Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.
San Francisco Veterans Affairs Health Care System, San Francisco, California.
J Am Geriatr Soc. 2021 Jan;69(1):234-244. doi: 10.1111/jgs.16801. Epub 2020 Sep 7.
BACKGROUND/OBJECTIVES: Advance care planning (ACP) has shown benefit in some, but not all, studies. It is important to understand the utility of ACP. We conducted a scoping review to identify promising interventions and outcomes.
Scoping review.
We searched MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, and Web of Science for ACP randomized controlled trials from January 1, 2010, to March 3, 2020. We used standardized Preferred Reporting Items for Systematic Review and Meta-Analyses methods to chart study characteristics, including a standardized ACP Outcome Framework: Process (e.g., readiness), Action (e.g., communication), Quality of Care (e.g., satisfaction), Health Status (e.g., anxiety), and Healthcare Utilization. Differences between arms of P < .05 were deemed positive.
Of 1,464 articles, 69 met eligibility; 94% were rated high quality. There were variable definitions, age criteria (≥18 to ≥80 years), diseases (e.g., dementia and cancer), and settings (e.g., outpatient and inpatient). Interventions included facilitated discussions (42%), video only (20%), interactive, multimedia (17%), written only (12%), and clinician training (9%). For written only, 75% of primary outcomes were positive, as were 69% for multimedia programs; 67% for facilitated discussions, 59% for video only, and 57% for clinician training. Overall, 72% of Process and 86% of Action outcomes were positive. For Quality of Care, 88% of outcomes were positive for patient-surrogate/clinician congruence, 100% for patients/surrogate/clinician satisfaction with communication, and 75% for surrogate satisfaction with patients' care, but not for goal concordance. For Health Status outcomes, 100% were positive for reducing surrogate/clinician distress, but not for patient quality of life. Healthcare Utilization data were mixed.
ACP is complex, and trial characteristics were heterogeneous. Outcomes for all ACP interventions were predominantly positive, as were Process and Action outcomes. Although some Quality of Care and Health Status outcomes were mixed, increased patient/surrogate satisfaction with communication and care and decreased surrogate/clinician distress were positive. Further research is needed to appropriately tailor interventions and outcomes for local contexts, set appropriate expectations of ACP outcomes, and standardize across studies.
背景/目的：预先医疗照护计划（ACP）在一些研究中显示出了益处，但并非所有研究都如此。理解 ACP 的实用性非常重要。我们进行了范围综述，以确定有前途的干预措施和结果。
范围综述。
我们从 2010 年 1 月 1 日至 2020 年 3 月 3 日，在 MEDLINE/PubMed、EMBASE、CINAHL、PsycINFO 和 Web of Science 中搜索了 ACP 随机对照试验。我们使用标准化的系统评价和荟萃分析报告项目方法来绘制研究特征，包括标准化的 ACP 结果框架：过程（例如，准备）、行动（例如，沟通）、护理质量（例如，满意度）、健康状况（例如，焦虑）和医疗保健利用。手臂之间的差异 P<.05 被认为是阳性的。
在 1464 篇文章中，有 69 篇符合入选标准；94%的文章质量较高。存在可变定义、年龄标准（≥18 岁至≥80 岁）、疾病（如痴呆和癌症）和环境（如门诊和住院）。干预措施包括促进讨论（42%）、仅视频（20%）、互动、多媒体（17%）、仅书面（12%）和临床医生培训（9%）。对于仅书面干预，75%的主要结果为阳性，多媒体计划的阳性率为 69%；促进讨论的阳性率为 67%，仅视频的阳性率为 59%，临床医生培训的阳性率为 57%。总体而言，72%的过程和 86%的行动结果为阳性。在护理质量方面，患者-代理人/临床医生一致性的结果有 88%为阳性，患者/代理人/临床医生对沟通的满意度有 100%为阳性，代理人对患者护理的满意度有 75%为阳性，但目标一致性则不然。在健康状况结果方面，减轻代理人/临床医生的困扰的结果为 100%为阳性，但患者的生活质量则不然。医疗保健利用数据参差不齐。
ACP 是复杂的，试验特征具有异质性。所有 ACP 干预措施的结果主要为阳性，过程和行动结果也是如此。尽管一些护理质量和健康状况结果参差不齐，但增加患者/代理人对沟通和护理的满意度以及降低代理人/临床医生的困扰是积极的。需要进一步研究，以根据当地情况适当调整干预措施和结果，对 ACP 结果设定适当的预期，并在研究之间实现标准化。
