European Geriatric Medicine 4 (2013) 310313

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Research paper

Impact of the intervention of a Mobile Geriatric Assessment Team on

the diagnosis of signicant comorbidities in elderly patients
hospitalised after a hip fracture
F. Bloch a,*, C. Kiffel b, F. Guilmineau c, V. Bellamy d, N. Brunetti e, C. Patry f, P. Rabier e,
V. Senegas b, N. Schwald a, J. Holstein c
a

MGAT of the Broca Hospital, Assistance publiqueHopitaux de Paris, Paris, France

MGAT of the Lariboisie`re Hospital, Assistance publiqueHopitaux de Paris, Paris, France
c
Department of the Medical Policy, Assistance publiqueHopitaux de Paris, Paris, France
d
MGAT of the Saint-Antoine Hospital, Assistance publiqueHopitaux de Paris, Paris, France
e
MGAT of the Hospital of Bicetre, Assistance publiqueHopitaux de Paris, Paris, France
f
MGAT of the Bichat Hospital, Assistance publiqueHopitaux de Paris, Paris, France
b

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 17 April 2013
Accepted 9 July 2013
Available online 6 September 2013

Purpose: Despite the fact that traumatic fractures of the femoral neck are common in elderly subjects, we
note that Mobile Geriatric Assessment Teams (MGATs) are rarely present in orthopaedic departments.
We set out to show that the assistance provided by MGATs in the diagnosis and data collection of
signicant comorbidities of patients over 75 years hospitalised in orthopaedic departments after a hip
fracture could directly benet the quality of care of these patients and indirectly enable greater
acceptance of MGAT in these departments.
Methodology We performed a prospective cohort study of patients over 75 years referred for surgical
treatment of traumatic fractures of the femoral neck. After the geriatric assessment of the patients
enrolled, a data collection sheet was completed containing the main pathologies most likely to be
identied.
Results: One hundred and eighty-three patients orthopaedic visits were analyzed (mean age was
86.3  5.3; 78% [143] were women). In this population, the MGAT increased the diagnosis of signicant
comorbidities in elderly patients hospitalised after a hip fracture from10 to 50%. The nancial evaluation of
each hospital stay was also improved: the mean daily rate by treated cases changed from 520 s to 688 s.
Conclusion: Our results reect the complementary role of geriatricians and surgeons for optimal care
management of elderly subjects operated for fracture. The improvement in the economic value of the
hospital stay can also be seen as an indirect method of evaluating the nancial value of services provided
by an MGAT.
2013 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.

Keywords:
Mobile Geriatric Assessment Teams
Elderly care
Performance improvement
Hip fracture

1. Introduction
In industrialised countries with an ageing population, certain
pathologies are common in elderly patients, particularly traumatic
fractures of the femoral neck [1]. Avoiding complications and
improving mortality rates after this injury is an important part of
medical management for this population. The rst Mobile Geriatric
Assessment Teams (MGAT) [2] were created by pioneering units in
the nineties but these teams became widely available in France
after the 2003 heatwave. Their roles have been specied in various
Health Ministry circulars including the one of March 18th, 2002 on
* Corresponding author. Hopital Broca (APHP), 54/56, rue Pascal, 75013 Paris,
France. Tel.: +33 1 44 08 35 21; fax: +33 1 44 08 35 25.
E-mail address: frederic.bloch@brc.aphp.fr (F. Bloch).

the overall improvement of geriatric care in the country [3]. These

teams consist of experienced geriatricians working with various
other professionals such as nurses, occupational therapists,
psychologists, social workers or secretaries, depending on the
specicity of each hospital. The mission of an MGAT is to make an
overall assessment of elderly patients from emergency, medical
and surgical departments in order to detect health problems that
could compromise their recovery. Their role is also to assist in
appropriate referral of these patients to improve the efciency of
geriatric health care throughput [4].
It can be noted in various hospitals that there is often a poor
presence of MGATs in orthopaedic units [5]. The major part of the
reporting carried out by orthopaedic departments, usually only in
the days preceding the patients discharge, is motivated by referral
to a geriatric rehabilitation unit, either because of refusal by

1878-7649/$ see front matter 2013 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
http://dx.doi.org/10.1016/j.eurger.2013.07.003

F. Bloch et al. / European Geriatric Medicine 4 (2013) 310313

traditional convalescence hospitals or on the criteria of proximity

of residence of the patient or his relatives. This method of reporting
is both inappropriate and simplistic compared to the expertise that
an MGAT can provide to patients.
However, it would appear [6,7] that the action of MGAT may be
more effective by anticipating surgical intervention on the patients
over 75 years hospitalised for non-scheduled surgery, in particular
concerning signicant morbidities including nutritional surveillance, pain management and other confounding disorders and
behaviours.
Our primary objective here was to show that, by optimising the
diagnosis and collection of signicant comorbidities of elderly
patients hospitalised in orthopaedic departments after a hip
fracture, MGATs could help to improve the coding of The French
Diagnosis Related Groups (DRG)-based information system
(Programme de medicalisation des syste`mes dinformation, PMSI)
[8,9] of patients for whom it made a systematic assessment, which
adds signicant value to the activity of the orthopaedic department.
Our secondary objectives were to show that the assistance
provided by the MGAT in the diagnosis and collection of signicant
comorbidities could directly benet the quality of care of these
patients and indirectly enable greater acceptance of MGAT in these
departments.

2. Patients and methods

We performed a prospective cohort study of elderly patients
referred by an emergency department to be surgically treated for
traumatic fractures of the femoral neck. Patients were selected if
they were (i) over 75 years of age, (ii) emergency hospitalised in an
orthopaedic department and (iii) surgically treated for traumatic
fractures of the femoral neck. Exclusion criteria were patient under
75 years, patient refusing a geriatric assessment, patients with no
hip fracture or with no indication for surgery and patients with a
scheduled operation.
Patients were recruited in ve orthopaedic departments of
ve University Public Hospitals of the Parisian region with
major activity in terms of femoral neck surgery over the period
April to June 2011; AprilMay, MayJune or AprilJune,
depending of the participating hospitals. They were included
consecutively and systematically when they fullled the
inclusion criteria and were identied by their individual patient
number.
At enrolment, participants, or their surrogates when appropriate, gave oral informed consent in accordance with the
guidelines of the local hospital ethics committee. The study did
not interfere with the usual care procedures delivered to them. The
following information was collected for each patient: name,
Administrative File Number, date of hospitalisation, inclusion (Y/
N), and date of assessment.
After the postoperative geriatric assessment (using various
assessment tools, according to the habits of the MGAT), a short
note was systematically added to the patient le detailing their
referral, diagnosis or treatments and a data collection sheet was
completed, containing PMSI codes for the pathologies most likely
to be identied. This data collection sheet was transmitted
following the normal procedures.
From the PMSI, hospital stay was dened as appropriate if (i) it
was for patients over 75 years, (ii) the hospital stay was from
home, (iii) it was surgical (i.e. within the Homogenous Group of
Patients [HGP] with surgery, in accordance with the classication
of the Agence technique de linformation sur lhospitalisation [ATIH])
[10] and (iv) if the following codes were used as primary diagnosis
in the PMSI: S72.0, S72.1, S72.2, S72.8, and S72.9.

311

The eligible population for the study period was compared to a

population with the same HGP and criteria but from a previous
period (March for patients included from 1st of April or March and
April for patients included from May to June). The population was
compared to the same populations during these two periods in
other orthopaedic departments of the area.
The data to be analysed were the number of comorbidities, the
severity level of the hospital stay (dened by age, length of stay and
dened comorbidities) and the nancial evaluation of each stay
using the Mean Daily Receipts linked to Patients Stay (MDRPS) (i.e.
the rate of each homogenous group of hospital stays with extreme
high and extreme low) and the mean daily rate by treated cases.
Continuous variables were expressed as mean (SEM) or median
(interquartile range), and qualitative variables as percentages.
Characteristics of the study population were compared to the
population in the period before the study and to all the orthopaedic
departments of the other public hospitals of the area by using
Fishers test for distributions and the Chi-square test for means.
Signicance was assumed at P < 0.05. StatView software version
5.0.1 (SAS Inc., Cary, NC, USA) was used for all analyses.

3. Results
During the study period, the MGAT included 168 patients and
183 hospital stays were eligible according to the PMSI. A
consistency analysis between these hospitals stays eligible from
the PMSI during the study period and the list of patients included
by the MGAT was performed.
Of the 168 patients seen by MGAT, 143 (85.1%) were present in
the population eligible from the PMSI. For the remaining 25
patients (14.9%), the reason explaining their exclusion was as
follows: four patients did not come from home, and, for 21
patients, the main diagnosis code was different from the ones
chosen as inclusion codes: in 50%, the mistaken code was the code
M8095: osteoporosis with pathological fracture, unspecied pelvic region and thigh.
Of the 183 hospital stays eligible according to the PMSI, 143
(78.1%) were seen by the MGAT. The explanation for this
incompleteness was studied in one centre. Thirty-six percent
were wrongly coded as hip fracture (and were femoral shaft or
periprosthetic fractures), 29% were patients hospitalised in
another department before their admission to the orthopaedic
department, 29% were non-operated patients and only 7% of the
patients were missed. Finally, the 183 patients with their
corresponding hospital stay in the PMSI were analysed.
For these 183 patients, age ranged from 75 to 101 years (mean
age was 86.3  5.3) and 78% (143) were women. The mean number of
comorbidities was 4.5  3 per patient. In this population, the MGAT,
according to the PMSI, made a diagnosis of psychological and
behavioural disorders in 23% of the patients, of dementia in 14%, of
risk factors and complications of falls in 48%, of social problems in
48%, of nutritional problems in 45%. Table 1 presents the percentage
of all the signicant comorbidities, which are compared to those in
the period before the study and to all the other orthopaedic
departments of the area. The mean number of distinct comorbidities
was 9.3 whereas it was of 3 in the previous period and of 3.6 in the
other orthopaedic departments indicating a signicant increase of the
diagnosis of comorbidities. The percentage of severe grading of
hospital stays (34) was multiplied by four during the study in
comparison to the period before (46% versus 12%, P < 0.001). Finally,
the nancial valuation of each stay was also improved: the ARTC
changed from 7021 s [65211,114] to 7835 s [65223,465] and the
mean daily rate by treated cases changed from 520 s to 688 s
whereas it was stable or slightly increased in the same period in the
other orthopaedic departments of the area.

F. Bloch et al. / European Geriatric Medicine 4 (2013) 310313

312

Table 1
Percentage of all signicant comorbidities, compared to those in the period before the study and to all the other orthopaedic departments of the area.
Hospital stays

Orthopaedic
departments

Participating in the study

Others
Total

Orthopaedic
departments

Dementia (%)

Risk factors and

complications
of falls (%)

Social
problems (%)

Urinary
disorders (%)

Before

During

Before

During

Before

During

Before

During

Before

During

Before

During

93
135
228

183
338
521

1
6
4

23
2
10

4
7
6

14
2
6

9
21
16

48
14
26

27
1
12

48
4
19

4
8
7

28
6
14

Hospital stays

During

Cutaneous
state (%)
Before

Other organic
comorbidities (%)

Nutritional
and digestive
problems (%)

Metabolic
disorders (%)

Sensory
disorders (%)

Before

During

Before

During

During

Before

During

Before

During

93

183

10

34

45

28

135
228

338
521

13
8

5
7

7
5

3
14

30
19

21
30

1
0

1
4

1
1

1
11

Before
Participating
in the study
Others
Total

Psychological and
behavioural
disorders (%)

Text in bold in the table highlight the data of the participating departments.

4. Discussion
Our study shows a mean increase of the diagnosis of signicant
comorbidities in elderly patients hospitalised after a hip fracture
by the intervention of a MGAT of 30% (10 to 50%). This result is
especially valuable as it has been underestimated since we have
analyzed the 40 medical stays that had not been seen by MGAT.
Being able to rene the characterisation of the comorbidities
presented by these patients can establish a prole of patients
requiring care by an MGAT. Indeed in our population, only half had
no nutritional disorders or were not affected by social problems,
and 77% have no neuropsychiatric disorders. All others could be
potential candidates for a geriatric assessment and should be
reported to the MGAT.
Our study also shows a mean increase of the economic value of
the hospital stay. The improvement of the economic value of the
hospital stay is an indirect method for the assessment of the
nancial value of services provided by the MGAT. In this study, we
focused on the economic value of incremental changes in the
detection of comorbidities that result in an improved quality of
patient care. Merely improving the coding of PMSI promotes the
value of stay because the main problems are related to a lack of
quality of administrative data, especially coding of diagnoses and
these errors come from missing or inappropriate codes. Moreover,
a more rapid identication and intervention on complications such
as malnutrition or psychological and behavioural disorders can
lead to a more rapid recovery that will also create medical savings
in the future.
However, it appears that the mode of action of an MGAT could
be made more effective by earlier intervention on people over
75 years, hospitalised for reasons other than being programmed
for a particular operation, involving signicant comorbidities.
One of the dangers of this study would be to conclude that the
MGAT are effective encoder agents for the PMSI allowing surgeons
to be relieved of this task. We must instead see in these results
evidence of the importance of the complementarities of these two
players for an optimal care management of elderly patients
operated for fracture.
This study can also be seen as a rst step in the process to prove
the value added by MGAT. As Deschodt et al. in their recent
systematic review and meta-analysis showed that the intervention
of MGAT has no signicant impact on functional status, readmission or length of stay [11], the next step will be to demonstrate
the impact of MGAT on length of stay, mortality, hospital

readmission, or the need for institutional care in older adults

with hip fracture.
The assistance provided by the MGAT to improve the value for
stays of patients over 75 years with femoral fracture could directly
benet the orthopaedic departments and indirectly allow for
greater acceptance of the MGAT in these departments. Improving
the continuing education of surgeons for them to be more aware of
these geriatric conditions could allow more frequent reports and
incidentally a better coding. This ultimately will be seen as leading
to improved quality of care of elderly patients and can question the
utility of a geriatric assessment in these departments and more
widely in all departments where elderly subjects are admitted.
On the contrary, a systematic geriatric evaluation in orthopaedic department does not appear to be the optimal solution as it has
not proved its effectiveness: Ellis et al. in their Cochrane review
showed that if there was a clear and signicant improvement in the
odds of patients being alive and in their own home if they receive a
geriatric evaluation, the effect was consistently seen from trials of
geriatric wards but was not so clearly seen for MGAT [12]. We must
rather think of simple and practical criteria that can be used by
non-geriatricians to seek MGAT assistance for the type of elderly
patients requiring it, avoiding the reporting of patients based only
on feelings or on impressions of pseudogeriatric fragility.
Disclosure of interest
The authors declare that they have no conicts of interest
concerning this article.
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