Predictors of advance care planning in 11 high-income nations

Elderly population is increasing in high-income countries. For instance, by 2050, 21.4% of the United States population is expected to be 65+, thus making advance care planning (ACP) increasingly important. We aim to identify predictors of ACP completion in 11 high-income countries and explore relationships between ACP and utilization factors.

Using the 2021 International Health Policy (IHP) survey data, we assessed the relationship between sociodemographic factors, healthcare utilization, and ACP. The primary outcome variable was a composite of three ACP activities. A generalized linear mixed model (GLMM) was used to identify predictors of ACP completion.

Analyses included 18,677 older adults who answered at least one ACP question. Only 5126 (27.4%) reported completion of three ACP activities. Germany (64.7%) showed the highest completion rates, while Sweden (5.0%) and France (5.0%) showed the lowest completion rates. Predictors of ACP completion identified in the GLMM were: increasing age (incidence rate ratio [IRR] range between 1.2 and 1.5), completion of high school education or more (IRR: 1.1, 95% CI: 1.1-1.1), higher income (IRR: 1.1, 95% CI: 1.1-1.2), presence of two or more health conditions (IRR: 1.1, 95% CI: 1.0-1.1), hospital stay in the past 2 years (IRR: 1.1, 95% CI: 1.1-1.1), and access to quality primary care (IRR: 1.0, 95% CI: 1.0-1.1). Male gender (IRR: 0.9, 95% CI: 0.8-0.9) had a negative association with ACP activity completion.

Several patient-specific and health system utilization factors were identified as predictors of ACP activity completion, which clinicians and policymakers could use to enhance ACP completion.