Objective and Subjective Clinical Swallowing Outcomes via Telehealth: Reliability in Outpatient Clinical Practice


Purpose: The COVID-19 pandemic has drastically increased the use of telehealth. Prior studies of telehealth clinical swallowing evaluations provide positive evidence for tele-management of swallowing. However, the reliability of these measures in clinical practice, as opposed to well-controlled research conditions, remains unknown. This study aimed to investigate the reliability of outcome measures derived from clinical swallowing tele-evaluations in real-world clinical practice (e.g., variability in devices and Internet connectivity, lack of in-person clinician assistance, or remote patient/caregiver training).

Methods: Seven raters asynchronously judged clinical swallowing tele-evaluations of 12 movement disorders patients. Outcomes included the Timed Water Swallow Test (TWST), Test of Masticating and Swallowing Solids (TOMASS), and common observations of oral intake. Statistical analyses were performed to examine inter- and intra-rater reliability, as well as qualitative analyses exploring patient and clinician-specific factors impacting reliability.

Results: Forty-four trials were included for reliability analyses. All rater dyads demonstrated “good” to “excellent” inter-rater reliability for measures of the TWST (ICCs ≥ 0.93) and observations of oral intake (≥ 77% agreement). The majority of TOMASS outcomes demonstrated “good” to “excellent” inter-rater reliability (ICCs ≥ 0.84), with the exception of number of bites (ICCs 0.43 – 0.99) and swallows (ICCs 0.21 – 0.85). Immediate and delayed intra-rater reliability were “excellent” for most raters across all tasks, ranging between ICC 0.63 – 1.00. Exploratory factors potentially impacting reliability included infrequent instances of suboptimal video quality, reduced camera stability, camera distance, and obstruction of the patient’s mouth during tasks.

Conclusions: Subjective observations of oral intake and objective measures taken from the TWST and TOMASS can be reliably measured via telehealth in clinical practice. Our results provide support for the feasibility and reliability of telehealth for outpatient clinical swallowing evaluations during COVID-19 and beyond.

American Journal of Speech-Language Pathology