FAQ

Below you will find an overview of the frequently asked questions on the PG-SGA© and the Pt-Global app©.
Please contact us at info@pt-global.org or by completing the contact form if you have any other question(s).

1. Can I use the PG-SGA© in clinical practice?

Yes. The PG-SGA© has been used clinically in several settings – inpatient, outpatient, homecare, and hospice. The use of the same tool in all settings provides a consistent means of identifying patients with malnutrition and measuring outcomes of nutrition intervention, as patients move through the spectrum of health care delivery systems. What is gained in each of these settings can be quite different, but can have a positive impact on clinical outcomes and potentially healthcare costs.

► Inpatient: If the patient is hospitalized and has pre-existing weight loss on admission, it is important to think about intervention (nutritional and/or symptom management) rather than waiting until the patient has a complication or an extended hospitalization. Even more important, patient assessment should be carried out at diagnosis already, to be able to prevent nutritional status from (further) deterioration.

In 2003, Mobley et al., US Army, Walter Reed Medical Center, Washington DC (abstract ADA) reported that the PG-SGA was the single best predictor of clinical outcomes in terms of length of stay for hospitalized medical, surgical or oncologic patients (n=63). Assessment were performed within 48 hours of admission and patients were followed until discharge.

Trained dietetic professionals performed a PG-SGA© with additional assessments including anthropometric measurements (height, weight, triceps skin fold and mid-arm circumference); calculation of body mass index, percent usual body weight, percent desirable weight, and mid-arm muscle circumference; handgrip strength by hand dynamometry and standard laboratory values such as albumin, hematocrit, hemoglobin, blood urea nitrogen, and creatinine. Data were analyzed using stepwise multiple linear regression models (significance, P<0.05).

The results from this study indicated that PG-SGA© is the single best predictor of length of stay and the authors suggested that based on the findings from the study that the PG-SGA© may be a valuable screening tool to identify those patients who may require intensive medical nutrition therapy, especially in hospital settings where laboratory data is limited and/or unavailable. Additionally, that early nutritional intervention in those patients with increased PG-SGA scores may lead to better clinical outcomes.

The relationship between the PG-SGA© and clinical outcome, as well as quality of life has been confirmed in several studies thereafter (e.g. Bauer et al., 2002; Isenring et al., 2003; Campbell et al., 2008; Shahmoradi et al., 2009; Laky et al., 2010; Capuano et al., 2010; Zalina et al., 2012; Esfahani et al., 2013; Citak et al., 2013; Malihi et al., 2013; Mohammadi et al., 2013).

► Outpatient: This has been widely used as a method of streamlining patient flow through clinic with the benefit of efficient and consistent assessment of weight and weight history; food intake; symptoms (often referred to as nutrition impact symptoms) and functionality of performance status. In many clinics that patient completes the PG-SGA© while in the waiting room or patient room, with the medical team able to spend their limited time spent with the patient addressing the identified issues rather than spending the time asking questions.

► Homecare: The same benefits can be achieved in this setting but also may help to either identify at risk patients or help to transition from hightech (parenteral or enteral) nutrition to oral.

► Hospice: Particularly important is the aspects of standardized, patient self-reported symptoms and quality of life in the context of functionality, weight and nutrition.

2. Can I use the PG-SGA© in research?

Yes. The PG-SGA© provides a consistent means of identifying patients with malnutrition and measuring outcomes of nutrition intervention. The PG-SGA© has been used extensively in multiple different patient populations and settings. During the past two decades, the PG-SGA and its Short Form (PG-SGA SF© or abridged version) has been the basis for almost 200 publications and scientific presentations; multiple masters and doctoral theses and dissertations; book chapters; and educational programs and has been formally translated, as well as reviewed for accuracy by professionals, and used broadly worldwide.

Please note: the PG-SGA© and its subcomponent known as the PG-SGA Short Form© (PG-SGA SF, Boxes 1-4), as well as the Pt-Global app©, are copyrighted and registered instruments, and permission is needed from Faith Ottery, MD, PhD, prior to any and all use outside of patient clinical care. See also FAQ #6.

3. In which populations can the PG-SGA© be used?

In the original study of the scoring in 1996, patient population was not limited to oncology patients, although they were the predominant group (Lung, Prostate, Colon, NHL, Rectal, Esophageal, Melanoma, Cervical), but included patients with End stage Renal Disease and Diabetes Mellitus as well.

Subsequently, results have been published or reported using the PG-SGA in the following patient populations: Cancer (lung, GI – general or gastric, esophageal, gastroesophageal, rectal colorectal), head and neck, gynecological, urological, acute leukemia, multiple myeloma, hematologic stem cell transplantation); Stroke; HIV; Parkinson’s Disease; Geriatrics; Chronic Kidney Disease; Hemodialysis; Radiotherapy or Chemoradiotherapy; General study; others.

The use of the same tool in different populations provides a consistent means of identifying patients with malnutrition and measuring outcomes of nutrition intervention, as patients move through the spectrum of health care delivery systems. In addition, results between the different populations can be compared with each other.

4. In which health care settings can the PG-SGA© be used?

The PG-SGA© has been used clinically in several settings – inpatient, outpatient, homecare, and hospice. The use of the same tool in all settings provides a consistent means of identifying patients with malnutrition and measuring outcomes of nutrition intervention as patients move through the spectrum of health care delivery systems. What is gained in each of these settings can be quite different but can have a positive impact on clinical outcomes and potentially healthcare costs.

► Inpatient: If the patient is hospitalized and has pre-existing weight loss on admission, it is important to think about intervention (nutritional and/or symptom management) rather than waiting until the patient has a complication or an extended hospitalization. Even more important, patient assessment should be carried out at diagnosis already, to be able to prevent nutritional status from further deterioration.

In 2003, Mobley et al., US Army, Walter Reed Medical Center, Washington DC (abstract ADA) reported that the PG-SGA© was the single best predictor of clinical outcomes in terms of length of stay for hospitalized medical, surgical or oncologic patients (n=63). Assessment were performed within 48 hours of admission and patients were followed until discharge.

Trained dietetic professionals performed a PG-SGA© with additional assessments including anthropometric measurements (height, weight, triceps skin fold and mid-arm circumference); calculation of Body Mass Index, percent usual body weight, percent desirable weight, and mid-arm muscle circumference; handgrip strength by hand dynamometry and standard laboratory values such as albumin, hematocrit, hemoglobin, blood urea nitrogen, and creatinine. Data were analyzed using stepwise multiple linear regression models (significance, P<0.05).

The results from this study indicated that PG-SGA© is the single best predictor of length of stay and the authors suggested that based on the findings from the study that the PG-SGA© may be a valuable screening tool to identify those patients who may require intensive medical nutrition therapy, especially in hospital settings where laboratory data is limited and/or unavailable. Additionally, that early nutritional intervention in those patients with increased PG-SGA scores may lead to better clinical outcomes.

The relationship between the PG-SGA© and clinical outcome, as well as quality of life has been confirmed in several studies thereafter (e.g. Bauer et al., 2002; Isenring et al., 2003; Campbell et al., 2008; Shahmoradi et al., 2009; Laky et al., 2010; Capuano et al., 2010; Zalina et al., 2012; Esfahani et al., 2013; Citak et al., 2013; Malihi et al., 2013; Mohammadi et al., 2013).

► Outpatient: This has been widely used as a method of streamlining patient flow through clinic with the benefit of efficient and consistent assessment of weight and weight history; food intake; symptoms (often referred to as nutrition impact symptoms) and functionality of performance status). In many clinics that patient completes the PG-SGA© while in the waiting room or patient room, with the medical team able to spend their limited time spent with the patient addressing the identified issues rather than spending the time asking questions.

► Homecare: The same benefits can be achieved in this setting but also may help to either identify at risk patients, or help to transition from hightech (parenteral or enteral) nutrition to oral.

► Hospice: Particularly important is the aspects of standardized, patient self-reported symptoms and quality of life in the context of functionality, weight and nutrition.

5. Do I need to ask for permission to use the PG-SGA© and/or Pt-Global app© in clinical practice?

The PG-SGA© and its subcomponent known as the PG-SGA Short Form© (PG-SGA SF, Boxes 1-4), as well as the Pt-Global app©, are copyrighted and registered instruments. Downloading the most recent version of the PG-SGA© paper version from the Pt-Global website or purchasing the Pt-Global app© automatically gives you permission to use it in your clinical practice.

If you use or consider future use data generated by the PG-SGA© or Pt-Global app© in research, abstract or publication presentation, book chapters, dissertations, etc., please see FAQ “Do I need to ask for permission to use the PG-SGA© and/or Pt-Global app© in research?”.

6. Do I need to ask for permission to use the PG-SGA© and/or Pt-Global app© in research?

Yes. The PG-SGA© and its subcomponent known as the PG-SGA Short Form© (PG-SGA SF, Boxes 1-4), as well as the Pt-Global app©, are copyrighted and registered instruments, and permission is needed from Faith Ottery, MD, PhD prior to any and all use outside of patient clinical care.

If you want to use the PG-SGA©, PG-SGA SF© or the Pt-Global app© in research, abstract or publication presentation, book chapters, dissertations, etc., the online Permission request form should be completed and returned to Dr. Ottery or info@pt-global.org.

Permission is being granted as a one time use for the specified project or publication. In general, permission for such use will not be withheld except under unusual circumstances and any reason for such withholding will be explained by Dr. Ottery. The purpose of requiring this form is to maintain records for use of the PG-SGA©. Any questions can be addressed to Dr. Ottery or info@pt-global.org.

Please note, that for publication of results, it is important to use PG-SGA as a key word so that a complete bibliography of relevant articles is available for researchers and clinicians.

7. How much time does it take to complete the PG-SGA©?

This is a patient-generated assessment and for patients, depending on their clinical status, reading ability, and vision, completion generally takes less than three minutes to complete; for some patients it may take longer. For the professional who uses the PG-SGA© routinely, scoring of the patient component of the PG-SGA© (Boxes 1-4), takes less than 1 minute. The time required for performance of the nutritional physical examination will depend on the professional’s experience and comfort with its performance. Time for the performance of this can be done as an integral part of the physical exam as routinely performed. The scoring of the PG-SGA© in the context of the Pt-Global app© is carried out by the software and is available at the completion of the assessment.

For professionals who routinely do physical exams, the exam from a physician examination adds nothing beyond the routine exam (specifically addressing the global aspects of muscle tone and mass, fat mass, and fluid status).

For professionals who do not have extensive experience with physical examination or who have not thought of this from a nutritional perspective, global assessment of muscle, fat and fluid are what is needed rather than performing all the granular assessments on the second (back) page of the PG-SGA© form. The degree of granularity was developed in conjunction with the Oncology Nutrition Dietetics Practice group of the Academy of Nutrition and Dietetics (1996) as an aid for dietitians, when physical examination was not as widely practiced by non-physician professionals. It is important to remember that the total score of the nutritional physical exam is three points (<8% of the total potential score). This realization places the exam into perspective, becoming an important but less intimidating part of the overall PG-SGA© assessment.

8. What is the difference between the numerical PG-SGA score and the PG-SGA Category?

The PG-SGA© was originally developed as a continuous rather than categorical assessment, whereas originally the SGA was considered a categorical assessment (A = well-nourished, B=moderate, or suspected malnutrition and C = severely malnourished).

Dr. Jeejeebhoy, Dr. Detsky and Dr. Baker developed the SGA at the University of Toronto and first published it in a usable form in 1987. The PG-SGA expanded the information captured but closely parallels this information of the SGA. Interestingly, after the development of the Scored PG-SGA©, a number of SGA variations which include scoring have been developed.

As a way to facilitate utilization more widely where nutritional screening and assessment were not integrated into physician standards of care, the creators of the Scored PG-SGA© (Ottery, Kasenic, and DeBolt) developed in the early 1990’s — in conjunction with input by patients receiving care at the Fox Chase Cancer Center in Philadelphia – a standardized form that patients would complete while waiting to see their physician, nurse, or dietitian. Soon after, a scoring system was developed with validation of the scoring in the setting of a volunteer research network through the Society of Nutritional Oncology Adjuvant Therapy (NOAT) in 1996, involving approximately 2,150 patients at 55 institutions internationally.

9. Is performing the physical exam in the PG-SGA© mandatory?

Performance of the physical examination is not mandatory but is important. The physicial exam is essential to determine the PG-SGA Category, because the PG-SGA Category is based on Boxes 1-4 of the paper version of the PG-SGA (also known as the PG-SGA Short Form©, which is equivalent to the patient component of the Pt-Global app© (Patient, Weight, Food Intake, Symptoms, Activity).

To score the numerical PG-SGA score it is important to note that the majority (generally 80-90%) of the total PG-SGA numerical score is being based on the patient-generated aspects (PG-SGA Short Form©).

Furthermore, it is important to note that muscle mass and tone, fat deficit and fluid status need to be evaluated just globally. The locations of the body described in Worksheet 4 are just to help in the global physical exam. Furthermore, the total score of the physical examination is just 3 points – so that even if one was not certain that the deficit was moderate vs severe or mild vs moderate, the difference would only be 1 point. Many find the appreciation of this as lessening some of the intimidation of doing a physical exam.

Also, appreciation of components of the physical examination can give additional insight. For example, the distribution of the loss of muscle mass can be important. If the patient is spending most of her time in bed or chair, the muscle loss you see below the waist will be a combination of disuse atrophy plus malnutrition, whereas that above the waist tends to be more prominently related to malnutrition. Also, while not specifically part of the PG-SGA©, when one is examining the patient, there may be markers of specific nutritional deficiencies that can also be appreciated, e.g., scaly dermatitis of zinc deficiency (and poor wound healing) in the patient with chronic high volume GI losses or a similar scaly dermatitis of essential fatty acid deficiency in a patient who a clinician chronically failed to order lipids with the patient’s parenteral nutrition.

10. Which cut-off scores for nutritional triage recommendations should I use when using the PG‑SGA Short Form©?

There is no clear indication that the cut-off values for the PG‑SGA Short Form© should differ from those used in the full version of the PG‑SGA. Although theoretically a patient might possibly be slightly  underscored if using the PG-SGA SF© only, but not overscored, it is important to note that the majority (generally 80-90% of a score for a given patient) of the total PG‑SGA numerical score is being based on the patient-generated aspects (PG‑SGA Short Form©). 

In general, it would be rather unlikely that a patient’s scoring would be low on the PG-SGA Short Form© and high on the professional-generated items (Worksheet 2 to 4).

Research utilizing the PG-SGA is ongoing globally with studies published on the use of the PG‑SGA Short Form, also known as the ‘abridged’ version of the PG-SGA in the literature. 

The study by Vigano et al. (Vigano AL, di Tomasso J, Kilgour RD, Trutschnigg B, Lucar E, Morais JA, Borod M. The Abridged Patient-Generated Subjective Global Assessment Is a Useful Tool for Early Detection and Characterization of Cancer Cachexia. J Acad Nutr Diet 2014;114(7):1088-98) which was prospectively performed in 207 advanced lung and gastrointestinal cancer patients, showed that ≥9 points as generated by the PG-SGA Short Form© was associated with unfavorable biological markers of cancer cachexia, decreased anthropometric and physical measures, such as body mass index, fat mass, handgrip and leg strength, an average 12% greater length of hospital stay, a dose reduction in chemotherapy, and increased mortality.

The study by Gabrielson et al. (Gabrielson DK, Scaffidi D, Leung E, Stoyanoff L, Robinson J, Nisenbaum R, Brezden-Masley C, Darling PB. Use of an abridged scored Patient-Generated Subjective Global Assessment (abPG-SGA) as a nutritional screening tool for cancer patients in an outpatient setting. Nutr Cancer 2013;65(2):234-9) performed in 90 oncology outpatients showed an area under curve of 0.956 by the PG‑SGA Short Form. In this study, ≥6 points, and ≥7 points were studied as cut-off values for sensitivity and specificity of the PG‑SGA SF© compared to the PG‑SGA Categories (A-Well nourished versus B/C-Moderately malnourished or suspected malnutrition/Severely malnourished). Using the cut-off of ≥6 points resulted in 93.8 sensitivity and 77.6 specificity. Using a cut-off value of ≥7 points improved the specificity to 89.7, but lowered the sensitivity to 84.4.

The optimal cut-off values to be used depend on the purpose or the objectives of the team using the instrument in clinical practice, e.g. aiming for prevention or treatment of malnutrition only; to support expanding or maintaining dietitian or nutritional support services; and/or various types of clinical and outcomes research. Therefore, each organization can make its own decisions on defining which cut-off values should result in referral to a dietitian and other disciplines, but in the context of research, until there are data to support changing the triage approach, the triage as described in the full PG‑SGA should be maintained.

11. How can I learn to use the PG-SGA©?

There are a number of resources found on the Pt-Global website at www.pt-global.org. In addition, Dr. Ottery, Dr. Jager-Wittenaar and others who have used the PG-SGA© extensively and are part of the Pt-Global Scientific Advisory Board or the Research Consortium may also be able to set up educational training sessions or workshops at your institution. Online training sessions will also be possible in the future.

12. Can the patient complete the patient part in the PG-SGA© independently?

The PG-SGA© was developed to be used by the patient independently. Obviously there may be some situations where this may be impossible currently, e.g., severe visual deficit, inability to read, or lack of availability of the relevant patient language. However, short of these impediments, it is always preferable for the patient to complete the PG-SGA©, particularly in the context of their eating/intake, their symptoms (that they may not tell the family, nurse or physician but that do impact ability to each and absorb adequate macro- and micronutrients), and functional status.

13. Is the PG-SGA© a validated instrument?

Predictive validity of the PG-SGA© (e.g. significant association with length of hospital stay) has been shown in both cancer patients (Laky et al., 2010) and non-cancer surgery patients (Huang et al., 2014). Furthermore, the PG-SGA© score has been associated with hospital re-admission (Bauer et al., 2002), duration of neutropenic fever in patients with acute leukemia during induction chemotherapy (Esfahani et al., 2013) and quality of life in both cancer patients (Citak et al., 2013; Malihi et al., 2013; Mohammadi et al., 2013; Zalina et al., 2012; Capuano et al., 2010; Shahmoradi et al., 2009; Isenring et al., 2003) and non-cancer patients (Campbell et al., 2008). For the full list of studies that used the PG-SGA© please see the full list of publications here.

Besides the full PG-SGA©, also the PG-SGA Short Form© (also known as abridged PG-SGA) has been studied. Higher scores on the PG-SGA Short Form© have also been associated with increased length of hospital stay, reduction in chemotherapy (decreased chemo tolerance) and increased mortality (Vigano et al., 2014).

14. What does 'patient-generated' mean?

The original SGA was developed as an assessment tool to be performed by a professional – originally the physician but this has expanded to performance by other professionals such as dietitians and nurses.

There were two key reasons that the creators of the PG-SGA© utilized patient (self) input rather than utilizing the commonly used question and answer approach.

1) Appropriate Use of Professional’s Limited Time
Professionals may agree that nutritional status, assessment, and intervention are important but unfortunately if time is short, nutrition screening/assessment tend to be very limited in scope or dropped from the standard clinical visit.

Use of the PG-SGA© allows the patient to complete this important information while waiting for the professional prior to the visit (in the waiting room, the exam room, or at home on the day of the visit). This approach served two purposes. First, it ensures that nutritional assessment is included in the patient’s visit and second, it streamlines the visit and serves to improve the outcomes of that interaction. Rather than spending the professional’s limited time asking questions, the PG-SGA allows the patient to identify issues that need to be addressed by the professional during the interaction.

Since there are numerous publications and research that support the importance of nutritional status, particularly protein status and/or lean tissue status as important predictors of clinical outcome, it is imperative that nutrition be included in every patient visit, particularly in chronic catabolic and potentially disabling medical conditions including cancer, HIV/AIDS, chronic pulmonary and cardiac disease, trauma, conditions/treatments such as brain radiation therapy, therapy of hematologic malignancies, or exacerbations of inflammatory bowel disease where high dose corticosteroids may be used for more a few days etc.

Some professionals may feel that the only way to stop catabolic weight loss is to “treat and cure” or “remove” the underlying cause of the catabolism. While this is an important component, an individual can loose very significant amounts of weight (e.g., predominantly lean tissue mass and compromised protein status with associated immunodepression) until that goal is reached.

2) Patient Involvement – identification and empowerment
Involvement of the patient gets to the core of the problem.

In the validation of the point scores in 1996 involving 2,150 patients and 55 centers, more than 1/3 of the professionals stated that use of the PG-SGA© changed their appreciation of treatable nutritional risk or nutritional deficit. Raters in the study were dietitians (52%), nurses (40%), physicians (0.1%), others (8%).

Importantly, the PG-SGA© involves the patient in the clinical process and gives them back some of the control they may feel they have lost by being a patient. With patients completing the form, one gets the information from their perspective, may identifiy symptoms that neither family nor professionals were aware of (perhaps from perspective of embarassment or not wanting to “complain”). Also, if the check off list is in the patient’s native language (the long term goal of the multilingual app) then the ability of the patient to be a part of the care can be significantly enhanced.

15. Can the PG-SGA© classify patients as being anabolic or catabolic?

Throughout the use of the PG-SGA© or the Pt-Global app©, it is important to think of the patient in terms of whether the patient is anabolic or catabolic. Lean tissue/non-fluid weight increase tend to represent anabolism (positive nitrogen balance) whereas lean tissue/non-fluid weight decrease may represent catabolism in an ill patient. Weight and physical examination are surrogate markers for anabolism or catabolism.

If a patient is anabolic, she will likely improve weight (slow/stop weight loss or increase weight) whereas if the patient is catabolic her weight may decrease and physical examination, particularly of muscle may deteriorate. But the best practical clinical approach to address anabolic competence (positive nitrogen balance) is a 24 hour urinary urea nitrogen (UUN or output) combined with calculation of protein nitrogen intake. If more nitrogen out than in, the patient is in negative nitrogen balance; if more nitrogen in than out, the patient is in positive nitrogen balance. One can only be anabolic in the face of positive nitrogen balance.

Practical consideration: For inpatients (and often for outpatients), Sunday is usually the best day to collect the urine for UUN, because  Sundays are characterized by fewer tests, fewer procedures, fewer activities, and collections tend to be much easier on patient and staff.

The other benefit of collecting the UUN is that one has a very specific target amount of nitrogen (protein) that should be added to intake, to convert from catabolism to anabolism. Sometimes patients can be much more catabolic than one realizes and with the target increase one can accomplish this conversation in a much shorter and precise time frame.

16. Why should the weight loss of the last month be used, if the weight loss of the last 6 months is also available?

Throughout the use of the PG-SGA© or the Pt-Global app©, it is important to think of the patient in terms of whether the patient is anabolic or catabolic. Lean tissue/non-fluid weight increase tends to represent anabolism (positive nitrogen balance) whereas lean tissue/non-fluid weight decrease may represent catabolism in an ill patient.

Weight information is addressed along a continuum – 6 months (chronic), 1 month (intermediate), and past two weeks (acute) change. For example, if the patient’s weight is 100 lbs or 100 kg at 6 months and then decreased by 10% or increased by 10% (e.g., from 100 lbs/kg to 90 lbs/kg or 110 lbs/kg, respectively), the weight that is more recent lets you know what is going on more recently in terms of the patient metabolically in an intermediate setting.

If weight decreased, perhaps that is related to treatment or poor symptom control. If increased, perhaps it was excellent intervention by the professional to stop what had previously been uncontrolled disease or treatment related weight loss. The previous two weeks is a gauge of what is going on in the patient now metabolically or physiologically.

One uses the 1 month weight, if available, since it represents the intermediately chronic situation for which there are data regarding the prognostic implications.

17. How should a patient be scored regarding Activities/Functioning if the first two weeks of the last month were normally active, but the last two weeks are pretty much in bed?

If the patient was bedridden with little physical therapy or resistance exercise, there has likely been significant loss of muscle mass. Even 1 week of complete bed rest in a healthy male volunteer can be associated with up to 4% loss of lean tissue, due to reduced protein synthesis.

If the patient is ill (catabolic), has fever, is on corticosteroids, nitrogen loss/muscle mass loss can be significantly accelerated and is an important reason that the professional should consider these variables in their assessment of the patient’s metabolic stressors. These are often overlooked and is the reason that these variables are included in the professional component of the PG-SGA© and the Pt-Global app©.

18. How should I score significant intentional weight loss?

This has not been validated in this specific aspect. However, it is interesting that there are times that a patient’s cancer has been diagnosed when the patient came in for evaluation because they thought they were being particularly successful in terms of their weight loss but then could not stop losing weight.

The scoring would be the same – but then the professional would need to address if the intentional weight loss was being done in a health or non-healthy manner.

19. Will the PG-SGA© be included in a certification program?

There has been much discussion about this and the creators of the PG-SGA© and the Pt-Global app© and members of our Scientific Advisory Board and Research Consortium are very interested in doing this in the future. We will keep you posted. If you have ideas or comments about this, please contact us at info@pt-global.org or by completing the contact form.

1. Can I use the Pt-Global app© in clinical practice?

Yes. The Pt-Global app© can be used clinically in several settings – inpatient, outpatient, homecare, and hospice, as is the paper version of the PG-SGA©. The use of the same tool in all settings provides a consistent means of identifying patients with malnutrition and measuring outcomes of nutrition intervention as patients move through the spectrum of health care delivery systems. What is gained in each of these settings can be quite different but can have a positive impact on clinical outcomes and potentially healthcare costs.

2. In which populations can the Pt-Global app© be used?

The Pt-Global app© can be used in any population, including older people, and in any health care setting, e.g. inpatient, outpatient, homecare, and hospice. The rationale behind the PG-SGA©, scoring all factors that might increase the risk for malnutrition or characterize malnutrition (weight change, food intake, symptoms, activities and functioning, disease, metabolic stress and altered body composition) applies to any population that may develop (risk for) malnutrition, including older people.

The use of the same tool in all settings provides a consistent means of identifying patients with malnutrition and measuring outcomes of nutrition intervention as patients move through the spectrum of health care delivery systems. In addition, results between the different populations can be compared with each other.

In the original study of the scoring in 1996, patient population was not limited to oncology patients, although they were the predominant group (lung, prostate, colon, NHL, rectal, esophageal, melanoma, cervical), but included patients with End stage Renal Disease and Diabetes Mellitus as well.

Subsequently, results have been published or reported using the PG-SGA© in the following patient populations: Cancer (lung, GI – general or gastric, esophageal, gastroesophageal, rectal colorectal), head and neck, gynecological, urological, acute leukemia, multiple myeloma, hematologic stem cell transplantation); Stroke; HIV; Parkinson’s Disease; Geriatrics; Chronic Kidney Disease; Hemodialysis; Radiotherapy or Chemoradiotherapy; General study; others.
For more information on the use of the PG-SGA© please see the full list of publications here.

3. In which health care settings can the Pt-Global app© be used?

The Pt-Global app© can be used in any health care setting, e.g. inpatient, outpatient, homecare, and hospice. The use of the same tool in all settings provides a consistent means of identifying patients with malnutrition and measuring outcomes of nutrition intervention as patients move through the spectrum of health care delivery systems. What is gained in each of these settings can be quite different but can have a positive impact on clinical outcomes and potentially healthcare costs.

► Inpatient: If the patient is hospitalized and has pre-existing weight loss on admission, it is important to think about intervention (nutritional and/or symptom management) rather than waiting until the patient has a complication or an extended hospitalization. Even more important, patient assessment should be carried out at diagnosis already, to be able to prevent nutritional status from further deterioration.

In 2003, Mobley et al., US Army, Walter Reed Medical Center, Washington DC (abstract ADA) reported that the PG-SGA© was the single best predictor of clinical outcomes in terms of length of stay for hospitalized medical, surgical or oncologic patients (n=63). Assessment were performed within 48 hours of admission and patients were followed until discharge.

Trained dietetic professionals performed a PG-SGA© with additional assessments including anthropometric measurements (height, weight, triceps skin fold and mid-arm circumference); calculation of body mass index, percent usual body weight, percent desirable weight, and mid-arm muscle circumference; handgrip strength by hand dynamometry and standard laboratory values such as albumin, hematocrit, hemoglobin, blood urea nitrogen, and creatinine. Data were analyzed using stepwise multiple linear regression models (significance, P<0.05).

The results from this study indicated that PG-SGA is the single best predictor of length of stay and the authors suggested that based on the findings from the study that the PG-SGA may be a valuable screening tool to identify those patients who may require intensive medical nutrition therapy, especially in hospital settings where laboratory data is limited and/or unavailable. Additionally, that early nutritional intervention in those patients with increased PG-SGA scores may lead to better clinical outcomes.

The relationship between the PG-SGA© and clinical outcome, as well as quality of life has been confirmed in several studies thereafter (e.g. Bauer et al., 2002; Isenring et al., 2003; Campbell et al., 2008; Shahmoradi et al., 2009; Laky et al., 2010; Capuano et al., 2010; Zalina et al., 2012; Esfahani et al., 2013; Citak et al., 2013; Malihi et al., 2013; Mohammadi et al., 2013).

► Outpatient: This has been widely used as a method of streamlining patient flow through clinic with the benefit of efficient and consistent assessment of weight and weight history; food intake; symptoms (often referred to as nutrition impact symptoms) and functionality of performance status). In many clinics that patient completes the PG-SGA© while in the waiting room or patient room, with the medical team able to spend their limited time spent with the patient addressing the identified issues rather than spending the time asking questions.

► Homecare: The same benefits can be achieved in this setting but also may help to either identify at risk patients, or help to transition from hightech (parenteral or enteral) nutrition to oral.

► Hospice: particularly important is the aspects of standardized, patient self-reported symptoms and quality of life in the context of functionality, weight and nutrition.

For more information on the use of the PG-SGA© please see the full list of publications here.

4. Can I use the Pt-Global app in research?

Yes. The Pt-Global app© facilitates consistent scoring, by the original PG-SGA© algorithms, and use of validated multilingual translations of the PG-SGA©. The PG-SGA© has been used extensively in multiple different patient populations and settings. During the past two decades, the PG-SGA© and its Short Form© (PG-SGA SF, aka abridged version) has been the basis for almost 200 publications and scientific presentations; multiple masters and doctoral theses and dissertations; book chapters; and educational programs and has been formally translated, as well as reviewed for accuracy by professionals, and used broadly worldwide.

Please note: the PG-SGA© and its subcomponent known as the PG-SGA Short Form© (PG-SGA SF, Boxes 1-4), as well as the Pt-Global app©, are copyrighted and registered instruments, and permission is needed from Faith Ottery, MD, PhD, prior to any and all use outside of patient clinical care. See also FAQ #6.

5. Do I need to ask for permission to use the PG-SGA© and/or Pt-Global app© in clinical practice?

The PG-SGA© and its subcomponent known as the PG-SGA Short Form© (PG-SGA SF, Boxes 1-4), as well as the Pt-Global app©, are copyrighted and registered instruments. Downloading the most recent version of the PG-SGA© paper version from the Pt-Global website or purchasing the Pt-Global app© automatically gives you permission to use it in your clinical practice.

If you use or consider future use data generated by the PG-SGA© or Pt-Global app© in research, abstract or publication presentation, book chapters, dissertations, etc., please see FAQ “Do I need to ask for permission to use the PG-SGA© and/or Pt-Global app© in research?”.

6. Do I need to ask for permission to use the PG-SGA© and/or Pt-Global app© in research?

Yes. The PG-SGA and its subcomponent known as the PG-SGA Short Form© (PG-SGA SF, Boxes 1-4), as well as the Pt-Global app©, are copyrighted and registered instruments, and permission is needed from Faith Ottery, MD, PhD prior to any and all use outside of patient clinical care.

If you want to use the PG-SGA©, PG-SGA SF© or the Pt-Global app© in research, abstract or publication presentation, book chapters, dissertations, etc., the online Permission request form should be completed and returned to Dr. Ottery or info@pt-global.org.

Permission is being granted as a one time use for the specified project or publication. In general, permission for such use will not be withheld except under unusual circumstances and any reason for such withholding will be explained by Dr. Ottery. The purpose of requiring this form is to maintain records for use of the PG-SGA©. Any questions can be addressed to Dr. Ottery or info@pt-global.org.

Please note, that for publication of results, it is important to use PG-SGA© as a key word so that a complete bibliography of relevant articles is available for researchers and clinicians.

7. How much time does it take to complete the questions in the Pt-Global app©?

The PG-SGA©, on which the Pt-Global app© is based, is a patient-generated assessment. For patients, depending on their clinical status, reading ability, and vision, completion generally takes less than three minutes to complete; for some patients it may take longer. For the professional who uses the PG-SGA© routinely, scoring of the patient component of the Pt-Global app© (Patient, Weight, Food intake, Symptoms and Activities, takes less than 1 minute. The time required for performance of the nutritional physical examination will depend on the professional’s experience and comfort with its performance. Time for the performance of this can be done as an integral part of the physical exam as routinely performed. The scoring of the PG-SGA© in the context of the Pt-Global app© is carried out by the software and is available at the completion of the assessment.

For professionals who routinely do physical exams, the exam from a physician examination adds nothing beyond the routine exam (specifically addressing the global aspects of muscle tone and mass, fat mass, and fluid status. For professionals who do not have extensive experience with physical examination or who have not thought of this from a nutritional perspective, global assessment of muscle, fat and fluid are what is needed rather than performing all the granular assessments as described in the Physical exam section in the app (and as described on the second (back) page of the PG-SGA© form). The degree of granularity was developed in conjunction with the Oncology Nutrition Dietetics Practice group of the Academy of Nutrition and Dietetics (1996) as an aid for dietitians, when physical examination was not as widely practiced by non-physician professionals. It is important to remember that the total score of the nutritional physical exam is three points (about 8% of the total potential score). This realization places the exam into perspective, becoming an important but less intimidating part of the overall PG-SGA© assessment.

8. Is performing the physical exam in the Pt-Global app© mandatory?

Performance of the physical examination, which is part of the Professional screen, is not mandatory but is important. The scoring of the PG-SGA© and the algorithm that supports the Pt-Global app© is based on the preponderance (generally 80-90%) of the total PG-SGA score being based on the patient component of the Pt-Global app© (e.g. the screens on Patient, Intake, Symptoms, and Activities). The patient-generated aspects are also referred to as the PG-SGA Short Form© (SF) or the abridged PG-SGA.

It is important to note that the total score of the physical examination is 3 points – so that even if one was not certain that the deficit was moderate vs severe or mild vs moderate, the difference would only be 1 point. Many find the appreciation of this as lessening some of the intimidation of doing a physical exam. The other aspects of the professional components of the PG-SGA©/Pt-Global app© are the presence of fever, fever duration and use of corticosteroids. Each of these variables can have significant acute or chronic effect on muscle mass and patient function.

These variables must be taken into consideration in the assessment of your patient, even if you only utilize the PG-SGA Short Form©. For example, if the patient has a score of 7 points but is on corticosteroids or has a fever, this should make the professional address the intervention based on a higher score than that captured with the data based on Boxes 1-4 of the PG-SGA© (also known as PG-SGA Short Form©).

Also, appreciation of components of the physical examination can give additional insight. For example, the distribution of the loss of muscle mass can be important. If the patient is spending most of her time in bed or chair, the muscle loss you see below the waist will be a combination of disuse atrophy plus malnutrition, whereas that above the waist tends to be more prominently related to malnutrition. Also, while not specifically part of the PG-SGA©, when one is examining the patient, there may be markers of specific nutritional deficiencies that can also be appreciated, e.g., scaly dermatitis of zinc deficiency (and poor wound healing) in the patient with chronic high volume GI losses or a similar scaly dermatitis of essential fatty acid deficiency in a patient who a clinician chronically failed to order lipids with the patient’s parenteral nutrition.

In the Pt-Global app©, points scored will be shown irrespective of the order in which the screens are completed and irrespective of completing the Professional screen. A completed screen will be marked by the green “check icon”.

9. What do the colors in the Results screen and Results email mean?

The colors represent a ‘traffic light system’: red means ‘severe problem’; orange means ‘caution’ , and green means ‘good’.

10. Can the patient download the Pt-Global app©?

The Pt-Global app© currently targets professional use, with the intent that the patient can complete the patient part independently. Version 1.1 includes the English, Dutch and Portuguese language. In the future, as we further develop the app and increase the available languages, we aim to make the patient part of the app downloadable for the patient, offering the opportunity to be completed independently by the patient.

11. Is the Pt-Global app© a validated instrument?

The Pt-Global app© is based on the PG-SGA©. Predictive validity of the PG-SGA© (e.g. significant association with length of hospital stay in both cancer patients (Laky et al., 2010) and non-cancer surgery patients (Huang et al., 2014). Furthermore, higher PG-SGA scores have been associated with hospital re-admission (Bauer et al., 2002), longer duration of neutropenic fever in patients with acute leukemia during induction chemotherapy (Esfahani et al., 2013) and lower quality of life in both cancer patients (Citak et al., 2013; Malihi et al., 2013; Mohammadi et al., 2013; Zalina et al., 2012; Capuano et al., 2010; Shahmoradi et al., 2009; Isenring et al., 2003) and non-cancer patients (Campbell et al., 2008).

Besides the full PG-SGA©, also the PG-SGA Short Form© (also known as abridged PG-SGA) has been studied. Higher scores on the PG-SGA Short Form© have also been associated with increased length of hospital stay, reduction in chemotherapy (decreased chemo tolerance) and increased mortality (Vigano et al., 2014).

For the full list of studies that used the PG-SGA©, please see Publications.

12. Can I use the app on a desktop computer?

Yes, in addition to the downloadable Pt-Global app© as available in the app stores, the Pt-Global application is also available as webtool. For more information, see ‘Pt-Global app©’.

13. What is meant by ‘Reference number’ in the Patient screen?

The Reference number refers to anonymous identification of the patient. Please give an anonymous code by which you can identify your patient.

14. Can I store data in the app?

In version 1.1 of the app, patient data will not be stored. In the future, we aim to facilitate prospective use of the Pt-Global app© for multiple patients, for example by including a database function to the app. We will keep you posted on these developments.

15. Will the Pt-Global app© be integrated in the Electronic Medical Records?

We are open for collaboration with medical institutions to enable integration of the Pt-Global app© in the Electronic Medical Records. If you have ideas or comments about this, please contact us at info@pt-global.org or by completing the contact form.

16. Can we get multiple licences for the Pt-Global app© at our institution?

We have special price offers for groups. If you have interest in multiple licenses for your institution, please contact us at info@pt-global.org or by completing the contact form.

17. Which languages will be included in the app?

In version 1.1 of the Pt-Global app, the English, Dutch and Portuguese language are available. We aim to include other languages of the PG-SGA© as well. The following languages are available or in preparation (in alphabetical order): Arabic – Israel; Chinese; English – US, Canada, UK; French – France, Belgium, Switzerland, Canada; German – Germany, Switzerland; Greek; Hebrew – Israel; Italian – Italy, Switzerland; Japanese; Korean; Norwegian; Polish; Portuguese; Russian – Israel, US; Spanish – US; Swedish; Thai; Vietnamese.

If you have any requests for other language translations of the PG-SGA©, please contact us at info@pt-global.org or by completing the contact form.

18. I am having technical problems with receiving the Results email in my mailbox. What should I do?

There are a number of things that could be causing this problem. Please ensure that you have given the correct email address and that the email does not show up in your spam folder. You could also try if an email of another account works better. Please note that after you have sent clicked the ‘Send’ button, you can go back by clicking ‘Back to Pt-Global’. Then you can go to the Results screen again, click on ‘Send’ and give another email address without losing the completed data. If you still have problems, or have any other technical problem, please contact us at info@pt-global.org or by completing the contact form, so that we can further assist you.

19. Can I send the results to multiple email addresses at the same time?

Yes. You can use a semicolon after each email address. Please note that for privacy reasons, the email address of the professional should be used.

20. How can I give feedback for further improvement of the app?

We very much appreciate sharing your suggestions and ideas to further improve and implement the Pt-Global app© in clinical practice and research. Therefore, we would kindly like to invite you to send your feedback to us at info@pt-global.org or by completing the contact form, or by sending the feedback in the feedback option in the Pt-Global app© itself.