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Original research article
Clinician-targeted interventions to improve advance care planning in heart failure: a systematic review and meta-analysis
  1. Markus Schichtel1,
  2. Bee Wee2,
  3. Rafael Perera3,
  4. Igho Onakpoya3,
  5. Charlotte Albury3,
  6. Sarah Barber4
  1. 1 Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, Cambridgeshire, UK
  2. 2 Sir Michael Sobell House Study Centre, Oxford University Hospital Trust NHS, Oxford, UK
  3. 3 Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  4. 4 Oxford Health NHS, Broadshires Health Centre, Carterton, Oxfordshire, UK
  1. Correspondence to Dr Markus Schichtel, Department of Public Health and Primary Care, University of Oxford, Cambridge CB2 0SR, UK; ms2591{at}


Objective Advance care planning (ACP) is widely advocated to contribute to better outcomes for patients suffering from heart failure. But clinicians appear hesitant to engage with ACP. Our aim was to identify interventions with the greatest potential to engage clinicians with ACP in heart failure.

Methods A systematic review and meta-analysis. We searched CINAHL, Cochrane Central Register of Controlled Trials, Database of Systematic Reviews, Embase, ERIC, Ovid MEDLINE, Science Citation Index and PsycINFO for randomised controlled trials (RCTs) from inception to January 2018. Three reviewers independently extracted data, assessed risk of bias (Cochrane risk of bias tool), the quality of evidence (GRADE) and intervention synergy according to Template for Intervention Description and Replication. ORs were calculated for pooled effects.

Results Of 14 175 articles screened, we assessed the full text of 131 studies. 13 RCTs including 3709 participants met all of the inclusion criteria. The intervention categories of patient-mediated interventions (OR 5.23; 95% CI 2.36 to 11.61), reminder systems (OR 3.65; 95% CI 1.47 to 9.04) and educational meetings (OR 2.35; 95% CI 1.29 to 4.26) demonstrated a favourable effect to engage clinicians with the completion of ACP.

Conclusion The review provides evidence from 13 published RCTs and suggests that interventions that involve patients to change clinical practice, reminder systems and educational meetings have the greatest effect in improving the implementation of ACP in heart failure.

  • palliative care
  • systemic review
  • health care delivery
  • meta-analysis

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  • Contributors The list of authors including the main author, MS, and the coauthors, BW, RP, IO, CA and SB, represents all those who can legitimately claim authorship by making a substantial contribution. MS had the idea for the review; wrote the protocol, extracted, evaluated and analysed the data; wrote, critically revised and submitted the entire manuscript. BW critically supervised the conduct of the review and revised the entire manuscript. RP critically revised the study protocol, the statistical meta-analyses and publication bias sections as well as the TIDieR analysis of intervention characteristics. IO independently screened papers, extracted data and evaluated risk of bias and study quality according to GRADE and the Cochrane risk of bias assessment tool. CA independently identified and coded and synthesised intervention evidence for the intervention synergy analysis. SB independently identified and coded Cochrane EPOC intervention components and synthesised the evidence for the intervention synergy analysis. All coauthors approved the version to be published.

  • Funding RP holds a grant from the UK NIHR Program of Applied Research for a different project during the conduct of the study.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.

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