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

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.