Comparative effectiveness of the use of game design elements to promote advance care planning: A protocol for systematic review and meta-analysis

Background: Advance care planning (ACP) can positively affect patients, families, and healthcare providers. However, challenges exist regarding its wider dissemination and implementation. The use of decision aids that incorporate game design elements, such as gamification, has been proposed as a strategy to overcome this issue. Nevertheless, their effectiveness compared with other interventions promoting ACP remains unclear. Therefore, we planned a systematic review to examine the comparative effectiveness of gamification to promote ACP. Methods: PubMed, EMBASE, MEDLINE, CENTRAL, CINAHL, and Ichushi-Web databases will be searched from inception to December 31, 2024, with no language restrictions. The following keywords and their synonyms will be searched: “advance care planning,” “game,” and “gamification.” Studies of any design that compared the effectiveness of ACP games with other interventions or controls (without any intervention) to promote ACP among prospective ACP engagers will be eligible. Dual screening and assessment of study eligibility, as well as dual data extraction and assessment of the risk of bias, will be performed using standard tools. The primary outcome will be ACP adoption, that is, the initiation of an ACP conversation. Secondary outcomes will be gaining knowledge of ACP, reducing end-of-life anxiety, designating healthcare surrogates, completing advanced directives, concordance between advanced directives and delivered care, and value. Furthermore, characteristics of the studies and participants, interventions, and clinical outcomes will be assessed qualitatively. Subsequently, random-effects model meta-analysis will be applied to obtain summary estimates, as appropriate. Finally, Grading of Recommendations, Assessment, Development, and Evaluations will be implemented to assess the certainty of the evidence. Discussion: This systematic review and meta-analysis will comprehensively evaluate and synthesize the existing comparative evidence on the effectiveness of ACP games in promoting ACP. Ethics and dissemination: As this is a secondary analysis of publicly available data, ethics approval is not required. The results will be submitted to a peer-reviewed journal for publication.