Husereau et al. BMC Medicine 2013, 11:80
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GUIDELINE

Open Access

Consolidated Health Economic Evaluation
Reporting Standards (CHEERS) statement
Don Husereau1,2,3,15*, Michael Drummond4, Stavros Petrou5, Chris Carswell6, David Moher7, Dan Greenberg8,9,Federico Augustovski10,11, Andrew H Briggs12, Josephine Mauskopf13, Elizabeth Loder14,16 and on behalf of theCHEERS Task Force

Abstract
Economic evaluations of health interventions pose a particular challenge for reporting. There is also a need toconsolidate and update existing guidelines and promote their use in a user friendly manner. The Consolidated
Health Economic Evaluation Reporting Standards (CHEERS) statement is an attempt to consolidate and update
previous health economic evaluation guidelines efforts into one current, useful reporting guidance. The primary
audiences for the CHEERS statement are researchers reporting economic evaluations and the editors and peer
reviewers assessing them for publication.
The need for new reporting guidance was identified by a survey of medical editors. A list of possible items basedon a systematic review was created. A two round, modified Delphi panel consisting of representatives fromacademia, clinical practice, industry, government, and the editorial community was conducted. Out of 44 candidate
items, 24 items and accompanying recommendations were developed. The recommendations are contained in auser friendly, 24 item checklist. A copy of the statement, accompanying checklist, and this report can be found on
the ISPOR Health Economic Evaluations Publication Guidelines Task Force website (www.ispor.org/TaskForces/
EconomicPubGuidelines.asp).
We hope CHEERS will lead to better reporting, and ultimately, better health decisions. To facilitate dissemination
and uptake, the CHEERS statement is being co-published across 10 health economics and medical journals. We
encourage other journals and groups, to endorse CHEERS. The author team plans to review the checklist for an
update in five years.

Background
Health economic evaluations are conducted to inform resource allocation decisions. Economic evaluation has been
defined as “the comparative analysis of alternative coursesof action in terms of both their costs and their consequences” [1]. All economic evaluations assess costs, but
approaches to measuring and valuing the consequences ofhealth interventions may differ (see Figure 1).
Economic evaluations have been widely applied inhealth policy, including the assessment of prevention
programmes (such as vaccination, screening, and healthpromotion), diagnostics, treatment interventions (suchas drugs and surgical procedures), organisation of care,* Correspondence: donh@donhusereau.com
1
Institute of Health Economics, Edmonton, Canada
2
Department of Epidemiology and Community Medicine, University ofOttawa, Ottawa, Canada
Full list of author information is available at the end of the article

and rehabilitation. Economic evaluations are increasingly
being used for decision making and are an importantcomponent of programmes for health technology assessment internationally [2].

Reporting challenges and shortcomings in healtheconomic evaluations

Compared with clinical studies, which report the consequences of an intervention only, economic evaluations
require more reporting space for additional items, suchas resource use, costs, preference related information,and cost effectiveness results. This creates challenges foreditors, reviewers, and those who wish to scrutinise a
study’s findings [3]. There is evidence that the quality ofreporting of economic evaluations varies widely andcould potentially benefit from improved quality assurance mechanisms [4,5].

© 2013 Husereau et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.

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Forms of economic evaluation [1]Specific forms of analysis reflect different approaches to evaluating the consequences of healthinterventions. Health consequences may be estimated from a single analytical (experimental or nonexperimental) study, a synthesis of studies, mathematical modelling, or a combination of modellingand study information.
Cost consequences analysis examines costs and consequences without attempting to isolate a single
consequence or aggregate consequences into a single measure
Cost minimisation analysis (CMA)—The consequences of compared interventions are required to beequivalent, and only relative costs are compared
Cost effectiveness analysis (CEA) measures consequences in natural units, such as life years gained,disability days avoided, or cases detected. In a variant of CEA, often called cost utility analysis,
consequences are measured in terms of preference-based measures of health, such as quality
adjusted life years or disability adjusted life years.
Cost benefit analysis—Consequences are valued in monetary units.
Readers should be aware that an economic evaluation might be referred to as a “cost effectivenessanalysis” or “cost benefit analysis” even if it does not strictly adhere to the definitions above.
Multiple forms may also exist within a single evaluation. Different forms of analysis provide uniqueadvantages or disadvantages for decision making. The Consolidated Health Economic Evaluation
Reporting Standards (CHEERS) statement can be used with any form of economic evaluation.

Figure 1 Forms of economic evaluation.

With the increasing number of publications available,
and opportunity costs from decisions based on misleading study findings, transparency and clarity in reportingare important. In addition, outside of economic evaluations conducted alongside clinical trials, there are
no widespread mechanisms for warehousing economic
evaluation data to allow for independent interrogation,such as ethics review proceedings, regulator dossiers, or
study registries. Instead, independent analysis may relyon the record keeping of individual investigators.
Even if measures to promote transparency exist, suchas registries, biomedical journal editors have increasingly
promoted and endorsed the use of reporting guidelines.
Endorsement of guidelines by journals for randomised
controlled trials has been shown to improve reporting[6]. The combination of the risk of making costly
decisions due to poor reporting with the lack of mechanisms that promote accountability makes transparency
in reporting economic evaluations especially importantand a primary concern among journal editors and decision makers [3,7].
Aim and scope

The aim of the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement is toprovide recommendations, in the form of a checklist, tooptimise reporting of health economic evaluations. The
need for a contemporary reporting guidance for economic evaluations was recently identified by researchers

and biomedical journal editors [8]. The CHEERS statement attempts to consolidate and update previous efforts [9-20] into a single useful reporting guidance.
The primary audiences for the CHEERS statement are
researchers reporting economic evaluations and the editors and peer reviewers evaluating their publication potential. We hope the statement (which consists of a 24
item checklist and accompanying recommendations on
the minimum amount of information to be included
when reporting economic evaluations) is a useful andpractical tool for these audiences and will improvereporting and, in turn, health and healthcare decisions.
To best understand and apply the recommendations
contained within the statement, we encourage readers toaccess the Explanation and Elaboration Report [21].
Development of the CHEERS statement

The statement was developed by a task force supportedby the International Society for Pharmacoeconomics andOutcomes Research (ISPOR), as part of a broader initiative to facilitate and encourage the interchange of expert
knowledge and develop best practices. The CHEERS
Task Force members were chosen by the chair of thetask force primarily based on their longstanding academic expertise and contribution to the multidisciplinary field of health economic evaluation. In addition
to four members of the task force with doctorates in
economics and its sub-discipline of health economics(AHB, MD, JM, SP), members included experts in healthHusereau et al. BMC Medicine 2013, 11:80
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Table 1 CHEERS checklist—Items to include when reporting economic evaluations of health interventions
Section/item

Item
No

Recommendation

Reported on
page No/ line No

1

Identify the study as an economic evaluation or use more specific terms such as“cost-effectiveness analysis”, and describe the interventions compared.

___________________

Provide a structured summary of objectives, perspective, setting, methods(including study design and inputs), results (including base case and uncertainty
analyses), and conclusions.

___________________

Title and abstract
Title
Abstract

2

Introduction
Background and objectives

3

Provide an explicit statement of the broader context for the study.
Present the study question and its relevance for health policy or practice decisions. ___________________

Methods
Target population and subgroups

4

Describe characteristics of the base case population and subgroups analysed,
including why they were chosen.

___________________

Setting and location

5

State relevant aspects of the system(s) in which the decision(s) need(s) to bemade.

___________________

Study perspective

6

Describe the perspective of the study and relate this to the costs being evaluated.

___________________

Comparators

7

Describe the interventions or strategies being compared and state why they werechosen.

___________________

Time horizon

8

State the time horizon(s) over which costs and consequences are being evaluatedand say why appropriate.

___________________

Report the choice of discount rate(s) used for costs and outcomes and say why
appropriate.

___________________

Describe what outcomes were used as the measure(s) of benefit in the evaluationand their relevance for the type of analysis performed.

___________________

Single study-based estimates: Describe fully the design features of the single
effectiveness study and why the single study was a sufficient source of clinicaleffectiveness data.

___________________

11b

Synthesis-based estimates: Describe fully the methods used for identification ofincluded studies and synthesis of clinical effectiveness data.

___________________

Measurement and valuation ofpreference based outcomes

12

If applicable, describe the population and methods used to elicit preferences foroutcomes.

___________________

Estimating resources and costs

13aSingle study-based economic evaluation: Describe approaches used to estimate
resource use associated with the alternative interventions. Describe primary or
secondary research methods for valuing each resource item in terms of its unit
cost. Describe any adjustments made to approximate to opportunity costs.

___________________

13b

Model-based economic evaluation: Describe approaches and data sources used toestimate resource use associated with model health states. Describe primary or
secondary research methods for valuing each resource item in terms of its unit
cost. Describe any adjustments made to approximate to opportunity costs.

___________________

Report the dates of the estimated resource quantities and unit costs. Describe
methods for adjusting estimated unit costs to the year of reported costs if
necessary. Describe methods for converting costs into a common currency baseand the exchange rate.

___________________

Describe and give reasons for the specific type of decision-analytical model used.
Providing a figure to show model structure is strongly recommended.

___________________

Discount rate
Choice of health outcomes
Measurement of effectiveness

9
10
11a

Currency, price date, and conversion 14

Choice of model

15

Assumptions

16

Describe all structural or other assumptions underpinning the decision-analyticalmodel.

___________________

Analytical methods

17

Describe all analytical methods supporting the evaluation. This could include
methods for dealing with skewed, missing, or censored data; extrapolation
methods; methods for pooling data; approaches to validate or make adjustments(such as half cycle corrections) to a model; and methods for handling population
heterogeneity and uncertainty.

_______________

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Table 1 CHEERS checklist—Items to include when reporting economic evaluations of health interventions (Continued)
Results
Study parameters

18

Report the values, ranges, references, and, if used, probability distributions for allparameters. Report reasons or sources for distributions used to represent
uncertainty where appropriate. Providing a table to show the input values isstrongly recommended.

___________________

Incremental costs and outcomes19

For each intervention, report mean values for the main categories of estimatedcosts and outcomes of interest, as well as mean differences between thecomparator groups. If applicable, report incremental cost-effectiveness ratios.

___________________

Characterising uncertainty

20aSingle study-based economic evaluation: Describe the effects of sampling
uncertainty for the estimated incremental cost and incremental effectivenessparameters, together with the impact of methodological assumptions (such as
discount rate, study perspective).

___________________

Characterising heterogeneity

20b

Model-based economic evaluation: Describe the effects on the results of uncertainty
for all input parameters, and uncertainty related to the structure of the model and___________________
assumptions.

21

If applicable, report differences in costs, outcomes, or cost-effectiveness that canbe explained by variations between subgroups of patients with different baselinecharacteristics or other observed variability in effects that are not reducible bymore information.

___________________

Summarise key study findings and describe how they support the conclusions
reached. Discuss limitations and the generalisability of the findings and how thefindings fit with current knowledge.

___________________

Describe how the study was funded and the role of the funder in theidentification, design, conduct, and reporting of the analysis. Describe other nonmonetary sources of support.

___________________

Discussion
Study findings, limitations,generalisability, and current
knowledge

22

Other
Source of funding

Conflicts of interest

23

24

Describe any potential for conflict of interest of study contributors in accordancewith journal policy. In the absence of a journal policy, we recommend authors
comply with International Committee of Medical Journal Editors recommendations. ___________________For consistency, the CHEERS statement checklist format is based on the format of the CONSORT statement checklist.

technology assessment and decision making (FA, AHB,
DH, MD, JM) and in clinical epidemiology and biostatistics (AHB, EL, DM), those in active clinical practice (EL,FA), and those with previous experience in reporting
guideline development (MD, DM). All members are researchers in applied health and health policy, with fivemembers currently serving as editors for journals in thefield (AHB, CC, MD, DG, EL).
The CHEERS Task Force followed current recommendations for developing reporting guidelines [22]. Briefly,
the need for new guidance was first identified through asurvey of members of the World Association of Medical
Editors. Of the 6% (55/965) who responded, 91% (n = 50)
indicated they would use a standard if one were widely
available [8]. Next, published checklists or guidance documents related to reporting economic evaluations wereidentified from a systematic review and survey of task
force members [23]. Both of these activities were used
to create a preliminary list of items to include whenreporting economic evaluations. Recommendations of theminimum set of reporting items were then developed
through a modified Delphi panel process. Forty eight individuals identified by the task force with broad geographical representation and representing academia, biomedical

journal editors, the pharmaceutical industry, government
decision makers, and those in clinical practice were invited
to participate. Thirty seven agreed to participate. Participants were asked to score importance on a Likert scale
and the average scores, weighted by each individual’s confidence in ability to score, were then used to rank items. A
cut-off point was applied to the ranked list to determine
the minimum number of items important for reporting.
The CHEERS statement recommendations have been
independently reviewed and subsequently revised by task
force members. The recommendations are entirely thoseof the task force—the sponsors of the study had no rolein study design, data analysis, data interpretation, or
writing of the final recommendations. A more complete
description of the methods and findings of the Delphi
panel are found in the larger explanation and elaboration
document [21].
Checklist items

The final recommendations are subdivided into six maincategories: (1) title and abstract; (2) introduction; (3)methods; (4) results; (5) discussion; and (6) other. The
recommendations are contained in a user friendly,
24 item checklist (Table 1) to aid users who wish toHusereau et al. BMC Medicine 2013, 11:80
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follow them. A copy of the checklist can also be foundon the CHEERS Task Force website. (www.ispor.org/
TaskForces/EconomicPubGuidelines.asp). In order to encourage dissemination and use of a single international
standard for reporting, the task force approached 14
journals identified as either the largest publishers of economic evaluations or widely read by the medical and research community. Thirteen journals responded, and 10
expressed their ability and interest in endorsing thisguidance. The CHEERS statement is being simultaneously
published in BMC Medicine, BMJ, BJOG: An International
Journal of Obstetrics and Gynaecology, Clinical Therapeutics, Cost Effectiveness and Resource Allocation, The
European Journal of Health Economics, International Journal of Technology Assessment in Health Care, Journal of
Medical Economics, Pharmacoeconomics, and Value in
Health. To facilitate wider dissemination and uptake of
this reporting guidance, we encourage other journals andgroups to consider endorsing CHEERS.
Concluding remarks

As the number of published health economic evaluations
continues to grow, we believe more transparent andcomplete reporting of methods and findings will be increasingly important to facilitate interpretation and comparison of studies. We hope the CHEERS statement,
consisting of recommendations in a 24 item checklist,
will be viewed as an effective consolidation and updateof previous efforts and serve as a starting point forstandard reporting going forward.
We believe the CHEERS statement represents a considerable expansion over previous efforts. The strengthof our approach is that it was developed in accordancewith current recommendations for the development ofreporting guidelines, using an international and multidisciplinary team of editors and content experts ineconomic evaluation and reporting [22]. Similar to theapproach taken with other widely accepted guidelines,
we have defined a minimum set of criteria though a
modified Delphi technique and have translated these
into recommendations, an explanatory document with
explanations, and a checklist. Unlike some previous
reporting guidance for economic evaluation, we havealso made every effort to be neutral about the conductof economic evaluation, allowing analysts the freedom tochoose different methods.
There may be several limitations to our approach. A
larger Delphi panel with a different composition could
have led to a different final set of recommendations [24].
Some less common approaches and contexts (such as
public health, developing countries, and system dynamic
models) for conducting health economic evaluation may
not be well represented by our sample of experts.
Additionally, like many Delphi panel processes, we based

Page 5 of 6

decisions to reject or accept criteria on arbitrary levelsof importance. However, we feel the group recruited tocreate the statement is sufficiently knowledgeable of themore common applications of economic evaluation, andthe rules used to select criteria were created a priori andare consistent with previous efforts.
We believe it will be important to evaluate the effects
of implementation of this statement and checklist onreporting in future economic evaluations. As methods
for the conduct of economic evaluation continue to
evolve, it will also be important to revisit or extend theguidance. The CHEERS Task Force feels that this statement should be reviewed for updating five years from its
release.
Competing interests
All authors have completed the ICMJE uniform disclosure form at www.
icmje.org/coi_disclosure.pdf and declare: FA served as board member for the
study funder; FA, AHB, CC, MD, DG, DH, EL, JM, and SP were provided
support for travel to a face-to-face meeting to discuss the contents of thereport; FA and MD have received payment from the study sponsor forserving as co-editors for Value in Health; no other relationships or activities
that could appear to have influenced the submitted work. Elizabeth Loder is
BMJ clinical epidemiology editor. She played no part in the peer review ordecision making of this paper at the editorial level, and contributed solely as
an author.
Authors’ contributions
All authors provided a substantial contribution to the design andinterpretation of the protocol and guidance, as well as writing sections ofdrafts, revising based on comments received, and approving the final
version. DH conducted the analysis of Delphi panel responses, drafted andrevised the protocol and the drafts of this paper, and is the guarantor for the
study. All authors read and approved the final manuscript.
Acknowledgements
The International Society for Pharmacoeconomics and Outcomes Research(ISPOR) Health Economic Evaluation Publication Guidelines—CHEERS Task
Force acknowledge the support of Elizabeth Molsen; Donna Rindress, whoprovided the initial leadership for this effort; and the reviewers and Delphi
panel participants, who are named in the larger explanation and elaboration
document and on the CHEERS Task Force website.
All CHEERS Task Force members are volunteers. Support for this initiative wasprovided by the International Society for Pharmacoeconomics andOutcomes Research.
This article is a joint publication by BMC Medicine, Cost Effectiveness andResource Allocation, BJOG: An International Journal of Obstetrics andGynaecology, BMJ, Clinical Therapeutics, The European Journal of Health
Economics, International Journal of Technology Assessment in Health Care,
Journal of Medical Economics, Pharmacoeconomics and Value in Health. Eachpublisher holds its own copyright.
Author details
1
Institute of Health Economics, Edmonton, Canada. 2Department of
Epidemiology and Community Medicine, University of Ottawa, Ottawa,
Canada. 3University for Health Sciences, Medical Informatics and Technology,
Hall in Tirol, Austria. 4Centre for Health Economics, University of York, York,UK. 5Warwick Medical School, University of Warwick, Coventry, UK. 6Adis
International, Auckland, New Zealand. 7Clinical Epidemiology Program,
Ottawa Hospital Research Institute, Ottawa, Canada. 8Department of Health
Systems Management, Faculty of Health Sciences, Ben-Gurion University of
the Negev, Beer-Sheva, Israel. 9Center for the Evaluation of Value and Risk in
Health, Tufts Medical Center, Boston, MA, USA. 10Health Economic Evaluation
and Technology Assessment, Institute for Clinical Effectiveness and Health
Policy (IECS), Buenos Aires, Argentina. 11Universidad de Buenos Aires, Buenos
Aires, Argentina. 12Institute of Health and Wellbeing, University of Glasgow,

Husereau et al. BMC Medicine 2013, 11:80
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Glasgow, Scotland, UK. 13RTI Health Solutions, Research Triangle Park, NC,
USA. 14Division of Headache and Pain, Brigham and Women’s/Faulkner
Neurology, Faulkner Hospital, Boston, MA, USA. 15D Husereau, 879
Winnington Ave, Ottawa ON K2B 5C4, Canada. 16Clinical Epidemiology Editor,
BMJ, London, UK.
Received: 5 March 2013 Accepted: 7 March 2013
Published: 25 March 2013
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doi: 10.1186/1741-7015-11-80
Cite this article as: Husereau et al.: Consolidated Health Economic
Evaluation Reporting Standards (CHEERS) statement. BMC Medicine 2013
11:80.

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