Association between advanced care planning and emergency department visits: A systematic review

a b s t r a c t

Background: Advance care planning can help provide optimal medical care according to a patient’s wishes as a part of patient-centered discussions on end-of-life care. This can prevent undesired transfers to emergency de- partments. However, the effects of advance care planning on emergency department visits and ambulance calls in varioUS settings or specific conditions remain unclear.

Aim: To evaluate whether advanced care planning affected the frequency of emergency department visits and ambulance calls.

Design: Systematic review. This study was registered in PROSPERO (CRD42022340109). We assessed risk of bias using RoB 2.0, ROBINS-I, and ROBINS-E.

Data sources: We searched the PubMed, Cochrane CENTRAL, and EMBASE databases from their inception until September 22, 2022 for studies comparing patients with and without advanced care planning and reported the frequency of emergency department visits and ambulance calls as outcomes.

Results: Eight studies were included. Regarding settings, two studies on patients in nursing homes showed that advanced care planning significantly reduced the frequency of emergency department visits and ambulance calls. However, two studies involving several medical care facilities reported inconclusive results. Regarding pa- tient disease, a study on patients with depression or dementia showed that advanced care planning significantly reduced emergency department visits; in contrast, two studies on patients with severe respiratory diseases and serious illnesses showed no significant reduction. Seven studies showed a high risk of bias.

Conclusions: Advanced care planning may lead to reduced emergency department visits and ambulance calls among nursing home residents and patients with depression or dementia. Further research is warranted to iden- tify the effectiveness of advanced care planning in specific settings and diseases.

(C) 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://


  1. Introduction

Advanced care planning (ACP) enables individuals to express their medical treatment and care preferences. Previous studies have reported that ACP improves satisfaction among family members regarding the quality of death [1] and potentially reduces undesired transfers to emer- gency departments (EDs) in residential aged care facilities [2] or pallia- tive home care settings [3].

ACP is recommended for individuals at any stage of their life [4]; however, the limitations impeding the promotion of ACP include short- age of sufficient resources, time, manpower, and staff preparation

* Corresponding author at: Department of Health Services Research, Institute of Medicine, University of Tsukuba, 1-1-1 Tenno-dai, Tsukuba, Ibaraki 305-8575, Japan.

E-mail address: [email protected] (R. Inokuchi).

required for ACP implementation [5]. Thus, there is a need to assess the effects of ACP implementation on the frequency of ED visits and am- bulance calls in various settings or among patients with specific diseases or conditions.

Therefore, we conducted this systematic review to assess whether ACP implementation affected the frequency of ED visits and ambulance calls without restrictions regarding study settings or patients’ diseases or conditions.

  1. Methods

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines 2020 [6]. Details regarding the study protocol are registered in PROSPERO (CRD42022340109).


0735-6757/(C) 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

    1. Eligibility criteria

Studies were included if they (i) used interventions or exposures that included ACP and if they compared groups with/without ACP im- plementation; (ii) reported the frequency of ED visits and ambulance calls as outcomes; and (iii) were published in peer-reviewed journals. There were no restrictions imposed on participants’ conditions or back- grounds. We included both observational and interventional studies; however, we excluded case reports and reviews. Additionally, we excluded studies that incorporated multiple components that were not directly related to ACP.

    1. Search strategy

We searched the MEDLINE (PubMed), Cochrane CENTRAL, and EMBASE databases from their inception to September 22, 2022. There were no restrictions on language or publication dates. The search terms were as follows: Advance Care Planning OR Advance directives OR Living wills AND Emergency Department OR Emergency Room OR Emergency Medical Services OR Ambulances. Details regarding the search strategy used for each database are provided in Appendix A.

    1. Study selection

To identify potentially eligible studies based on our inclusion and ex- clusion criteria, full-text screening was performed independently by two reviewers to confirm the eligibility of the papers for inclusion (A.F. and R.I.). Discrepancies were resolved through discussion and con- sensus with a third reviewer (M.I.).

    1. Data extraction

We extracted data regarding the study characteristics (author, pub- lication year and country, study design, and setting), participant charac- teristics, intervention characteristics, and outcome measures with respect to the frequency of ED visits and ambulance calls, ACP-related documentation type, and proportion of individuals with documenta- tion. We requested the authors to share the data in case of missing details.

Two reviewers independently assessed the risk of bias (A.F. and R.I.); moreover, disagreements were resolved through discussion (M.I.). The risk of bias was assessed using the revised version of the Cochrane Risk-of-bias tool 2.0 (RoB 2.0) for Randomized controlled trials , Risk-of-Bias In Non-Randomized Studies of Interventions (ROBINS-I) for non-randomized studies, and Risk-of-Bias In Non-Randomized Stud- ies of Exposure (ROBINS-E) tool for observational studies [7,8].

  1. Results
    1. Study selection

The screening process is summarized in Fig. 1. We identified 1545 records during the initial search of the electronic databases. An addi- tional search yielded 135 records. Following the screening process, 40 reports were considered to be potentially eligible for inclusion in the re- view. After assessing the full texts, we excluded two systematic reviews [2,9]; three study protocols [10-12]; five studies that did not include ACP as an intervention/exposure [13-17]; nine studies in which the in- terventions/exposures included multiple components that were not di- rectly related to ACP [18-26]; four studies that did not distinguish ED visits and other hospital transfers or admissions [27-30]; two studies that only compared the ED costs [31,32]; and seven studies that did not compare groups with/without ACP [33-39]. We did not exclude

the report by O’Sullivan et al. [40], which compared the cost of ambu- lance transfer calculated by multiplying the estimated cost for one transfer since we considered that this cost reflected the number of transfers. Finally, eight articles were included in this systematic review.

    1. Study characteristics

Table 1 shows the study characteristics of the eight studies. There were four interventional studies, including one randomized controlled trial [41], one non-randomized controlled trial [42], two before-after trials [40,43], and four observational studies that were all retrospective cohort studies [44-47]. According to the country of origin, four, three, and one studies were conducted in the United States [43-45,47], Australia [41,42,46], and Ireland [40], respectively.

Regarding the study settings, two studies included participants from nursing homes and long-term care facilities [40,42], two studies covered medical care facilities of various levels [41,46], and four studies did not restrict participants according to the facilities [43-45,47]. Regarding pa- tient disease or condition, three studies targeted participants with par- ticular diseases or conditions, namely severe respiratory disease [41], depression or dementia [43], and serious illness [45].

    1. Intervention/exposure

Among the four interventional studies, nurses or coordinators con- ducted ACP interventions in three studies [40,41,43]. Among them, nurses working in the targeted facilities, including nursing homes or clinics, conducted the intervention after an ACP intervention training program in two studies [40,41]. Some additional interventions were used together with ACP training. These included education on the natu- ral course of the end of life for nursing home residents and their families, nursing home staff members, and primary care physicians [42]; assess- ment of cognitive impairment before implementing any intervention [40,42]; format of electronic health records that support ACP discussion and recording [43]; holding regular meetings with staff members con- ducting the ACP process [40]; and provision of manuals and materials on how to perform ACP [40].

Among the four observational studies, two studies used the ACP bill- ing code as exposure [45,47], while two studies identified the use of ACP via interviews or from records [44,46].

    1. Outcomes

The outcomes are summarized in Table 2. Five of the eight studies (three interventional studies and two observational studies) concluded that the frequency of ED visits and ambulance calls was significantly re- duced by ACP implementation.

Regarding study settings, two studies reported a significant reduc- tion in the number of ambulance calls from nursing homes after ACP im- plementation [40,42]. Caplan et al. reported that an ACP intervention for nursing home residents reduced the annual ambulance calls in the re- gion (-1%/year in the intervention region vs. +21%/year in the control region, P = 0.0019) [42]. O’Sullivan et al. demonstrated cost reduction in Ambulance transfer after implementing an ACP program in long- term care facilities (EUR891,761 within 2 years before the intervention to

EUR468,308 within 2 years after the intervention, which equated to

-EUR423,453/2 years (95% confidence interval [CI] of the average differ- ence, EUR0.19-0.73 million) [40]. Among the two studies involving several medical care facilities, Sinclair et al. concluded that the number of ED visits in the last 90 days before death was not significantly reduced [41]. Contrastingly, Oo et al. reported that the number of ED visits was significantly reduced among patients whose prognosis was estimated at <12 months (mean number of ED visits: pre-intervention, 1.6 +- 2.0; post-intervention, 3.2 +- 4.2; P < 0.001) [46]). Among three studies that used Claims data, Gupta et al. reported that among patients aged

>=65 years, the number of patients who visited the ED within the last

Image of Fig. 1

Fig. 1. Study Selection process.

ACP, advanced care planning; ED, emergency department.

30 days before death was significantly reduced after receiving ACP (identified via ACP claims) compared with the number of patients with- out ACP claims (odds ratio, 0.77; 95% CI, 0.75-0.80; P < 0.0001) [47]. Conversely, Bischoff et al. and Ashana et al. reported no significant re- duction in the number of ED visits within the last month before death and at 180 days after the first ACP claim, respectively [44,45].

Regarding patient diseases or conditions, Litzelman et al. reported a reduction in the number of ED visits after implementing an ACP

intervention based on an electronic health record system among pa- tients aged >65 years with dementia or depression (relative risk, 0.73 [95% CI, 0.62-0.86, P = 0.001]) [43]. In contrast, Sinclair et al. and Ashana et al. reported no significant reduction in the number of ED visits among patients with severe respiratory disease and serious illness, respectively [41,45].

Table 2 summarizes the status of the documentation related to ACP. Various types of documentation, including legal and non-legal

Table 1

Characteristics of the included studies.




Study design










Tertiary hospital respiratory


Nurse-led, facilitated ACP intervention


department, General practice clinics,


– one or more appointment with the trained nurse

residential aged-care facilities, regional


facilitator. The ACP discussion was recorded.

hospital in town

– for the facilitator, a full-day training workshop, detailed

study protocol, and regular meeting, were implemented.

– interventions was delivered in an outpatient clinic,

participant’s home, general practice room, or by

telephone (follow-up discussion only)





Nursing home

“Let Me Decide” Advance Care Directive

– education for residents, families, staff members, and

general practitioners about the terminal nature of

dementia, ACP, and Hospital in the Home

– screening residents’ capacity using the Mini-Mental

State Examination and the Decisional Aid for Scoring

Competency to Complete an Advance Directive. (If the

capacity was insufficient, the “person responsible” gave

consent for ACP.)





Long-term care facilities

“Let Me Decide” ACP program consisted of the following


four steps:

i) Screening cognition, using the Standardized

Mini-mental state Examination

ii) Education by trained senior nurses for residents and

families about directives

iii) Assessment of competency using the Screening

Instrument to Assess capacity to Complete an Advanced


iv) The directives were documented and signed if the

resident was deemed competent.





Age >= 65 years

ACP interventions consisted of the following three steps:



i) Care Coordinator Assistants (CCAs) ACP interaction

depression or

The CCAs were trained using workshops and simulation;


then, they visited the patient multiple times over many


ii) ACP electronic health record decision-support tool

This allows documentation of biopsychosocial-spiritual

histories, goals for living, and care preferences,

healthcare representative, power of attorney, Living Will,

and POLST form.

iii) Ongoing case conferences

Weekly case conference with the CCA and palliative care

providers, monthly review of ACP, and discussion of





Health and Retirement study

Age >= 65 years

difficult cases between the CCA and ACP training team. ACP engagement (detected by exit interviews)






Medical and pharmacy claims data

Age >= 65 years

ACP billing code


Serious illness





ACP registry


Documenting patient’s preferences in the ACP form


<12 months


RACFs, general






Medicare fee-for-service

Age >= 65 years

ACP billing code


US, United States; ACP, Advanced Care Planning; RCT, randomized control trials; NRCT, Non-Randomized Control Trials, ED, Emergency Department; POLST, Physician’s Orders for Life- Sustaining Treatment; RACFs, residential aged care facilities.

documentation, were used. In four interventional studies, the propor- tion of individuals with ACP documentation was low in the ACP inter- vention/exposure group (11-76%) [40,42,43].

    1. Risk of bias

Fig. 2 shows the results of the risk-of-bias assessment. Seven studies were assessed as having a high risk of bias or above. Domain 2 of the RoB2 (deviations from intended interventions) was assessed as being of “some concern” in the RCT since the intervention characteristics did not allow blinding. Among non-RCTs and observational studies, Domain 1 of the ROBINS-I (confounding) was assessed as high owing to the presence of multiple confounding factors, including immeasurable fac- tors, although each trial attempted to adjust for some of the

confounding factors. In the observational studies, Domain 4 of the ROBINS-E (the risks of post-exposure interventions) was assessed as high because many choices in patients’ care and medical procedures were affected by ACP exposure beyond what is expected.

  1. Discussion
    1. Main findings

In this systematic review, we found that ACP significantly reduced the number of ambulance calls from nursing homes. Additionally, it re- duced the frequency of ED visits among patients with depression or de- mentia but not among those with severe respiratory diseases or serious illnesses. To the best of our knowledge, this is the first review on the

A. Sakamoto, R. Inokuchi, M. Iwagami et al.

American Journal of Emergency Medicine 68 (2023) 8491


Table 2

Outcomes of the included studies.



Follow-up period


ED related outcome

Proportion of ACP documentation


(Intervention/exposure group: Control group)

Intervention/exposure group

Control group

Comparison result

Type of documentation

Intervention/ exposure group

Control group

Sinclair (2020)

ED visit

(Last 90 days before

1 year

Total: 149

Target for outcome evaluation:

1.73 visits

1.23 visits

P = 0.26






Ambulance calls from

3 years

54 deaths

(41: 13)

Intervention group: 2 Hospitals



P < 0.001

ACP discussion recorded

5 (11.0%)




+21 NHs


1 (2.2%)



Cost-reduction in

2 years

Control group: 1 Hospital+13 NHs




-EUR423,453/2 years

Plan of Treatment

?among 45 persons who received ACP intervention Some form of EOL care plan

3 (6.7%)






ambulance transfer

ED visit

1 year


EUR468,308/2 years (estimate



EUR891,761/2 years


(95%CI of difference average:

EUR0.19-0.73 million)

RR = 0.73

Health care representative

251 (64.0%)



95%CI = 0.62-0.86


89 (22.7%)


p = 0.001

Goals of Living


22 (5.6%)


Bischoff (2013)


ED visit

(Last month before death)

ED visit

N/A (exit interview)

180 days after first




1.0 visit


0.8 visits

adjusted RR 0.91

p = 0.27

IRR 1.11









ED visit

ACP claim

pre-12 months and

(864: 17,620)

Analysis A (confirmed survivors

Analysis A:

3.2 +- 4.2

95%CI (0.99-1.24)

Statement of Choices forms





ED visit

post-12 months

1-2 years

at 12 months): 108 Analysis B (confirmed and presumed survivors): 128


mean 1.6 +- 2.0 visits Analysis B:

mean 1.7 +- 2.1 visits

7715 persons (51.5%)

3.3 +- 4.3

117,923 persons

P < 0.001

P < 0.001

P < 0.001





(last 30 days before death)

(14,986: 223,003)


N/A, Not Available; ED, Emergency Department; ACP, Advanced Care Planning; AD, Advanced Directive; EOL End of Life; LW, Living Will; POA, Power of Attorney; POLST, Practitioner Orders for Life Sustaining Treatment; MOST, Medical scope of treatment form; RR, relative risk; IRR, Incidence rate ratio; CI, confidence interval.

Image of Fig. 2

Fig. 2. Risk-of-bias summary.

RCT, randomized controlled trial; ROBINS-I, Risk-of-Bias In Non-Randomized Studies of Interventions; ROBINS-E, Risk-of-Bias In Non-Randomized Studies of Exposure; RoB2, Risk-of-bias tool 2.0.

association of ACP with the frequency of ED visits and ambulance calls without any restriction on patients’ diseases or conditions.

The introduction of ACP in accordance with the wishes of patients and their families who do not wish to be admitted to hospital and re- ceive intensive care may lead to a reduction in ED visits and ambulance calls. Therefore, it is important to review studies in which the introduc- tion of ACP was or was not effective. Interestingly, we found that ACP in- troduction among nursing homes could lead to a reduction in the frequency of ED visits and ambulance calls. However, our findings are inconsistent with those of a previous systematic review [48]. This could be attributed to the fact that we excluded studies that did not dis- tinguish between ED visits and hospitalization and those that per- formed complex interventions. This allowed a simple assessment of the relationship between ACP and the number of ED visits. As a limited number of studies have focused on specific diseases, it is important to conduct further research to identify populations in which ACP is more effective.

Among four interventional studies, three studies, which included ad- ditional interventions besides ACP training, concluded that ACP inter- vention significantly reduced ED visits or ambulance calls. Specifically, in addition to introducing ACP, these studies variably included educa- tion of residents, families, and nursing home staff on the terminal nature of dementia, ACP, and the “hospital in the home” concept [42]; assess- ment of cognitive impairment before implementing the intervention [40,42]; provision of manuals and materials for ACP [40], and use of a supportive format for the electronic health records [43]. Education could be more effective for nursing home-setting carers than for in- home-care family carers. A previous study also recommended the com- prehensive approach rather than only discussing ACP with the person concerned, including sharing one’s goals and preferences with families and healthcare professionals and preparing advance care directives of

a structured format to more easily identify goals and preferences in emergency situations [4]. Thus, a comprehensive approach may be more effective than an ACP discussion process only.

In our review, only four studies mentioned the proportion of individ- uals who had ACP-related documentation. Therefore, we could not com- pare these proportions between studies with and without a significant difference in the frequency of ED visits and ambulance calls after ACP implementation. Although we could not determine the extent that doc- umentation affected the outcomes, the presence of signed documents could have affected the actual actions performed under emergency conditions.

    1. What this study adds

This study highlights that ACP may lead to a reduction in the fre- quency of ED visits and ambulance calls among nursing home residents and patients with depression or dementia. Moreover, we state that the comprehensive approach might be more effective rather than ACP dis- cussion only. However, this review also highlights a shortage of evi- dence regarding the effects of ACP implementation on the frequency of ED visits and ambulance calls in various settings or patients with spe- cific diseases or conditions. Given the limited medical human resources, further studies are warranted to identify populations in which ACP may be more effective to allow efficient implementation.

    1. Limitations of the study

This study had several limitations. First, there was a high risk of bias in the included studies. Although each study attempted to extensively minimize bias, blinding was impossible owing to the characteristics of ACP in an RCT; moreover, adjustment of confounding factors was

limited since ACP and ED transfer could be influenced by various factors. Second, as the participants’ backgrounds and intervention details varied widely, we could not compare or summarize them. Therefore, we did not conduct a meta-analysis to avoid reporting misleading results due to heterogeneity and a high risk of bias. Third, ACP and the preferences for end-of-life care varied according to country [49,50] and thus need to be considered when interpreting our results. Finally, none of the in- cluded studies overlapped with the COVID-19 pandemic; therefore, it is important to assess the effect of the COVID-19 pandemic on ACP be- cause the pandemic may have changed the situation and patients’ per- spectives regarding ACP [51].

  1. Conclusions

We found that ACP may lead to a reduction in the frequency of ED visits and ambulance calls among nursing home residents and patients with depression or dementia. Further research on specific settings and diseases is warranted to align ACP intervention methods, facilities, and patient characteristics.


All authors meet authorship criteria. They all contributed substan- tially to the review’s concept and design. They all took part in drafting or revising it critically and approved the final version.


This work was supported by Fast DOCTOR, Ltd.

Ethics and consent

Ethical approval was not required for this systematic review.

Data sharing

All available data are reported within the manuscript.

CRediT authorship contribution statement

Ayaka Sakamoto: Writing – original draft, Resources, Project ad- ministration, Methodology, Data curation. Ryota Inokuchi: Writing – review & editing, Validation, Project administration, Methodology, In- vestigation, Formal analysis, Data curation, Conceptualization. Masao Iwagami: Writing – review & editing, Supervision, Project administra- tion. Yu Sun: Writing – review & editing, Supervision, Project adminis- tration. Nanako Tamiya: Writing – review & editing, Supervision, Funding acquisition, Conceptualization.

Declaration of Competing Interest

RI’s joint appointment as an associate professor was sponsored by Fast DOCTOR Ltd. from October 2019 to date. Fast DOCTOR, Ltd., played no role in this study. AS, MI, YS, and NT report no conflict of interest.


We are deeply grateful to Prof. Debra K. Litzelman for kindly sharing undisclosed data for this systematic review.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2023.03.004.


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