Evaluating Photographs as a Replacement for the In-Person Physical Examination of the Scored Patient-Generated Subjective Global Assessment in Elderly Hospital Patients

Published:February 21, 2018DOI:



      Undernourished patients discharged from the hospital require follow-up; however, attendance at return visits is low. Teleconsultations may allow remote follow-up of undernourished patients; however, no valid method to remotely perform physical examination, a critical component of assessing nutritional status, exists.


      This study aims to compare agreement between photographs taken by trained dietitians and in-person physical examinations conducted by trained dietitians to rate the overall physical examination section of the scored Patient Generated Subjective Global Assessment (PG-SGA).


      Nested cross-sectional study.


      Adults aged ≥60 years, admitted to the general medicine unit at Flinders Medical Centre between March 2015 and March 2016, were eligible. All components of the PG-SGA and photographs of muscle and fat sites were collected from 192 participants either in the hospital or at their place of residence after discharge.

      Main outcome measures

      Validity of photograph-based physical examination was determined by collecting photographic and PG-SGA data from each participant at one encounter by trained dietitians. A dietitian blinded to data collection later assessed de-identified photographs on a computer.

      Statistical analyses performed

      Percentage agreement, weighted kappa agreement, sensitivity, and specificity between the photographs and in-person physical examinations were calculated. All data collected were included in the analysis.


      Overall, the photograph-based physical examination rating achieved a percentage agreement of 75.8% against the in-person assessment, with a weighted kappa agreement of 0.526 (95% CI: 0.416, 0.637; P<0.05) and a sensitivity-specificity pair of 66.9% (95% CI: 57.8%, 75.0%) and 92.4% (95% CI: 82.5%, 97.2%).


      Photograph-based physical examination by trained dietitians achieved a nearly acceptable percentage agreement, moderate weighted kappa, and fair sensitivity-specificity pair. Methodological refinement before field testing with other personnel may improve the agreement and accuracy of photograph-based physical examination.


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      M. Miller is a professor and an advanced accredited practising dietitian, Flinders University. Bedford Park, South Australia, Australia.


      J. Thomas is an accredited practising dietitian, Flinders University. Bedford Park, South Australia, Australia.


      J. Suen is an accredited practising dietitian, Flinders University. Bedford Park, South Australia, Australia.


      D. S. Ong is a dietitian, Flinders University. Bedford Park, South Australia, Australia.


      Y. Sharma is a consultant physician, Flinders University. Bedford Park, South Australia, Australia.