Health economic evaluations are comparative analyses of alternative courses of action in terms of their costs and consequences. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement, published in 2013, was created to ensure health economic evaluations are identifiable, interpretable, and useful for decision making. It was intended as guidance to help authors report accurately which health interventions were being compared and in what context, how the evaluation was undertaken, what the findings were, and other details that may aid readers and reviewers in interpretation and use of the study. The new CHEERS 2022 statement replaces previous CHEERS reporting guidance. It reflects the need for guidance that can be more easily applied to all types of health economic evaluation, new methods and developments in the field, as well as the increased role of stakeholder involvement including patients and the public. It is also broadly applicable to any form of intervention intended to improve the health of individuals or the population, whether simple or complex, and without regard to context (such as health care, public health, education, social care, etc). This summary article presents the new CHEERS 2022 28-item checklist and recommendations for each item. The CHEERS 2022 statement is primarily intended for researchers reporting economic evaluations for peer reviewed journals as well as the peer reviewers and editors assessing them for publication. However, we anticipate familiarity with reporting requirements will be useful for analysts when planning studies. It may also be useful for health technology assessment bodies seeking guidance on reporting, as there is an increasing emphasis on transparency in decision making.
Economic evaluations of health interventions are comparative analyses of alternative courses of action in terms of their costs and consequences. They can provide useful information to policy makers, payers, health professionals, patients, and the public about choices that affect health and the use of resources. Economic evaluations are a particular challenge for reporting because substantial information must be conveyed to allow scrutiny of study findings. Despite a growth in published economic evaluations123 and availability of reporting guidance,4 there is a considerable lack of standardisation and transparency in reporting.56 There remains a need for reporting guidance to help authors, journal editors, and peer reviewers in their identification and interpretation.
The goal of the original Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement,4 was to recommend the minimum amount of information required for reporting of published health economic evaluations. The statement consisted of a 24-item checklist and Explanation and Elaboration Report.4 CHEERS was intended to help authors provide accurate information on which health interventions are being compared and in what context, how the evaluation was undertaken, what the findings are, and other details that may aid readers and reviewers in interpretation and use of the study. In doing so, it can also aid interested researchers in replicating research findings. Some checklist items (such as title, abstract) were also included to aid those researching economic evaluation literature. The CHEERS statement consolidated previous health economic evaluation reporting guidelines789101112131415161718 into one current, useful reporting guidance.
Since the original publication of the CHEERS statement, there have been several developments that have motivated an update. These include feedback on perceived limitations of CHEERS, including criticism of its neglect of addressing reporting of cost-benefit analyses.19 CHEERS has also been observed to be used inappropriately, as a tool to assess quality of methods, for which other tools exist,20 rather than the quality of reporting.5 It has also been used as a tool to quantitatively score studies in systematic reviews, an approach that could mislead readers and reviewers21 as it has not been designed for this purpose.
There have also been methods developments in economic evaluation motivating an update. This includes an update of methods proposed by the Second Panel on Cost-Effectiveness in Health and Medicine (“Second Panel”), which contained new recommendations concerning the perspective of economic evaluations, the classification of costs and benefits in a structured table, and the inclusion of related and unrelated healthcare costs in added years of life.22 Health technology assessment bodies have also updated their guidance on conducting and appraising economic evaluations.2324
There have also been increasing calls for the use of health economic analysis plans25 and the use of open source models.2627282930 The latter may be of particular importance as published economic evaluations are increasingly available in journals with broad data-sharing policies. Increased use of, and guidance for, economic evaluations to support policy decisions in immunisation programmes3132 and global health in lower and middle income countries33 have also motivated an update. There has also been an increase in the number of economic evaluations that attempt to capture consequences extending beyond health outcomes, such as equity and distributional effects.3435
Finally, the increased role of stakeholder involvement in health research and health technology assessment, including patients and the public, suggests the need for reporting guidance to recognise a broader audience.363738 All of these developments suggest the scope of guidance for reporting economic evaluations should be expanded and updated.
The objective of this article is to provide a brief overview of the CHEERS 2022 statement, which consists of a 28-item checklist, and an Explanation and Elaboration report with accompanying user tools and guidance. More detailed guidance and illustrative examples on how to use the checklist can be found in the larger Explanation and Elaboration report.39
The process of revising CHEERS followed that of ISPOR Good Practices Task Force reports40 as well as guidance developed by the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) network,41 where the CHEERS 2022 update is also registered. An informal review was undertaken of reporting guidelines published since CHEERS, and new items were proposed and consolidated along with the existing CHEERS Checklist. In parallel with this, a task force was convened and a group of patient and public involvement and engagement (PPIE) contributors was formed to review the consolidated checklist and provide suggestions on language and the need for additional items. The draft checklist was finalised by CHEERS Task Force members.
Experts in economic evaluation, as well as those with perspectives in journal editing, decision making, health technology assessment, and commercial life sciences were invited to participate in a modified Delphi Panel (“Delphi”) process. Further details on how the Task Force and PPIE members were chosen is available in the Explanation and Elaboration document.39 Panellists along with the PPIE contributors were subsequently invited to participate by email and directed to a web based survey. Feedback from each round of the Delphi process was discussed by Task Force members, who ultimately finalised the checklist based on the input provided. A guiding principle for CHEERS is that economic evaluations made available publicly should be understandable, interpretable, and replicable to those who use them.
A completed Guidance for Reporting Involvement of Patients and the Public-Version 2 (GRIPP2)42 checklist is in Appendix A. The protocol for the Delphi process, as well as panel composition, size, response rates, and analytic approach can be found in Appendix B.
The CHEERS 2022 statement is intended to be used for any form of health economic evaluation.43 This includes analyses that only examine costs and cost offsets (that is, cost analysis) or those that examine both costs and consequences. The latter include analyses that consider health consequences (such as, cost-effectiveness/utility analyses (CEAs/CUAs), cost minimisation, cost-benefit/benefit-cost analyses (CBAs)), and broader measures of benefit and harm to individuals (such as extended CEAs/CBAs), including measures of equity (such as distributional CEAs). While we are aware some studies comparing costs are labelled as CBAs, we recommend the use of this term for studies which include a monetary valuation of health outcomes. Although linked to economic evaluation, budget impact analyses and constrained optimisation studies are beyond the scope of CHEERS guidance, as they require additional reporting that addresses population dynamics and feasibility constraints and are addressed in other guidance reports.4445
The primary audiences for the CHEERS 2022 statement are researchers reporting economic evaluations as well as peer reviewers and editors assessing them for publication. While the statement is not intended to guide the conduct of economic evaluation, familiarity with reporting requirements will be useful for analysts when planning studies. CHEERS may be similarly useful for health technology assessment bodies seeking guidance on reporting, as there is an increasing emphasis on transparency in decision making.46 Health technology assessment and the use of economic evaluation is also becoming more commonplace globally.3 In developing the guidelines, the CHEERS Task Force considered issues that may be specific to regions with developing economies and healthcare systems, including providing examples of these by item in the larger report,39 to ensure the reporting guidance will be useful in any social or political context.
CHEERS is relevant for any intervention intended to affect health and should also be widely applicable for both simple and complex interventions, including programmes of care involving researcher-driven or commercialised products (such as drugs, macromolecules, cell, gene, and tissue based therapies, vaccines, and medical devices); public health and social care interventions; processes of care (such as e-health, care coordination, clinical decision rules, clinical pathways, information and communication, medical and allied health services); and re-organisation of care (such as insurance redesign, alternative financing approaches, integrated care, scope of practice change, and workplace interventions).
CHEERS is also applicable to studies based on mathematical modelling or empirical research (such as patient level or cluster level human studies). Although CHEERS can be used for systematic reviews of economic evaluation, its use should be limited to assessing the quality of reporting of a study rather than the quality of its conduct. As there is no validated scoring system for the checklist, using it as a scoring tool could lead to misleading findings and is strongly discouraged.21 If used to assess the quality of reporting in a systematic review, a qualitative assessment of completeness of reporting by item is a more appropriate approach. When applying the CHEERS statement, users may need to refer to additional reporting guidance (for example, for randomised controlled trials, patient and public involvement, modelling, health state preference measures), and these are referenced throughout the Explanation and Elaboration report.39
The CHEERS 2022 statement (checklist and Explanation and Elaboration report) replaces the 2013 CHEERS statement, which should no longer be used. The new CHEERS checklist contains 28 items with accompanying descriptions (table 1). Major changes from CHEERS 2013 are described in box 1. Checklist items are subdivided into seven main categories: (1) Title; (2) Abstract; (3) Introduction; (4) Methods; (5) Results; (6) Discussion; and (7) Other relevant information. Users of the checklist should first consult the Explanation and Elaboration report39 to ensure the appropriate interpretation of each item description.
The CHEERS 2022 checklist