# Mapping neurogenic dysphagia diagnostics in Germany: accessibility, implementation practices, and barriers to swallowing endoscopy

## TL;DR

This study maps the availability and challenges of swallowing endoscopy for neurogenic dysphagia in Germany, highlighting regional disparities and barriers to outpatient access.

## Contribution

The study provides the first nationwide analysis of FEES implementation and accessibility in Germany, identifying systemic barriers and regional disparities.

## Key findings

- FEES is primarily conducted in acute hospitals and rehabilitation clinics but is limited in outpatient settings.
- Geospatial analysis revealed significant regional disparities in FEES accessibility, especially in rural and eastern Germany.
- Insufficient reimbursement and lack of online visibility hinder equitable access to outpatient FEES services.

## Abstract

Flexible Endoscopic Evaluation of Swallowing (FEES) is a core diagnostic tool in neurogenic dysphagia. Despite a structured national training curriculum in Germany, little is known about current implementation practices and outpatient accessibility. This study mapped nationwide FEES practice patterns, workforce structures, and geographic access, and identified barriers to comprehensive service provision.

A nationwide web-based survey was conducted among certified FEES instructors in Germany. The survey assessed provider characteristics, implementation practices, diagnostic–therapeutic integration, and perceived systemic barriers. In parallel, institutional websites were screened for publicly advertised outpatient FEES services and geocoded for travel-time isochrone analyses.

Eighty-two instructors completed the anonymous survey (response rate 52.6%). FEES was predominantly delivered in acute hospitals (74%) and rehabilitation clinics (46%) and embedded within interdisciplinary workflows. Outpatient availability remained limited (54%), with most institutions lacking statutory reimbursement pathways; additionally, many existing outpatient services were not visible to patients online. Geospatial analysis revealed substantial regional disparities, particularly in rural and eastern regions, with only a minority of residents able to reach a publicly identifiable outpatient FEES provider within 30 min. Procedural experience varied widely, and higher monthly FEES volumes were associated with shorter examination duration (r = − 0.27, p = 0.020).

FEES is well implemented in German inpatient dysphagia care but structurally underdeveloped in the outpatient sector. Insufficient reimbursement, workforce shortages, and lack of transparency significantly impede equitable access. Strengthening outpatient infrastructure, establishing sustainable reimbursement mechanisms, and improving national visibility of services are critical steps toward ensuring continuity of dysphagia care.

The online version contains supplementary material available at 10.1186/s42466-026-00473-9.