Fiberoptic endoscopic evaluation of swallowing in German stroke units: a retrospective diagnosis-related group analysis (2019-2024).

Abstract

Background: Fiberoptic Endoscopic Evaluation of Swallowing (FEES) is a safe and effective tool for post-stroke dysphagia assessment. The German Stroke Organization implemented FEES quality benchmarks for stroke unit certification in 2025. This study establishes baseline data on FEES implementation across German stroke units.

Methods: A retrospective analysis of national diagnosis-related group data (2019-2024) was performed. We analyzed data on cases with stroke unit treatment, examining coding of FEES, dysphagia, and PEG placement, and their relationships with stroke type, institutional service level, and patient demographics.

Results: A total of 1,540,947 cases with stroke unit treatment were analyzed across the six-year study period. FEES procedures were coded in 2.7% of cases, increasing from 2.4% (2019) to 3.1% (2024). FEES coding was more common in cases with intracerebral hemorrhage (5.7%) and ischemic stroke (3.4%). Dysphagia was coded in 13.3% of cases, with higher rates in intracerebral hemorrhage (28.5%) compared to ischemic stroke (16.4%). Cases treated in comprehensive stroke units coded FEES procedures (3.6%) more frequently than regional (2.5%) and basic stroke units (1.5%). Sex-based disparities emerged: cases with males were coded with FEES more often (3.1%) than females (2.4%), despite dysphagia being documented more frequently among cases with females (males 13.0%, females 13.8%). The proportion of cases with documented dysphagia among those coded with FEES was 76.2% and remained stable throughout the study period, suggesting broadly consistent case selection.

Conclusion: Documentation of FEES among cases with stroke unit treatment has increased but remains substantially below the dysphagia documentation rates, suggesting room for broader implementation. Sex-based disparities in FEES documentation need further investigation. Institutional factors impact documentation rates, indicating a need for tailored quality benchmarks by stroke service level. Improving reimbursement, staff training, and streamlined workflows could enhance access to FEES in German stroke units.