I really love videofluoroscopy. The value of being able to visualise a swallow (instead of making what at times feels like large inferences at bedside) should not be understated.
It is a procedure that I often find myself advocating for and getting frustrated when access to it is limited.
It is however undoubtedly a resource intensive procedure which is being requested in the context of an ever-stretched health service. It requires access to a clinic room with specialist equipment, sufficiently trained SLTs and radiographers, and ample time for the whole process, from referrals to the clinic room to report writing.
With Greener AHP week upon us I have been wondering what the role of VF is in a sustainable healthcare system.
I definitely don’t have the answer but want to suggest how as a profession we could use the lens of the triple bottom line to consider its role and raise further questions we need to ask.
According to Sus QI framework, sustainable value is the value for patients and populations divided by the environmental, social and financial impacts.
The value of VF for patients and populations lies in having the reassurance of a diagnosis and management plan based on the most objective assessment available. Much has been written (more eloquently) about this and I wonder which of our outcome measures are best suited to capture this (I dare say they may be different according to caseload).
The financial impact is clearly greater than a bedside assessment. I hazard that several services have got costings but it would be interesting to have greater transparency nationwide re what these may be, especially in comparison to bedside assessments.
Beyond this, is data being collected on the value of VF in supporting patient flow, referrals and discharges? Often I have seen that a VF can help pinpoint more appropriate referrals and identify more concretely who does not need further SLT. Furthermore it would be great if there were evidence re impact on aspiration -related healthcare costs (though I appreciate just how methodologically messy and difficult this is to capture).
The social impact may lie in increasing awareness as to importance of dysphagia management and the value of SLT. Yet again, I am sure there are other quantifiable measures that could be considered.
Lastly, what is the carbon footprint of a VF? There have been some recent studies re the carbon footprint of different radiological procedures which perhaps we could lean on. Environmental considerations should include the energy (which may vary according to how a Trust is sourcing its energy) as well as contrast agents. There are some newer studies looking at the contamination of water supply by iodinated contrast materials such as iohexol (aka omnipaque). Whilst it may pail in the scale of NHS plastic use, disposable items such as cups and spoons, should also be accounted for.
I am focusing on VF because it is a procedure extremely relevant to my caseload but the process of analysing sustainable value is one that could be applied to many other clinical processes. It would be great to have more holistic reference points in discussions about service management.
If there are any other SLTs who are wanting to explore this, please do get in touch.
Hi Sivan
I lead the VFS service for Oxfordshire and am very interested in this - would be great to explore it further! I also have a consultant radiographer colleague who is very interested in sustainability.
Sam
Hi Sivan, great post!
Since becoming interested in sustainability and it's impact on our profession, I have definitely found myself referring fewer patients for VF, for many of the reasons you listed above, but agree that it remains a really valuable tool. Since attending cervical auscultation training, I use this a lot more. It's far from perfect and doesn't give the same level of information as a VF, but in some cases I find it the better option - for sustainability, patient acceptance and timeliness of assessment/intervention.
Hi Iona
Really interesting point re. the issue over timeliness of access in particular.
My understanding of and approach to decarbonising clinical pathways / interventions is that there needs to be a point of equipoise before sustainability can be the determining factor in the choice of which intervention is provided. As far as I know, the sensitivity and specificity of CA is far poorer than that of videofluoroscopy, hence there is no equipoise. If CA were chosen over VFS purely in view of its carbon footprint, this could potentially have implications for the wider carbon footprint of a patient's dysphagia care i.e. if someone was not identified as silently aspirating (because they were assessed through CA instead of a VFS) and developed aspiration-related complications resulting in a prolonged hospital stay, or someone who was provided with ineffective swallow rehabilitation exercises as these hadn't been evaluated sufficiently under fluoroscopy, opting for CA over VFS could actually be a 'false economy' in terms of trying to decarbonise this part of our clinical pathway. But equally, if you have a patient languishing on a ward awaiting a videofluoroscopy slot, that also has implications for the carbon intensity of their bed days etc. It's so complex!
I personally feel there is great scope in terms of ways that we can optimise the referral, triaging and performance of videofluoroscopy - as Sivan said, it's a carbon intensive procedure, and we should be following the principles of 'choosing wisely' alongside with ALARP and sustainable practice in the way that we utilise this resource. Hopefully we can get some good discourse going on these issues as we start to consider the way forward.
Please log in or sign up to comment.