Dysphagia (2023) 38:1224–1237

https://doi.org/10.1007/s00455-022-10547-w

ORIGINAL ARTICLE

A Systematic and Universal Artificial Intelligence Screening Method

for Oropharyngeal Dysphagia: Improving Diagnosis Through Risk
Management
Alberto Martin‑Martinez1,4 · Jaume Miró1,2 · Cristina Amadó1 · Francisco Ruz3 · Antonio Ruiz3 · Omar Ortega1,4 ·
Pere Clavé1,4

Received: 5 July 2022 / Accepted: 12 December 2022 / Published online: 28 December 2022
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022

Abstract
Oropharyngeal dysphagia (OD) is underdiagnosed and current screening is costly. We aimed: (a) to develop an expert system
(ES) based on machine learning that calculates the risk of OD from the electronic health records (EHR) of all hospital-
ized older patients during admission, and (b) to implement the ES in a general hospital. In an observational, retrospective
study, EHR and swallowing assessment using the volume-viscosity swallow test for OD were captured over 24 months in
patients > 70 yr admitted to Mataró Hospital. We studied the predictive power for OD of 25,000 variables. ES was obtained
using feature selection, the final prediction model was built with non-linear methods (Random Forest). The database included
2809 older patients (mean age 82.47 ± 9.33 yr), severely dependent (Barthel Index 47.68 ± 31.90), with multiple readmis-
sions (4.06 ± 7.52); 75.76% had OD. The psychometrics of the ES built with a non-linear model were: Area under the ROC
Curve of 0.840; sensitivity 0.940; specificity, 0.416; Positive Predictive Value 0.834; Negative Predictive Value 0.690; posi-
tive likelihood ratio (LH), 1.61 and negative LH, 0.146. The ES screens in 6 s all patients admitted to a 419-bed hospital,
identifies patients at greater risk of OD, and shows the risk for OD in the clinician’s workstation. It is currently in use at our
institution. Our ES provides accurate, systematic and universal screening for OD in real time during hospital admission of
older patients, allowing the most appropriate diagnostic and therapeutic strategies to be selected for each patient.

Keywords Dysphagia · Swallowing disorders · Machine learning · Aging · Screening methods · Diagnostics

Introduction

Definition, Demographic Data and Complications

Managing older patients is one of the most pressing chal-

lenges for healthcare systems. It is expected that by 2050,
* Alberto Martin‑Martinez one in six people will be over 65, while those over 80 will
amartinma@csdm.cat triple [1]. Oropharyngeal dysphagia (OD) is a symptom of
* Pere Clavé a swallowing disorder defined by the difficulty in forming
pere.clave@ciberehd.org or moving the alimentary bolus safely/effectively from the
1 oral cavity to the esophagus. OD is a condition recognized
Gastrointestinal Physiology Laboratory, CIBERehd
CSdM‑UAB, Hospital de Mataró, Universitat Autònoma de by the WHO [2] and classified in the International Clas-
Barcelona, Carretera de Cirera 230, 08304 Mataró, Spain sification Diseases (ICD) with codes 787.2 (ICD-9), R13
2
Fundació Salut Consorci Sanitari del Maresme, Mataró, (ICD-10) and MD93 (ICD-11). It has also been recognized
Spain as a geriatric syndrome by 2 European societies (European
3
IT Department, Consorci Sanitari del Maresme, Mataró, Society for Swallowing Disorders and European Union Geri-
Spain atric Medicine Society) [3]. OD is very prevalent among
4
Centro de Investigación Biomédica en Red de Enfermedades several phenotypes of patients: 38–78% in post-stroke,
Hepáticas Y Digestivas (CIBERehd), Barcelona, Spain between 18–28% in Parkinson disease, 47.5% in hospitalized

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A. Martin-Martinez et al.: A Systematic and Universal Artificial Intelligence Screening Method
older patients [4], 80% in Alzheimer [5], 85% in patients
with dementia admitted to an intermediate care hospital [6]
and rises to 91% in patients hospitalized with community-
acquired pneumonia (CAP) [7]. The main complications
of OD are malnutrition (MN) and dehydration, respiratory
infections such as aspiration pneumonia (AP), readmissions,
institutionalization and morbimortality, increased healthcare
costs and reduced quality of life [4, 8, 9]. The prevalence
of OD among patients over 65 years is comparable to that
of diabetes [10], although awareness is much lower despite
the fact that an estimated 30, 16 and 10 million European,
USA and Japanese citizens, respectively, suffered OD at the
beginning of the twenty-first century [11].
Appropriate management of OD is still a major chal-
lenge for healthcare systems and poor treatment can lead
to high rates of complications [4]. In addition, health-
economic studies have explored the costs associated with
OD, estimating that each undetected hospitalized patient
has an increased cost of 40.36% and length of hospital stay
of 8.42 days [12]. In a cost of illness study carried out at
the Mataró Hospital, OD was independently associated
with higher costs during hospitalization (p < 0.011) and at
3 months follow-up. Patients with dysphagia and malnour-
ished who suffer from respiratory infections had higher costs
compared to those without dysphagia at 12 months follow-
up (€19,817.58 vs. €7,242.8, p < 0.0004) [8].
Fig. 1  Diagnostic algorithm for oropharyngeal dysphagia: screening, clinical assessment and instrumental assessment. Team specialist of the
multidisciplinary team who performs the examination in Europe. ENT ear, nose, and throat medical doctor
1225
Diagnosis of OD—Three Steps (Screening, Clinical
Assessment and Instrumental Assessment)
The procedure to establish a diagnosis of OD consists of
three steps: (1) clinical screening, (2) clinical and (3) instru-
mental assessment (Fig. 1). The screening phase aims to
detect patients at risk of OD and need further clinical and
instrumental assessment. It should be quick, easy, cheap, low
risk, and applicable at the first line of care of older patients
admitted to healthcare centers by nurses or nursing assis-
tants without specific training in OD [3]. Depending on the
country, health professionals have different roles in the mul-
tidisciplinary team involved in the diagnostic and therapeutic
management of OD.
To date, the screening for OD consisted of a specific
anamnesis (swallowing difficulty, choking, cough during
meals, a sensation of residue in the pharynx, increased
mealtime and recent weight loss) and the use of specific
validated questionnaires that aim to screen for OD risk such
as: (1) EAT-10, a self-reported questionnaire on the symp-
toms associated with OD [13, 14]; (2) Sydney Swallowing
Questionnaire (SSQ), which assesses the severity of OD in
patients with OD; [15] and finally, (3) the Swallowing Dis-
turbance Questionnaire, a self-administered 15-item ques-
tionnaire on swallowing disturbances [16]. Failure to detect
patients at risk of OD by screening results in decreased rates
13
1226 A. Martin-Martinez et al.: A Systematic and Universal Artificial Intelligence Screening Method
of clinical and instrumental diagnosis, and increased clinical
risks and healthcare costs associated with undetected OD
[17]. Anamnesis’ results require time and patient knowledge
(normally unaware of their OD symptoms) and the involve-
ment of carers and relatives. Questionnaires and screening
tests have modest psychometric characteristics and are time-
consuming [18] and are seldom used in general hospitals
because: (a) nurses are not specifically trained to perform
them; (b) speech language therapist (SLTs) are usually not
available in the wards; and (c) awareness of OD among
healthcare professionals is still very low in many hospitals.
It is well known that older adults living within the commu-
nity admitted to acute hospitals and those living in a nursing
home may have undetected or underdiagnosed swallowing
impairments that are not systematically screened for [19].
If the screening process is positive, a clinical assessment
is carried out with the following elements: (a) specific swal-
low patient history, (b) assessment of cognition and com-
munication, (c) evaluation of oral, laryngeal, and pharyngeal
physiology, anatomy, and functioning with special focus
on cranial nerve examination, and (d) oral intake assess-
ment [20]. OD diagnosis aims to evaluate two deglutition
characteristics: (a) efficacy of swallow, the ability to ingest
the calories and fluid needed to be correctly nourished and
hydrated, and; (b) safety of swallow, or the capacity to take
fluids and food without risking respiratory complications.
The Volume-Viscosity Swallow Test (V-VST) is a clinical
diagnostic method we developed for the clinical diagnosis
of OD that uses an algorithm with different volumes and
viscosities to identify signs that affect swallowing efficiency
(such as lip seal, oral and pharyngeal residue) and also
swallowing safety (cough, wet voice, and oxygen desatu-
ration between 3 and 5%) [21]. When used by adequately
trained personnel, the V-VST showed a 93.17% sensitivity
and 81.39% specificity for the clinical diagnosis of OD; and
86.07 and 68.47% for the clinical diagnosis of impaired
safety of swallow [22]. The V-VST also identifies the opti-
mal bolus viscosity and volume needed for each patient [21].
The third phase, the instrumental assessment, consists of
the use of gold standard techniques to objectively evaluate
deglutition such as videofluoroscopy (VFS), fiberoptic endo-
scopic evaluation of swallowing (FEES), and more recently
high resolution pharyngo-oesophageal manometry associ-
ated with impedance [23–25]. These techniques detect OD
and assess the specific mechanisms of swallow dysfunction.
All of them enable us to understand the pathophysiology of
OD including aspiration mechanisms and alteration of safety
and swallowing efficiency in each patient (Fig. 1).
OD Underdiagnosis
OD affects several population groups causing serious com-
plications, however most patients are undiagnosed and
13
untreated [5, 26]. In a retrospective study where the rela-
tionship between OD and frailty was analyzed based on
the International Statistical Classification of Diseases and
Related Health Problems version 9 (ICD-9) in more than 6
million hospitalized North American patients over 50 years
of age, it was established that only 2.88% of them presented
OD, 4.44% being over 80 years of age according to hospital
discharge coding. [27]. It is well known that real prevalence
is much higher for example in hospitalized older patients
(47%) and those with community-acquired pneumonia
(55%–91.7%) and admitted for stroke (51%–78%) [5]. Many
patients are diagnosed when safety impairment leads to res-
piratory infections and pneumonia requiring hospitalization
[28]. A study of older patients with community-acquired
pneumonia found that 9 out of 10 patients had OD and sug-
gested it should be considered an independent risk factor for
developing this pathology [7]. Given the high prevalence
described, especially among the older age groups, we must
consider under-diagnosis both clinically and in the coding
of the pathology.
Risk Factors for OD in Older People
The pathophysiology of oropharyngeal dysphagia in older
people is characterized by an impairment of both biome-
chanical and neurophysiological swallow responses. The
first involves delayed times to laryngeal vestibule closure
and to upper esophageal sphincter opening, which leads
to a high prevalence of swallowing safety and efficiency
impairment signs, respectively [29]. The neurophysiologi-
cal alteration is characterized by a delay in the conduc-
tion and integration velocity of sensory inputs, reduced
activation of brain areas related to swallowing control
and decreased pharyngeal sensitivity [29–31]. Impaired
swallow function in older people is also associated to loss
of muscle mass and function (sarcopenia), a reduction of
tissue elasticity, changes in the cervical spine, reduction
of saliva production, poor dental status, reduced oral and
pharyngeal sensitivity, and reduced olfactory and gusta-
tory function [32]. Over the last 15 years, our group has
generated evidence that OD in the elderly is related to poor
functional status, frailty, sarcopenia, the severity of the
acute and chronic stroke, neurodegenerative pathologies
and dementia, nutritional status, and other comorbidities
and we found these factors are systematically repeated in
hospitalized, institutionalized and community-dwelling
elderly people with OD. [6, 28, 33–37]. Another relevant
factor is the effect of medication on deglutition as sev-
eral drugs have been related with impaired swallowing
function like antipsychotics, sedatives and neuroleptics,
particularly in older patients [38]. These and many other
potential risk factors for OD, such as age, fractures, surgi-
cal procedures, readmissions, and consultancy to primary
A. Martin-Martinez et al.: A Systematic and Universal Artificial Intelligence Screening Method
care or emergency rooms are recorded in the patient's elec-
tronic health records (EHR) through the ICD [39]and the
Anatomical Therapeutic Chemical (ATC) classification
system for drugs [40].
Artificial Intelligence and Machine Learning Based
on EHR Applied to Clinical Care
The creation of complex algorithms and the unstoppable
revolution in computing power has enabled the evolution
of a new branch of computer science, artificial intelligence
(AI). AI is not globally defined, but a good approximation
is offered by Andreas Kaplan and Michael Haenlein as”the
ability of a system to correctly interpret external data, to
learn from that data and to use that knowledge to achieve
specific tasks and goals through flexible adaptation”[41].
Machine learning is a branch of AI and can be defined as:
“A computer program is said to learn from experience with
respect to some class of tasks T and performance measure P,
if its performance at tasks in T, as measured by P, improves
with experience E” [42]. Machine learning has been used
in numerous fields. In the food industry, computer vision
techniques are used to assess the quality of foodstuffs [43].
Significant advances have also been made in natural lan-
guage, called Natural Language Processing [44]. Even in one
of today's notable challenges, climate prediction, machine
learning techniques are used because of the non-linear
dynamic complexity of the Earth and the high dimensional-
ity of observational data sets and models [45]. In medicine,
machine learning has been used to create classification mod-
els to detect and diagnose diseases [46]. Among the fields in
healthcare, some notable uses are: (a) personalized medicine
[47], (b) epidemiological analysis of large databases [48,
49], and (c) clinical decision support systems through the
development of classifiers that predict the risk of a patient
suffering or developing a disease [47, 50, 51].
Machine learning algorithms can be widely grouped
into linear and non-linear models [52]. Linear mod-
els predict a target variable based on linear relationships
between one or more predictors. The assumption of the
linear models is that the relationship between the target
variable yi and( the) predictors x(j is) given by the equation
yi = 𝛽0 + 𝛽1 𝜑1 x1 + ⋯ + 𝛽n 𝜑n xn + 𝜀i, where 𝛽j are coef-
ficients, 𝜑j may be a non-linear function and 𝜀i is an inde-
pendent noise term. Known examples are linear regression
[53] and logistic regression [54]. In contrast, non-linear
models can fit non-linear relationships between variables,
represented by yi = 𝜑i (x1 , x2 , ⋅ ⋅ ⋅, xn , 𝛽1 , 𝛽2 , ⋅ ⋅ ⋅, 𝛽j ) + 𝜀i .
Among non-linear models a widely used one is Random
Forest [55]. Predictive modeling, based on machine learning,
with EHR can lead to improvements in healthcare quality
and cost-effectiveness [56, 57].
1227
Aim of the Study
OD is rarely systematically screened despite its prevalence
and complications, and most hospitalized patients with dys-
phagia are not treated or even diagnosed. To prevent the
severe complications related to OD, an automatic and sys-
tematic tool is needed to help detect OD at an early stage and
to identify patients who are at high risk for OD and might
develop impaired safety of swallow. It should be remem-
bered that all patients suffering OD have the right to be
diagnosed and treated for this condition, and that healthcare
systems have the mission to provide the appropriate, simi-
lar and state of the art care to all these patients. The aim of
this study was to develop and implement an expert system
(ES) based on machine learning that calculates the risk of
OD from the EHR of all hospitalized older patients during
admission at the Mataró Hospital, and to assess its clinical
utility and psychometrics with linear and non-linear models.
Methods
Study Design
This was an observational, retrospective study where each
patient’s clinical information was captured from EHR
over the 24 months prior to the swallowing assessment.
The study was performed on older patients consecutively
admitted for acute diseases to Hospital de Mataró and its
intermediate care hospital (IMCH) Hospital St. Jaume i Sta.
Magdalena, of the Consorci Sanitari del Maresme (CSdM),
Spain, between 1st January 2013 and 31 December 2018.
The CSdM has a catchment area of 275,000 inhabitants and
makes more than 21,000 admissions per year. Both hospitals
work in coordination and have a total of 419 beds, of which
316 are for acute hospitalization and 103 for IMCH. Expert
nurses specifically trained performed the V-VST to deter-
mine the presence of OD and signs of impaired safety and
efficacy of swallow during hospitalization [22].
Workstation and Software to Collect all EHR
The software containing the EHR of the patients in the
CSdM is TESISHCE version 2022.1.0 (Nexus/sisinf S.L,
Sabadell, Spain). This software has been in use since 2012.
The anonymized clinical information is extracted from
TESISHCE and stored in.csv format for exploitation.
Database
In line with the published literature and our team's expert
knowledge of OD in older people, more than 25,000 poten-
tial variables were selected as being directly or indirectly
13
1228 A. Martin-Martinez et al.: A Systematic and Universal Artificial Intelligence Screening Method
related to OD. These consisted of the presence or absence
of pathologies described in patients’ EHR in the 24 months
prior to admission, examples being diabetes mellitus
(E08.0), cerebral vascular accidents (I63) and renal insuf-
ficiency (N18). Of those codes, only 279 were diagnosed
in our database. To account for dysphagia, we have used
the ICD code (R13) that were diagnosed as a result of the
test V-VST [21]. Additionally, we included the anatomical
therapeutic chemical codes (ATC) of dispensed medication
and sociodemographic variables, such are age, sex, hospital
readmissions during previous 2 years, and length of stay of
each hospitalization. Finally we accounted for other clini-
cal variables related to functionality and frailty, such as the
Barthel Index. Table 1 shows a summary of the variables
included in the ES.
Machine Learning Approach
This section explains the two main strategies presented in
this paper for predicting dysphagia: the linear and the non-
linear approach. In the first case, we used the traditional
procedure of finding independent risk factors of OD and
used those variables to create a logistic regression model to
predict the risk of OD [54]. In the non-linear case, we used
a purely data-driven approach. We selected the variables and
created a predictive model without any previous assumptions
of correlation and linearity, and only accounted for the com-
bination of them that led to higher performance metrics [58].
Data Pre‑Processing
The database was split randomly into two datasets, one for
training and one of testing. The training had 20% of the orig-
inal database (582 cases) and the training kept 80% (2326
cases). The split was done ensuring that the prevalence of
OD was as similar as possible in both datasets. Regarding
the categorical variables, those with a ratio between the
most common and the second most common value of 95
to 5 were discarded. Variables with a prevalence smaller
than 10% were also discarded. For categorical variables with
more than two values, we encoded them into binary dummy
Table 1  Variables used in the Data type
study
Demographic data
Diagnosis codes
Validated scales and indexes
Administrative data
Dispensed medication
ICD indicates international code of diseases; N depicts the number of variables included in the algorithm
13
variables. Numerical variables were standardized for linear
and logistic regression.
Linear Model
For the linear model, starting from the processed database,
we selected risk factors for OD through a bivariate corre-
lation analysis. We used the Chi-square test to assess the
relationship of different categorical variables or the Fisher’s
exact test for small sample sizes, i.e., if any expected value
in the contingency tables was smaller than five. For the con-
tinuous variables, we used Student's t-test when the distribu-
tion was normal and homoscedastic. However, in the case of
normality but heteroscedasticity, we used Welch's correction
and Mann–Whitney’s U test when normality could not be
ensured. To find independent OD risk factors, we built a
logistic regression with variables that had a significant cor-
relation with OD (p-value < 0.05), except those that were not
clinically relevant according to our expertise. Finally, vari-
ables with a significant coefficient in the logistic regression
were used to build the final linear model.
Non‑Linear Model
For the non-linear model, we used a Random Forest. Before
the training, we performed a feature selection step: we used
a recursive feature elimination algorithm based on random
forests to find the combination of predictive variables which
led to higher accuracy [59]. The idea behind the algorithm
consists in creating a large sample of models through boot-
strap and recursive feature steps to find a model with high
performance and keep the variables used to build it. We used
this model to assemble an ES, as described in subsection
Artificial Intelligence Massive Screening—Oropharyngeal
Dysphagia (AIMS-OD).
Evaluation Metrics
To quantify the predictive performance of machine learning
algorithms for detecting the risk of OD in the study popula-
tion, we used area under curve receiver operating charac-
teristics (AUC ROC) [60], sensitivity [61], specificity [61],
Description N
Sex and age 2
ICD-10 codes 279
Functionality and frailty scores 12
Admissions, readmissions and medical visits to emergency 3
room
Medication potentially associated with dysphagia 22
A. Martin-Martinez et al.: A Systematic and Universal Artificial Intelligence Screening Method
positive predictive value (PPV) [62], negative predictive
value (NPV) [63] and positive and negative likelihood ratio
(LHR) [63].We discarded other standard metrics such as
Cohens Kappa, due to their pitfalls for machine learning
models [64] (See Fig. 2)
Statistical Analysis
We have used the bivariate analysis described in the linear
model section to estimate the risk factors for OD.
Artificial Intelligence Massive Screening—Oropharyngeal
Dysphagia
We built the ES, called AIMS-OD, after performing experi-
ments using the processed database to establish the best
model between linear and non-linear.
Technical Issues and Implementation AIMS-OD was cre-
ated as a service for acute hospitals, rehabilitation centers,
and nursing homes to measure the risk of suffering from
dysphagia based on anonymised data (age, sex, Barthel
Index, ICD code, …). In countries with a personal EHR for
each citizen such as in Catalonia, Spain, it can also estimate
the risk for OD in all the population with an EHR including
primary care centers. The risk estimation service is offered
through an application programming interface (API) or web
Fig. 2  Graphical representation of under-screening of oropharyngeal
dysphagia among hospitalized older people leading to underdiagnosis
of this condition
1229
API, which enables any center that has an individualized
EHR to ask for their patients’ risk of OD. The web ser-
vice offered has some steps and implications: (a) first the
healthcare center anonymizes the clinical data from EHR
and sends a query through the HyperText Transfer Protocol
Secure (HTTPS) using JavaScript Object Notation (JSON)
international standard; (b) our API receives the query and
checks the authorisation of the user (hospital, rehabilitation
center, etc.) and whether it contains the required fields and
security (c) finally, the API sends the query to the internal
ES which predicts the risk of OD. The risk is returned as a
number between 0 and 1, to the consultant healthcare center
via HTTPS (Fig. 3). The ES is composed of a patented
algorithm that uses non-linear machine learning methods to
predict the risk of OD. The ES and the API are built using
open-source software and are fully scalable, as the system
includes several API-based microservices. This architecture
enables an immediate response to any number of consulting
hospitals.
Innovation, Valorization and Intellectual Property The
technology transfer process for the ES started in 2019 with
the participation in the Mentor in Health Innovation Pro-
gram (Consorci Sanitari del Maresme—TecnoCampus;
https://​mentor.​csdm.​cat/). Subsequently, the innovation was
chosen for participation in two accelerator programs during
2020, StartHealth (TecnoCampus; https://​www.​tecno​cam-
pus.​cat/​en/​accel​eracio-​de-​negoc​is/​progr​ama-​start​health),
and Caixa Impulse Validate (“LaCaixa” Research Foun-
dation; https://​funda​cionl​acaixa.​org/​es/​convo​cator​ia-​caixa​
resea​rch-​valid​ate-​descr​ipcion-​progr​ama). Researchers have
received training and mentoring in these several programs
to help validate assets and define a valorisation plan. This
project has been awarded the Creative Awards for the best
business initiative in technology and innovation in 2021.
Finally, in 2022, AIMS-Medical S.L. was created, the spin-
off to which the asset has been licensed to bring it to the
market. AIMS-OD, is the subject of an international patent
application—PCT/ES2020/070723; OEPM-P201931028—
with a priority date of November 2019
Ethical and Legal Considerations
The study was conducted following the recommendations
contained in the Declaration of Helsinki, the WHO recom-
mendations, and current Spanish legislation. The Ethics
Review Board of Hospital de Mataró approved the study
protocol (code 40/17). The hospital's Information Technol-
ogy Department carried out irreversible anonymization after
the data was transferred and the ES does not store any query
information once the risk is returned. Following the Regu-
lation (EU) 2016/679 of the European Parliament and of
the Council of 27 April 2016 on the protection of natural
13
1230 A. Martin-Martinez et al.: A Systematic and Universal Artificial Intelligence Screening Method
Fig. 3  Graphical representation of the process of sending, receiving
and answering the query (what is the risk of OD of each hospital-
ized patient?) by the hospital and the prediction server. This banner
has been designed with resources from Flaticon.com IT information
persons concerning the processing of personal data and the
free movement of such data, we performed a Data Protec-
tion Impact Assessment (DPIA) [65]. It was approved by the
data protection officer of the Catalan Department of Health,
resulting in “low risk” of data processing for individuals
in the use of new technologies, nature, scope, context and
purpose of the processing.
Results
Demographic, Clinical Characteristics and Swallow
Capacity of Patients Included in the Database
The expert database includes 2809 patients, 1539 (54.79%)
women, with a mean age of 82.47 ± 9.33. Of these, 1459
(51.97%) were admitted to the acute hospital and the rest
to an intermediate care hospital. Older patients included in
the database have a high prevalence of comorbidities. Main
diagnoses were chronic respiratory disease (25.45%), dia-
betes mellitus (22.96%), chronic kidney disease (21.72%),
neurodegenerative diseases (19.01%) and cerebral vascu-
lar accident (18.55%). The majority of individuals showed
severe dependence (61.30% Barthel Index 21–60, with a
mean score of 47.66 ± 31.89). The main clinical character-
istics of the sample are presented in Table 2.
According to the V-VST, 2,128 (75.76%) of patients
showed clinical signs of OD, 1,740 (81.76%) presented
efficacy impairment, 1,464 (68.80%) safety impairment,
and 1,082 (50.85%) suffered both. Of the individuals who
had OD, only 824 (38.72%) could swallow liquid viscosity
(< 50 m.Pa.s) safely, and 1,115 (61.28%) required thickened
products, 699 (32.85%) with medium viscosity (250 m.Pa.s)
13
technology; Icd International code disease; JSON javascript object
notation; HTTPS hypertext transfer protocol secure; AI artificial intel-
ligence
and 446 (20.95%) needed high viscosity (> 800 m.Pa.s). The
most prevalent sign of impaired efficacy of swallow was
oropharyngeal residue, present in 512 (24.06%) at medium
viscosity and 587 (27.54%) at high viscosity.
Main Risk Factors Associated with OD
The primary health conditions and pathologies significantly
associated with OD after a bivariate analysis in the database
study sample were old age (p < 0.0001) , poor functional
status (p < 0.0001), chronic kidney pathology (p < 0.0001),
neurodegenerative disease (p < 0.0001), delirium (p <
0.0001), chronic respiratory disease (p = 0.0098), diabe-
tes mellitus (p < 0.0001) and malnutrition (p < 0.0001)
(Table 2). In addition, older people with OD showed more
acute hospital admissions in the previous 24 months (p =
0.0178) and a higher rate of bronchoaspirations (p < 0.0001)
and lower tract respiratory infections (LTRI) (p = 0.0181)
than those without OD. No significant differences were
observed in the rates of diagnosis of pneumonia between
the two groups (Table 2).
Machine Learning Approach for Predicting Risk
of OD
The linear model is composed of 31 variables that showed
statistical significance after bivariate analysis. After multi-
variate analysis and logistic regression only age remained
significant. This ES showed AUCROC of 0.734 (95% CI
0.713—0.755), with a sensitivity of 0.964, specificity of
0.191, PPV of 0.788, and NPP of 0.628 to detect OD in our
database.
A. Martin-Martinez et al.: A Systematic and Universal Artificial Intelligence Screening Method 1231

Table 2  Clinical conditions Total OD NO OD p-value

of database sample and
comparison between individuals N % (n) 2809 75.76 (2128) 24.24 (681) –
with and without dysphagia
Sex (Female) % (n) 54.79 (1539) 55.03 (1171) 54.04 (368) p = 1.000
with the information recorded in
the EHR for the 2 years prior to Age (Years) mean ± SD 82.47 ± 9.33 83.38 ± 8.51 79.61 ± 11.05 p < 0.0001
the V-VST clinical assessment Acute admissions previous 24 months 4.06 ± 7.52 4.39 ± 7.96 3.02 ± 5.81 p = 0.0178
mean ± SD
Functional capacity (Barthel) 47.66 ± 31.89 43.49 ± 30.81 60.77 ± 31.73 p < 0.0001
Independent (100–95) %(n) 12.14 (341) 8.22 (175) 24.38 (166) p < 0.0001
Mild dependence 26.52 (745) 25.42 (541) 29.96 (204) p < 0.0001
(94–60) % (n)
Severe dependence 61.30 (1,722) 66.31 (1411) 45.67 (311) p < 0.0001
(< 60) % (n)
Swallowing evaluation (V-VST)
Efficacy impairment % (n) 81.76 (1,740) – –
Safety impairment % (n) 68.80 (1,464)​ – –
Acute respiratory events
Bronchoaspiration % (n) 4.34 (122) 5.22 (111) 1.62 (11) p < 0.0001
LTRI % (n) 12.64 (355) 13.20 (281) 10.87 (74) p = 0.0181
Pneumonia % (n) 1.28 (36) 1.32 (28) 1.17 (8) p = 1.000
Comorbidities
Heart disease % (n) 13.24 (372) 13.44 (286) 12.63 (86) p = 1.000
Chronic hepatopathy % (n) 5.27 (148) 5.64 (120) 4.11 (28) p = 0.1388
Chronic kidney disease 21.72 (610) 23.31 (496) 16.74 (114) p < 0.0001
% (n)
Cerebrovascular disease 18.55 (521) 18.56 (395) 18.50 (126) p = 1.000
% (n)
Neurodegenerative disease 19.01 (534) 21.66 (461) 10.72 (73) p < 0.0001
% (n)
Delirium % (n) 16.30 (458) 18.66 (397) 8.96 (61) p < 0.0001
Chronic respiratory disease % (n) 25.45 (715) 26.83 (571) 21.15 (144) p = 0.0098
Diabetes mellitus % (n) 22.96 (645) 23.73 (504) 20.56 (140) p < 0.0001
Malnutrition % (n) 11.78 (331) 12.55 (267) 9.40 (64) p < 0.0001

Bold values indicate statistical differences (p-values)

OD indicates oropharyngeal dysphagia; V-VST, volume-viscosity swallow Test; LTRI, lower tract respira-
tory infection

The non-linear model or ES uses 103 variables. After

selecting the variables and building the prediction model
with Random Forest, we achieved the AUCROC of 0.840
(95% CI: 0.829–0.867), with a sensitivity of 0.940, specific-
ity of 0.416, PPV of 0.834, and NPP of 0.690 (Fig. 4).
When comparing the psychometrics between both ES we
found statistically significant differences in several param-
eters: AUCROC (p < 0.0001), sensitivity (p = 0.0464), speci-
ficity (p < 0.0001), PPV (p < 0.0001) and NPV (p < 0.0001).

ES Risk Management Capacity

The resultant ES allows the user (hospital management) to
decide the OD risk thresholds to be displayed to develop
strategies for risk management, both in diagnosis and thera-
peutic approach. As shown in Table 3, as the user increases
Fig. 4  ROC curves of the linear and non-linear models to detect OD
with respect to the V-VST findings. Blue curve depicts the AUCROC
of the linear model (multivariate logistic regression analysis) and the
red curve depicts the AUCROC of the non-linear model (Random
Forest)

13
1232 A. Martin-Martinez et al.: A Systematic and Universal Artificial Intelligence Screening Method

Table 3  Psychometrics of ES according to the several risk cut-offs The result can be seen in several computer systems, such as
between 0.3 and 0.8 the EHR, the drug prescription and administration software
Pre-defined Sensitivity Specificity PPV NPV and the diet prescription software (Fig. 5).
risk

0.3 0.975 0.182 0.788 0.701

0.4 0.964 0.231 0.796
0.5 0.950 0.304 0.810
0.6 0.923 0.413 0.831
0.7 0.847 0.565 0.859
0.8 0.665 0.752 0.893
PPV indicates positive predictive value; NPV negative predictive
value
the risk threshold, showing those patients at higher risk of
OD, the specificity and PPV increase. As the user lowers the
risk threshold, showing all patients at risk, sensitivity and
NPV increase. The ability to pre-determine the risk thresh-
old enables the ES user to adapt the sensitivity and speci-
ficity of the system according to the needs and resources
available at any given time leading to an increase in the
number of at-risk patients detected as well as increasing the
cost-efficiency of each new case.
Utility and Feasibility ES Properties
As described in methods, the ES automatically screens all
patients admitted in both our acute and intermediate care
hospital with 419 beds in 6 s, and provides the risk of each
patient at the clinician’s workstation. The ES allows the
consulting hospital to query as many times as they want
by providing real-time data. It shows a color-coded alert
with icons and the individual’s risk is green when low risk
(< 0.45), orange when medium risk (0.46–0.70) and red
when high risk (> 0.71). The CSdM pilot implementation
performs an hourly query on all inpatients. After weeks of
implementation, the ES is stable in determining risk, with
a daily percentage of high risk patients of 10.55% ± 0.61;
medium risk, 45.43% ± 2.14, and low risk, 44.02% ± 2.22.
0.671
Discussion
0.661
The main result of this study is that it is possible to develop
0.631
an ES that provides accurate, systematic and universal
0.542
screening for OD in real time during hospital admission of
0.418
all older patients admitted to a general hospital, allowing the
most appropriate diagnostic and therapeutic strategies to be
selected for each patient. Our study describes the process
used to develop this ES. Information from the EHR of 2807
patients was used, taking into account up to 25,000 variables
during the training and feature selection process. Based on
Random Forest for both feature selection and training, the
best model provides an AUCROC of 0.840 and allows the
systematic screening of a 400 + bed general hospital in 6 s.
Therefore AIMS-OD fits the qualities for screening tools
in older patients with OD: easy to use, quick, inexpensive,
accurate, without risk for the patient, and usable by care
providers without specific knowledge of OD [3]. The com-
bined strategy of massive screening with AIMS-OD, clinical
diagnosis with V-VST, and therapeutic management of older
patients with dysphagia with minimal/optimal massive inter-
ventions could be a paradigm shift in providing universal
clinical care for all older patients with OD.
For many years, we have developed studies assessing the
risk factors for OD in older persons [28]. We also identified
these risk factors in our ES training database, as we observed
that individuals with OD compared to those without OD
were significantly older, had more hospital readmissions,
worse functional capacity, neurodegenerative pathologies,
and delirium as well as a higher rate of malnutrition. These
data have also been described in the scientific literature by
several authors and corroborate that the learning database
used by AIMS-OD to establish the risk of OD describes
the reality of older hospitalized patients with OD. [4, 6, 28,
33–36, 66]. Regarding complications related to impaired

Fig. 5  Information shown on

the clinicians' workstation, with
a value between 0 and 1. This
banner has been designed with
resources from Flaticon.com. IT
information technology

13
A. Martin-Martinez et al.: A Systematic and Universal Artificial Intelligence Screening Method
swallow safety, we observed that OD was significantly asso-
ciated with a higher rate of broncho-aspirations and LTRI
in our sample, as previously described by Almirall et al. in
a similar sample of older patients [7]. In contrast to what
was expected, OD patients had a similar rate of pneumonia
to those without OD. The term pneumonia collected in the
EHR in the 24 months prior to the V-VST assessment of the
study sample is composed of a set of up to 46 CIM10 codes,
including CAP, pneumonia of viral origin and also AP. Most
of these respiratory infections are not related to OD. AP
occurs when there is radiological evidence of pulmonary
condensation caused by the entry of oropharyngeal secre-
tions contaminated by pathogenic bacteria into the bronchial
tree in patients with swallow dysfunction [67]. It has been
estimated that up to 50% of older patients with OD will
present an oropharyngeal aspiration, and from those, 50%
will develop an AP with an associated mortality of up to
50% [68].
The EAT-10 developed and validated by Belafsky et al.
suggests that with this screening tool for OD, a score equal
to or higher than 3 points can be considered a positive result
[13]. Later, Rofes et al., by setting the cut-off point at 2 or
more points, showed an AUCROC of 0.89 with outstand-
ing sensitivity and specificity (0.85 and 0.82, respectively)
when studying a population with a prevalence of OD of 87%
[17]. Other studies found the EAT-10 demonstrated good
discriminant ability to accurately identify ALS penetrator/
aspirators (PAS ≥ 3) with a cut off score of 3 (AUC: 0.77,
sensitivity: 88%, specificity: 57%) [69]. The SSQ also has
good sensitivity and specificity for detecting OD in differ-
ent aetiologies (0.73 and 0.793, respectively) [16]. Despite
their good psychometrics, the added value of AIMS-OD lies
in the ability to screen a large number of patients in a few
seconds, thus, universalizing OD screening by detecting
those patients who should be clinically assessed for OD.
This increases efficiency in carrying out clinical tests like
the V-VST by a healthcare professional in patients with a
positive screening. Unlike self-administered tests, our sys-
tem does not require any participation of healthcare staff or
patients or their caregivers, an advantage given the difficulty
of communication that can exist with older patients and, on
many occasions, with neurodegenerative pathologies. More-
over, being a machine learning-based technology, each new
case and each new clinical or instrumental evaluation will
improve the predictive capacity of the model.
Other authors have conducted studies developing predic-
tive models based on machine learning to detect patients at
risk for OD prior to hospitalization. Lienhart et al. developed
a predictive model based on information collected from the
medical records of more than 33,000 hospitalized individu-
als. Those who during the study period had had an ICD-10
codification for dysphagia (R13) or AP (J69) (n = 12,068)
were determined to be positive. As a control group, those
1233
who did not have these codes in the electronic medical
record were randomized and selected (n = 21,716). The best
model chosen by the authors was the Random Forest, which
was fed by clinical variables (ICD-10, procedures, labora-
tory data, nursing protocols, etc.) demographic variables
(age, sex), and medication related to dysphagia. It presented
an AUCROC of 0.94 with a sensitivity and specificity of
0.88 [70]. However, given the existing under-diagnosis and
under-coding of OD and AP, relying exclusively on ICD-10
to determine the presence or absence of the condition can
easily lead to false negatives and false positives. This under-
diagnosis is shown in the study by Cohen S et al., which
describes only 4.44% of hospitalized patients over 80 years
of age in North America had diagnosis codes related to OD
in their EHR [27]. This prevalence differs greatly from that
described by Cabré et al. (47%) [28] in hospitalized older
people. It is also very far from that described by Martino in
patients with acute (51–55%) and chronic (25–45%) stroke
[71]. In both cases, the evaluation of swallowing was per-
formed by clinical examination. Our ES takes as a reference
for OD diagnosis the clinical evaluation carried out using
the V-VST clinical test to establish a clinical diagnosis of
OD, which presents sensitivity and specificity of 0.93 and
0.81, respectively [22]. Taking as a reference for training and
modeling patients clinically evaluated allows us to get closer
to determining true positives and negatives.
We believe that the solution to the under-diagnosis
of OD in hospitalized older patients is the combination
of AIMS-OD system screening with clinical assessment
using the V-VST (93.17% sensitivity and 81.39% spec-
ificity) in patients at risk for OD [22]. The V-VST has
high diagnostic sensitivity and high PPV to detect OD,
impaired safety, and aspirations (including silent aspira-
tions), clearly showing a high discriminating ability [21,
22]. In a recent systematic review, we found that more
than a decade from its description and initial validation
by our team [21], the V-VST is now used internationally
for clinical screening and clinical diagnosis of OD, to
select the most appropriate bolus volume and viscosity in
patients with OD, to determine the prevalence of the con-
dition, and to assess the clinical outcome and the effect of
treatments applied to patients with OD. The two reviews
included in this manuscript showed very good psychomet-
ric properties of the V-VST for OD and impaired safety
and efficacy of swallow, and good reliability when applied
by trained and experienced professionals [22]. The V-VST
should be administered by trained healthcare profession-
als at all medical facilities and can be repeated according
to the natural progression of the disease. With the use
of AIMS-OD, nurses, who spend most of their time with
the patient, and physicians will have real-time informa-
tion to determine the patients who are at high risk for OD
and should be prioritized, explored with the V-VST and
13
1234 A. Martin-Martinez et al.: A Systematic and Universal Artificial Intelligence Screening Method
receive treatment for OD. Treatment in older hospitalized
patients following diagnosis is feasible and well defined
with minimal-massive interventions (MMI) aimed at treat-
ing the maximal number of patients with cost-effective and
simple interventions such as fluid and texture adaptation,
nutritional supplementation, and oral hygiene [66]. A pilot
study with the MMI concluded that the functional and
nutritional status of patients who received the interven-
tion improved and there was a reduction in hospital read-
missions, LTRI incidence, and mortality after 6 months
follow-up versus the control group without the MMI.
Recently we have improved the MMI and developed the
optimal massive intervention (OMI) (Clinical trial identi-
fier NCT04581486) by intensifying nutritional support by
providing patients with recipes, video recipes, and culi-
nary training, explaining step by step how to make triple
adapted diets (rheological, caloric-protein, and organolep-
tic) for patients with OD. Oral nutritional supplements
are also included for patients with poor nutritional status.
Regarding oral hygiene improvement in the OMI, profes-
sional dental cleaning is proposed during admission and
in the first month of follow-up, as well as personalized
recommendations to patients and caregivers (Clinical trial
identifier NCT04581486). The combination of AIMS-OD,
V-VST and OMI offers a feasible and effective treatment
solution for all hospitalized patients with OD (Fig. 6).
Finally, AIMS-OD allows risk management for the
screening of OD. AIMS-OD gives the clinician a risk
value between 0 and 1. Once installed in the hospital EHR,
the ES allows healthcare managers to pre-determine the
risk boundary at which to highlight, for example, high-
risk patients and make decisions by adjusting sensitivity
and specificity for patient detection. They will have the
option to improve the diagnosis process efficiency by: (a)
detecting the same number of patients with fewer clinical
tests; or (b) detecting a higher number of patients with OD
with the same clinical tests. This proposal for systematic
screening, clinical assessment with V-VST, and treatment
with MMI will allow many hospitalized older patients with
OD to be identified, treated through cost-effective policies
and to democratize the diagnosis and treatment of this
Fig. 6  Proposed diagram with the combination of a systematic screening tool, clinical assessment and compensatory treatment for all older peo-
ple with oropharyngeal dysphagia admitted to a healthcare center. AIMS-OD artificial intelligence massive screening—oropharyngeal dysphagia
13
highly prevalent condition. Moreover the use of our ES
will help reduce OD-associated complications, improve
patient quality of life and reduce healthcare-associated
costs [8].
Limitations
In general, in cases where the information on frailty and
functionality of patients was not recorded in the EHR, the
model presented difficulties in predicting OD. Not having
the validation of the ES vs the gold standard for diagnosis
of OD was also a limitation in predicting the risk of this
condition. Ideally, in order to improve the tool's sensitiv-
ity and specificity, the individuals in the training database
should have been more evenly distributed between those
with and without swallowing disorders, as the population
included in the database of the study presented a high
prevalence of OD (75.74%). In an ideal situation, this
population should mimic the clinical and demographic
characteristics of the population where the screening sys-
tem will be used [60]. Finally, although the study sample
was from an acute and an intermediate care hospital, the
population was collected from a single healthcare institu-
tion, and there may be a bias in the management and clini-
cal outcomes of these patients.
Future Work
Although the ES uses the V-VST to determine whether
or not the patient has OD, an improvement on previous
evidence-based diagnostic coding, clinical validation
of AIMS-OD against the gold standard for OD diagno-
sis (VFS or FEES) is necessary as the next step for the
validation of the system. In addition, once it has been
implemented in an acute and intermediate care hospital,
the impact of the improved diagnostic process on: (a) the
number of patients diagnosed; (b) the clinical outcomes of
patients, and (c) the healthcare costs of hospital admission
in older patients with OD should be evaluated. In addi-
tion, incorporating new variables, in particular those of a
A. Martin-Martinez et al.: A Systematic and Universal Artificial Intelligence Screening Method
non-linear nature, and an incremental number of patients
into the database will enable continuous improvement of
the AIMS-OD prediction model. It will also be neces-
sary in the future for professionals to be trained in the use
of clinical decision support systems in standard clinical
practice.
Conclusions
In this study, an ES with good psychometric characteristics
has been developed and implemented in the information
systems of a general hospital. This software, AIMS-OD,
provides systematic and universal screening for OD in real
time during hospital admission, allowing the most appropri-
ate diagnostic and therapeutic strategies to be selected for
each patient. The results of this screening process are used to
select and prioritize patients at high risk for OD to undergo
the V-VST for clinical diagnosis and subsequent treatment
with OMI for OD [Clinical trial identifier NCT04581486].
As a result, more OD patients will be diagnosed and treated
and thus, we believe there will be a reduction in the main
complications associated with the disease (malnutrition, AP,
and mortality), an improvement in the quality of life of hos-
pitalized older patients with dysphagia and an amelioration
of healthcare-associated costs.
Acknowledgements We would like to thank the IT Department of the
Consorci Sanitari del Maresme for their support and collaboration dur-
ing the study. We thank Mrs Jane Lewis for reviewing the English of
the manuscript.
Author contributions AMM, JM, PC: conceptualization. AMM, JM,
PC: methodology. JM, CA: formal analysis and investigation. AMM,
JM: writing—original draft preparation. OO, PC: writing—review
and editing. AMM: funding acquisition. FR, AR: resources. PC:
supervision.
Funding Financial support received from: a) The Acadèmia de Cièn-
cies Mèdiques de Catalunya i Balears, filial del Maresme, b) by the
Centro de Investigación Biomédica en Red en el Área de Enfermedades
Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, c)
The project leading to these rules has received funding and support
from “la Caixa” Foundation, under the CaixaImpulse Grant (CI20-
00158), d) The Territorial Competitiveness Specialization Project
(PECT) of Mataro-Maresme (PRE/161/2019) financed by the Govern-
ment of Catalunya-Generalitat de Catalunya within the framework of
the European Regional Developments Funds of Catalonia Operational
Program 2014–2020 and Strategic Plan for Research and Innovation
in Health (PERIS), Generalitat de Catalunya (intensification grant of
AM; SLT017/10/000219).
Declarations
Conflict of interest The authors declare no financial conflicts of inter-
est.
1235
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Alberto Martin‑Martinez MD, PhD
Pere Clavé MD, PhD
13