How healthcare systems evaluate their advance care planning initiatives: Results from a systematic review

Palliat Med. 2016 Sep;30(8):720-9. doi: 10.1177/0269216316630883. Epub 2016 Feb 23.


Background: Advance care planning initiatives are being implemented across healthcare systems around the world, but how best to evaluate their implementation is unknown.

Aim: To identify gaps and/or redundancies in current evaluative strategies to help healthcare systems develop future evaluative frameworks for ACP.

Design: Systematic review.

Methods: Peer-reviewed and gray literature searches were conducted till February 2015 to answer: "What methods have healthcare systems used to evaluate implementation of advance care planning initiatives?" A PICOS framework was developed to identify articles describing the implementation and evaluation of a health system-level advance care planning initiative. Outcome measures were mapped onto a conceptual quality indicator framework based on the Institute of Medicine and Donabedian models of healthcare quality.

Results: A total of 46 studies met inclusion criteria for analysis. Most articles reported on single parts of a healthcare system (e.g. continuing care). The most common outcome measures pertained to document completion, followed by healthcare resource use. Patient-, family-, or healthcare provider-reported outcomes were less commonly measured. Concordance measures (e.g. dying in place of choice) were reported by only 26% of studies. The conceptual quality indicator framework identified gaps and redundancies in measurement and is presented as a potential foundation from which to develop a comprehensive advance care planning evaluation framework.

Conclusion: Document completion is frequently used to evaluate advance care planning program implementation; capturing the quality of care appears to be more difficult. This systematic review provides health system administrators with a comprehensive summary of measures used to evaluate advance care planning and may identify gaps in evaluation within their local context.

Keywords: Advance care planning; evaluation; healthcare systems; systematic review.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Advance Care Planning / standards*
  • Humans
  • Outcome and Process Assessment, Health Care / methods*
  • Program Evaluation / methods*
  • Quality Assurance, Health Care / methods