探討經信效度驗證之非儀器類吞嚥困難篩檢工具：對工具操作者之探討

Abstract

研究背景與目的：目前已有超過100種非儀器類吞嚥困難篩檢工具，分別針對不同疾病族群和操作者使用。儘管有大量的篩檢工具可供臨床人員使用，但臨床上吞嚥困難篩檢仍未普及。其中可能的原因是醫療人員面對如此多的篩檢工具選擇時感到困惑和不確定，而部分篩檢工具缺乏完整信效度檢測或良好的心理計量特性恐進一步增加工具選擇的複雜度。本研究目的為回顧所有吞嚥困難篩檢工具之文獻，找出已開發且經信效度驗證之非儀器類吞嚥困難篩檢工具，並依工具發展時建議之操作者及篩檢疾病族群分類。 研究方法：本研究採範疇界定回顧研究，截至2021年7月31日，使用五個關鍵詞：“dysphagia”、“deglutition”、“screening”、“test”和“measure”，並通過搜索CINAHL、Embase、PsycINFO、PubMed和Web of Science等資料庫，納入發展工具之最初版文獻，篩選出所有吞嚥困難篩檢工具，再依已驗證信效度之工具進行彙整，最後針對工具操作者及篩檢疾病族群分項分類，依其信效度表現，進一步討論工具的臨床使用性。 研究結果：本研究最終納入47個經信效度驗證之非儀器類吞嚥篩檢工具。在此47個工具中，大多發表於2001年之後，至此相關吞嚥篩檢工具研究數量迅速增長。篩檢對象中，神經肌肉疾病佔比最高，達49%，操作者則以病人/照顧者最多，佔45%。這47個工具由不同的操作者使用，包括：醫生(7種工具)、語言治療師(9種工具)、護理師(8種工具)、病人/照顧者(21種工具）和非特定人員(2種工具)，而篩檢對象可包含八種不同疾病族群，其中神經肌肉疾病，特別是中風病人，不論由誰擔任工具操作者，皆有可用的篩檢工具。針對信效度及心理計量特性部分，有9個工具表現良好。然而部分仍受到一些使用上的限制，舉例來說，Bedside Screening Tool for Dysphagia為義大利文版本，故無法直接在其他語言地區使用，而Two-Step Thickened Water Test需搭配使用旋轉黏度計來測量食物黏度，也會降低此工具在臨床操作之可行性。另外，47個經信效度驗證之非儀器類吞嚥篩檢工具也有部分心理計量特性表現不佳，例如：Dysphagia Trained Nurse Assessment, Dysphagia Disorder Survey, Kubota Water Drinking Test，可能需要進一步的研究來驗證其篩檢效能。 結論：非儀器類吞嚥困難篩檢工具及文章發表數量眾多，然而僅47個工具在首次發表時，經過完整的信效度驗證。且並非所有的疾病族群都有經過完整信效度驗證的篩檢工具可用。即便具備完整信效度檢測，部分工具仍受限於語言版本、需額外設備輔助使用或心理計量特性表現不佳等因素，進而降低臨床使用價值。臨床人員在選擇非儀器類吞嚥困難篩檢工具時，可參考本研究結果作為選擇工具之重要依據。

Background & Objectives: Despite the availability of over 100 non-instrumental dysphagia screening tools targeting various disease populations and users, the screening and diagnosis of dysphagia in clinical practice remain limited. This insufficiency may be attributed to confusion and uncertainty among healthcare providers when confronted with the multitude of tool options. Moreover, the lack of comprehensive reliability and validity testing or absence of robust psychometric properties in some dysphagia screening tools further complicates the tool selection process. This study aims to comprehensively review the literature on dysphagia screening tools, identify non-instrumental dysphagia screening tools that have been tested for reliability and validity, and categorize them by the suggested tool administrators and targeted disease populations indicated in their initial development reports. Method: This study employed a scoping review approach. Up to July 31, 2021, five keywords, "dysphagia," "deglutition," "screening," "test," and "measure," were used to search databases such as CINAHL, Embase, PsycINFO, PubMed, and Web of Science. The initial development documents of the tools were included and examined to identify all dysphagia screening tools. Tools that had undergone validated reliability and validity testing were then compiled and categorized based on their suggested administrators and targeted disease populations. Their clinical utility was discussed based on their reliability and validity performance. Results: This study ultimately included 47 non-instrumental dysphagia screening tools that had undergone reliability and validity testing. The majority of these 47 tools were published after 2001, indicating a rapid growth in the research of related dysphagia screening tools. Most tools were developed for patients with neuromuscular disorders, accounting for 49% (23/47). On the other hand, patients/caregivers were the most common administrators, accounting for 45% (21/47). These 47 tools were used by various administrators, including physicians (7 tools), speech-language therapists (9 tools), nurses (8 tools), patients/caregivers (21 tools), and non-specified personnel (2 tools). The targeted disease populations encompassed eight different groups. Among them, the group with neuromuscular diseases, particularly stroke patients, had accessible screening tools regardless of who the tool administrator was. Regarding the reliability, validity, and psychometric properties, while 9 tools demonstrated satisfactory reliability and validity, certain tools remain encumbered by practical constraints. For instance, the Bedside Screening Tool for Dysphagia is available only in Italian, limiting its direct applicability in other language regions. Additionally, the Two-Step Thickened Water Test requires the use of a rotational viscometer to measure food viscosity, which diminishes its clinical feasibility. Furthermore, some of the 47 validated dysphagia screening tools exhibited poor psychometric properties, such as Dysphagia Trained Nurse Assessment, Dysphagia Disorder Survey, and Kubota Water Drinking Test, which might require further research to validate their screening performance. Conclusion: While a plethora of non-instrumental dysphagia screening tools and associated literature exists, only 47 tools were subjected to comprehensive reliability and validity testing upon their initial publication. Notably, access to validated screening tools varies across different disease populations. Even with fully established reliability and validity, certain tools are constrained by factors such as language variations, additional equipment needs, or suboptimal psychometric performance, subsequently diminishing their practical value in clinical settings. Therefore, the findings of this study can provide clinicians with valuable guidance in their selection of suitable dysphagia screening tools in the future.