Reliability of Patient-Led Screening with the Malnutrition Screening Tool: Agreement between Patient and Health Care Professional Scores in the Cancer Care Ambulatory Setting

Published:February 15, 2018DOI:



      The prevalence of malnutrition in patients with cancer is reported as high as 60% to 80%, and malnutrition is associated with lower survival, reduced response to treatment, and poorer functional status. The Malnutrition Screening Tool (MST) is a validated tool when administered by health care professionals; however, it has not been evaluated for patient-led screening.


      This study aims to assess the reliability of patient-led MST screening through assessment of inter-rater reliability between patient-led and dietitian-researcher–led screening and intra-rater reliability between an initial and a repeat patient screening.


      This cross-sectional study included 208 adults attending ambulatory cancer care services in a metropolitan teaching hospital in Queensland, Australia, in October 2016 (n=160 inter-rater reliability; n=48 intra-rater reliability measured in a separate sample).

      Main outcome measurements

      Primary outcome measures were MST risk categories (MST 0-1: not at risk, MST ≥2: at risk) as determined by screening completed by patients and a dietitian-researcher, patient test–retest screening, and patient acceptability.

      Statistical analysis

      Percent and chance-corrected agreement (Cohen’s kappa coefficient, κ) were used to determine agreement between patient-MST and dietitian-MST (inter-rater reliability) and MST completed by patient on admission to unit (patient-MSTA) and MST completed by patient 1 to 3 hours after completion of initial MST (patient-MSTB) (intra-rater reliability).


      High inter-rater reliability and intra-rater reliability were observed. Agreement between patient-MST and dietitian-MST was 96%, with “almost perfect” chance-adjusted agreement (κ=0.92, 95% CI 0.84 to 0.97). Agreement between repeated patient-MSTA and patient-MSTB was 94%, with “almost perfect” chance-adjusted agreement (κ=0.88, 95% CI 0.71 to 1.00). Based on dietitian-MST, 33% (n=53) of patients were identified as being at risk for malnutrition, and 40% of these reported not seeing a dietitian. Of 156 patients who provided feedback, almost all reported that the MST was clear (92%), questions were easy to understand (95%), and completion time was ≤5 minutes (99%).


      Patient-led screening with the MST is reliable and well accepted by patients. Patient-led screening in the cancer care ambulatory setting has the potential to improve patient autonomy and screening completion rates.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the Academy of Nutrition and Dietetics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Read J.
        • Choy B.
        • Beale P.
        • Clarke S.
        An evaluation of the prevalence of malnutrition in patients with cancer attending the outpatient oncology clinic.
        Asia Pac J Clin Oncol. 2006; 2: 80-86
        • Ollenschlager G.
        • Viell B.
        • Thomas W.
        • Konkol K.
        • Burger B.
        Tumor anorexia: Causes, assessment, treatment.
        Recent Results Cancer Res. 1991; 121: 249-259
        • Cinda S.
        • Chima M.
        • Barco K.
        • et al.
        Relationship of nutritional status to length of stay, hospital costs, and discharge status of patients hospitalized in the medicine service.
        JAMA. 1997; 97: 975-978
        • Correia M.I.
        • Waitzberg D.L.
        The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis.
        Clin Nutr. 2003; 22: 235-239
        • Isenring E.A.
        • Capra S.
        • Bauer J.D.
        Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area.
        Br J Cancer. 2004; 91: 446-452
        • Isenring E.
        • Zabel R.
        • Findlay M.
        • et al.
        Updated evidence-based practice guidelines for the nutritional management of patients receiving radiation therapy and/or chemotherapy.
        J Nutr Diet. 2013; 70: 312-324
        • Arends J.
        • Bachmann P.
        • Baracos V.
        • et al.
        ESPEN guidelines on nutrition in cancer patients.
        Clin Nutr. 2017; 36: 11-48
      1. Cancer Guidelines Wiki. Evidence based practice guidelines for the nutritional management of adult patients with head and neck cancer. Revised June 6, 2014. Accessed November 20, 2017.

      2. The National Safety and Quality Health Service Standards. Standard 2: Partnering with Consumers, Safety and Quality Improvement Guide. October 2012. Accessed November 20, 2017.

      3. Care Quality Commission. Joint Commission on Accreditation Manual for Hospitals: Regulation 14: Meeting nutritional and hydration needs Published 2014. Revised May 29, 2017. Accessed October 10, 2017.

      4. National Guideline Clearinghouse (NGC). Guideline summary: Oncology evidence-based nutrition practice guideline. In: National Guideline Clearinghouse (NGC): Agency for Healthcare Research and Quality (AHRQ). Published August 01, 2013. Accessed October 10, 2017.

        • Watterson C.
        • Fraser A.
        • Banks M.
        • et al.
        Evidence based practice guidelines for the nutritional management of malnutrition in adult patients across continuum of care.
        J Nutr Diet. 2009; 66: 1-34
        • Schindler K.
        • Pernicka E.
        • Laviano A.
        • et al.
        How nutritional risk is assessed and managed in European hospitals: A survey of 21,007 patients’ findings from the 2007-2008 cross-sectional nutritionDay survey.
        Clin Nutr. 2010; 29: 552-559
        • Agarwal E.
        • Ferguson M.
        • Banks M.
        • et al.
        Nutrition care practices in hospital wards: Results from the Nutrition Care Day Survey 2010.
        Clin Nutr. 2012; 31: 995-1001
        • Green S.M.
        • James E.P.
        Barriers and facilitators to undertaking nutritional screening of patients: A systematic review.
        J Hum Nutr Diet. 2013; 26: 211-221
        • Gabrielson D.K.
        • Scaffidi D.
        • Leung E.
        • et al.
        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: 234-239
        • Cawood A.L.
        • Elia M.
        • Sharp S.
        • Stratton R.J.
        Malnutrition self-screening by using MUST in hospital outpatients: Validity, reliability and ease of use.
        Am J Clin Nutr. 2012; 96: 1000-1007
      5. Institute of Medicine Committee on Quality of Health Care in America. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: The National Academies Press. Revised 2001. Accessed October 10, 2017.

      6. Department of Health. The NHS Constitution of England. Published March 2012. Revised October 14, 2015. Accessed October 10, 2017.

      7. World Health Organization. Service delivery and safety: WHO framework on integrated people-centered health services. Revised April 15, 2016. Accessed October 10, 2017.

      8. Picker Institute (2016). Principles of Patient Centered Care. Revised 2013. Accessed October 10, 2017.

        • Ferguson M.
        • Capra S.
        • Bauer J.
        • Banks M.
        Development of a valid and reliable malnutrition screening tool for adult acute hospital patients.
        Nutrition. 1999; 15: 458-464
        • Ferguson M.
        • Bauer J.
        • Gallaher B.
        • Capra S.
        • Christie D.
        • Mason B.
        Validation of a malnutrition screening tool for patients receiving radiotherapy.
        Australas Radiol. 1999; 43: 325-327
        • Shaw C.
        • Fleuret C.
        • Pickard J.M.
        • Mohammed K.
        • Black G.
        • Wedlake L.
        Comparison of a novel, simple nutrition screening tools for adult oncology inpatients and the Malnutrition Screening Tool (MST) against the Patient-Generated Subjective Global Assessment (PG-SGA).
        Support Care Cancer. 2015; 23: 47-54
        • Skipper A.
        • Ferguson M.
        • Thomson K.
        • Castellanos V.
        • Porcari J.
        Nutrition screening tools: An analysis of the evidence.
        J Parenter Enteral Nutr. 2012; 36: 292-298
        • Isenring E.
        • Elia M.
        Which screening method is appropriate for older cancer patients at risk of malnutrition?.
        Nutrition. 2015; 31: 594-597
        • Marshall L.
        • Vaughan V.
        • Matin P.
        • Van Berkel K.
        • Lewandowski P.
        Evaluation of nutritional screening and assessment methods for cancer associated malnutrition and cachexia.
        J Nutr Intermed Metab. 2016; : 21
        • McGurk P.
        • Jackson J.
        • Elia M.
        Rapid and reliable self-screening for nutritional risk in hospital outpatients using an electronic system.
        Nutrition. 2013; 29: 693-696
        • Sandhu A.
        • Mosli M.
        • Yan B.
        • et al.
        Self-screening for malnutrition risk in outpatient inflammatory bowel disease using the Malnutrition Universal Screening Tool (MUST).
        JPEN J Parenter Enteral Nutr. 2016; 40: 507-510
        • Marshall S.
        • Young A.
        • Isenring E.
        The malnutrition screening tool in geriatric rehabilitation: A comparison of validity when completed by health professionals with and without screening training has implications for practice.
        J Acad Nutr Diet. 2017; (S2212-2672(17)30329-5)
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
      9. IBM SPSS Statistics for Windows [computer program]. Version 23. Armonk, NY: IBM Corp; 2014.

        • Jones M.
        Reliability of nutritional screening and assessment tools.
        Nutr Methodol. 2004; 20: 307-311
        • Wall L.R.
        • Cartmill B.
        • Ward E.C.
        • et al.
        “ScreenIT”: Computerized screening of swallowing, nutrition and distress in head and neck cancer patients during (chemo)radiotherapy.
        Oral Oncol. 2016; 54: 47-53
      10. Australian Commission on Safety and Quality in Healthcare. Patient-centred care: Improving quality and safety by focusing care on patients and consumers. Revised September 2010. Accessed October 5, 2017.


      A. Di Bella is an accredited practising dietitian, Nutrition and Dietetics, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia.


      C. Blake is an accredited practising dietitian, Nutrition and Dietetics, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia.


      A. Young is an accredited practising dietitian, Nutrition and Dietetics, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia.


      T. Brown is an advanced accredited practising dietitian, Nutrition and Dietetics, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia.


      A. Pelecanos is a biostatistician, Statistics Unit, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia.