Table 2.

Overview of included studies.

Study	Study design	Participants/setting	Further patient characteristicsa	Intervention/comparator	Cost components measured	Results: costs over observation period (per patient)	Results: other effects	Study qualityb
Chambers et al.36	Retrospective cohort study	474 Medicare decedents in a large US hospital	Average age: 73 yearsGender: 53% male and 47% femaleEthnicity: 77% White, 19% Black and 4% otherReligion: 38% Catholic, 39% Protestant, 16% Jewish, 5% other and 2% none	Advance planning was assumed when discussion with patient about AD was documented in medical record	Total inpatient healthcare charges during last hospitalisation	Mean costs with AD discussion: USD30,478Mean cost without AD discussion: USD95,305Reduction: USD64,827 (68%) (p not given)	No further effects measured	III
Edes et al.37	Before-after study	43 US veterans suffering from end-stage heart and/or lung disease and being cared for at home	Average age: 75 yearsGender: 100% maleEthnicity: 97% White and 3% other	Intervention: advance directive discussion conducted by nurse/social worker as part of a home-based primary care programmeComparator: standard care received before	Inpatient and outpatient care costs (including ACP intervention costs) incurred 6 months before and 6 months after intervention start	Median costs before enrolment: USD16,750Median costs after enrolment: USD5511Reduction: USD11,239 (67%) (significance and p not reported)	Patient satisfaction improved; reduction of hospital days (p = 0.0019)	II
Engelhardt et al.38	Randomised controlled trial	US Veterans Affairs medical centres; 275 patients suffering from COPD, CHF, cancer	Average age: 71 yearsGender: 79% male and 21% femaleEthnicity: 87% White, 11% Black and 2% otherReligion: 54% Catholic, 39% Protestant, 2% Jewish and 5% other	Intervention: care coordinators assisted in formulating and documenting ADs as part of intervention to improve care coordinationComparator: usual care	Inpatient, outpatient, nursing home, inpatient hospice and ‘other’ care cost (time frame for measurement unclear)	Mean costs intervention group: USD12,123Mean costs in control group: USD16,295Reduction: USD4172 (25.6%) (not significant, p not reported)	Patients and surrogates more satisfied with care, more ADs completed (overall and per patient), less days until completion of AD, no difference in survival rates	I
Hamlet et al.39	Secondary analysis of data from randomised controlled study	4742 US Medicare decedents that suffered from diabetes and/or heart failure with high risk of death	Average age: 77 yearsGender: 52% male and 48% femaleEthnicity: 79% White, 20% Black and 1% other	Intervention: telephonic EOL counselling with trained nurses given alongside a chronic care management interventionComparator: usual care	All Medicare claims incurred during the 6 months prior to death except those incurred after hospice enrolment	Mean adjusted costs intervention group: USD40,363Mean adjusted costs control group: USD42,276Reduction: USD1913 (4.5%) (p = 0.05)	No effect on hospice admission or length of stay in hospice	I
Molloy et al.40	Randomised controlled trial	Six nursing homes with 1292 residents (1133 agreed to participate) in Canada	Average age: 83 yearsGender: 26% male and 74% femaleEthnicity: 97% White and 3% other	Intervention: education about ADs facilitated by specifically trained nurses, offer of AD and system interventionComparator: standard care	Hospitalisation, nursing home drug and programme implementation costs over 18 months	Mean costs intervention homes: CAD3490Mean costs control homes: CAD5239Reduction: CAD1748 (33.4%) (p = 0.013)	No effect on resident and family satisfaction, less hospitalisations/days spent in hospital in intervention group, similar death rates	I
SUPPORT41	Cluster-randomised controlled trial	4804 US teaching hospital patients with serious illnesses	Average age: 65 yearsGender: 56% male and 44% femaleEthnicity: 79% White, 16% Black and 5% other	Intervention: trained nurses elicited and documented patient and family preferences/ADs as part of an intervention to improve communication and decision-makingComparator: usual care	Patients’ hospital charges during hospital stays	Median cost estimates given only for major disease categories (e.g. advanced cancer → Intervention: USD6100; Control: USD5100)Overall no impact on costs (adjusted ratio: 1.05)	No effect on incidence and timing of written DNR orders, physicians’ awareness of patients’ preferences, level of pain, days spent in ICU, coma, or receiving mechanical ventilation	I
Zhang et al.42	Prospective cohort study	627 US hospital patients with advanced cancer	Average age: 59 yearsGender: 51% male and 49% femaleEthnicity: 71% White, 15% Black, 12% Hispanic and 2% otherReligion: 43% Catholic, 19% Protestant, 3% Jewish, 11% Baptist, 17% other and 5% none	Advance planning was assumed when patients reported EOL discussion with physician. Controls reported no EOL discussion.	Costs for hospital stays and hospice use in the last week of life	Mean costs with EOL discussion: USD1876Mean cost without EOL discussion: USD2917Reduction: USD1041 (37.5%) (p = 0.002)	Intervention group experienced less physical distress, less ventilations, resuscitations or ICU admissions, more outpatient hospice care and longer stays in outpatient hospice; no difference in survival rates, psychological distress, quality of death, chemotherapy, and inpatient hospice services utilised	III

AD: advance directive; ACP: Advance Care Planning; COPD: chronic obstructive pulmonary disease; CHF: congestive heart failure; SUPPORT: Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments; DNR: do-not-resuscitate; ICU: intensive care unit; EOL: end of life.

^aOnly information that was presented in all studies is given here with the exception of religion as a potentially influential factor for EOL decision-making.

^bThe study quality was assessed in levels of evidence ranging from I (randomised controlled trials) over II (other interventional studies) to III (observational studies).