OBJECTIVES: In ALSYMPCA, the first-in-class alpha-emitting Ra-223 significantly improved overall survival vs placebo and was well tolerated in castration-resistant prostate cancer (CRPC) patients with symptomatic bone and no visceral metastases regardless of prior D use. We studied whether treatment benefit in prior-D and no-prior-D subgroups relates to healthcare resource utilization differences in European patients. METHODS: Hospitalization, nursing home visits, home healthcare and adult day care use, and physician visit data were captured. Treatment groups were compared based on percentage needing each healthcare resource (Fisher’s exact tests). To account for observation time differences due to differing survival, patient resource use was annualized. Mean number and duration of encounters/year were compared (t-tests).  RESULTS: Percentage of prior-D patients needing hospitalization was nominally lower for Ra-223 vs placebo (44.0% vs 51.0% [P=P=0.001)], as was mean hospitalizations/year (1.3 vs 1.9 [P=0.017]). For prior-D patients with ≥1 hospitalization, mean hospitalization days/year for Ra-223 vs placebo were 20.1 vs 35.0 (P=0.003). For no-prior-D patients, percentage of hospitalizations was lower for Ra-223 vs placebo (39.5% vs 53.2% [P=P=0.249]), but mean hospitalization days/year was significantly different (8.7 vs 14.0 [P=0.042]). For no-prior-D patients with ≥1 hospitalization, mean hospitalization days/year for Ra-223 vs placebo were 22.0 vs 26.9 (P=0.308). No significant between-treatment-group differences were found in annual number of visits or time in nursing homes, amount of adult day care and home healthcare use, and number of physician visits. CONCLUSIONS: Of prior-D patients, Ra-223 patients experienced 8.9 fewer hospitalization days/patient/year, driven by a reduced number of hospitalizations/year and shorter hospitalizations. Of no-prior-D patients, Ra-223 patients experienced 4.9 fewer hospitalization days/patient/year, primarily driven by shorter hospitalizations and fewer patients needing hospitalization.