CHEERS 2022

What it is

— CHEERS 2022 is the Consolidated Health Economic Evaluation Reporting Standards, the consensus reporting guideline for health economic evaluations. It is a 28-item checklist developed and maintained by an ISPOR (Professional Society for Health Economics and Outcomes Research) Good Practices Task Force (the "CHEERS II" task force) and is registered on the EQUATOR Network library of reporting guidelines. The 2022 update replaces the 2013 statement, expanding and clarifying items on perspective, model structure, heterogeneity and distributional effects, engagement of patients and stakeholders, and approach to uncertainty. Crucially, CHEERS is a reporting instrument: it specifies what must be disclosed so a reader can understand, appraise, and reproduce the economic evaluation. It is not a how-to for conducting an analysis, not a methods or reference-case standard (those are NICE/CADTH/ICER/ISPOR methods guidance), and not a critical-appraisal or risk-of-bias tool. The canonical statement (Husereau et al., 2022) was co-published in Value in Health and the BMJ, with a companion Explanation and Elaboration paper that expands each item.

When to use

— Apply CHEERS 2022 whenever you report a health economic evaluation that compares costs and consequences of two or more courses of action: cost-effectiveness analysis (CEA), cost-utility analysis (CUA), cost-benefit analysis (CBA), or cost-minimization analysis (CMA), whether trial-based, model-based, or built on real-world data. It applies across decision contexts — a peer-reviewed journal submission, an HTA/payer reimbursement dossier (NICE, CADTH, ICER, G-BA, PBAC), a value-message file, or the economic section of a regulatory or market-access package. Decision rules for which guideline: (1) if the deliverable is a full economic evaluation, CHEERS is the reporting standard; (2) if the deliverable is the underlying comparative clinical or RWE study feeding the model (the effectiveness, safety, or HCRU inputs), report that study with STROBE or RECORD/RECORD-PE for observational data, CONSORT for trials, and pre-specify it with HARPER/STaRT-RWE — CHEERS does not cover those inputs; (3) for a budget-impact analysis, CHEERS is not the design standard — follow the ISPOR BIA Good Practice — though CHEERS-style transparency on assumptions, perspective, and time horizon is still good practice; (4) for a systematic review of economic evaluations, use PRISMA, not CHEERS, for the review itself.

What it requires

— The 28 items map to the structure of an economic evaluation and force disclosure of the choices that determine its credibility. Substantively, CHEERS 2022 requires: a clear title/abstract identifying it as an economic evaluation; a stated research question, target population, subgroups, setting, and comparators; the perspective (e.g., healthcare-sector vs societal) and its justification; the time horizon and the discount rate for costs and effects; the choice and structure of any model with rationale and assumptions; the sources and methods for clinical effectiveness, health-state utilities/preferences, resource use, and unit costs, with the measurement and valuation approach for each; handling of currency, price date, and conversion; the analytic methods, including how heterogeneity, uncertainty, and distributional effects were characterized; full results (incremental costs and effects, ICERs, net benefit) with deterministic and probabilistic sensitivity analysis; a discussion of findings, limitations, generalizability, and equity; and disclosure of funding, conflicts of interest, and stakeholder/patient engagement. For evaluations built on real-world data, this means the report must make transparent how RWE inputs were used in the model — which estimands, data sources, and time horizons the effectiveness and cost inputs came from, and how their uncertainty was propagated — even though CHEERS does not itself adjudicate the validity of those inputs.

When NOT to use — limitations and common misapplications

— CHEERS is a reporting checklist, not a risk-of-bias instrument and not a quality score: a fully "CHEERS-compliant" paper can still report a biased, poorly-specified, or non-credible analysis. The single most dangerous misapplication for RWE-informed economics is treating CHEERS as a substitute for reporting the underlying real-world study. Completing CHEERS on a CEA whose effectiveness or cost inputs come from a claims/EHR analysis does not discharge the obligation to report that observational study to STROBE/RECORD-PE standards (design transparency, time-zero alignment, phenotype/algorithm validation, confounding control, attrition, sensitivity analysis) — CHEERS does not ask for, and does not certify, any of that. Other failure modes: using CHEERS where a methods/reference-case standard is required (CHEERS reports a choice; it does not tell you the correct perspective or discount rate for a given jurisdiction — that comes from NICE/CADTH/ICER); using CHEERS as the design guideline for a budget-impact analysis (separate ISPOR BIA good practice applies); checklist-as-theater, where item numbers are ticked in an appendix while the corresponding content is vague or absent; and applying CHEERS to a study that is not an economic evaluation at all (a cost-of-illness or HCRU descriptive study is not a comparative economic evaluation and is better served by STROBE plus costing good practice). Completing the checklist also does not make an observational comparative-effectiveness input causal.

How it maps to this catalog

— CHEERS sits at the reporting layer over the economic evaluation; the implementing concepts in this repo supply the methods whose reporting it governs. The four evaluation types are the design concepts CHEERS reports: cost-effectiveness (cost-effectiveness), cost-utility (cost-utility), cost-benefit (cost-benefit), and cost-minimization (cost-minimization); the adjacent budget-impact (budget-impact) is reported under ISPOR BIA guidance, not CHEERS proper. CHEERS items on model structure and analysis map to health-economic-modeling-methods-rwe, markov-transition-probabilities-rwe, partitioned-survival-models-rwe, and discrete-event-simulation-rwe; the survival-input item maps to survival-extrapolation-hta-rwe. The utilities/preferences item is implemented by qaly-utility-mapping-rwe; the discounting item by discounting-costs-effects-rwe; the results/outcome metrics by icer-net-monetary-benefit-rwe; and the uncertainty item by probabilistic-sensitivity-analysis-hea-rwe. The cost and resource-use inputs map to healthcare-costs-pppm-pppy-pmpm, all-cause-vs-attributable-costs-rwe, and hcru-healthcare-resource-utilization. When the effectiveness or cost inputs are drawn from real-world data, the inputs (not CHEERS) are governed by target-trial-emulation, fit-for-purpose-data-assessment-rwe, and claims-analysis — report those to STROBE/ RECORD-PE, then report the economic evaluation that consumes them to CHEERS.

Applied note (claims/EHR/registry RWE)

When a CEA or CUA is parameterized from administrative claims, EHR, or registry data — e.g., real-world progression and discontinuation feeding survival extrapolation, or PPPM costs feeding the cost arm — a credible submission reports two things to two standards. The economic evaluation (model structure, perspective, time horizon, discounting, ICER/NMB, PSA) is reported to CHEERS 2022; the real-world inputs (data source fitness, phenotype/algorithm validation, time-zero, attrition, confounding control, the estimand and how its uncertainty was carried into the model) are reported to STROBE/RECORD-PE and pre-specified with HARPER/STaRT-RWE. Conflating the two — ticking CHEERS and omitting the provenance and validity of the RWE inputs — is the most common reason an HTA reviewer rejects a real-world-evidence-based economic model as non-transparent.