Health economic reports

A health economic report should make the decision question, perspective, model, assumptions and results clear enough for readers to interpret the evaluation. CHEERS provides reporting guidance, with its 2022 revision addressing transparency, distributional effects and patient involvement as well as the clinical and economic results.

Reporting standards and transparency

Economic evaluations report health consequences alongside resource use, costs, preferences and cost-effectiveness, requiring more space than clinical studies and making scrutiny more demanding. ^{1, 2} In 2021, reporting quality varied widely, published evaluations were increasing, and registration and independent data access lacked widely implemented mechanisms. ³ Misleading findings can affect resource allocation, making transparent, structured reporting a concern for editors and decision makers. ^{2, 3}

CHEERS, the Consolidated Health Economic Evaluation Reporting Standards, consolidated earlier recommendations from 1996–2011 into one standard. ⁴ The original 24-item checklist appeared in 2013, endorsed and co-published by ten journals, and became an EQUATOR guideline. ^{5, 1, 3} Its explanation and elaboration gives rationales and examples for each item. ⁵

CHEERS assesses reporting rather than prescribing or judging study methods, leaving analysts free to make methodological choices that they report clearly. ³ Its main audiences are researchers, editors and peer reviewers. ³ A study found that it was often misused to judge methodological quality. ⁶ Sufficient reporting for interpretation and replication can require substantial text; supplementary material and open data sharing can help accommodate it. ⁷

CHEERS 2022 was released on 11 January 2022 and co-published in 16 journals, with a recommendation to use it in place of CHEERS 2013. ⁸ Medical writers are encouraged to apply it when helping authors report economic evaluations. ^{9, 10}

Study question and perspective

The report should explain the study's broader context, question and relevance to policy or practice decisions. ¹¹ If commissioned for a decision maker, this should be stated; otherwise the question's importance should be explained. ¹² A question should name the population, intervention, comparators and setting: for example, etanercept versus infliximab for rheumatoid arthritis inadequately controlled by methotrexate within the UK NHS. ¹² An evaluation of intranasal corticosteroids for otitis media with effusion provided context by describing existing nonsurgical options, limited evidence of benefit and the need to assess efficient resource use. ¹²

The study perspective should be described and related to the costs evaluated. ¹³ Because perspectives lack standard definitions, the report should specify included costs and components and explain their fit to the audience and decision problem. ¹⁴ A societal analysis should consider also reporting health-system or payer results, and cited jurisdictional guidance should be accompanied by reasons for choosing it. ¹⁴

For example, an Australian health-sector analysis included government and patient costs, including time and travel, but excluded time from changed physical activity and intervention start-up costs to compare steady-state interventions. ⁷ Another report defined its payer perspective through hospital charges and professional fees for surgery and managing complications. ⁷

Model and uncertainty reporting

Methods should detail model structure, perspective, time horizon, inputs, outputs, payer or policy-maker validation, and sensitivity analyses, including their type and the assumptions varied. ¹⁵ For discrete-state models, the report should describe health states and transition probabilities and their clinical-trial evidence, including Kaplan–Meier analyses, and transition matrices. ¹⁶ Model inputs, outputs, assumptions and prespecified sensitivity analyses should be stated. ¹⁷ Base-case assumptions, model verification and face validity with decision makers should be addressed. ^{18, 15}

A budget-impact report should explain access restrictions, therapy costs, horizon, eligible population and changing case mix, uptake and displacement of existing therapies, inputs and outputs, validation and sensitivity analyses. ¹⁵ It should distinguish annual per-patient from per-member outputs and can use a tornado plot to show influential assumptions. ¹⁵

CHEERS 2022 checklist

The 28-item checklist spans title, abstract, introduction, methods, results, discussion and other information. ^{19, 20} It recommends:

1. Identify the study as an economic evaluation and specify the interventions compared.
2. Provide a structured abstract covering context, key methods, results and alternative analyses.
3. Give the context, study question and practical relevance for policy or practice.
4. State whether a health economic analysis plan was developed and where it is available.
5. Describe study population characteristics, such as age range, demographics and socioeconomic or clinical characteristics.
6. Give relevant setting and location information that may influence findings.
7. Describe the comparators and why they were chosen.
8. State the study perspectives and why they were chosen.
9. State the time horizon and why it is appropriate.
10. Report discount rates and why they were chosen.
11. Describe outcomes measuring benefits and harms.
12. Describe how those outcomes were measured.
13. Describe populations and methods used to measure and value outcomes.
14. Describe how costs were valued.
15. Report dates for resource quantities and unit costs, currency and conversion year.
16. If modelling is used, describe it in detail, explain why it is used and state whether and where the model is publicly available.
17. Describe analytical and statistical transformations, extrapolation and model-validation methods.
18. Describe methods for estimating variation between subgroups.
19. Describe how impacts are distributed among individuals or adjusted for priority populations.
20. Describe methods for characterising uncertainty.
21. Describe approaches to engaging patients, service recipients, the public, communities or other stakeholders in study design.
22. Report all analytical inputs, including values, ranges, references and uncertainty or distributional assumptions.
23. Report mean costs and outcomes in the main categories and summarise them in the appropriate overall measure.
24. Describe effects of uncertain judgements, inputs and projections, including discount rate and horizon where applicable.
25. Report how engagement changed the study approach or findings.
26. Report key findings, limitations, unrepresented ethical or equity considerations and implications for patients, policy or practice.
27. Describe funding and funder involvement in identifying, designing, conducting and reporting the analysis.
28. Report author conflicts under journal or ICMJE requirements.

^{19, 20}

Reasons for the 2022 revision

ISPOR reconvened the task force in 2020 following concerns about inadequate coverage of cost-benefit analyses and misuse as a methods-quality checklist, alongside advances in preferences, modelling, uncertainty and distributional effects. ^{6, 21} Patients and the public were increasingly involved in research and assessment and wanted to know to whom results applied, whether patient-relevant outcomes were assessed and whether patients shaped the design. ⁶

The revised explanation recognises valuation approaches including willingness to pay and discrete-choice experiments. ²² Distributional effects address equity alongside efficiency; reporting analysis plans and model availability addresses selective reporting and transparency. ²² A patient and public involvement group advised the task force and prompted items on engagement and its effects. ²² The revision added methodological experts and planned to report patient involvement using GRIPP2. ⁶

In March 2022, supporting resources included item-specific videos and interactive forms; teaching presentations and a lay users’ guide with glossary were in development through ISPOR and EQUATOR. ^{22, 20} The checklist was developed in US English. ²⁰

CHEERS 2013 checklist

CHEERS 2013 recommended the following reporting items. ^{5, 23, 24, 25} Its recommendations were to:

• identify the study as an economic evaluation, or use more specific terms such as "cost-effectiveness analysis", and describe the interventions compared (title)
• provide a structured summary of objectives, perspective, setting, methods, including study design and inputs, results, including base case and uncertainty analyses, and conclusions (abstract)
• give an explicit statement of the broader context for the study, and present the study question and its relevance for health policy or practice decisions (background and objectives)
• describe the characteristics of the base case population and of the subgroups analysed, including why they were chosen (target population and subgroups)
• state relevant aspects of the system or systems in which the decision needs to be made (setting and location)
• describe the perspective of the study and relate it to the costs being evaluated (study perspective)
• describe the interventions or strategies being compared and state why they were chosen (comparators)
• state the time horizon over which costs and consequences are evaluated and say why it is appropriate (time horizon)
• report the choice of discount rate for costs and outcomes and say why it is appropriate (discount rate)
• describe the outcomes used as the measure of benefit in the evaluation and their relevance for the type of analysis performed (choice of health outcomes)
• for single study-based estimates, describe fully the design features of the single effectiveness study and why it was a sufficient source of clinical effectiveness data (measurement of effectiveness)
• for synthesis-based estimates, describe fully the methods used to identify the included studies and to synthesise the clinical effectiveness data (measurement of effectiveness)
• if applicable, describe the population and the methods used to elicit preferences for outcomes (measurement and valuation of preference-based outcomes)
• for a single study-based evaluation, describe the approaches used to estimate resource use associated with the alternative interventions, the primary or secondary research methods for valuing each resource item in terms of its unit cost, and any adjustments made to approximate opportunity costs (estimating resources and costs)
• for a model-based evaluation, describe the approaches and data sources used to estimate resource use associated with the model's health states, the primary or secondary research methods for valuing each resource item in terms of its unit cost, and any adjustments made to approximate opportunity costs (estimating resources and costs)
• report the dates of the estimated resource quantities and unit costs, the methods for adjusting unit costs to the year of reported costs if necessary, and the methods for converting costs into a common currency base and the exchange rate (currency, price date and conversion)
• describe and give reasons for the specific type of decision-analytic model used, with a figure showing the model's structure strongly recommended (choice of model)
• describe all structural or other assumptions underpinning the decision-analytic model (assumptions)
• describe all analytical methods supporting the evaluation, which could include methods for dealing with skewed, missing or censored data, extrapolation methods, methods for pooling data, approaches to validate or make adjustments to a model, such as half-cycle corrections, and methods for handling population heterogeneity and uncertainty (analytical methods)
• report the values, ranges, references and, if used, probability distributions for all parameters, with the reasons or sources for distributions used to represent uncertainty where appropriate, and a table of the input values strongly recommended (study parameters)
• for each intervention, report mean values for the main categories of estimated costs and outcomes of interest and the mean differences between the comparator groups, and, if applicable, incremental cost-effectiveness ratios (incremental costs and outcomes)
• for a single study-based evaluation, describe the effects of sampling uncertainty for the estimated incremental cost, incremental effectiveness and incremental cost-effectiveness, together with the impact of methodological assumptions such as the discount rate and the study perspective (characterising uncertainty)
• for a model-based evaluation, describe the effects on the results of uncertainty for all input parameters, and uncertainty related to the structure of the model and its assumptions (characterising uncertainty)
• if applicable, report differences in costs, outcomes or cost-effectiveness that can be explained by variations between subgroups of patients with different baseline characteristics or other observed variability in effects that is not reducible by more information (characterising heterogeneity)
• summarise the key study findings and describe how they support the conclusions reached, and discuss the limitations, the generalisability of the findings and how they fit with current knowledge (study findings, limitations, generalisability and current knowledge)
• describe how the study was funded and the role of the funder in the identification, design, conduct and reporting of the analysis, and other non-monetary sources of support (source of funding)
• describe any potential for conflict of interest among study contributors in accordance with journal policy or, in the absence of one, with the International Committee of Medical Journal Editors' recommendations (conflicts of interest)

^{26, 27, 23, 24, 25}