitative and quantitative analysis, and remains close to the direct quotes from the participants. Interview transcripts were split into meaning units (i.e., key ideas condensed) which were coded (i.e., labelled) and organised into subcategories (i.e., related ideas grouped) by the lead author (K.M.) and checked by the coauthors (E.F. & A.M.). All authors then identified categories (i.e., overarching/unifying ideas) and selected the quotes that best demonstrated these categories via consensus decision‐making. Examples of the development of subcategories and categories are outlined in Table 1.

TABLE 1.

Examples of the development of subcategories and categories.

Quote	Meaning unit	Code	Subcategory	Category
“I think overall it is great to have a comprehensive picture of the patient's overall swallow, not just the oropharyngeal phase but the oesophageal phase.” (SLT8)	Oesophageal screening provides an overview of whole swallow system	Including oesophageal screening in VFSS adds to our understanding of the patient's dysphagia	Including oesophageal screening in VFSS is time and resource‐efficient and can provide useful information for the overall dysphagia diagnostic work‐up	Oesophageal screening in VFSS adds clinical information but has limitations
“it can help reduce the number of return visits for standard barium swallows due to the nature of it being a more complete study where you can see the middle to distal oesophageal region.” (MRT1)	Oesophageal screening is time‐efficient and opportunistic	Including oesophageal screening in VFSS is time and resource‐efficient
“if they were asymptomatic and we were screening them … does it actually add anything to the management?” (RAD2)	Oesophageal screening may not add to the clinical management	Need to weigh risks versus benefits of including oesophageal screening	It is important to consider the risk versus benefit of including oesophageal screening in VFSS and some oesophageal abnormalities may not need or benefit from treatment	Oesophageal screening in VFSS adds clinical information but has limitations
“it's difficult to decide what to do with the patients after that's (oesophageal screening) done … that applies with our own (barium) swallow studies as well … there aren't great management options for lower oesophageal dysmotility.” (RAD5)	Limited treatment options if abnormalities are identified on oesophageal screening	Not all oesophageal disorders are treatable
“a letter to the treating team and to gastro(enterology) saying this is what the screening identified, and this is what we suggest. And then if it goes to multiple parties, it's more likely to get actioned than to just one. Including the GP of course.” (GE2)	Disseminating VFSS report widely is optimal	VFSS reports need to be disseminated widely for optimal patient care	Clear and succinct VFSS reports that are available to all care providers and include a summary of both SLT and RAD impressions assist in decision‐making for dysphagia assessment and treatment	Specific knowledge, skills and organisational factors are needed to optimise oesophageal screening in VFSS, including in procedure, interpretation, reporting, GE referral pathway and intervention selection
“ (SLTs) are probably a bit better at reporting things like transit times and motility and things like that whereas the radiologist is probably reporting some of that, but also structural things that they might notice. So, I think they're complementary and it's useful to have both.” (MED5)	Separate SLT and RAD reports are optimal	Separate SLT and RAD VFSS reports provide different information and perspectives of swallowing

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Abbreviations: GE, gastroenterologist; GP, general practitioner; MED, referring medical officer; MRT, medical radiation technician/radiographer; RAD, radiologist; SLT, speech‐language therapist; VFSS, videofluoroscopic swallow studies.

Rigour

Twenty percent (n = 4/19) of the corrected transcripts were reviewed for accuracy against the recordings by one coauthor (E.F.). Transcripts were not shared with or reviewed by participants due to potential risks to confidentiality and/or professional reputation. Quotes from all participants were included in the data analysis, including those that were contradictory to others. During the transcription process, the lead author (K.M.) made notes, collated key quotes and considered possible subcategories and categories within and across health professional groups. All authors met regularly throughout the study to discuss the transcripts and possible subcategories and categories. Data were managed using Microsoft Word and an audit trail of category development was recorded. Representatives from RAD, SLT, GE and MED professions at the research site provided feedback on the revised clinical pathway for oesophageal screening in VFSS (Figure 2). The GEs interviewed endorsed the oesophageal behavioural strategies outlined in the revised clinical pathway.

Refined local clinical pathway for oesophageal screening in videofluoroscopic swallow studies. Abbreviations: IDDSI, International Dysphagia Diet Standardisation Initiative; VFSS, videofluoroscopic swallow studies.

Outcomes and Results

Participants

Twenty‐six health professionals from the multidisciplinary dysphagia team at the research site were interviewed for this study between March and August 2023. All participants completed their focus group/interview and nil participants withdrew from the study. Participant demographics are outlined in Table 2. Focus groups and interviews were conducted across both virtual and in‐person modalities (Supporting Information 2).

TABLE 2.

Participant demographics.

Profession	Study code	Number of participants	Profession experience (years) Median (range)	VFSS experience (years) Median (range)
Speech‐language therapist	SLT	8	13.5 (3–25)	13.5 (1.5–25)
Medical officer: radiology	RAD	6	6.21 (3.5–9)	1.38 (0.33–4.5)
Medical officer: gastroenterology	GE	3	13.75 (10–30)	9 (4–30)
Referring medical officer ^a	MED	5	12 (10–20)	10 (8–20)
Medical radiation technician (radiographer)	MRT	4	2.21 (1.75–3)	1.25 (0.92–3)

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^aMedical specialties: ear, nose and throat; radiation oncology; neurology and stroke; general medicine and geriatrics.

Abbreviation: VFSS, videofluoroscopic swallow studies.

Categories and subcategories

Table 1 shows examples of how meaning units, codes, subcategories and categories were developed from quotes. Tables 3, 4, 5, 6 show how four categories were identified from 17 subcategories and includes the number of coded meaning units associated with each subcategory and category. Multiple coded meaning units could relate to one participant in a single subcategory. The four categories identified were: (1) oesophageal screening in VFSS adds clinical information but has limitations; (2) specific knowledge, skills and organisational factors are needed to optimise oesophageal screening, including in procedure, interpretation, reporting, GE referral pathway and intervention selection; (3) multidisciplinary consensus is needed regarding normal versus abnormal oesophageal transit on oesophageal screening and GE referral criteria; and (4) patient context, preferences and reported symptoms should primarily guide dysphagia decision‐making.

TABLE 3.

Category 1: Oesophageal screening in VFSS adds clinical information but has limitations (n = 90).

Subcategories	Coded meaning units (n)
Subcategories	MEDs	GEs	MRTs	RADs	SLTs	Total
Including oesophageal screening in VFSS is time and resource‐efficient and can provide useful information for the overall dysphagia diagnostic work‐up	8	6	4	3	2	23
The introduction of this oesophageal screening protocol has standardised a quick and simple multidisciplinary procedure that can identify possible oesophageal abnormalities in VFSS	0	3	7	8	10	28
Not all patients will be suitable for oesophageal screening due to positioning limitations	0	0	4	2	1	7
It is important to consider the risk versus benefit of including oesophageal screening in VFSS, as some oesophageal abnormalities may not need or benefit from treatment	1	0	0	6	0	7
The results of oesophageal screening in isolation are not sufficient to guide dysphagia management, as further diagnostic assessment is required	0	1	1	3	0	5
Each type of dysphagia assessment provides useful clinical information, and more than one type of assessment is often required for diagnosis and treatment planning	3	0	1	1	0	5
The appropriateness of alternative imaging views, imaging periods and textures used for oesophageal screening should be considered by the VFSS multidisciplinary dysphagia team to increase patient access	0	0	6	0	9	15

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Note: N.B.: multiple coded meaning units (n) could relate to one participant in a single subcategory.

Abbreviations: GEs, gastroenterologists; MEDs, referring medical officers; MRTs, medical radiation technicians/radiographers; RADs, radiologists; SLTs, speech‐language therapists; VFSS, videofluoroscopic swallow studies.

TABLE 4.

Category 2: Specific knowledge, skills and organisational factors are needed to optimise oesophageal screening in VFSS, including in procedure, interpretation, reporting, GE referral pathway and intervention selection (n = 119).

Subcategories	Coded meaning units (n)
Subcategories	MEDs	GEs	MRTs	RADs	SLTs	Total
Specific knowledge, skills and experience are required for multidisciplinary dysphagia team confidence and competence in oesophageal screening	1	0	6	7	5	19
The oesophageal screening protocol is optimally performed when there is clear communication, written resources available and clinicians are familiar with the procedure	0	0	5	1	6	12
Clear and succinct VFSS reports that are available to all care providers and include a summary of both SLT and RAD impressions assist in decision‐making for dysphagia assessment and treatment	6	7	0	3	5	21
Both internal and external factors impact the efficiency of the current GE referral pathway and further streamlining would be beneficial	3	4	2	0	4	13
There are a range of factors that guide decision‐making regarding order and selection of dysphagia assessment type, including patient symptoms, patient suitability/safety, timely access, cost and referring clinicians’ knowledge and experience	3	2	6	8	7	26
The multidisciplinary dysphagia team's knowledge of treatment options for oesophageal symptoms could be improved and clarity regarding discipline‐specific roles in decision‐making and patient education would be helpful	5	7	0	2	14	28

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Note: N.B.: multiple coded meaning units (n) could relate to one participant in a single subcategory.

TABLE 5.

Category 3: Multidisciplinary consensus is needed regarding normal versus abnormal oesophageal transit on oesophageal screening and GE referral criteria (n = 46).

Sub‐categories	Coded meaning units (n)
Sub‐categories	MEDs	GEs	MRTs	RADs	SLTs	Total
The VFSS multidisciplinary dysphagia team needs to establish and share agreed parameters for normal versus abnormal oesophageal transit on oesophageal screening	0	2	1	12	14	29
Clear GE referral criteria are needed which are generated by GE and shared with the multidisciplinary dysphagia team	5	0	1	7	4	17

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Note: N.B.: multiple coded meaning units (n) could relate to one participant in a single subcategory.

TABLE 6.

Category 4: Patient context, preferences and reported symptoms should primarily guide dysphagia decision‐making (n = 64).

Subcategories	Coded meaning units (n)
Subcategories	MEDs	GEs	MRTs	RADs	SLTs	Total
Selection of treatment for oesophageal symptoms should be well‐considered and patient‐specific	6	5	0	1	5	17
The patient's medical history, current medical status, reported symptoms and treatment preferences should be considered during decision‐making for dysphagia assessment and treatment	7	13	2	12	13	47

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Note: N.B.: multiple coded meaning units (n) could relate to one participant in a single subcategory.

Category 1: Oesophageal screening in VFSS adds clinical information but has limitations.

Category 1 incorporates both the benefits and limitations of oesophageal screening in VFSS identified by the multidisciplinary dysphagia team during the focus groups/interviews. Category 1 was the largest category with seven component subcategories (Table 3).

In terms of benefits, all five of the health professions interviewed reported that including oesophageal screening in VFSS is time and resource‐efficient and can provide useful information for the overall dysphagia diagnostic workup.

“…I think that's (oesophageal screening) valuable for us. If someone's undergoing any assessment, any extra information is useful…” (MED3)

“…I think it's (oesophageal screening) great actually… that way you get as much information as possible prior to making the correct referral. I think that saves a lot of time in terms of the referral pathway … and adds a lot more clarity to the diagnostic work‐up as well…” (MED5)

As an additional benefit, four out of the five health professions interviewed (SLTs, RADs, MRTs and GEs) reported that the introduction of the oesophageal screening protocol has standardised a quick and simple multidisciplinary procedure that can identify possible oesophageal abnormalities in VFSS.

“…I like it that the (oesophageal transit time) norms are available … so that you can very quickly see what's in the normal range and what's not and that's very useful to me…” (SLT5)

“The standardisation of how it's (oesophagus) being screened is good … it is very uniform…” (RAD1)

Regarding the limitations of oesophageal screening in VFSS, all MRTs interviewed (n = 4/4) reported that positioning patients for oesophageal screening in VFSS can be challenging.

“…the (VFSS) chair is quite a limitation because sometimes you can't do the (oesophageal) follow through, (be)cause you can't move down … sometimes it's the patient's body habitus that gets in the way.” (MRT3)

Three out of the five health professions interviewed who routinely conduct oesophageal imaging (RADs, GEs and MRTs) reported that the results of oesophageal screening in isolation are not sufficient to guide dysphagia management, as further diagnostic assessment, including barium swallow study (also known as oesophagram) and endoscopy, is required.

“…to see if there's any oesophageal dysmotility, I always do a supine study to remove gravity out of the equation … so, if we don't see anything on the oesophageal screen then I guess it doesn't exclude a motility disorder.” (RAD2)

Two out of the five health professions interviewed who routinely conduct VFSS (SLTs and MRTs) identified that some procedural aspects of the oesophageal screening protocol, such as the imaging periods and the use of IDDSI Level 0 (thin fluids), impacted the information obtained and excluded some patients from having oesophageal screening in VFSS.

“…in the part where we actually stop screening (imaging) … I think particularly if the bolus has cleared, we don't really know exactly when…would it be worthwhile actually just screening until we see it go (into the stomach)…” (SLT6)

“…can you view the patient's oesophageal phase on (texture‐)modified food and fluid? … if you're measuring (oesophageal transit time) norms … you're not going to be able to comment on that, but you might be able to comment on other criteria that would then still show up … like the anatomy … (and/or) if there's any change to … the (bolus) flow…” (SLT1)

However, in contrast, one RAD and one GE interviewed reported that IDDSI Level 0 (thin fluids) is the optimal texture for oesophageal screening in VFSS.

“…thin fluids is best … if it becomes too thick, then you get all that residue and if you haven't seen a lot of them, then you can sometimes mistake that for hold up.” (RAD6)

Category 1 highlighted the value oesophageal screening can offer to healthcare teams, along with potential limitations of the procedure that need to be considered. The next category expands on optimising oesophageal screening by exploring key factors that influence its success.

Category 2: Specific knowledge, skills and organisational factors are needed to optimise oesophageal screening, including in procedure, interpretation, reporting, GE referral pathway and intervention selection.

Category 2 outlines a broad range of factors that interviewees identified as important to the successful application of oesophageal screening in VFSS. Interviewees reported that both clinician‐specific factors (i.e., knowledge and skills) and environment‐specific factors (i.e., organisational processes and available resources) contribute to the success or otherwise of oesophageal screening in optimising patient outcomes. Category 2 was the second largest category with six component subcategories (Table 4).

All the health professions that are present during VFSS at the research site (i.e., SLTs, MRTs and RADs) reported that the oesophageal screening protocol is optimally performed when there is clear communication, written resources available and clinicians are familiar with the procedure.

“…I found it really helpful having the protocol in clinic, written down, available.” (SLT3)

“…I think that (the oesophageal screening procedure) is just something that would come with practice … people new to it may not be getting it exactly right, which then influences the results…” (SLT2)

Four out of the five health professions interviewed (RADs, MRTs, SLTs and MEDs) reported that specific knowledge, skills, and experience are required for confidence and competence in oesophageal screening. However, this aspect of oesophageal screening was discussed more by the disciplines who were present during VFSS at the research site (i.e., RADs, MRTs and SLTs).

“…you have very junior registrars who initially don't know what they're doing and haven't had any didactic teaching about how to do the study or how to report the study. And so that just comes, you know, over a period of weeks and months from doing enough and looking at your (SLT) reports and taking (images and reports) to our consultants.” (RAD6)

When asked how VFSS with oesophageal screening should fit into the suite of instrumental assessments for patients with possible oesophageal dysphagia (e.g., barium swallow studies, also known as oesophagrams, and manometry), MEDs, MRTs and RADs reported that determining the optimal order and selection of assessments is not always clear and that decision‐making may be influenced by safety and availability.

“I don't think there's a specific (assessment) pathway or process that's gonna work for all, a large cohort of patients … it's such a heterogeneous group…” (RAD5)

“I think we should probably do the least invasive (dysphagia assessment) first…” (MED1)

“…what's more accessible, what's fast, quicker to access…” (RAD3)

Interviewees identified that there are a range of treatment options available to patients with oesophageal symptoms, including behavioural strategies, medications, and surgery. However, interviewees reported that the multidisciplinary dysphagia team's knowledge of these treatment options and their appropriate selection could be improved. The disciplines involved in patient treatment decisions (i.e., GEs, MEDs and SLTs) provided the most input on this topic.

“… (are) there other things that we should be recommending that might help? Yeah, I'm not sure myself. So that probably is something that stops me doing more targeted strategies or recommendations.” (SLT3)

“…basic prokinetics … that's probably all I have up my sleeve … otherwise, anything more than that, I'd have to consult gastroenterology…” (MED2)

Four out of the five health professions interviewed (GEs, SLTs, MEDs and MRTs) reported that both internal and external factors impact the efficiency of the current GE referral pathway. Examples of these factors included reduced time and resources to generate GE referrals, limited access to specialty GE dysphagia clinics, and transparent documentation regarding GE referral decision‐making. Interviewees also suggested that further streamlining of the GE referral pathway would be beneficial.

“…we have to speak to whoever the referring team was to then get them to refer to gastroenterology. So, it's not like a direct path of referral…” (SLT8)

“…I think it'd be good if there was … suspicion for a severe oesophageal dysmotility, for some sort of communication pathway straight from speech path (SLT) to gastro(enterology).” (GE2)

Category 2 highlighted factors beyond the oesophageal screening protocol itself that should be considered when introducing this procedure into a VFSS setting. The next category examines what further work is needed by the multidisciplinary dysphagia team to continue to optimise oesophageal screening and patient outcomes.

Category 3: Multidisciplinary consensus is needed regarding normal versus abnormal oesophageal transit on oesophageal screening and GE referral criteria.

Category 3 explores the challenges in gaining consensus across the multidisciplinary dysphagia team regarding what is normal and what is abnormal on oesophageal screening and which patients would most benefit from referral to GE. Interviewees identified that agreed‐upon multidisciplinary definitions of what is within and outside the scope of normal oesophageal transit is imperative to the interpretation of oesophageal screening in VFSS. Interviewees also reported that clear agreed‐upon inclusion and exclusion criteria for GE referral following VFSS would be beneficial. Category 3 had two component subcategories (Table 5).

SLTs and RADs reported that there is variable clinician perception regarding normal versus abnormal oesophageal transit and that oesophageal transit time norms had not been fully accepted by the multidisciplinary dysphagia team. The challenge in achieving interpretation consensus, both within and across professions, was also raised.

“…the perception of what's normal and not is extremely variable. I think it's because oesophageal screening through barium studies is very insensitive and non‐specific. And so, everybody has their own opinions on what exactly is dysmotility or not … there are a select few consultants here who have special interest in swallow studies. And so, I think if we can get their opinions … get a consensus among them, what is considered abnormal and normal in terms of dysmotility, that would be very useful for us.” (RAD1)

“…a challenge was when the radiologist says yes, it's okay in terms of transit, however, our (oesophageal transit) timing is not within the norms … could we do some education sessions together, including gastroenterology … we potentially need to come to that agreement” (SLT4)

“…I think one of the big challenges is the interpretation, particularly with the oesophageal transit time when it is just slightly increased … I think that's where sometimes the discrepancy with the radiology report is that they don't think it's clinically significant … I think they're using more their just overall clinical judgement and experience.” (SLT8)

Some interviewees across SLT, RAD and MRT disciplines identified that further education for the multidisciplinary dysphagia team regarding normal versus abnormal oesophageal transit would be valuable.

“Maybe just education again, if you have a certain (oesophageal transit) time like, what is abnormal? What's normal? … even just a quick guide of transit times would be nice.” (MRT4)

“I wouldn't mind just learning a little bit more about general oesophageal screen(ing) and what you'd expect to see, what normals are, what they're not…” (SLT5)

Four out of the five health professions interviewed (RADs, MEDs, SLTs and MRTs) called for clear GE referral criteria which are generated by GE and shared with the multidisciplinary dysphagia team. Interviewees questioned whether referral to GE should be blanket for all patients with possible oesophageal abnormality or whether GE consultation is indicated only for specific conditions or symptoms.

“…a nice clear decision tree with some of those … symptoms and characteristics that could … trigger referral to gastro(enterology) would definitely be very useful…” (SLT1)

“…in conjunction with the patient's reported symptoms sort of maybe have a matrix of the patients ticking three out of the four boxes and that warrants a referral to gastroenterology.” (SLT6)

Category 3 highlighted that more work is required by the multidisciplinary dysphagia team to establish agreed interpretation and onward referral parameters for oesophageal screening in VFSS. The fourth and final category will underscore the importance of keeping the patient at the centre of all dysphagia decision‐making.

Category 4: Patient context, preferences and reported symptoms should primarily guide dysphagia decision‐making.

Category 4 summarises the patient‐specific factors that should be considered by the multidisciplinary dysphagia team at all stages of dysphagia assessment and treatment. The importance of patient‐specific and patient‐centred decision‐making was a common thread throughout the focus groups/interviews with the multidisciplinary dysphagia team. Category 4 had two component subcategories (Table 6).

All five health professions interviewed reported that the patient's medical history, current medical status, reported symptoms and treatment preferences should be considered during dysphagia decision‐making. This was most evident throughout the GE and SLT interviews.

“…where we have a underlying cause and they're malnourished, and they could do with potentially a PEG [percutaneous endoscopic gastrostomy] insertion, those are the ones we will change management. For the ones that are sort of nursing home, comorbid, no reversible aetiology, sometimes a conservative approach is the best way and further investigating isn't gonna change their overall trajectory…” (GE2)

“…clinical common sense whom you refer (to GE) … it should not be futile … a frailty assessment could ultimately be helpful … I think it needs to be individualised. What is the bigger problem … what's the priority and … the worst symptom? If they have significant weight loss, they should be seen … I think key is really symptoms. A symptom assessment.” (GE1)

“…some of the patients who would have met criteria for referral to gastro(enterology) based on their oesophageal screening results may have been asymptomatic and have had no concerns…” (SLT6)

However, patient‐specific considerations were also raised during the MED and RAD interviews.

“If there was a medication that could be trialled, they won't take it … once you start talking about side effects of any medication they tend to say, ‘no, thanks’…” (MED3)

Category 4 highlights that all disciplines working in dysphagia should engage in collaborative decision‐making with patients to ensure assessment and treatment decisions meet their specific needs and are in accordance with their wishes.

Clinical pathway for oesophageal screening in VFSS

Based on the interview feedback from the multidisciplinary dysphagia team, a refined clinical pathway for oesophageal screening in VFSS at the research site was drafted by the research team (all authors) via consensus decision‐making. This draft was then reviewed by representatives from MED, RAD, GE and SLT, who provided further clarity regarding discipline‐specific roles before, during and after VFSS. The refined clinical pathway for oesophageal screening at the research site is shown in Figure 2. Several additions to the existing clinical pathway (Figure 1) were made, including defined multidisciplinary dysphagia team roles, an SLT‐led patient‐reported symptom measure (e.g., the Eating Assessment Tool‐10, Belafsky et al., 2008), the option for additional oesophageal imaging at the time of VFSS, more specific GE referral criteria, patient consultation regarding onward referral and treatment planning, and oesophageal behavioural strategy advice.

DISCUSSION

Despite the recognised benefits of including oesophageal screening in VFSS, there has been limited uptake of oesophageal screening protocols internationally (McCarthy et al., 2023a; Regan et al., 2020). Implementation research is needed that supports clinicians in embedding oesophageal screening into routine VFSS practice. Although some researchers have commenced this work through informal discussions with some dysphagia team members (Watts et al., 2020), and the training of SLTs in oesophageal screening protocols (Gregor & Watts, 2023; Miles, 2017; Stanley et al., 2023), in‐depth engagement with the entire multidisciplinary dysphagia team is required for meaningful and sustainable practice change.

This study builds on previous research in oesophageal screening conducted at the research site by addressing two main aims: (1) to provide insight into multidisciplinary dysphagia team perspectives of oesophageal screening, including its benefits, limitations and contribution to the clinical management of dysphagia; and (2) to use this information to refine the clinical pathway for oesophageal screening in VFSS. Interviewees across all professional groups confirmed that VFSS findings are only one component of the dysphagia workup and that the results of other assessments, the patient's history and clinician impressions are also needed for accurate diagnosis and appropriate treatment selection (Martin‐Harris et al., 2020).

This study employed three sources of evidence recognised as important for optimising clinical practice (Rycroft‐Malone et al., 2004), including previous quantitative research in oesophageal screening, the knowledge and experience of dysphagia clinicians and local environmental factors. Greenhalgh et al. (2014) also recognised that the knowledge and experience of clinicians are necessary to complement research evidence for clinical decision‐making. These different sources of evidence were all utilised in refining the local clinical pathway for oesophageal screening in VFSS (Figure 2). Clinical pathways have been used internationally in a variety of healthcare settings for several decades to standardise care and to assist in the implementation of best practice (Lavelle et al., 2015; Lawal et al., 2016; Wendel et al., 2023). To date, a clinical pathway for oesophageal screening in VFSS has not been published. The clinical pathway developed in this study aims to support the multidisciplinary dysphagia team at the research site with decision‐making regarding appropriate actions for onward referral for possible oesophageal abnormalities detected on oesophageal screening in VFSS or via patient‐reported symptoms. It also aims to bridge the gap identified by McCarthy et al. (2023b) between the identification of possible oesophageal abnormality on oesophageal screening and the utilisation of that information in decision‐making for dysphagia management.

Rycroft‐Malone et al. (2004) identified perspectives from patients and/or caregivers as the fourth source of evidence integral to optimising clinical practice. The patient perspective is also valued by Starmer et al. (2020) who highlighted the importance of a comprehensive case history and detailed patient description of dysphagia symptoms in assessment selection and treatment decision‐making. Greenhalgh et al. (2014) added that clinical decision‐making needs to be completed with the patient and incorporating their specific context and preferences. Although patient and/or caregiver perspectives were not within the scope of this study, the clinicians interviewed frequently commented that patient‐specific factors and preferences should be at the centre of all dysphagia decision‐making.

The importance of patient‐specific factors and perspectives was most evident in the GE interviews. All three GEs interviewed suggested that patient‐reported symptoms should direct the sequence and selection of dysphagia assessments, that the cause of dysphagia should guide intervention and that intervention for possible oesophageal abnormalities is not always appropriate. As a result of these findings, a patient‐reported symptom measure and patient consultation post‐VFSS regarding intervention options were included in the refined clinical pathway (Figure 2). The refined clinical pathway also indicates where oesophageal behavioural strategies alone are more appropriate than further diagnostic assessment for possible surgical intervention, such as for frail patients with multiple comorbidities.

This study also confirmed that specific knowledge and skills are needed to optimise oesophageal screening. It has been established that SLTs are able to reliably interpret oesophageal screening on VFSS following specific training (Miles, 2017; Stanley et al., 2023). However, comments from participants in this study indicate that targeted and systematic training in oesophageal screening should be considered for all health professions involved in VFSS. Along with training in the procedural components of oesophageal screening, Gregor and Watts (2023) suggested that all health professions working in dysphagia should have a thorough understanding of the interrelationship between oropharyngeal and oesophageal swallowing to ensure optimal patient outcomes.

It should be noted that at the research site, RADs are present for VFSS. It is recognised that in many settings internationally RADs are not present during VFSS (Benfield et al., 2021; Bonilha et al., 2023; Coman et al., 2022). Carbo et al. (2021) reported that the presence and/or supervision of RADs in VFSS assists in linking patient‐reported symptoms with radiological imaging findings and emphasised the importance of RAD reports in guiding further assessment and treatment planning. RADs should lead the decision‐making regarding additional oesophageal imaging following VFSS (Carbo et al., 2021), however completing a barium swallow study on the same day as VFSS is not possible in many settings (Bonilha et al., 2023). The value of RADs presence in VFSS at the research site was considered when developing the key roles of RADs in the refined clinical pathway for oesophageal screening (Figure 2).

The results of this study indicate that further research is needed by multidisciplinary dysphagia teams to establish a consensus regarding: (1) the optimal protocol for oesophageal screening in VFSS, including textures used and imaging periods; (2) what constitutes normal versus abnormal oesophageal transit on oesophageal screening in VFSS; and (3) which patients are the most appropriate for GE referral. The challenges in establishing best practice for both the procedural and interpretation components of oesophageal imaging in VFSS are like the challenges in establishing best practice for both the procedural and interpretation components of oropharyngeal imaging in VFSS. Currently, there are a variety of approaches available to clinicians regarding VFSS protocols and interpretation methods, including standardised protocols (e.g., the MBS Measurement Tool for Swallow Impairment, MBSImP, Martin‐Harris et al., 2008) versus informal patient‐specific protocols, and visuo‐perceptual interpretation (Swan et al., 2021) versus objective measures (Leonard, 2019). Although an oesophageal screening protocol and oesophageal transit time norms (Miles et al., 2016) had been in use at the research site for several years, some interviewees indicated that they had not been fully accepted by the multidisciplinary dysphagia team.

LIMITATIONS AND FUTURE DIRECTIONS

This study had several limitations for consideration. This study occurred at a single site and likely attracted participants with an interest in dysphagia and VFSS. Participant views are individual in nature and do not represent all health professionals working in VFSS. It is acknowledged that the focus group/interview facilitator (lead author K.M.) was an SLT working in VFSS at the research site and was known to some participants. However, every effort was made to minimise coercion, bias and conflicts of interest, including the use of template questions and prompts, coauthor data review and adherence to research integrity principles. Furthermore, the facilitator's role in VFSS at the research site may have positively contributed to interview quality and participant engagement in this study. Planned future research includes trialling the refined clinical pathway for oesophageal screening with VFSS patients at the research site and evaluating its impact on patient dysphagia outcomes.

CONCLUSIONS AND IMPLICATIONS

This study improves our understanding of multidisciplinary dysphagia team perspectives regarding oesophageal screening in VFSS, including procedure, interpretation and clinical utility. A local clinical pathway for oesophageal screening in VFSS was refined. Clinical pathways that are developed by the multidisciplinary dysphagia team are more likely to lead to the successful implementation of routine standardised oesophageal screening in VFSS and optimise patient outcomes. This offers clinicians internationally a practical pathway for incorporating oesophageal screening into their diagnostic decision‐making. The findings from this study regarding gathering multidisciplinary team perspectives could also have broader application to other areas of quality improvement and system change for other health services nationally and internationally.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Supporting Information

JLCD-60-0-s002.docx^{(16.9KB, docx)}

Supporting Information

JLCD-60-0-s001.docx^{(17.3KB, docx)}

ACKNOWLEDGEMENTS

This research was supported by an Australian Government Research Training Program (RTP) Scholarship. This scholarship was awarded to the lead author Kellie McCarthy and no other funding support was received for this study. The authors would like to thank the participants for giving up their time to participate in this study and their managers for supporting this study. Participant time was provided in kind.

Open access publishing facilitated by The University of Queensland, as part of the Wiley ‐ The University of Queensland agreement via the Council of Australian University Librarians.

McCarthy, K. , Finch, E. , & Miles, A. (2025) Oesophageal screening in videofluoroscopic swallow studies: Perspectives from the multidisciplinary dysphagia team to refine the clinical pathway. International Journal of Language & Communication Disorders, 60, e70006. 10.1111/1460-6984.70006

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supporting Information

JLCD-60-0-s002.docx^{(16.9KB, docx)}

Supporting Information

JLCD-60-0-s001.docx^{(17.3KB, docx)}

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

[jlcd70006-bib-0001] Allen, J.E. (2019) Radiographic evaluation of the pharynx and esophagus. In: Leonard R.L. & Kendall K.A. (Eds.) Dysphagia: assessment and treatment planning, a team approach , 4th edition, San Diego, CA: Plural Publishing. pp. 73–84. [Google Scholar]

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PERMALINK

Oesophageal screening in videofluoroscopic swallow studies: Perspectives from the multidisciplinary dysphagia team to refine the clinical pathway

Kellie McCarthy

Emma Finch

Anna Miles

Abstract

Background

Aim(s)

Methods and Procedures

Outcomes and Results

Conclusions and Implications

WHAT THIS PAPER ADDS

What is already known on the subject

What this study adds

What are the clinical implications of this work?

INTRODUCTION

Study aims

METHODS AND PROCEDURES

Context

FIGURE 1.

Participants

Procedure

Data analysis

TABLE 1.

Rigour

FIGURE 2.

Outcomes and Results

Participants

TABLE 2.

Categories and subcategories

TABLE 3.

TABLE 4.

TABLE 5.

TABLE 6.

Clinical pathway for oesophageal screening in VFSS

DISCUSSION

LIMITATIONS AND FUTURE DIRECTIONS

CONCLUSIONS AND IMPLICATIONS

CONFLICT OF INTEREST STATEMENT

Supporting information

ACKNOWLEDGEMENTS

DATA AVAILABILITY STATEMENT

REFERENCES

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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