**7. The integrated clinical evaluation**

The instrumental criterion of severity (endoscopic or radiological) needs to be contextualised according to a more general clinical criterion of severity, of the patient and of the swallowing disorder, considering that the non-instrumental assessment tends to underestimate the risk of aspiration, whereas the instrumental assessment tends to overestimate it [45].

It is therefore a relative criterion, which is identified through its parametrization. In clinical practice, aspiration is the most significant event that marks a swallowing disorder, yet it is not the only one. It is worth considering that during an instrumental assessment, we check the outcome of a very low number of swallowing acts, compared to the number of swallowings that are performed, for instance, during a meal or a whole day. It should be considered that many variables affect the successful outcome of pharyngeal transit of a bolus (Table 3). Swallowing patterns may be modified in real time in response to the functional status of swallowing effectors, in their turn related to sensation, volume, consistency and position of the bolus in the mouth when the pharyngeal reflex is elicited.

In 2008 [46], in a perspective study, the P-score and the P-SCA score (Table 6) were applied to a sample of 556 consecutive patients (inpatients and outpatients, 318M/238F, mean age 65.56±10.36 years), seen at our Swallowing Centre.

The correlation between the two tests was determined by the Spearman correlation coeffi‐ cient. The agreement between the two scores has been calculated (Cohen's Kappa) consider‐ ing the categories of risk corresponding to the totalized scores (no dysphagia, mild, moderate, severe). The categories of risk individualized with the two scores have been stud‐ ied with the aim to underline possible systematic divergences in the attribution of the se‐ verity to the cases. Subsequently, the P-score and the P-SCA score were dichotomized, dividing the patients without risk from those with middle and high risk of aspiration. By the comparison of the dichotomic scores with the result of the FEES evaluation (considered as gold standard), the values of sensitivity and specificity have been obtained.

The results of this study documented a close correlation between the P-score and P-SCA score (rho=0.88) (Table7): The correlation is significant (p<0,001).

The agreement among the scores as regards the categories of risk attributed results discrete (Cohen's Kappa=0,46 p <0,001).

**Table 7.** Correlation between P-score and P-SCA score

The double Table 8 shows how the two scores have classified the patients in the different categories of risk.


**Table 8.** Double table comparing the P-score and the P-SCA score and the classification of risk.

The table shows that the P-SCA score tends to "increase" the severity in the category with lower risk, while in those with higher risk it tends to be more cautious, attributing a category with lower severity in comparison to P-score. Overall the patients classified as at risk of aspiration by the P-score are 50%, while the P-SCA score considers at risk 67% of the patients. Comparing the two scores it is shown that the P-SCA score tends to have a lower value than the P-score (Wilcoxon signed-rank test p<0.001) (Table 9).


**Table 9.** P-score and P-SCA score and risk of aspiration

In 2008 [46], in a perspective study, the P-score and the P-SCA score (Table 6) were applied to a sample of 556 consecutive patients (inpatients and outpatients, 318M/238F, mean age

The correlation between the two tests was determined by the Spearman correlation coeffi‐ cient. The agreement between the two scores has been calculated (Cohen's Kappa) consider‐ ing the categories of risk corresponding to the totalized scores (no dysphagia, mild, moderate, severe). The categories of risk individualized with the two scores have been stud‐ ied with the aim to underline possible systematic divergences in the attribution of the se‐ verity to the cases. Subsequently, the P-score and the P-SCA score were dichotomized, dividing the patients without risk from those with middle and high risk of aspiration. By the comparison of the dichotomic scores with the result of the FEES evaluation (considered as

The results of this study documented a close correlation between the P-score and P-SCA

The agreement among the scores as regards the categories of risk attributed results discrete

Lowess smoother

0 5 10 15 P-SCA

The double Table 8 shows how the two scores have classified the patients in the different

gold standard), the values of sensitivity and specificity have been obtained.

score (rho=0.88) (Table7): The correlation is significant (p<0,001).

(Cohen's Kappa=0,46 p <0,001).

84 Seminars in Dysphagia

0

categories of risk.

bandwidth = .8

**Table 7.** Correlation between P-score and P-SCA score

5

10

Pscore

15

65.56±10.36 years), seen at our Swallowing Centre.

The judgement expressed by the scores has been dichotomized setting the cut-off point between patients without risk and those with any kind of risk, with the purpose of comparing the evaluation of the scores with the result of the FEES (gold standard) regarding "aspiration" and to get for both, values of sensibility and specificity.

The P-score has reached values of sensibility of 96% and specificity of 60%, with an area underlying the ROC curves of 0.78, while the P-SCA score has reached values of sensibility of 98% and specificity of 40%, with an area underlying the ROC curves of 0.69. With such dichotomization, the P-SCA score recognizes more patients at risk, resulting more sensitive than the P-score, but also less specific (more false positive).

In conclusion, the assessment of patients with deglutition disorders has to consider as many elements as are available from the clinical and instrumental evaluation (integrated clinical evaluation).

The possibility of an instrumental evaluation sharpens the diagnostic precision with margins of error that vary for every procedure, but with the possibility of over estimating the risk of aspiration. In fact, patients with higher risk according to the P-score are attributed by P-SCA score to lower risk categories. Both have a high sensibility to individualize patients with a risk of inhalation from minimum to high. Nevertheless, the P-score is more specific, more skilled in recognizing the false positive and therefore more reliable in correctly classifying patients without dysphagia and patients with a risk of any degree of dysphagia.

In other words, while in patients considered without risk by the P-score, the clinical variable considered by the P-SCA-score increases the evaluation of the risk, in patients classified by Pscore in the categories of higher severity, the evaluation of such clinical variables tends to mitigate the judgement expressed by the P-score and to put back patients into the categories with lower risk.

The association of endoscopy and elements of the CSE in the evaluation of the severity of dysphagia, tends to mitigate the gravity of the clinical case, allowing a more careful estimate in a routine clinical context.
