Enhancing speech-language pathology head and neck cancer service provision in rural Australia: Using a plan, do, study, act approach.

PURPOSE: People with head and neck cancer (HNC) require ongoing speech-language pathology (SLP) services into the post-acute recovery phase of care. However, there are recognised service inequities/barriers for people from rural areas who are unable to access SLP services locally, necessitating travel to metropolitan centres. This study implemented strategies to assist rural speech-language pathologists to work to full scope of practice and support post-acute rehabilitation services for people with HNC. METHOD: The study involved five SLP departments within a rural health referral network (one tertiary cancer centre, four rural sites). It involved a Plan-Do-Study-Act (PDSA) method, across two six month cycles, to achieve implementation of a model to support local SLP delivery of HNC care. Data collected included service activity, consumer feedback from people accessing local care, staff perceptions of the model and changes to local SLP service capabilities. RESULT: Staff identified four objectives for change across the two PDSA cycles including resource development, upskilling/training and improving communication, and handover processes. In cycle 1, multiple resources were developed such as an eLearning program for training and skill development. In cycle 2, a pilot trial of a shared-care model was implemented, which successfully supported a transfer of care to local services for eight people with HNC. The majority of consumers accessing HNC care locally were satisfied with the service and would recommend future people with HNC receive similar care. CONCLUSION: The PDSA process supported development and implementation of a model enabling local speech-language pathologists to offer post-acute care for people with HNC. This model helps rural people with HNC to access care closer to home by supporting rural clinicians to work to full scope of practice.

Clinician and consumer perceptions of head and neck cancer services in rural areas: Implications for speech pathology service delivery.

OBJECTIVE: Individuals with head and neck cancer residing in rural areas face numerous challenges accessing post-acute rehabilitation services, including speech pathology services. In order to inform future service enhancements, the key issues impacting access to, and the provision of, speech pathology head and neck cancer services in rural areas was explored through the perspectives of patients, carers, speech pathology clinicians and service managers. SETTING: A rural health referral network in Queensland consisting of tertiary, regional and remote hospitals. PARTICIPANTS: Twenty-eight participants, including 12 speech pathology staff/managers and 16 consumers (people with head and neck cancer/carers). DESIGN: Qualitative methodology using semi-structured interviews was analysed using content analysis. RESULTS: Two themes were identified from the consumer group including (a) navigating health services for head and neck cancer management and (b) burden of accessing head and neck cancer care. Speech pathology staff/managers interviews raised 3 themes: (a) transfer of care and access to local services, (b) workforce and workload and (c) travelling impacts the service our patients can receive. An integrative theme across both groups highlighted the perceived disparity in health care access that existed for people with head and neck cancer in rural areas. CONCLUSIONS: In rural areas, consumers face multiple barriers navigating the head and neck cancer treatment pathway, while health services encounter specific challenges ensuring access and equity in care. Despite the complexities, possible avenues for service change and service enhancement are proposed. Speech pathology services in rural areas need to proactively evaluate services and address existing disparities in order to enact positive change for people with head and neck cancer living outside metropolitan locations.

Swallowing Safety and Efficiency Impairment Profiles in Individuals with Amyotrophic Lateral Sclerosis.

Dysphagia is common in individuals with amyotrophic lateral sclerosis (ALS) and associated with reductions in quality of life and health-related outcomes. Despite the high prevalence of dysphagia in ALS, functional impairment profiles of swallowing safety and efficiency have not been comprehensively examined. We therefore aimed to determine the relative prevalence of unsafe and inefficient swallowing in a large cohort of individuals with ALS. We further sought to examine the impact of global and bulbar disease progression (Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised "ALSFRS-R" total and bulbar scores, respectively), disease duration, and onset type on swallowing impairment profiles. One hundred individuals with ALS completed a standardized videofluoroscopic swallowing examination Two independent and blinded raters performed validated ratings of safety (Penetration-Aspiration Scale, PAS) and efficiency (Analysis of Swallowing Physiology: Events, Kinematics, and Timing, ASPEKT % residue). Binary classifications of safety (unsafe: PAS ≥ 3), efficiency (inefficient: total residue ≥ 3% of C2-42) and global swallowing status were derived. The ALSFRS-R was completed to derive ALSFRS-R total and bulbar subscale scores. Demographic data (disease duration and onset type) for each participant was also recorded.  Descriptives, 2 × 2 contingency tables with Fishers exact test, and independent samples t-tests were performed (α = 0.05). Prevalence of unsafe and inefficient swallowing was 48% and 73%, respectively. Global swallowing profiles were, in rank order: unsafe and inefficient (39%), inefficient but safe (34%), safe and efficient (18%), and unsafe but efficient (9%). There were no differences in global disease progression or disease duration across swallowing impairment profiles. ALSFRS-R bulbar subscale scores were significantly lower in unsafe versus safe swallowers, p < 0.05. Spinal onset patients had a greater proportion of safe swallowers as compared to bulbar onset patients (p = 0.000, Fisher's exact test). Both spinal and bulbar onset patients demonstrated a higher prevalence of inefficient swallowers as compared to efficient swallowers (p = 0.04, Fisher's exact test). Dysphagia was prevalent in this group of individuals with ALS. Approximately half demonstrated safety impairments and two-thirds had impairments in swallowing efficiency. Inefficient swallowing was approximately four times more likely to be the initial functional impairment in patients with one pathophysiologic functional impairment. A longitudinal study is needed to examine the temporal evolution of dysphagia in ALS.

Speech pathology service enhancement for people with head and neck cancer living in rural areas: Using a concept mapping approach to inform service change.

BACKGROUND: Speech pathology (SP) services provide swallowing and communication intervention to people with head and neck cancer (HNC) across the continuum of care. However, difficulties exist with access and delivery of services in rural areas. The study aim was to identify actionable goals for SP change, utilizing a concept mapping approach. METHODS: Eleven SP staff from two regional/remote services completed the concept mapping process. Multivariate analysis and multidimensional scaling were used to develop a final set of prioritized goals for change. RESULTS: Between the two participating health services, 30 actionable goals were identified within the "green-zone" on the go-zone graph of importance and changeability. Among the most highly rated areas for change was the need to deliver and receive more support for training, mentoring, and supervision to consolidate skills. CONCLUSIONS: This methodology enabled identification of prioritized, actionable changes to improve SP services for people with HNC living in regional/remote areas.