Health care utilization by men with prostate cancer during ... · and in SNH by ambulatory teams...

Progrès en urologie (2019) 29, 995—1006

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ORIGINAL ARTICLE

Health care utilization by men withprostate cancer during the year beforetheir death: A 2015 population-based studyRecours aux soins des hommes présentant un cancer de la prostate dansl’année précédant leur décès: une étude en population en 2015

A. Tanguy-Melaca, T. Lesuffleura,A. Fagot-Campagnaa, C. Gastaldi-Ménagera,X. Rébillardb, P. Tuppina,∗

a Caisse nationale de l’assurance maladie (Cnam), Paris, Franceb EA2415, service d’urologie, clinique Beau Soleil, Montpellier, France

Received 12 June 2019; accepted 28 September 2019Available online 8 November 2019

KEYWORDSProstate cancer;Place of death;End of life;Health careutilization;Costs

SummaryIntroduction. — To study the characteristics and health care utilization of men with prostatecancer (PCa) during their last year and last month of life, as these data have been rarelyreported to date.Subjects and method. — Men covered by the national health Insurance general scheme (77%of the French population) treated for PCa (2014—2015), who died in 2015 were identified inthe national health data system, including reimbursed hospital and outpatient care, and theircauses of death.Results. — A total of 11,193 men (mean age: 81 years, SD: 9.6) were included. Almost 58% ofthese men died in a short-stay hospital (SSH), 4% died in hospital-at-home, 9% died in Rehab, 9%died in skilled nursing homes and 21% died at home. During the last year of life, almost all menwere hospitalised at least once in SSH and 47% received hospital palliative care (HPC), immedi-ately prior to death in 8% of cases. During the last month of life, 76% of men were hospitalised atleast once in SSH, 43% attended an emergency department and 14% were admitted to intensive

care, 7% received a chemotherapy session, and 24% received an antineoplastic agent dispensedby a retail pharmacy. Cancer was the main cause of death for 63% of men, corresponding to PCain 40% of cases, and cardiovascular disease was the main cause of death for 13% of men withmarked variations according to age, place of death, and use of HPC. The mean cost reimbursedper man during the last year of life was D 38,750 (D 48,601 including HPC).

∗ Corresponding author: Caisse nationale de l’assurance maladie(Cnam), Paris, France.

E-mail address: [email protected] (P. Tuppin).

https://doi.org/10.1016/j.purol.2019.09.0061166-7087/© 2019 Elsevier Masson SAS. All rights reserved.

https://doi.org/10.1016/j.purol.2019.09.006http://www.sciencedirect.com/science/journal/11667087http://crossmark.crossref.org/dialog/?doi=10.1016/j.purol.2019.09.006&domain=pdfmailto:[email protected]://doi.org/10.1016/j.purol.2019.09.006

996 A. Tanguy-Melac et al.

Conclusions. — In France, end-of-life management of men with PCa, regardless of the causeof death, is centered on SSH and HPC, essentially at the time of death. Certain indicators ofend-of-life management were particular high.Level of evidence. — 4.© 2019 Elsevier Masson SAS. All rights reserved.

MOTS CLÉSCancer de laprostate ;Coûts ;Fin de vie ;Lieu de décès ;Recours aux soins

RésuméIntroduction. — Étudier les caractéristiques et recours aux soins des hommes présentant uncancer de la prostate (CP) lors de leur dernière année et mois de vie, qui sont peu connus.Matériel et méthodes. — Les hommes traités pour un CP (2014—2015) décédés en 2015 et cou-verts par le régime général de l’Assurance maladie (77 % de la population française) ont étérepérés dans le système national des données de santé incluant les soins remboursés en ville,à l’hôpital et leurs causes de décès.Résultats. — Ont été inclus, 11 193 hommes (âge moyen 81 ans, SD 9,6). Près de 58 % étaientdécédés en hôpital de court séjour (HCS), 4 % lors d’une hospitalisation à domicile, 9 % ensoins de suite et de réadaptation, 9 % en Ehpad et 21 % à domicile. L’année du décès, laquasi-totalité a été hospitalisée au moins une fois en HCS et 47 % ont eu des soins palliatifshospitaliers (SPH), dont 8 % avant leur décès. Le dernier mois, 76 % ont été admis au moins unefois en HCS, 43 % ont eu recours aux services d’urgence et 14 % de réanimation, 7 % à une séancede chimiothérapie, 24 % ont eu une délivrance en ville d’un agent antinéoplasique. Un cancerétait la cause principale de décès pour 63 % des hommes dont un CP pour 40 % et une causecardiovasculaire pour 13 % avec de fortes variations selon l’âge, le lieu de décès, le recoursaux SPH. Le coût moyen remboursé par homme la dernière année était de 38 750 D (avec SPH48 601 D ).Conclusions. — En France, la prise en charge de la fin de vie des personnes avec un CP quelque soit la cause du décès est centrée sur les SSH et les SPH essentiellement lors du décès Lesvaleurs de certains indicateurs de prise en charge le dernier mois sont élevés.Niveau de preuve.— 4.© 2019 Elsevier Masson SAS. Tous droits réservés.

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he end-of-life care pathway of individuals with certain can-ers has been described as a period of progressive declinever several years, followed by a marked and sudden dete-ioration during the last weeks or months of life [1]. Earlyccess to palliative care (PC) provides patients with aetter quality of life prior to their death [2,3]. Indica-ors designed to measure the intensity of end-of-life carendicate a high rate of hospitalisations, emergency depart-ent visits and intensive care admissions and chemotherapyuring the last month of life, which may appear to benappropriate [4—7].

Prostate cancer (PCa) is one of the most common can-ers in men with an estimated incidence in France of almost0,000 cases and 8,100 deaths in 2018 [8]. The annualost for national health insurance of patients managed forCa in France in 2014 was D 1,009 million, i.e. 8% of allancer-related expenditure and 0.6% of total reimbursedxpenditure [9]. The Système National des Données de

anté (SNDS) [National Health Data System], which is beingrogressively deployed in France, includes, for each individ-al, information about reimbursed hospital and outpatient

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ealth care consumption, including hospital palliative careHPC), as well as vital status and cause of death [10,11].

The objective of this study, based on SNDS data, was toescribe the characteristics and comorbidities of men man-ged for PCa during the year before their death in 2015, theirospital pathway during the last year of life and the intensityf care during the last month of life, including HPC manage-ent, their cause of death and the expenditure reimbursedy French national health insurance.

atients and methods

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he SNDS comprehensively collects individual outpatientata, as well as healthcare prescriptions and procedureseimbursed, but it does not provide any clinical data. Never-heless, it includes information on the presence of long-term

ealthcare expenditure. All this information is linked to dataoncerning public and private hospital stays: short stay hos-itals (SSH), rehabilitation (Rehab) and hospital at home

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Healthcare utilization by men with prostate cancer the year

(HaH) and a specific database indicating whether or not theperson is a resident of a skilled nursing home (SNH). Hospitaldischarge diagnoses and LTD diagnoses are coded accordingto the International Classification of Diseases 10th revision(ICD 10). Causes of death (ICD 10) are linked in the SNDSusing an indirect matching procedure. The overall matchingrate was 90% in 2015. The Caisse Nationale d’Assurance Mal-adie (CNAM), as a health research institute, has permanentaccess to the SNDS database approved by decree and theFrench data protection authority.

Cases

The general health scheme fund has developed a tool basedon SNDS data with algorithms designed to identify benefi-ciaries reimbursed for chronic or expensive diseases eachyear [12]. Algorithms identify 56 non-exclusive groups of dis-eases, based on principal diagnoses, related or significantassociated diagnoses in short-stay hospitals and psychiatrichospitals, LTD, dispensing of specific drugs, and specificprocedures. In this tool, algorithms designed to identify peo-ple on cardiovascular prevention drugs (antihypertensivesor lipid-lowering drugs) or psychotropic drugs are consid-ered on the basis of three annual reimbursements. Cancers,including PCa, are defined by short-stay hospitalisations overa 5-year period and/or LTD status based on specific can-cer diagnoses. Cases of actively treated cancer are definedas those requiring, over a 2-year period, either hospitalisa-tion for treatment, with the exception of hospitalisations forassessment only, or hospitalisation for metastasis, or initia-tion of management for an LTD, or treatment with certainspecific therapies indicated (androgen deprivation therapy,chemotherapy). The remaining cases were defined as PCaunder surveillance (follow-up, watchful waiting, palliativecare, etc.). Actively treated cancers were included in pref-erence to cancers under surveillance.

Population

Of the 66 million inhabitants in France at the end of 2015,the general scheme covers about 77% of the population livingin France [10]. This retrospective observational study con-cerned beneficiaries with PCa treated in 2014 or 2015 andwho died in 2015.

Variables

In France, SSH have acute wards and palliative care facil-ities and specific beds; rehab hospitals are devoted torehabilitation as well as palliative care depending on theirrehabilitation specialisation; and HaH care delivered athome by hospital teams. Palliative care is also provided athome and in SNH by ambulatory teams not attached to hos-pital units, but this information is not available in the SNDS.In this study, HPC included palliative care delivered duringthe year, either before death or at the time of death.

Antineoplastic agents consisted of drugs dispensed bya retail pharmacy and reimbursed by national health

insurance, using ATC codes L01 to L04: antineoplas-tic, immunomodulating agents and anti-androgens (LHRHanalogues or antagonists, first- or second-generation anti-androgens, oestrogen therapy).

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Information on the place of death is available for deathsccurring during hospital stays or in SNH. Death at homeannot be distinguished from death outside home: in aetirement home, in public places, etc.

tatistical analysis

or all health care benefits reimbursed by French nationalealth insurance, SNDS indicates the sums correspond-ng to the expenditure billed to the beneficiary and theum reimbursed to the beneficiary. Regarding healthcarexpenditures, direct healthcare costs are included. Theyncompass outpatient, inpatient expenditures but also sick-eaves and disability benefits. However, drugs dispenseduring a hospital stay are not individually reimbursed andere consequently not included in this study except for

hose billed by the hospital in addition to diagnosis-relatedroups funding. All these expenditures are calculated fromhe CNAM’s perspective.

Data are expressed as the mean ± standard deviationSD). The rates of at least one healthcare reimbursementuring the study period were reported. Means were calcu-ated only for those people with at least one reimbursementuring the period considered. The total and mean lengths oftay during the year per patient in the same type of hospitalere determined. Chi2, ANOVA, Student’s t test, Wilcoxon’s

est and Kruskal—Wallis test were used for comparison. Aankey diagram was used to illustrate patient flow accordingo the presence and the types of hospitalisation during theear or during the last 28 days before death. SAS softwareversion 7.11, SAS Institute Inc., Cary, NC, USA) was usedor statistical analysis and R software (3.4.3.) was used forankey diagrams.

esults

total of 11,193 men, with a mean age of 81 years (SD: 9.6ears) including 61% of men 80 years or older, who died in015 after being managed for PCa during the previous year2014-2015), were included (Table 1). About 58% of men diedn SSH, 4% died in HaH, 9% died in Rehab, 8% died in SNH and1% died at home.

At least one other cancer, either actively treated or underurveillance during the previous five years, was identifiedor one-third of men (lung: 3%, colorectal: 4%, other: 26%). Aower proportion of other cancers was observed for men whoied in SNH (17%). Almost two-thirds of men had been man-ged for cardiovascular disease, 26% for chronic respiratoryisease, and 20% for neurological or degenerative disease.igher frequencies of comorbidities were observed amonghe men who died in SNH, who were also older. Men man-ged by HPC during the year, i.e. 47%, were younger (meange: 79 years vs 83 years) and more often presented anotherancer (43%).

During the year before death, 94% of men had been hos-italised at least once, all causes combined: 94% in SSH, 28%n Rehab, 9% in HaH and 15% in SNH (Table 1). The annualean length of stay was 80 days in the presence of HPC vs 42

ays in the absence of HPC. The Fig. 1 illustrates the morentense flows during the last two months of life, predomi-antly from home to SSH and, to a lesser extent, from SSH toehab. When focusing on the last 28 days, flows from home

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Table 1 Description of the study population one year before death in 2015.

Total Place of death Hospital palliative care

Home orother

SNH HaH Rehab SSH No Yes

N 11,193 2,333 953 449 975 6,483 5,943 5,250% 100.0 20.9 8.5 4.0 8.7 57.9 53.1 46.9

% % % % % % P % % PAge at inclusion(years)

Mean (± SD) 80.8 ± 9.6 81.8 ± 9.4 87.5 ± 6.6 79.0 ± 9.8 81.9 ± 9.0 79.4 ± 9.5 *** 82.5 ± 9.2 78.8 ± 9.6 ***< 60 2.4 2.5 0.0 3.8 1.9 2.7 *** 1.6 3.4 ***60—69 12.0 9.0 1.7 14.7 9.3 14.8 9.1 15.270—79 24.7 22.2 8.8 28.7 22.9 27.9 20.7 29.180—89 42.7 46.0 47.2 39.0 45.7 40.7 45.5 39.7> 90 18.2 20.3 42.3 13.8 20.2 13.9 23.1 12.6

ComorbiditiesLung cancer 2.6 1.5 0.6 3.6 2.4 3.3 *** 1.5 3.9 ***Colorectal

cancer4.3 3.3 2.4 5.3 2.5 5.2 *** 3.3 5.5 ***

Other cancers 26.4 18.6 14.1 29.4 25.9 30.9 *** 19.7 34.0 ***Cardiovascu-

lar/neurovascular65.1 58.7 69.8 59.5 67.3 66.8 *** 68.9 60.9 ***

Diabetes 23.1 23.7 17.4 24.3 21.9 23.9 ** 23.9 22.2 .Psychiatric 6.9 6.3 13.2 5.3 8.5 6.0 *** 7.9 5.7 ***Neurological or

degenerative20.2 19.2 48.7 17.8 20.6 16.4 *** 23.7 16.2 ***

Respiratorychronic

25.8 23.2 19.0 24.3 23.1 28.2 *** 26.6 24.9 ***

Inflammatorychronic

3.0 2.5 2.2 2.7 3.3 3.4 . 3.1 3.0 .

Rare diseases 0.6 1.0 0.4 0.7 0.4 0.5 . 0.6 0.5 .HIV or AIDS 0.2 0.3 0.0 0.0 0.0 0.2 . 0.2 0.2 .Chronic dialysis 1.2 0.8 0.5 0.7 1.0 1.5 ** 1.3 1.1 .Liver or

pancreas8.1 4.0 4.3 7.3 7.4 10.3 *** 7.0 9.4 ***

TreatmentsPsychotropic

drugs47.0 46.8 64.6 49.2 46.5 44.4 *** 47.6 46.3 ***

Hypnotics 18.9 18.3 23.0 18.7 18.1 18.6 ** 18.9 18.8 **

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Table 1 (Continued)

Total Place of death Hospital palliative care

Home orother

SNH HaH Rehab SSH No Yes

Anxiolytics 25.8 26.0 35.6 29.2 23.8 24.4 *** 25.9 25.8 *Neuroleptics 5.4 5.4 17.5 5.6 3.5 3.9 *** 6.9 3.8 ***

Antidepressants21.8 20.3 38.0 22.0 20.0 20.3 *** 22.3 21.4 **

Antihypertensives71.4 71.7 65.9 69.5 73.1 72.0 *** 73.7 68.8 ***

Lipid-loweringdrugs

38.3 37.3 25.3 39.2 40.1 40.2 *** 38.8 37.7 **

At least one staySSH 93.5 77.1 81.8 97.1 99.4 100.0 *** 88.2 99.6 ***Mean length of

stay during theyear (SD)

44.4 ± 42.5 32.3 ± 33.3 31.4 ± 31.2 43.8 ± 33.1 46.7 ± 38.8 49.0 ± 45.86 *** 33.6 ± 38.8 55.2 ± 43.3 ***

HaH 8.8 2.1 1.9 100.0 3.6 6.6 *** 1.7 16.7 ***Rehab 28.2 17.3 31.9 18.0 100.0 21.5 *** 23.1 34.1 ***All typesa 93.9 77.8 82.9 100.0 100.0 100.0 *** 88.5 100.0 ***Mean length of

stay during theyear (SD)

60.0 ± 64.5 34.7 ± 47.8 46.4 ± 58.9 99.3 ± 79.3 99.1 ± 71.3 62.5 ± 63.6 *** 41.9 ± 53.6 80.0 ± 67.1 ***

SNH 14.7 3.0 100.0 8.9 2.9 8.6 *** 20.1 8.6 ***Palliative care* 46.9 16.9 15.8 92.9 69.2 55.7 ***

Other than theend-of-life stay

7.8 16.9 15.8 3.8 4.8 4.1 ***

In SNH: skilled nursing home + Rehab: rehabilitation hospital + HaH: hospital at home, palliative care at home and in SNH cannot be identified. ***P < 0.001, **P < 0.01, *P < 0.05.a Sum of stays in SSH: short-stay hospital + Rehab + HaH.


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igure 1. Hospital and SNH pathway during the last year and the

o SSH intensified before death: 56% of men were at home8 days before death and 21% were at home at the time ofeath, while 24% of men were in SSH 28 days before deathersus 58% at the time of death.

During the month before death (Table 2), 76% of individ-als had been admitted at least once to SSH. At least onemergency department visit was identified for 43% of men.uring these hospital stays, 14% of men were admitted tohe intensive care unit at least once, more often betweenhe ages of 60 and 69 years (20%). At least one chemotherapyession was administered for 7% of men during the last 30ays of life and for 4% of men during the last 14 days of life.n antineoplastic agent was dispensed by a retail pharmacyo 24% of men (18% with HPC vs 29% without HPC) during theast month of life.

The main cause of death was cancer for 63% of menTable 3). This proportion decreased with increasing age andaried according to the place of death and the presence orbsence of HPC (83% versus 46%). The second most commonause of death was cardiovascular disease for 13% of men,specially for those who died at home (18%) or in SNH (17%).he third most common cause of death (5%) was ill- definedonditions. PCa was indicated as the cause of death for 40%f men managed for PCa, with higher rates for the youngesten (52% for men < 60 years). Among all men for whom PCaas indicated as the cause of death, 59% died in SSH, 8%ied in SNH, 17% died at home and 61% had received HPC.

The overall cost of the last year of life was D 434illion (D 179 M with HPC, D 255 M without HPC), com-rising D 260 M for hospital expenditure, D 170 M for officeedicine expenditure and D 4 M for other benefits. Theean annual expenditure per man was D 38,750 (D 48,601ith HPC, D 30,048 without HPC) and the growth of the meanonthly expenditure accelerated during the last month of

ife (Fig. 2).

iscussion

n France, compared to other countries, end of life andeath are more hospital-centered, especially in short-stay

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four weeks of life.

ospitals, with less frequent management at home or in SNH13—16]. A similar study conducted in France on all peopleho died in 2013 showed that 61% of deaths occurred inospital (SSH 51%), 13% in SNH and 26% at home or outsidef hospital for deaths from all causes, and 77% (64%), 7%nd 16%, respectively, for cancer deaths [11]. In the presenttudy, a smaller proportion of men with PCa died in hospitalith a higher proportion who died at home, i.e. 71% (58%),% and 21%, respectively. An Australian study of men withetastatic PCa reported 77% of deaths in hospital and 23%

n the community [7]. The proportion of each place of deathnd the mode of management may vary between countriesccording to the inclusion criteria (patient managed for can-er or cancer as the actual cause of death), the stage ofancer, other concomitant cancers, comorbidities, organi-ation of end-of-life care [17—20]. In the United States, anncreasing number of deaths in hospices was reported anden diagnosed with prostate cancer are less likely to die

rom prostate cancer than from another cause [21]. Never-heless, in France, an intense flow, corresponding to transferf men at the end of life from their home or nursing homeo SSH hospitalisation, was observed. This flow was accentu-ted during the last month and could be related to clinicalrogression of PCa (responsible for 40% of deaths), all can-ers (PCa and other tumours) (67%), but also other reasons,ncluding complications. More moderate flows to Rehab unitsere also observed for older men, who more often pre-

ented psychiatric or neurological comorbid conditions, butn whom the proportion of cancer deaths was higher (72%)han in SSH, and which may require HPC management.

Few published studies have described intensity of carendicators for prostate cancer during the last month of life.hese indicators can also be influenced by the variations

isted above. Although the Australian study [7] concernedatients with metastatic PCa, some intensity of care indi-ators were higher in this study: admission to an SSH duringhe last month of life for 48% of men (76% in our study),

ength of stay longer than 14 days for 55% of men (meanength of stay of 16 days in our study), emergency depart-ent visits for 7% (vs 43% in our study, but almost all

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Table 2 Intensity of care indicators during the last 30 days before death in 2015.

Total Place of death Hospital palliative care Age-group

Home SNH HaH Rehab SSH No Yes < 60years

60—69years

70—79years

80—89years

≥ 90years

N 11,193 2,333 953 449 975 6,483 5,943 5,250 271 1,341 2,762 4,785 2,034% 100.0 20.8 8.5 4.0 8.7 57.9 53.1 46.9 2.4 12.0 24.7 42.7 18.2

% % % % % % % % % % % % %

SSH stayAt least

one stay76.2 35.3 31.8 59.9 66.3 100.0 65.5 88.2 83.4 86.4 82.4 74.3 64.4

Number ofstaysb

1.7 ± 1.4 1.6 ± 1.6 1.4 ± 1.1 1.7 ± 1.9 1.5 ± 1.6 1.8 ± 1.4 1.7 ± 1.5 1.8 ± 1.4 2.0 ± 1.4 2.1 ± 1.7 1.9 ± 1.6 1.6 ± 1.4 1.4 ± 0.8

Length ofstay(days ± SD)b

15.8 ± 10 11.1 ± 9.1 13.3 ± 9.4 14.3 ± 9.4 16.5 ± 9.2 16.5 ± 10.112.8 ± 9.6 18.3 ± 9.7 16.8 ± 10.717.1 ± 10.117.2 ± 10.215.4 ± 9.9 13.2 ± 9.4

Rehab stayAt least

one stay15.5 4.6 6.3 5.6 100.0 8.8 10.5 21.2 12.5 11.4 15.2 16.8 16.0

HaH stayAt least

one stay7.4 1.2 0.5 100.0 1.8 5.0 1.1 14.4 14.0 10.9 9.1 6.3 4.4

Emergencydepartmentvisit

At leastone visit

43.1 17.1 19.4 25.4 33.3 58.7 42.9 43.4 32.8 40.3 40.9 44.7 45.7

Followedby hospitali-sation

42.4 16.2 18.7 24.7 32.7 58.1 42.2 42.7 32.1 39.2 40.3 44.0 45.1

Number ofvisitsb

1.2 ± 0.4 1.1 ± 0.3c 1.1 ± 0.2c 1.1 ± 0.5c 1.1 ± 0.3c 1.2 ± 0.5c 1.2 ± 0.4c 1.2 ± 0.5c 1.2 ± 0.4 1.2 ± 0.5 1.2 ± 0.5 1.1 ± 0.4 1.2 ± 0.4

Stay fororgan failure

At leastone stay

13.8 2.7 1.8 4.0 6.1 21.5 17.0 10.3 8.1 19.9 16.2 13.8 7.5

Antineoplasticagentsa

During last14 days

Chemother-apysession

4.2 2.6 0.5 6.2 3.2 5.3 3.7 4.7 11.4 8.7 6.9 2.5 0.5

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Table 2 (Continued)

Total Place of death Hospital palliative care Age-group

Home SNH HaH Rehab SSH No Yes < 60years

60—69years

70—79years

80—89years

≥ 90years

N 11,193 2,333 953 449 975 6,483 5,943 5,250 271 1,341 2,762 4,785 2,034% 100.0 20.8 8.5 4.0 8.7 57.9 53.1 46.9 2.4 12.0 24.7 42.7 18.2

% % % % % % % % % % % % %

Antineo-plasticagents

9.9 14.1 12.7 2.9 3.3 9.4 13.2 6.1 7.7 8.5 8.9 9.9 12.1

During last30 days

Chemother-apysession

7.3 4.2 0.9 8.9 5.3 9.5 5.5 9.3 21.4 17.5 11.7 3.8 0.8

Antineo-plasticagents

23.6 28.3 27.1 12.2 9.9 24.2 28.9 17.6 19.9 21.8 20.9 24.7 26.4

Radiotherapy(session)

During last14 days

2.0 0.6 0.6 2.0 1.5 2.8 1.1 3.0 6.6 3.5 3.0 1.4 0.4

During last30 days

3.0 1.0 1.0 3.8 3.0 3.9 1.5 4.7 7.4 5.9 4.2 2.3 0.5

All P-values are < 0.05.a Antineoplastic agents consisted of drugs dispensed by a retail pharmacy and reimbursed by national health insurance, using ATC codes L01 to L04: antineoplastic, immunomodulatingagents and androgen deprivation (LHRH analogues or antagonists, first- or second-generation anti-androgens, oestrogen therapy).b Among those men with at least one visit, with or without an overnight stay,c All P-values that are not < 0.05.

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1003Table 3 Main causes of death for men who died in 2015 and who were managed for PCa during the previous year.

Total Place of death Hospital palliative care Age

Home SNH HaH Rehab SSH No Yes < 60 60—69 70—79 80—89 ≥ 90All causes

N causes (%) 10,328(100.0)

2,030(19.7)

885(8.6)

388(3.8)

923(8.9)

6,102(59.1)

4,891(47.4)

5,437(52.6)

250(2.4)

1,242(12.0)

2,560(24.8)

4,421(42.8)

1,855(18.0)

% % % % % % P % % % % % % % PProportion of PCa 40,1 35.6 35.6 55.1 47.5 40.2 32.7 46.8 52.0 43.3 42.8 39.2 35.0% 100,0 (17.4) (7.6) (5.2) (10.6) (59.2) (38.6) (61.4) (3.1) (13.0) (26.4) (41.8) (15.7)

Tumours 63.1 51.3 46.4 83.5 72.2 66.8 < 0.001 45.6 82.5 82.8 78.5 73.0 58.9 46.3 < 0.001Cardiovascular 13.2 18.0 17.1 5.2 9.5 12.1 19.6 6.1 1.2 6.7 9.7 15.0 19.8Ill-defined

conditions5.4 11.6 11.2 4.4 2.9 2.9 7.5 3.0 5.2 3.5 4.5 5.1 8.5

Gastrointestinalsystem

2.2 0.9 1.0 0.3 1.5 3.0 3.3 0.9 2.0 2.3 1.7 2.4 2.3

Respiratorysystem

4.5 3.5 4.4 1.0 3.6 5.1 6.8 1.8 2.0 1.9 3.0 5.2 6.7

External causes 3.3 6.7 2.1 0.5 2.5 2.6 5.2 1.1 3.6 3.1 2.7 3.5 3.6

Neurodegenerative2.1 2.1 6.9 2.1 1.7 1.4 3.0 1.0 0.8 1.0 1.3 2.6 2.7

Endocrine 1.6 2.6 2.8 1.5 1.1 1.2 2.2 1.0 0.4 0.8 1.1 2.0 2.2Infectious 1.0 0.3 0.7 0.5 0.5 1.3 1.5 0.4 0.0 0.7 0.7 1.1 1.2Genitourinary 1.3 0.6 1.1 1.0 1.0 1.7 1.7 0.9 0.0 0.6 0.8 1.6 2.2Other 2.3 2.4 6.3 0.0 3.5 1.9 3.6 1.3 2.0 0.9 1.5 2.6 4.5

Distribution oftumours

Prostate 63.6 69.3 76.6 66 65.8 60.2 < 0.001 64.4 63.0 62.8 55.1 58.6 66.5 75.6 < 0.001Larynx, trachea,

bronchus, lung8.3 6.1 1.9 6.5 7.5 9.8 7.9 8.6 8.7 13.9 10.2 6.9 2.1

Bladder 4.2 3.9 4.1 4 4.2 4.3 4.4 4.1 4.8 4.3 4.5 4.1 3.7Colon 3.1 3.5 2.9 3.7 2.4 3.1 3.1 3.1 1.4 2.6 3.1 3.4 3.1Lymphatic tissue 2.3 1.8 1.5 1.2 1.5 2.7 2.5 2.1 0.5 1.5 2.7 2.2 2.6Liver 2.1 1 1.2 2.2 1.5 2.6 1.8 2.3 1.4 2.8 2.7 2.1 0.5Pancreas 2.1 1.6 0.2 1.5 1.5 2.5 1.6 2.4 3.4 2.8 2.8 1.4 1.4rectal 1.2 0.9 0.2 0.6 1.1 1.5 1.0 1.3 0.5 1.4 1.6 0.9 1.4Kidney 1 0.6 1.5 1.2 1.5 0.9 0.9 1.0 1.0 1.0 1.1 1.0 0.6Oesophagus 1 0.8 0.2 0.6 0.8 1.1 1.0 0.9 1.0 1.4 1.2 0.8 0.3Stomach 0.9 0.8 0.5 0.9 1.1 1.0 0.6 1.1 1.4 1.3 0.6 1.0 0.6Lip, oral cavity,

pharynx0.7 0.9 0.2 0.3 0.5 0.7 0.9 0.5 2.4 1.0 1.0 0.4 0.1

Other, notspecified

12.1 11.3 9.9 13.1 13.0 12.4 12.4 12.1 15.5 14.6 12.7 11.5 9.0

***P < 0.001, **P < 0.01, *P < 0.05.


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igure 2. Mean monthly expenditure reimbursed by national hea

ospitalisations were preceded by an emergency depart-ent visit), intensive care unit stay for 2% (vs 14% in our

tudy), an antineoplastic agent during the 14 days beforeeath for 12% (vs hospital chemotherapy sessions for 4% andhemotherapy dispensed by a retail pharmacy for 10% in ourtudy). A recent study did not reveal any effect on survivalnd quality of life of more intensive health care consumptionn men with metastatic PCa [22].

Utilization of HPC during the last year of life was iden-ified for 47% of men treated for PCa. The indication forPC was not reported, but cancer was indicated as the mainause of death for 83% of men managed by HPC. By exclu-ively considering causes of death, 61% of men with PCaere managed at least once by HPC, similar to the propor-

ion of men managed by palliative care in the Australiantudy: 60% of men with metastatic PCa were managed in aospital-based palliative care referral and 39% in a palliativeare hospital bed [7]. As in other studies, patients managedy HPC were younger and presented fewer comorbidities.hese studies also reported higher rates of metastatic dis-ase and aggressive cancer among men managed by HPC23]. Nevertheless, in our study, only 8% of men were man-ged by HPC prior to their end-of-life stay. This proportionas higher for those men who died at home or in SNH (16%),

or whom continuation of HPC after their transfer or returnome could not be detected in the SNDS. Although hospitalhemotherapy sessions were slightly more frequent amongen managed by HPC, retail pharmacy dispensing of anti-

eoplastic agents was slightly less frequent. Nevertheless,nalysis of the impact of HPC on intensity of care is limitedy the fact that the great majority of HPC was administereduring the end-of-life stay.

The active PCa inclusion algorithm in this study identified3% of all men with PCa as the main cause of death, whilehe remaining men were classified as PCa under surveil-ance for 1% of cases, other active cancer in 5% of cases,ther cancers under surveillance in 7% of cases and no PCar other active cancer or cancer under surveillance in 4%

f men. The survival and cause of death of men with PCare markedly influenced by a combination of factors suchs age, competitive comorbidities including cardiovascular

it$

surance. HPC: Hospital palliative care.

isease, presence of another cancer or the characteristicsf PCa (initial stage, response to treatment) [24]. In ourtudy, 37% of deaths were due to non-neoplastic causescardiovascular disease in 13% of cases), 23% were due tother cancers and 40% were due to PCa. An American studynalysed causes of death of patients derived from a can-er registry (1973—2012) and revealed a reduction of theroportion of patients for whom the main cause of deathause was PCa (50% in the 1970s and 20% in 2012), about0% for other cancers and 60% for other causes (cardiovas-ular disease: 20%) [25]. A number of hypotheses, especiallypidemiological, can be proposed to explain these differ-nces of comorbidities between these populations, as wells the nature and the frequency of the treatments admin-stered, such as anti-androgens [26]. The availability offfective chemotherapy, starting with docetaxel and nowecond- generation anti-androgens, may have contributed tohis reduction. The benefits of these treatments have beenemonstrated in terms of the quantity and quality of life ofatients with castration-resistant metastatic PCa. Anothermerican study, published in 2000, evaluating a cohort ofeceased patients with PCa, reported PCa as the causef death in 39% of cases, as our study, [27]. For patientsith PCa, included in the Thames cancer registry between997—2006, 50% of deaths were due to PCa, 12% of deathsere due to other cancers, and 38% of deaths were due tother causes (cardiovascular disease: 18%) [28]. Our studyeports the presence of another treated cancer or cancernder surveillance in 30% of men and another cancer waseported as the cause of death for 23% of men. An Americanohort (1973—2006) of patients with PCa and another cancereported 41% of cancer-related deaths among the men whoied at the end of 2011: PCa in 19%, other cancer in 23%29].

Few studies have specifically reported the mean cost peran treated for PCa during the last year of life, which repre-

ented D 38,750 for national health insurance in the presenttudy. In the United States, the mean cost of health care dur-

ng the last year of life for men who died from PCa was lowerhan that for people dying from another cause ($43,572 vs.45,830), and very similar to the cost of D 38,200 identified

bef

[

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[

[

[

[

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Healthcare utilization by men with prostate cancer the year

in our study [30]. A Canadian study on the direct costs dur-ing the last 6 months of life, calculated from administrativedata, revealed a cost of $16,020 per 100-day period [31].A recent review of the literature reported lower costs forpatients managed by palliative care [32], but this was notthe case in our study (D 48,601 with HPC, D 30,048 with-out HPC), in which HPC was identified during the end-of-lifestay and the cost difference was observed right from thefirst months of the last year of life. Mean expenditure dis-parities can thus be the result of differences in populationstructure. The aim of our paper is report descriptive statis-tics regarding healthcare expenditures and not to directlycompare healthcare expenditures for individuals with andwithout of HPC (such a study would require the constitu-tion of a ‘‘control’’ population comparable to that withHPC even if the SNDS is not necessarily the most appropri-ate). Variation in the definition of palliative care can alsolead to different result. Nevertheless, these findings suggestmore intensive management of PCa or other diseases priorto death in hospital for men managed by HPC. The pres-cription of second-generation endocrine therapy, recentlymarketed for advanced and usually metastatic castration-resistant PCa, should increase the cost of management ofmany patients during their last year of life.

Conclusions

This study provides a wealth of new data concerning thecharacteristics and management of men with PCa, regard-less of the cause of death, during their last year of life ina country with predominant hospital-based management.These results must be refined for PCa with the help ofhealthcare professionals and patients, in order to guide andevaluate end-of-life health policies and improve monitoringand assessment of palliative care use.

Acknowledgements

The authors would like to thank the members of the Centrenational de la fin de vie et des soins palliatifs, especiallyDr V. Fournier and S. Bretonnière, for their participation, aswell as Prof. R. Aubry and Dr Russo.

Disclosure of interest

The authors declare that they have no competing interest.

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