Background Evidence regarding the degree and direction of economic impacts of implementing Advance Care Planning (ACP) is inconsistent. Also, available reviews have not systematically assessed the quality of the costing data in the primary studies. We aimed to synthesize current evidence on the economic impacts of implementing ACP and explore implications for policy and practice.

Methods We conducted a comprehensive search of online bibliographic databases. Reference lists of included articles were also reviewed. We assessed the quality of costing in studies using the Consensus on Health Economics Criteria Checklist (CHEC).

Results We included 33 studies; the majority were from the USA (78.8%). Studies were conducted in various settings, mostly hospitals (60%). Almost 64% of studies reported cost savings from the healthcare systems’ perspectives; no study included patients’ perspectives (out-of-pocket-costs). Assessing quality of costing using CHEC revealed weaknesses in studies including: flaws with costs identification (37.9%), measurement (39.3%), and valuation (44.8%); no consideration of intervention costs (87.9%); not including all relevant variables in sensitivity analyses (34.5%); and not discounting the costs (55.6%).

Discussion We detected substantial methodological issues with current economic evaluations of ACP that compromise the validity of evidence. To inform policy makers about ACP, which is a multifaceted process, methodologically robust studies are needed that capture costs of the program from all major payers. A comprehensive report on cost evaluations is highly recommended. Meanwhile, respecting patient choice remains a valid clinical basis for promoting use of ACP.