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Validity and Reliability of the Eating Assessment Tool (EAT-10)

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Annals of Otology. Rhinology A Laryngology ll7(l2):9l9-924.
© 2008 Annals Publishing Company. All rights reserved.

Validity and Reliability of the Eating Assessment Tool (EAT-10)

Peter C. Belafsky, MD, PhD; Debbie A. Mouadeb, MD; Catherine J. Rees, MD;
Jan C. Pryor, MA; Gregory N. Postma, MD; Jacqueline Allen, MBChB, FRACS;
Rebecca J. Leonard, PhD

Objectives: The Eating Assessment Tool is a self-administered, symptom-specific outcome instrument for dysphagia.
The purpose of this study was to assess the validity and reliability of the lO-item Eating Assessment Tool (EAT-10).
Methods: The investigation consisted of 4 phases: 1) line-item generation, 2) line-item reduction and reliability, 3) nor-
mative data generation, and 4) validity analysis. All data were collected prospectively. Internal consistency was assessed
with the Cronbach alpha. Test-retest reliability was evaluated with the Pearson product moment correlation coefficient.
Normative data were obtained by administering the instrument to a community cohort of healthy volunteers. Validity was
assessed by administering the instrument before and after dysphagia treatment and by evaluating survey differences be-
tween normal persons and those with known diagnoses.
Results: A total of 629 surveys were administered to 482 patients. The internal consistency {Cronbach alpha) of the final
instrument was 0.960. The test-retest intra-item correlation coefficients ranged from 0.72 to 0.91. The mean {±SD) EAT-
10 score of the normal cohort was 0.40 ± 1.01. The mean EAT-IO score was 23.58 ± 13.18 for patients with esophageal
dysphagia, 23.10 ± 12.22 for those with oropharyngeal dysphagia, 9.19 ± 12.60 for those with voice disorders, 22.42 ±
14.06 for those with head and neck cancer, and 11.71 ±9.61 for those with reflux. The patients with oropharyngeal and
esophageal dysphagia and a history of head and neck cancer had a significantly higher EAT-10 score than did those with
reflux or voice disorders {p < 0.001). The mean EAT-IOscoreof the patients with dysphagia improved from 19.87 ± 10.5
to 5.2 ± 7.4 after treatment (p < 0.001).
Conclusions: The EAT-10 has displayed excellent internal consistency, test-retest reproducibility, and criterion-based
validity. The normative data suggest that an EAT-10 score of 3 or higher is abnormal. The instrument may be utilized to
document the initial dysphagia severity and monitor the treatment response in persons with a wide array of swallowing
disorders.
Key Words: data collection, dysphagia, outcome assessment, quality of life, questionnaire, survey, swallowing, SWAL-
QOL.

INTRODUCTION lem with their doctor.** In stroke patients, the preva-

lence of dysphagia exceeds 50%, and it may be as
Dysphagia, or difficulty swallowing, is associated
high as 84% in patients with Parkinson's disease.^-'^
with significant morbidity and mortality. Swallow-
Other causes of dysphagia include head and neck
ing disorders have profound social, emotional, and
cancer, neuromuscular diseases, gastroesophageal
socioeconomic implications.'""^ Persons with dys-
reflux disease, and primary esophageal abnormali-
phagia are more likely to be anxious and depressed.'*
ties {including motility disorders and Zenker's di-
More than 40% of persons with dysphagia experi-
verticulum [ZD]).
ence panic or anxiety during meals, causing them
to eat in isolation.^ The disorder is underrecognized The majority of dysphagia research has focused
by most clinicians and is frequently underreported on disease pathophysiology, diagnosis, and thera-
by patients."^ In a survey of 947 adults in 12 family py.^' A paucity of the current literature is dedicated
medicine office waiting rooms in Georgia, 22.6% to outcome assessment and quality of life in those
reported problems swallowing that occurred at least persons afflicted with swallowing problems. There
several times per month, and only 46.3% of the re- is need for a patient-centered outcome measure that
spondents with dysphagia had discussed the prob- incorporates not only the physiologic implications
From the Center for Voice and Swallowing, Department of Otolaryngology-Head and Neck Surgery, University of California-Davis,
Sacramento, California (Belafsky. Mouadeb, Rees. Pryor. Allen, Leonard), and the Center for Voice and Swallowing Disorders, Depart-
ment of Otolaryngology-Head and Neck Surgery, Medical College of Georgia, Augusta, Georgia (Postma).
Presented at the meeting of the Atnerican Broncho-Esophagological Association, Orlando, Florida, May 1-2, 2008.
Correspondence: Peter C. Belafsky. MD, PhD, Center for Voice and Swallowing, Dept of Otolaryngology, University of Califomia-
Davis. 2521 Stockton Blvd. Suite 7200, Sacramento. CA 95825.

919
920 Belafsky et ai Eating Assessment Tool
of dysphagia, but also the emotional, social, and
psychological consequences.
The SWAL-QOL is a symptom-specific outcome
instrument that was developed to assess the sever-
ity of oropharyngeal dysphagia."''^ The instrument
consists of 44 items and can be cumbersome to com-
plete. Because of this limitation, the instrument has
not been widely accepted into clinical practice. In a
survey of 200 speech pathologists in California who
treat dysphagia, none of the respondents indicated
that they used the SWAL-QOL regularly (Belafsky.
unpublished data). Reasons cited included the length
of time required for the patient to complete the sur-
vey and for the clinician to score the survey. Other
attempts to develop quality-of-Iife measures and/or
symptom surveys have either focused on a certain
subset of dysphagic patients (such as the M. D. An-
derson Dysphagia Inventory IMDADI] for head and
neck cancer patients) or are too cumbersome for cli-
nicians to readily score and utilize expeditiously in
the clinic.1^1-^
There remains a clinical need for a rapidly admin-
istered and easily scored dysphagia instrument that
can be administered on each patient visit in order to
assess symptom severity, quality of life, and treat-
ment efficacy. The sur\'ey should be applicable to a
broad range of dysphagic patients, including those
with both oropharyngeal and esophageal phase dys-
phagia. The purpose of this study was to assess the
validity and reliability of a comprehensive dysphagia
outcome instrument designed to meet these clinical
needs: the Eating Assessment Tool (EAT-10).
MATERIALS AND METHODS
Approval to conduct this investigation was grant-
ed by the Institutional Review Board at the Univer-
sity of California-Davis. All data were collected
prospectively and coded and recorded into SPSS
11.0 for Macintosh (SPSS Inc. Chicago. Illinois).
The study consisted of 4 separate phases.
Phase J: Line Item Generation. A multidisci-
plinary group of dysphagia experts was assembled to
construct the original survey instrument. The group
consisted of gastroenterologists. otolaryngologists,
speech-language pathologists, and nutritionists.
Each clinician was asked to review the dysphagia
literature, draw from his or her own clinical experi-
ence, examine other dysphagia questionnaires, and
contribute 10 questions he or she deemed to have
excellent face validity to the original survey. All
items were arranged in a 5-point Likert scale. The
group of clinicians then met in committee to review
all of the generated questions. Redundant line items
were removed. A list of 35 questions was then short-
ened by open ballot voting to produce the original
20-item Eating Assessment Tool (EAT-20).
Phase 2: Line Item Reduction and Reliahility
Analysis. To assess single line item test-retest re-
producibility. we administered the EAT-20 on 2
separate occasions to normal controls and to per-
sons with previously diagnosed voice or swallow-
ing disorders. One hundred healthy persons with no
past medical history of voice, swallowing, reilux,
airway, neurologic, rheumatologic. hématologie,
or neoplastic disorders were administered the sur-
vey on 2 separate occasions separated by at least 24
hours. The survey was also given to a large cohon
of persons with voice and swallowing disorders (n
= 235) on 2 separate occasions separated by at least
24 hours. Internal consistency was assessed with the
Cronbach alpha. Test-retest reliability was evalu-
ated with the Pearson product moment correlation
coefficient. Inter-item correlations were utilized to
evaluate line item redundancy. The 10 most redun-
dant and poorly reliable items were removed from
the survey instrument, and the lO-item Eating As-
sessment Tool (EAT-10) was derived.
Phase 3: Normative Data Generation. Norma-
tive data were obtained by giving the instrument to
a community cohort of 100 healthy volunteers with
no medical history of voice, swallowing, reflux, air-
way, neurologic, rheumatologic, hématologie, or
neoplastic disorders. The mean total symptom sur-
vey score plus 2 SD of this normal cohort was con-
sidered the upper limit of normal for the EAT-10.
Phase 4: Validity Analysis. The EAT-10 was ad-
ministered to a cohort of 46 individuals before and
after treatment. Criterion-related validity was as-
sessed by comparing pretreatment and posttreat-
menl EAT-10 survey results with the paired-samples
/-test. EAT-10 scores were also compared between
diseased and normal populations with the indepen-
dent samples /-test. A Bonferroni correction (ct/n)
was used to adjust for the evaluation of multiple
comparisons.
RESULTS
Phase J: Line ¡tern Generation. The original
EAT-20 devised by the multidisciplinury panel is
displayed in Table 1. AH items were deemed to have
excellent face validity on committee open ballot vot-
ing. The internal consistency of the original EAT-20
was excellent (Cronbach alpha = 0.947).
Phase 2: Line item Reduction and Reliability
Analysis. The single intra-item test-retest correla-
tions ranged from 0.38 to 0.91 for all questions on
the EAT-20 (Table 2). The inter-item correlations
 Belafsky ei al. Fating Assessment Toiil 921

TABLE I. EATING ASSESSMENT TOOL (EAT-20)

Circle the appropriate response.
To what extent are the following scenarios problematic for you? 0 =: No problem 4 . - Severe problem
1. My swallowing problem has caused me io lose weight. 0 1 ~\ 3 4
2. My swallowing problem interferes with my ability to go out for meals. 0 1 2 3 4
3. My swallowing problem interferes with my work or oihcr activities. 0 1 2 3 4
4. Swallowing liquids takes extra effort. 0 1 2 3 4
5. Swallowing solids takes extra effort. 0 1 2 3 4
6. Swallowing pills lakes extru effort. 0 1 2 3 4
7. I have altered my diet because of my swallowing problem. 0 1 2 3 4
8. Swallowing is painful. 0 1 T 3 4
9. T^c pleasure of eating is affected by my su allowing. 0 1 -} 3 4
10. When 1 swallow f(x>d sticks in my tlintat. 0 1 2 3 4
11. When I swallow food sticks in mychesl. 0 1 3 4
12. I L'oujzh when I cat. 0 1 T 3 4
13. I am afraid to eat because of my swallowing problem. 0 1 T 3 4
14. My swallowing problem is a burden to my family. 0 1 -> 3 4
15. I get tired when 1 eat. 0 1 -> 3 4
16. I avoid eating in front of people. 0 1 T 3 4
17. I am afraid of choking in my sleep. 0 1 T
3 4
18. I become short of breath when I eat. 0 1 1
3 4
19. People perceive me as sick because of niv SWLIHOU ing problem. 0 I T 3 4
20. Swallowing is stressful. 0 1 1 3 4
T(ïtal EAT-20

ranged from 0.16 to 0.87. The 10 least reliable and cients of the EAT-10 indicated that the instrument is
most redundant items were removed from the instru- highly reproducible; they ranged from 0.72 to 0.91.
ment to devise the EAT-10 (Table 3). The line item
reduction improved the internal consistency (Cron- Phase 3: Normative Data Generation. The mean
bach alpha) of the survey instrument from 0.947 to (±SD) age of the normal population (n= 100) was 48
0.960. The test-retest Intra-item correlation coeffi- ± 16 years. Fifty-three percent of the subjects were
TABLE 2. INDIVIDUALTEST-RETEST LINE ITEM MEASURES FOR EAT-20
EAT-20 Survey Question Correlation Coefficient
1. My swallowing problem has caused me to lose weight. 0.848
2. My swallowing problem interferes wiih my ability io go oui for meals. 0,911
3. My swallowing problem interferes wiih my work or other activities. 0.866
4. Swallowing liquids takes extra effort. 0.845
5. Swallowing solids takes extra effort. 0.786
6. Swallowing pills takes extra effort. 0.880
7. I have altered my diet because of my swallowing problem. 0.797
8. Swallowing is painful. 0.861
9. The pleasure (if eating is affected hy my swallowing, 0.860
10. When 1 swallow food sticks in mv throat. 0.858
11. When I swallow food sticks in my chest. 0.383
12. I cough when I eat. 0.724
13. I am afraid to eat because of m\ sw;ilU>\\ing problem. 0.689
14. My swallowing problem is a burden to my family. 0,691
15. I get tired when I eat. 0.750
16. 1 avoid eating in front of people. 0.816
17. I am afraid of choking in my sleep. 0.780
18. I become short of breath when I eat. 0.727
19. People perceive me as sick becuuse of my swallowing problem. 0.653
20. Swallowing is stressful. l>.799
Total EAT-20 Ü.958
922 Belafsky et al. Eating Assessment Tool
TABLE 3. EATING ASSESSMENT TOOL (EAT-10)
Circle the appropriate response.
To what extent are the following scenarios problematic for you?
1. My swallowing problem has caused me to lose weight.
2. My swallowing problem interferes with my ability to go out for meals.
3. Swallowing liquids takes extra effort.
4. Swallowing solids takes extra effort.
5. Swallowing pills takes extra effort.
6. Swallowing is painful.
7. The pleasure of eating is affected by my swallowing.
8. When I swallow food sticks in my throat.
9. I cough when I eat.
10. Swallowing is stressful.
male. The mean EAT-10 score for the normal cohort
was 0.40 ± 1.01. The mean plus 2 SD yielded an
upper limit of normal for the EAT-10 score of 2.41.
The normative data suggest that an EAT-10 score of
3 or higher (mean + 2 SD) is abnormal.
Phase 4: Validity Analysis. The instrument was
administered to a ¡arge cohort of 235 individuals
with voice and swallowing disorders. The mean age
of this cohort was 62 ± 14 years. Fifty-four percent
were male. Sixty-six patients (28%) had reflux dis-
ease, 51 (22%) had a voice disorder, 50 (21%) had
a known source of oropharyngeal dysphagia, 42
(18%) had a history of head and neck cancer, and 26
(11%) had a known cause of esophageal phase dys-
phagia. The oropharyngea! dysphagia group consist-
ed largely of persons with a history of stroke or pro-
gressive neurologic disease such as Parkinson's dis-
ease, amyotrophic lateral sclerosis, or pseudobulbar
palsy. The group with esophageal phase dysphagia
included those individuals with esophageal motility
disorders, neoplasia, webs, strictures, or rings. The
mean EAT-10 score was 11.71 ±9.61 for those with
reflux disease, 9.19 ± 12.60 for those with a voice
disorder, 23.10 ± 12.22 for those with oropharynge-
al dysphagia, 22.42 ± 14.06 for those with a history
of head and neck cancer, and 23.58 ±13.18 for those
with esophageal phase dysphagia (Fig 1). The EAT-
Fig 1. Mean Eating Assessment Tool (EAT-10) scores
stratified by diagnostic category.
0 = No problem 4 = Severe problem
0 1 2 3 4
0 1 2 3 4
0 I 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
Total EAT-10
10 score was similar in individuals with oropharyn-
geal and esophageal dysphagia and in those with a
history of head and neck cancer (p > 0.05). Persons
with oropharyngeal and esophageal dysphagia and
a history of head and neck cancer had signiflcantly
higher EAT-10 scores than those with reflux or voice
disorders (p < 0.001 ). There was no difference in the
EAT-10 score between those with a voice disorder
and those with reflux disease (p > 0.05). The EAT-
10 scores of all of these diagnostic categories were
significantly higher than the normative data in the
healthy community cohort (p < 0.001).
The EAT-10 was given to 46 persons who were
undergoing treatment for dysphagia. The mean age
of this cohort was 65 ± 16 years. Fifty-flve percent
were female. Twenty-three patients (50%) had a di-
agnosis of ZD, 14 (30%) had a diagnosis of pH- or
endoscopy-proven reflux disease, and 9 (20%) had
a diagnosis of esophageal stricture. All persons witb
ZD underwent endoscopie diverticulotomy. Per-
sons with reflux disease underwent treatment with
once- or twice-daily proton pump inhibitors, and
those with an esophageal stricture underwent esoph-
ageal dilation with a balloon or bougie. The mean
pretreatment EAT-10 score was 19.87 ± iO.5. This
improved signiflcantly, to 5.2 ± 7.4, after treatment
(p < 0.001). All variables on the EAT-10 showed a
highly significant improvement with intervention,
indicating excellent criterion-based validity (Fig 2).
Patients with reflux disease had a mean improve-
ment in EAT-10 score of 9.6 ± 11.2, those with ZD
had a mean improvement of 16.4 ± 7.1, and those
with an esophageal stricture had a mean improve-
ment of 18.6 ± 6.2 (p < 0.001 ). AU of these improve-
ments remained signiflcant after adjusting for the
number of tests performed (adjusted Bonferroni a =
0.0125). Patients treated for a stricture and ZD dis-
played greater improvement on the EAT-10 than did
those treated for reflux disease (p < 0.05). This dif-
ference was not signiflcant with the adjusted a.
 Belafsky et al, Eating Assessment Tool
35-
30- • Before Ireatmenl
• After treatment
25-
20-
1
1 n
L to bolus flow measurements as assessed retrospec-
•
15-
10-
5-
0- • the SWAL-QOL provides "independent but comple-
Reflux Stricture Zenker s
Fig 2. Mean reduction in EAT-10 scores stratified by
clinical diagnosis.
DISCUSSION
Dysphagia is simply difficulty swallowing. It is
a symptom, not a disease. Patients with the symp-
tom of dysphagia can have a vast array of clinical
diagnoses, ranging from mild acid reflux to terminal
esophageal cancer. Because dysphagia is a symp-
tom, it is essential that the clinician be able to docu-
ment the severity of a patient's self-perception of the
disability caused by the swallowing problem. The
EAT-10 is a self-administered survey instrument for
the subjective assessment of dysphagia. Normative
data suggest that an EAT-10 score of 3 or greater
is abnormal. The instrument has displayed excellent
internal consistency, test-retest reproducibility, and
criterion-based validity. The EAT-10 has been uti-
lized in our center to document initial dysphagia se-
verity and to monitor response to treatment in per-
sons with a wide range of swallowing disorders.
Other dysphagia inventories were developed and
validated before the EAT-10. None of these instru-
ments are in widespread clinical use. The SWAL-
QOL was developed to assess quality of life and out-
comes in patients with oropharyngeal dysphagia.""'-^
The final version of the SWAL-QOL (and its partner
instrument, the 15-item SWAL-CARE, which was
designed to assess patient-perceived quality of care)
was developed from an initial 185-item survey ad-
ministered by mail to 106 dysphagia patients." This
group was primarily male (76%), with a mean age
of 67.9 years. The initial survey took an average of
56 minutes to complete. The survey length was re-
duced by 50% and then administered by mail to 386
patients with known oropharyngeal dysphagia, pri-
marily from a US Veterans Administration hospital
population. From this work, the final versions of the
SWAL-QOL and SWAL-CARE were developed. Al-
though this important work is to be commended, the
923
43-item SWAL-QOL is lengthy and time-consuming,
so it is somewhat burdensome to use in the average
clinical setting.!^ The SWAL-QOL uses a 5-point
scale, with different instructions to the patient for dif-
ferent sections of the survey, and a lower score indi-
cates a worse quality of life.
The authors of the SWAL-QOL also compared it
tively on videofluoroscopy in the same 386 patients
used for the validation studies.''' The SWAL-QOL
correlated modestly to most bolus flow measure-
ments; oral transit time and total swallow duration
had the best correlation. The authors concluded that
mentary" information about the dysphagic patient's
experience.
The MDADI was designed to assess dysphagia-
related quality of life in patients with head and neck
cancer.'•* With the recent focus on organ preserva-
tion in head and neck cancer treatment, there is a
need for clinicians to better understand the various
aspects of quality of life. ' ^ The MDADI incorporates
3 domains (emotional, functional, and physical), as
well as 1 global question. This 20-item instrument
is shorter than the SWAL-QOL. but scoring is still
complicated, witb 2 questions being scored contrary
to the others. A lower score indicates a worse qual-
ity of life. This instrument was validated on 100 pa-
tients with head and neck cancer, and test-retest reli-
ability was assessed on 29 patients.
Wallace et al^^ developed a 17-item survey in-
strument designed to assess symptom severity in pa-
tients with oropharyngeal dysphagia. This was vali-
dated on 45 patients with oropharyngeal dysphagia
and 11 patients with ZD. In the ZD group, the instru-
ment was able to demonstrate an average of 70% im-
provement in scores after treatment. Tbe maximum
possible score on this inventory is 1,700, with worse
symptom severity indicated by a higher score. This
instrument has not been adopted into widespread
use, primarily because it is based on a visual analog
scale, which makes scoring difficult.
The validity and reliability of the EAT-10 has
been demonstrated in a large cohort of patients with
a wide variety of causes of dysphagia. Tbe instru-
ment is not limited to oropharyngeai dysphagia or
to patients with bead and neck cancer. The develop-
ment and validation methods are similar to those of
other accepted patient-administered surveys, such
as the Voice Handicap Index-10.'^"23 j ^ g survey is
rapidly administered and can be completed in less
than 2 minutes. The instrument is worded in a man-
ner that makes it simple to total. There are no sub-
scales to address, no visual analog scale to measure.
924 Belafsky et al, Eating Assessment Tool
and no formulas required to calculate a raw score.
The clinician only needs to add up the numbers. An
elevated EAT-10 score indicates a higher self-per-
ception of dysphagia. Tbe omission of specific do-
mains precludes the stratiflcation of subset disabil-
ity into social, emotional, and functional categories.
We think that this limitation is offset, however, by
the test's simplicity, ease of administration and scor-
ing, and utility in persons with a wide range of dys-
phagia causes.
Future research is necessary to replicate these
findings in a diverse sample of persons with a va-
riety of causes of dysphagia. Evaluation of EAT-10
data across age groups is necessary to ensure that the
normative data are valid for both young and elder-
ly populations. Normative data should also be con-
firmed across categories of socioeconomic status.
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