We are the provider of choice for Mobile Modified Barium Swallow Studies in Dallas/Fort Worth and surrounding areas for Skilled nursing facilities, Rehab hospitals, long-term care facilities, home health, and outpatient services.
Phone: 1-888-514 MBS1
We accept Medicare and Medicaid and are providers for BCBS, PacifiCare, Secure Horizons, and others.
DiagnosTEX is recognized by Medicare as a group medical practice. A group medical practice must have a physician in a direct ownership position; therefore, it is held to the highest standards by the Texas State Board of Medical Examiners, Texas Bureau of Radiation Control, the Community Standard of Practice, Medicare Guidelines, and the Hippocratic Oath that professes, “...to do no harm and to act in the best interest of the patient.”
What is the purpose of Modified Barium Swallow Studies?
Dysphagia is the medical term describing a condition of swallowing difficulty that occurs from an underlying condition. Fifteen million people in the United States suffer from dysphagia (J. Logemann, 1991), and 40-60% of those are residents of a long-term care facility.
The process of swallowing occurs in four stages: oral preparatory, oral, pharyngeal, and esophageal. Dysfunction in swallowing is termed dysphagia. Signs of dysphagia are exhibited by 68% of nursing home residents (Steel, Greenwood, Ens, Robertson, and Seidman-Carlson, 1997)
A clinical swallowing evaluation (i.e. bedside swallowing exam) can help determine the presence of dysphagia. However, only symptoms of pharyngeal (throat) and esophageal (esophagus) dysphagia can be identified clinically, while dysphagia in the stages of oral, pharyngeal, and esophageal cannot be officially diagnosed at bedside. Research has shown that even the most experienced clinician/Speech Pathologist will fail to identify approximately 40% of the patients who aspirate during a bedside swallow examination (Logemann, 1983). Aspiration occurs when material penetrates the larynx, which sits at the top of the trachea, and then falls below the vocal cords into the airway leading to the lungs. Continuous aspiration of food or liquid is likely to cause aspiration pneumonia, which affects 44% of the residents in long term care (Langmore et al, 1998)
A Modified Barium Swallow Study (MBSS) is an objective radiological diagnostic tool that assesses swallow function. The MBSS can diagnose pharyngeal and esophageal stage of dysphagia and presence of aspiration, as well as determine appropriate diet and liquids consistencies, swallowing precautions/strategies, and appropriate treatment techniques to reduce aspiration risk. A Modified Barium Swallow Study allows the swallow to be viewed in real time and all phases of the swallow be evaluated on various consistencies. The Modified Barium Swallow Study is the Gold Standard in evaluating dysphagia. Identification of aspiration and elimination of the risk of aspiration pneumonia is cost-effective in that overall medical costs will be reduced. It is estimated that in 1985 the direct and indirect costs of various disorders related to dysphagia totaled nearly $2.5 billion (Brown & Everhart, 1994).
The benefits of an MBSS
According to Quality Assurance (QA) results obtained monthly from 2002 to the present, by DiagnosTEX in the Dallas Ft. Worth area, many positive factors can be acknowledged. Therapy discharge rates averaged 52% after the MBSS was completed, and tube feeding was eliminated at an average of 61.8%. In the past 6 months an average of 23% of the patients evaluated by the mobile MBSS were diagnosed with silent aspiration. The term silent aspiration is when aspiration occurs without overt signs (coughing, choking etc). Therefore, 23% percentage indicates the number of patients aspirating that may have gone undetected if an MBSS had not been completed. Because dysphagia can have serious consequences, it is important to identify groups of patients with conditions that predispose them to this disorder. Such identification allows for more immediate efforts to diagnose dysphagia in high-risk patients, so that treatment can be initiated before they develop complications such as malnutrition, dehydration, and/or pneumonia.
A measure of economic burden of dysphagia is the cost for tube feeding: in 1992 Medicare covered tube feedings for 73,000 patients at home and 133,000 patients in nursing homes at a cost of $505 million (80% of the allowable charge). The implication from these figures is that untreated and undiagnosed dysphagia can have considerable financial burden. A Resident Assessment Protocol for feeding tubes appear in CMS’s Long Term Care Facility Resident Assessment Instrument User’s Manual (1995, reprinted 1998). Page C-62 which states that …… all possible alternatives should be explored prior to using such an approach (tube feeding) for long term feeding and restoration to normal feeding should remain the goal through the treatment program. In the best interest to all involved, it is important to provide safety for patients during swallowing by implementing measures, such as instrumental evaluations like the MBSS, to prevent aspiration on those patients identified as high risk.
Why a Mobile Unit?
The philosophy behind the mobile MBSS is that overall results of the test are more representative of a patients swallowing function, because the issue of fatigue, disorientation and testing delays, related to transportation to a hospital are eliminated.
A mobile MBSS is a modification in the equipment of the traditional MBSS performed in a hospital setting. The MBSS is performed inside the mobile clinic that is parked outside the facility. This is not portable equipment that is transferred into a facility. The patient is brought outside to the clinic in their wheelchair or Neuro-chair and with the assistance of an electric wheelchair lift, similar to those used in public transportation settings; they are allowed easy access to the clinic. The mobile clinic is equipped with numerous safety equipment features including suction apparatus, cellular phone, and a CPR certified staff.
A mobile video fluoroscopy clinic used for the MBSS allows for assessment of swallowing disorders in a private, controlled, efficient environment that eliminates disorientation, fatigue, and/or agitation often involved with medical transportation and/or clinical appointments. Furthermore, the overall results of the evaluation are more representative of a patient’s swallow function, since they are in their own wheelchair as used during meals. Such functional evaluations are unable to be completed at a hospital location.
A team of licensed professionals are staffed to evaluate the patient:
- ASHA certified Speech Pathologist with specialty training in dysphagia and MBSS.
- Trained Technician
- Consulting and Supervising Medical Doctor
Benefits to a Mobile Clinic vs. a Hospital
Inside the clinic, a full evaluation of their swallow function is easily accessed by the A-P (anterior posterior) view in addition to the lateral (side) view. The A-P view is not usually completed in the hospital setting due to positioning restrictions. The use of a specialized fluoroscopic system designed for the mobile MBSS exposes the patient to less radiation than what typically is found in a hospital setting. Approximately 1 Rad per minute is used during fluoroscopy on the mobile unit, compared to 2-3 Rad per minute in the hospital environment. The physician operates the radiological equipment and the technician documents the total fluoro time and archives the videotape with footage markers for the permanent medical record.
During the evaluation, the physician exposes the patient using X-ray perimeters and collimating (more focal x-ray) suitable for each projection. Real-time Super VHS video recorders not only captures a full dynamic range of high quality images of all three phases (oral, pharyngeal, and esophageal) of the swallow function, but it also captures the audio explanations as well. Additionally, the study is displayed on two-real time viewing monitors for the Speech Pathologist to evaluate and those in attendance to observe. The mobile clinic allows the facility and/or facility Speech Pathologist to have a copy of the evaluation on the videotape to be used for review or education. Furthermore, written and verbal results, recommendations, along with the Speech Pathology and physician’s detailed evaluation reports are immediate. This availability to the videotape and immediate results/evaluation report is not available in a hospital setting.
An additional time saving benefit is the complete evaluation time. Total time to complete an evaluation on the mobile clinic, from arriving at the facility to leaving the facility averages 30-45 minutes, whereas the hospital may take a total of 3 hours including transportation, admission, waiting, and the procedure itself.
How is an MBSS done?
Equipment and Material
The equipment in the mobile unit is designed for this procedure, which makes it more physically accommodating to the residents, unlike the equipment in the hospital, which is designed for numerous other diagnostic procedures and is unable to accommodate a wheelchair.
The barium substance utilized in the mobile clinic is the same as used in local hospital settings.
- Thick Ba (Barium) suspension diluted as necessary to produce desired liquid thickness
- Esophatrast (Ba in food consistencies)
Barium Sulfate (BaSO4) base is a positive contrast agent that is radiopaque to produce a dark, black image on fluoroscopy. Barium is effectively inert in the body. This means that barium is neither absorbed nor metabolized and is eliminated unchanged by the body. It is available in powder, liquid, or paste form.
There are many misunderstandings regarding the use of barium in a procedure of a Modified Barium Swallow Study (MBSS). Amounts of barium given in a Modified Barium Swallow Study are often mistaken for the amounts given in an Upper GI/Barium Swallow Study. In an MBSS, small amounts of liquid ranging from 1mL to 5mL, by spoon and small sips, are given and also barium paste is mixed with a food consistency. This is unlike the Upper GI/Barium Swallow that requires several ounces of liquid by large cup drinks, which is used to highlight the gastrointestinal area (stomach and intestinal areas).
Assessing Different Consistencies
The various consistencies of foods that cause Dysphagia provide significant diagnostic information because patient/resident is never given uniform consistencies on their trays during their meals at long-term care facilities. During the MBSS, all consistencies that the patient can tolerate are assessed for accuracy.
The following consistencies are typically administered during an MBSS: thin liquid, nectar thick liquid, thin, and thick puree, mechanical soft and solid. The amounts administered are typically teaspoon and controlled cup sips (10ml and 15-20ml), teaspoon amounts of puree and 1/2x1/2 piece of solid (i.e.: cookie or cracker). Patients are typically given two to three trials of each consistency/amount, depending on swallow function. Thick liquids are usually given for the first trial since small amounts of thicker consistencies are less likely to be aspirated than thin liquid. Review of literature (Logemann, 1993, 1983), training in dysphagia diagnostics and management, and experience will allow the SLP to hypothesize that a thinner, less viscous liquid would be aspirated. Therefore, nectar thick liquid is usually the first liquid consistency administered. Depending on swallow performance, liquids may be administered via straw or consecutive swallows. In addition, dependent on swallow performance a decisions may be made not to give all consistencies, such as thin liquids (Logemann, 1983), or to give other consistencies, such as honey thick liquids. These decisions are made by the qualified SLP performing the study. The well being of the patient is a priority. We will not put the patient at any unnecessary risks. Not administering all of the above mentioned consistencies and amounts DOES NOT INDICATE THAT THE STUDY WAS INCOMPLETE. The study is completed on the patient’s capabilities.
DiagnosTEX Policy and Procedures
With neuromuscular dysfunction of the pharynx (i.e. result of a stroke, Parkinson Disease, Alzheimer’s etc.), liquids frequently cause greater problems than more viscous material/boluses. Therefore each consistency assessed is an important part of the complete evaluation, allowing the Speech Pathologist to determine the safest consistency for PO (per oral) feeding. As an example, the different types of consistencies recommended for diets in the month of November 2004 as documented in DiagnosTEX QA report, is as follows: Regular/solid consistencies: 40 cases; Mechanical Soft: 59 cases; Puree: 96 cases; Nectar thick liquid: 56 cases; Thin liquids: 98 cases; Honey thick liquid: 33 cases; NPO (non per oral) 28 cases. During the month of November 2004, 52 patients were noted to have silent aspiration on certain consistencies, therefore diets were altered or recommended as appropriate to eliminate the risk of aspiration. Silent aspiration occurs in 50% of all people who aspirate (Logemann, 1988).
The radiographic study should not always be terminated when the patent aspirates (Logemann, 199). Depending on the cognitive/mental status of the patient and the nature/amount of aspiration, compensatory strategies may be introduced. Strategies may include postural changes of head and/or body, treatment strategies, changes in consistencies of liquids, solids or volume changes. Introduction of compensatory strategies may vary depending on the individual patient’s performance but can be the difference between the recommendations of PO (per oral) versus NPO (nothing per oral). Inaccurate determination of when the aspiration and or penetration occur and why, can lead to inappropriate recommendations of compensatory strategies which may not decrease or eliminate the patients risk for aspiration. Furthermore an incorrect strategy or technique implemented at bedside can actually increases penetration and aspiration risks. The best way to assess the effectiveness of compensatory strategies and facilitative techniques is with a Modified Barium Swallow Study.
Quality Assurance (QA)
Quality Assurance and outcome measures of the DiagnosTEX Mobile MBSS program are completed on a monthly basis and are a unique service , not available diagnostic imaging companies in the DFW area. There is follow-up on each and every patient evaluated to ensure tolerance of diet and follow-through of recommendations within 7-14 days. The intent of this Modified Barium Swallow Study (MBSS) Quality Assurance (QA) is to review the results and outcome measures taken on a monthly basis on studies/consultation completed by DiagnosTEX. This QA is completed in order to assist DiagnosTEX in establishing, maintaining, and ultimately improving mobile MBSS studies that we do. MBSS outcome measures are intended to document if method of nutrition, diet, and liquid recommendations as well as management/treatment recommendations are being followed and if the patient is benefiting from the recommendations. Also if the recommendations are not followed, why? It is documented in the DiagnosTEX policies and procedures for MBSS that if the recommendations are not followed, DiagnosTEX is not responsible for any adverse outcomes.
Why DiagnosTEX uses their own trained Speech Pathologists?
Employing and utilizing our own trained Speech Pathologist for every study allows DiagnosTEX to have a controlled MBSS program. This includes compliance with set policies and procedures, use of consistent MBSS evaluation forms, and a QA program to document the clinical relevance and cost effectiveness of the study. This protects our program from liability by documenting clinical outcomes and instances of non-compliance with recommendations. DiagnosTEX also protects itself from liability by using specialty trained Speech Pathologists with extensive experience in performing and interpreting MBSS who have completed the training program offered by DiagnosTEX. Many Speech Pathologists do not have the required training and experience to perform Modified Barium Swallow Studies at the level of expertise necessary for this environment and evaluation protocol.
The mobile unit affords a cost reduction avenue for facilities by eliminating acute costs through reduction of resident’s external expenses. The average cost of transportation can range from $350.00-$450.00 (usually $7.50 per mile with additional cost). An MBSS performed at the hospital, under the Prospective Payment System (PPS), is billed back to the SNF, and depletes the dollars allocated to the patient. The most cost effective method to managing the patient’s needs is the availability of the mobile MBSS service.