Strata Academy

Health Economics in Systematic Reviews (Intro)

When to include cost-effectiveness evidence, CHEERS reporting, and how students should appraise economic summaries in reviews without becoming health economists

1. Why economics appears in systematic reviews

Clinical effectiveness alone does not tell the NHS whether an intervention is affordable or offers value for money. Health technology assessment bodies (NICE, SMC, AWMSG) routinely need cost per quality-adjusted life year (QALY) alongside relative risk reductions.

Systematic reviews of interventions sometimes include a parallel economic component: search for economic evaluations linked to included trials, extract incremental cost-effectiveness ratios (ICERs), or map cost-utility results in a narrative synthesis.

Dedicated economic systematic reviews exist — they follow similar search and appraisal steps but use CHEERS (Consolidated Health Economic Evaluation Reporting Standards) and often assess risk of bias with Evers et al. or PHAROS checklists rather than ROB 2.

As a medical student, you will most often encounter economics as a subsection in a Cochrane or NICE review — not as a standalone MSc health economics dissertation. Knowing how to read that subsection prevents you mis-citing ICERs in SSC write-ups.

2. Types of economic evaluation (minimal vocabulary)

Cost-minimisation: interventions assumed equally effective — compare costs only. Rare in modern reviews.

Cost-effectiveness: costs per natural unit (e.g. cost per mmHg reduction). Useful when outcomes match clinically.

Cost-utility: costs per QALY gained — allows comparison across disease areas. Dominant language in NICE.

Budget impact: total cost to a payer if adopted — not the same as cost-effectiveness.

Students do not need to build Markov models for SSC — you need to recognise which type a included study reports and whether comparators match your clinical question.

• ICER — incremental cost-effectiveness ratio
• QALY — quality-adjusted life year
• Perspective — NHS and personal social services vs societal
• Time horizon — lifetime vs 1-year (matters enormously)

3. When to include economics in your review plan

Include economic searches when your review question is explicitly HTA-oriented (supervisor is health economist, or brief says 'effectiveness and cost-effectiveness').

Cochrane Intervention Reviews sometimes publish clinical and economic supplements separately — check both.

For standard student dissertations focused on clinical outcomes, a full economic synthesis is usually out of scope. Mention economics as limitation ('future work should summarise cost-effectiveness') rather than promising ICER meta-analysis you cannot deliver.

If including economics, pre-specify in PROSPERO: eligible study designs (trial-based CEAs, model-based CEAs), perspective (NHS preferred for UK), and currency/year adjustment methods.

4. CHEERS checklist — student-level appraisal

CHEERS guides reporting of economic evaluations. Use it to ask: Are intervention comparators described? Is the analytic perspective stated? Are costs and outcomes discounted appropriately? Is uncertainty explored (sensitivity analysis)?

Poor reporting does not always mean the intervention is poor value — but you cannot trust the ICER if methods are opaque.

Key student questions: Was the model structure justified? Were utility values from UK population preferences? Did authors report both deterministic and probabilistic sensitivity analyses?

You are not expected to rebuild the model — flag when conclusions depend on one fragile assumption (e.g. drug price held constant over 20 years).

5. Why ICERs are not interchangeable

An ICER of £15,000/QALY from a 1-year NHS perspective trial-based analysis is not comparable to £15,000/QALY from a lifetime societal model using US costs — yet students paste both into tables as if they vote.

Check currency year (2020 GBP vs 2024 GBP), discount rates (NICE uses 3.5%), and whether the comparator is standard care in the NHS or an older drug no longer used.

Systematic reviews of economics often present ranges or narrative synthesis rather than pooling ICERs — meta-analysis of ICERs is methodologically specialist.

When a clinical review's discussion cites 'cost-effective' without ICER, trace the claim to the economic supplement or NICE technology appraisal.

6. GRADE and economic certainty

GRADE has extensions for economic evidence. Certainty may be lower when studies use different models, perspectives, or outdated costs.

NICE committees downgrade economic certainty for indirect comparisons, short time horizons on chronic conditions, and missing sensitivity analyses.

Students reading GRADE SoF tables should separate clinical certainty from economic statements — they appear in related but distinct columns in full HTA reports.

7. Practical student workflow

Reading a Cochrane clinical review: open linked economic supplement if present; note whether any included trial had within-trial CEA.

SSC appraisal coursework: pick one NICE technology appraisal; summarise clinical effectiveness and economic ICER in one page; use CHEERS on one model-based evaluation.

Conducting a review: unless you have health economics supervision, scope clinical outcomes only and discuss economics as future work.

Journal club: when presenting a trial, ask 'Is there a linked economic publication?' — separates EBM teaching from HTA reality.

• Read NICE TA summaries for integrated clinical + economic story
• CHEERS on one economic paper — feasible SSC task
• Do not pool ICERs without economist supervision
• State perspective and time horizon whenever citing QALYs

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