Is the French palliative care policy effective everywhere? Geographic variation in changes in inpatient death rates among older patients in France, 2010–2013

Background: Recently, French policymakers have tried to improve care at the end-of-life, by improving access to community-based palliative care, particularly for patients with cancer and neurological diseases. If effective, these efforts should reduce the proportion of such patients who die in the hospital. In light of these policies, we sought to determine the effectiveness of these efforts on reducing inpatient deaths by conducting a retrospective, observational analysis of patients aged 65 and older who were admitted to hospitals in France between 2010 and 2013 for 1 of 3 non-surgical conditions. Methods: We calculated department-specific age- and sex-adjusted inpatient death rates for 3 types of non-surgical admissions and modeled expected number of inpatient deaths had their rates for patients with cancer or neurological disease tracked those of patients with non-cancer non-neurological diseases. Results: We found that patients admitted with a cancer diagnosis experienced 20,394 (13.0%) fewer inpatient deaths that expected had non-surgical cancer diagnosis admission rates tracked those of non-surgical non-cancer and non-neurological admission rates; patients admitted with a primary neurological disease diagnosis experienced 513 (4.5%) fewer inpatient deaths than expected. During the study period, observed-to-expected inpatient deaths fell more dramatically and consistently for patients admitted with cancer diagnoses than for those admitted with neurological diseases. Observed-to-expected ratios fell least in departments that were on the periphery of the French mainland. Conclusions: Our findings suggest that, in France, efforts to reduce inpatient death rates among patients with cancer or neurological disease diagnoses appear to be effective. However, their effectiveness varies geographically, suggesting that targeted efforts to improve lower performing departments may generate substantial performance improvements.