Evaluating the Cost-Effectiveness of Comprehensive Geriatric Assessment: Protocol for a Systematic Review of Economic Evaluations

Amanuel Yigezu; Rose Galvin; Dominic Trépel

doi:10.12688/hrbopenres.14066.2

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Study Protocol

Revised

Evaluating the Cost-Effectiveness of Comprehensive Geriatric Assessment: Protocol for a Systematic Review of Economic Evaluations

[version 2; peer review: 1 approved, 1 approved with reservations]

Amanuel Yigezu ^1,2, Rose Galvin³, Dominic Trépel^1,2

PUBLISHED 11 Nov 2025

Author details Author details

¹ Trinity College Institute for Neuroscience, Trinity College Dublin, Dublin, Ireland
² School of Medicine, Trinity College Dublin, Dublin, Ireland
³ School of Allied Health, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland

Amanuel Yigezu
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Software, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Rose Galvin
Roles: Conceptualization, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing

Dominic Trépel
Roles: Conceptualization, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Ageing Populations collection.

Abstract

Background

Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining an older person's medical, psychological, and functional capabilities to inform a coordinated and integrated health plan. It is a multifactorial intervention requiring longitudinal planning and care coordination, which can utilize variable healthcare resources and have difference health outcomes. This systematic review aims to identify evidence of the cost-effectiveness of CGA in various care settings.

Methods and analysis

Full economic evaluation studies (comparing both the costs and the consequences of alternatives) on CGA will be searched for in the Embase, Medline, CINAHL, CEA registry, and NHSEED databases. Two independent reviewers will screen the studies against the eligibility criteria and extract data using a pretested extraction form. We will include either randomized control trials or model-based economic evaluations, and the outcomes will include the mean costs and effectiveness, incremental cost, and incremental effectiveness. Reporting quality will be assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS-2022) checklist. Narrative summary tables and figures will be used to present the study characteristics.

Ethics and dissemination

Ethics approval is not required for this systematic review because we will only utilize publicly available economic evaluation studies rather than individual patient data. The findings of this review will be presented at national and international conferences and published in peer-reviewed journals.

PROSPERO registration no.: CRD42023492586.

Keywords

Comprehensive geriatric assessment, Economic evaluation, systematic review

Corresponding author: Amanuel Yigezu

Competing interests: No competing interests were disclosed.

Grant information: Health Research Board [RL-2020-010].
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2025 Yigezu A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Yigezu A, Galvin R and Trépel D. Evaluating the Cost-Effectiveness of Comprehensive Geriatric Assessment: Protocol for a Systematic Review of Economic Evaluations [version 2; peer review: 1 approved, 1 approved with reservations]. HRB Open Res 2025, 8:26 (https://doi.org/10.12688/hrbopenres.14066.2) First published: 05 Feb 2025, 8:26 (https://doi.org/10.12688/hrbopenres.14066.1) Latest published: 11 Nov 2025, 8:26 (https://doi.org/10.12688/hrbopenres.14066.2)

Revised Amendments from Version 1

The revised version of “Evaluating the Cost-Effectiveness of Comprehensive Geriatric Assessment: Protocol for a Systematic Review of Economic Evaluations” underwent several key textual and conceptual changes in response to reviewer feedback. Overall, these revisions aimed to clarify the study’s objectives, improve methodological transparency, and enhance readability and precision across sections.
The Abstract was updated to emphasize that the review specifically targets economic evaluations of CGA.
In the Background, unclear or redundant phrasing was corrected, including revising “identifying to improve that improve healthy ageing” to a grammatically correct and conceptually precise version. The explanation of CGA was rewritten to better describe its multidisciplinary nature, inclusion of frail older adults, and engagement of patients in care planning. Reference formatting and wording around “frailty” were standardized for consistency and tone.
Methodological sections were strengthened substantially. The inclusion and exclusion criteria were revised to broaden eligibility. We allowed studies with less than six months’ follow-up and clarifying that CGA must be delivered by personnel with gerontology training.
The methods section now differentiates between trial-based and model-based economic evaluations, specifies the PROSPERO registration (number and date), and ensures consistent future-tense phrasing throughout. Additionally, the risk of bias (ROB-1) assessment was removed. Limitation of not conducting methodological assessment is acknowledged.
Figures and tables were also revised.

See the authors' detailed response to the review by Jonas Ammundsen Ipsen
See the authors' detailed response to the review by Robert Murphy

Background

With increasing life expectancy and changes in demography¹, the demand for healthcare is increasingly rapidly in line with the growth of the older population². The World Health Organization (WHO) defines "healthy ageing" as "the process of developing and maintaining the functional ability that enables well-being in older age"³. To realize healthy aging, health and social care systems advocate a shift from acute management of cases coordinated, longitudinal, and integrated care for older adults⁴. As a result, researchers are increasingly focused on identifying interventions that improve healthy ageing.

Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining an older person's medical, psychological, and functional capabilities to develop a coordinated and integrated care plan⁵. CGA is considered for older adults living with frailty or at risk of adverse outcomes⁶. To improve the trajectory of aging, CGA considers various factors, including medical, psychological, and functional impairment, as well as environmental and social issues. CGA requires an interdisciplinary team that may include geriatric specialists, doctors, nurses, and allied health professionals, and aims to produce a coordinated and integrated care plan for treatment, rehabilitation, support, and long-term care with active engagement of the older adults in decision-making.

Over the last decade, CGA is being increasingly used in various health conditions and healthcare settings. For example, reviews have assessed the effectiveness of CGA across various care settings including emergency departments^7–9, primary/outpatient care^10,11, community settings^5,12, hospital inpatient departments^13,14, acute geriatric units^15,16, and long-term care facilities¹⁷. Similarly, the effectiveness of CGA in certain population groups, such as surgical patients^18–20, cancer patients^21,22, and in the prevention of delirium²³, has been reviewed. The resource implications of CGA can vary between studies due to differences in the settings, target population, or the intensity of the intervention²⁴, resulting in heterogeneity in treatment outcomes⁵.

Although there is strong evidence to support the clinical effectiveness of CGA in managing older adults living with frailty, health systems are increasingly interested in knowing the situations in which CGA can be implemented most efficiently. To examine efficiency, economic evaluation is defined as a comparative analysis of alternative courses of action in terms of both costs and consequences^25,26. Economic evaluation can be classified into two categories: partial and full²⁷. Full economic evaluations constitute cost-utility, cost-effectiveness, cost-consequence, cost-minimization, and cost-benefit analyses. Full economic evaluations compare both the costs and effects of alternative comparisons. The cost of the comparators includes the cost of the intervention (the input cost for comparators) and resource-use consequences (health service utilization after the intervention).

T c = Ci + Cc

Where: Tc: Total cost; Ci: Cost of intervention; Cc: resource use consequence

Effectiveness in the comparison groups can be measured in quality-adjusted life-years (QALYs) or other outcomes such as life-years gained, deaths averted, and improvement in frailty.

With respect to design, economic evaluations can be classified into trial-based and model-based economic evaluations. Trial-based economic evaluation is conducted alongside a randomised controlled trial (RCT) by tracking relevant costs and effectiveness data of comparison groups throughout the trial. Model-based economic evaluations define a set of multiple factors within a single decision-analytic framework, generating expected costs and effects for comparison groups and facilitating decision-making under uncertainty.

As the number of economic evaluations of CGA has increased, systematic reviews have contributed to knowledge by systematically identifying the evidence base and providing critical appraisal of reporting quality^28,29. Previous systematic reviews exist but offer opportunities for improvement:1) Ellis et al.¹³ included economic evaluation of CGA in inpatient settings, but primarily to inform a decision analytic model; 2) Briggs et al.⁵ described the costs of CGA in community settings, but did not critique full economic evaluations; and 3) Garrard et al. mentioned the cost-effectiveness of CGA in primary care, but did not critically appraise reporting quality¹⁰. To date, we have not found a systematic review or critical appraisal of the full economic evaluation of CGA. Therefore, this protocol aims to appraise full economic evaluation studies on CGA and assess the cost-effectiveness of the intervention by focusing on various care settings, economic perspectives, and sub-group characteristics.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols 2015 (PRISMA-P) was used to develop the protocol³⁰. The PRISMA-P checklist can be found online (see supplementary Appendix 1)³¹. This review will be conducted and reported in accordance with the 2020 PRISMA guidelines³². This review was registered in PROSPERO (registration number CRD42023492586) on December 11, 2023.

Criteria for eligibility of studies

Inclusion criteria

Types of studies: We will include full economic evaluation studies, either model-based or trial-based, conducted in the English language. Studies with at least six months of follow-up (or time horizon) will be included to appropriately capture the impact on costs and effectiveness^5,29.

Population: This review will encompass individuals aged 65 years or older (or 55 years or older if the average age of study participants exceeds 70 years)⁵. The participants may or may not be acutely unwell, and they should be identified as either frail or at risk of adverse outcomes (e.g., falls, functional decline, nursing home admission).

Intervention: Comprehensive geriatric assessment provided at all levels of care, including home, nursing home, primary care, and tertiary health facilities by a multidisciplinary team for older adults.

Comparison: the comparator is care as usual or standard care

Outcomes: The primary outcomes will include the mean costs, mean effects, incremental costs, and incremental effectiveness.

Setting

All healthcare settings, including CGA provided at home, GP practice, emergency/acute care departments, outpatient departments, inpatient departments, and long-term care facilities, will be considered.

Exclusion criteria

We will exclude studies that do not define population groups as "at risk.” Studies with CGA interventions provided without the explicit involvement of geriatric expertise will not be included. Studies that applied partial economic evaluation will be excluded from the review^25,27. Studies with less than six months of follow-up (time horizon) will be excluded. Commentaries, reviews, methodological articles, and editorials will also be excluded. We will exclude studies that are conducted on a single disease condition¹⁰.

Table 1 below presents the inclusion and exclusion criteria.

Table 1. Inclusion and exclusion criteria.

Criteria	Inclusion	Exclude
Population	- Older adults ≥65 years (or ≥ 55 years if the average age is >70 years). - Identified as either living with frailty or at risk of adverse outcomes (e.g., falls, functional decline, cognitive decline, nursing home admission	- Population with a specific disease. For example, if CGA is provided to cancer patients. - Population not identified as either living with frailty or at risk of adverse outcomes.
Intervention	- CGA delivered by personnel with training or expertise in gerontology.	- CGA delivered by personnel with no training or expertise in gerontology.
Comparator	- Usual care, standard care, or do-nothing	- Head-to-head comparison. For example, comparing CGA at inpatient versus CGA at home.
Outcome	- Average cost, average effectiveness, AND/OR - Incremental cost and incremental effect AND/OR - Incremental Cost Effectiveness Ratio.	- All outcomes from partial economic evaluations.
Study types	- Full economic evaluations (model-based or trial-based).	- Partial economic evaluation (cost-analysis, cost- description, outcome description). - Commentaries, - Methodological articles
Setting	- All care settings (inpatient, outpatient, GP, Home- based, Emergency, long-term facilities and others).

Search methods for identification of studies

Using pilot search terms, a preliminary search was conducted on PROSPERO, PubMed, and Embase to identify any similar systematic reviews, either in progress or published, to mitigate the duplication of work. However, no on-going studies identical to the present systematic review were found.

A search strategy will be devised with support from a librarian at Trinity College Dublin and the literature⁵. This strategy will be applied across various databases including Embase, MEDLINE, and CINAHL (Supplementary Appendix 2)³¹. Our approach will include a manual search of reference sections in the identified studies and searches for cited references. Additionally, relevant databases specific to economic evaluations, such as the Tufts CEA Registry and NHS Economic Evaluation Database, will be explored. EndNote 21 will be used to import studies, and Covidence will be utilized to manage search results and remove duplicate records.

Selection of studies

The study selection will be outlined using a PRISMA flow diagram. Two authors will independently screen the eligible titles and abstracts. The full text of potentially eligible studies will be identified, and a decision to include these full-text articles will be made independently by these two authors. Disagreements to include eligible studies will be approved by discussion in the presence of a third or fourth author (DT or RG). Figure 1 summarises the flow of the selection process.

Figure 1. PRISMA flow diagram for the identification of studies.

Data extraction and management

Two reviewers independently will extract data from selected studies using a structured data collection form on COVIDENCE after a pilot study. If there are disagreements between the two reviewers, the decision will be made by the third and fourth reviewers.

Appraisal of quality

The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement provides guidelines for proper reporting of economic evaluations²⁹. This statement includes 28 criteria outlining the minimum standards for such reports. The CHEERS-2022 checklist will be used to evaluate the reporting quality of economic evaluations³³.

To enhance the interpretability of the reporting quality of papers, we will employ a traffic light color-coding system to visually represent the degree to which the key elements of the CHEERS checklist were addressed:

1. Green: Indicates that all elements were fully addressed.
2. Yellow: Indicates that some parts of the elements were only partially addressed.
3. Red: Indicates that the elements were not addressed at all.
4. Black: Indicates that the elements were not applicable.

Figure 2 shows the traffic-light system of the reporting quality of the studies.

Figure 2. Traffic light system of the reporting quality of the studies.

Data analysis and synthesis

A description of the characteristics of the studies and the results will be displayed using a narrative summary and tables. The general characteristics of the included studies will be presented in Table 2.

Table 2. General characteristics of the studies.

Characteristics	Description of characteristics	Number	Reference
Year of publication
Country of study
Setting
Target population
Study design
Type of economic evaluation
Perspective of the study
Time horizon
Subgroup analyses
Sponsorship
Analyses of uncertainty

Narrative reports and tables will be categorized into three sections: intervention characteristics, study characteristics, and study findings. Intervention characteristics encompass the country where the study was conducted, the name of the CGA intervention being investigated, specifics about the services provided to the CGA group, the composition of the team delivering the CGA intervention, details about the target population, and care settings (such as outpatient, inpatient, emergency, and home long-term care facilities). Figure 3 shows a description of the characteristics of the interventions being compared.

Figure 3. Description of characteristics of interventions.

Study characteristics include the analytical approach (trial-based or model-based), the health economic perspective of the study, the resources used to measure costs, the time horizon, discount rates for both cost and effectiveness, outcomes measured, the instruments used to measure these outcomes, how outcomes are valued, the threshold applied, and the analysis of uncertainty.

Descriptions of resource use (health service utilization) for both groups are presented in Figure 4.

Figure 4. Measurements of health service utilisation for comparison groups.

A description of the presentation of study characteristics is shown in Table 3.

Table 3. Description of characteristics of the studies.

Study ID	Country of study	Target population	Setting	Analytic approach	Perspective of the study	Time horizon	Outcome	Instrument used to measure outcome	Valuation of outcome
Study 1
Study 2
Study 3
Study 4
Study 5

For cost-utility studies, we will present the difference in costs and quality-adjusted life-years on a cost-effectiveness plane. The cost-effectiveness plane is used to plot the difference in cost and QALY between the intervention and control groups. It is divided into four quadrants: 1) the northeast (NE) quadrant indicates that the intervention is costlier and more effective; 2) the northwest (NW) quadrant indicates higher cost and lower effect; 3) the southwest (SW) quadrant indicates lower cost and lower effect; and 4) the SE quadrant indicates lower cost and lower effect. To allow comparability, all costs reported in the cost-effectiveness plane will be converted to and the price year of 2024 in Euro using the purchasing power parity and gross domestic product deflator index³⁴. Figure 5 illustrates the cost-effectiveness plane that will be used to report the incremental costs and QALYs by care setting.

Figure 5. Cost-effectiveness plane for reporting cost-utility studies.

NW: Northwest; SW: Southwest; NE: Northeast; SE: Southeast; UC: Usual care.

A detailed description of the cost-utility analysis, including the country of study, setting, base-year currency, willingness to pay per QALY, incremental QALY (95% CI), perspective, incremental cost (95% CI), and the authors’ conclusion about the intervention, will be presented in Table 4.

Table 4. Description of results of from the studies.

Author, country	Setting	Base year, currency	WTP per QALY	Incremental QALY (95%CI)	Perspective	Incremental cost (95%CI)	Authors’ conclusion about the intervention
Study 1
Study 2
Study 3
Study 4

WTP: willingness to pay

Patient and public involvement

Patients and the public will not participate in the design, execution, reporting, or dissemination of this research.

Discussion

This review protocol aims to evaluate the cost-effectiveness of CGA. This systematic review will support decision making by assessing and appraising cost-effectiveness across different characteristics, including different care settings and economic perspectives. Reporting summary findings with attention to intervention characteristics, study characteristics, and results will facilitate appraisal and a robust interpretation of the findings. We will appraise approaches to the identification, measurement, and valuation of costs and outcomes which will support proper interpretation of the cost-effectiveness evidence and guide the conduct of future economic evaluations³⁵.

Ethics and dissemination plan

Ethics approval is not required for this systematic review, as it solely involves the use of publicly available economic evaluation studies and does not involve individual patient data. Therefore, there are no ethical concerns regarding patient confidentiality or informed consent. The findings of this review will be disseminated through presentations at national and international conferences, to reach a wide audience of researchers and practitioners. Additionally, the results will be published in a peer-reviewed journal to contribute to academic literature and inform future research and policymaking in the field of economic evaluation.

Abbreviations

CHEERS, Consolidated Health Economic Evaluation Reporting Standards; CGA, Comprehensive Geriatric Assessment; CPI, Consumer Price Index; DALY, Disability Adjusted Life Year; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life year.

Data availability

Underlying data

No data are associated with this article.

Extended data

Figshare: Evaluating the Cost-Effectiveness of Comprehensive Geriatric Assessment: Protocol for a Systematic Review of Economic Evaluations, https://doi.org/10.6084/m9.figshare.28239149³⁶

The project contains the following extended data

Supplementary Appendix 2-Search strategy

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). 

Reporting guidelines

Figshare: PRISMA -P checklist for ‘Evaluating the Cost-Effectiveness of Comprehensive Geriatric Assessment: Protocol for a Systematic Review of Economic Evaluations’, https://doi.org/10.6084/m9.figshare.28239149³⁶

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). 

Acknowledgements

We express our gratitude to David Mockler, a librarian at Trinity College Dublin, for his support with the initial preparation of search strategies.

Faculty Opinions recommended

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Version 2

VERSION 2 PUBLISHED 05 Feb 2025

Author details Author details

Rose Galvin
Roles: Conceptualization, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing

Dominic Trépel
Roles: Conceptualization, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

Health Research Board [RL-2020-010].
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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© 2025 Yigezu A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Yigezu A, Galvin R and Trépel D. Evaluating the Cost-Effectiveness of Comprehensive Geriatric Assessment: Protocol for a Systematic Review of Economic Evaluations [version 2; peer review: 1 approved, 1 approved with reservations]. HRB Open Res 2025, 8:26 (https://doi.org/10.12688/hrbopenres.14066.2)

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Jonas Ammundsen Ipsen, Lillebaelt Hospital, University Hospital of Southern Denmark,, Kolding, Denmark

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Robert Murphy, Galway University Hospital, Galway, Ireland

Approved with Reservations

https://doi.org/10.21956/hrbopenres.15448.r45708

Thank you for the opportunity to review this paper. I am not an expert in economic evaluations but have given my perspective on this from a Geriatric Physician viewpoint and I do think this will be a valuable addition to the literature when considering the cost effectiveness of CGA in different settings. I have a few small suggestions.

Abstract:

I think the last sentence in the background of the abstract could mention that economic evaluations are being specifically looked at. In the first section of the methods and analysis in the abstract the average reader who is not familiar with economic evaluations might not understand the difference between full and partial.

Main Text:

Background:

Suggest rewording the end of the second sentence for better clarity: "research is increasingly focused on identifying to improve that improve healthy ageing".

I don't think "frailty" in the second paragraph needs to be in "".

The wording of the last sentence in paragraph three could be improved. I suggest to simplify it to make the point that costs can differ from study to study because of the different settings CGA is used in.

The last section of the last sentence in the background could be a bit clearer from a wording point of view - it is not immediately clear to me what 'explain plans to seek optimal configuration of CGA means'

I think in the background you could include an explanation of what is the difference between model based or trial based economic evaluations.

Methods:

I think you could include in the methods section that you have it registered on PROSPERO and include what date you registered on PROPERO.

Population: For the frailty inclusion criteria does there need to be a standardised tool to measure frailty? I wonder about also including at risk of cognitive decline as one of the adverse outcomes.

Outcome: Is there one main primary outcome? Or is the primary outcome a composite of the "mean costs, mean effects, incremental costs, and incremental effectiveness".

Exclusion Criteria; could you explain a bit more what is meant by Geriatric expertise - is this that the explicit involvement of a Geriatric medicine physician? Or is it the members of the MDT must have specific geriatric medicine training? I know that some (not all) models of CGA do not include a geriatric medicine physician but the rest of a team might have extensive geriatric training which is why I suggest you make this a little clearer.

In the search methods for identification of studies section there is some interspersing of tenses: some in the past tense and some in the future tense which makes it read a little disjointed. This is also the case in some other sections of the methods e.g. in the appraisal of quality.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Geriatric Medidine

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Author Response 11 Nov 2025

Amanuel Yigezu, Trinity College Institute for Neuroscience, Trinity College Dublin, Dublin, Ireland

11 Nov 2025

Author Response
Dear Reviewer,
We sincerely appreciate your thoughtful and constructive feedback, which has significantly enhanced the quality of our manuscript. In response, we have carefully considered each comment and revised the ... Continue reading
Dear Reviewer,
We sincerely appreciate your thoughtful and constructive feedback, which has significantly enhanced the quality of our manuscript. In response, we have carefully considered each comment and revised the protocol to improve its clarity, methodological transparency, and adherence to reporting standards. Presented below is our detailed point-by-point response to your comments.

Abstract

I think the last sentence in the background of the abstract could mention that economic evaluations are being specifically looked at.

Authors’ response: We thank the reviewer for the comments. We have revised the section as: "This systematic review aims to identify, appraise, and synthesize economic evaluation studies on CGA across various care settings.”

In the first section of the methods and analysis in the abstract the average reader who is not familiar with economic evaluations might not understand the difference between full and partial.

Authors’ response: Thank you. We have revised the section as:
Full economic evaluation studies (comparing both the costs and the consequences of alternatives) on CGA will be searched for in the Embase, Medline, CINAHL, CEA registry, and NHSEED databases.

Main text

Suggest rewording the end of the second sentence for better clarity: "research is increasingly focused on identifying to improve that improve healthy ageing".

Authors’ response: Thank you. We have revised the sentence as:
With increasing life expectancy and changes in demography (1), the demand for healthcare is increasingly rapidly in line with the growth of the older population (2). The World Health Organization (WHO) defines "healthy ageing" as "the process of developing and maintaining the functional ability that enables well-being in older age" (3)”.To realize healthy aging, health and social care systems advocate a shift from acute management of cases to coordinated, longitudinal, and integrated care for older adults (4). As a result, researchers are increasingly focused on identifying interventions that improve healthy ageing.

I don't think "frailty" in the second paragraph needs to be in "".

Authors’ response: Thank you. We have revised the sentence as:
CGA is considered for older adults living with frailty or at risk of adverse outcomes.

The wording of the last sentence in paragraph three could be improved. I suggest to simplify it to make the point that costs can differ from study to study because of the different settings CGA is used in.

Authors’ response: Thank you. We have revised the sentence as follows:
The resource implications of CGA can vary between studies due to differences in the settings, the target population, or the intensity of the intervention, resulting in heterogeneity in treatment outcomes.

The last section of the last sentence in the background could be a bit clearer from a wording point of view - it is not immediately clear to me what 'explain plans to seek optimal configuration of CGA means'.

Authors’ response: Thank you. We have revised the sentence as follows:
Therefore, this protocol aims to appraise full economic evaluation studies on CGA and assess the cost-effectiveness of the intervention by focusing on various care settings, economic perspectives, and sub-group characteristics.

I think in the background you could include an explanation of what is the difference between model based or trial based economic evaluations.

Authors’ response: Thank you. We have included about model-based and trial based economic evaluations. With respect to design, economic evaluations can be classified into trial-based and model-based economic evaluations. Trial-based economic evaluation is conducted alongside a randomised controlled trial (RCT) by tracking relevant costs and effectiveness data of comparison groups throughout the trial. Model-based economic evaluations define a set of multiple factors within a single decision-analytic framework, generating expected costs and effects for comparison groups and facilitating decision-making under uncertainty

I think you could include in the methods section that you have it registered on PROSPERO and include what date you registered on PROPERO.

Authors’ response: Thank you. We have added the Prospero registration detail.
This review was registered in PROSPERO (registration number CRD42023492586) on December 11, 2023.

Population: For the frailty inclusion criteria does there need to be a standardised tool to measure frailty? I wonder about also including at risk of cognitive decline as one of the adverse outcomes.

Authors’ response: Thank you, we have included cognitive decline as an example of population at risk of adverse outcome.

Outcome: Is there one main primary outcome? Or is the primary outcome a composite of the "mean costs, mean effects, incremental costs, and incremental effectiveness".

Authors’ response: Thank you. We have used AND/OR to show it is either or combination of the lists.

Exclusion Criteria; could you explain a bit more what is meant by Geriatric expertise - is this that the explicit involvement of a Geriatric medicine physician? Or is it the members of the MDT must have specific geriatric medicine training? I know that some (not all) models of CGA do not include a geriatric medicine physician but the rest of a team might have extensive geriatric training which is why I suggest you make this a little clearer.

Authors’ response: Thank you. We have revised the criteria as “CGA delivered by personnel with no training or expertise in gerontology”.

In the search methods for identification of studies section there is some interspersing of tenses: some in the past tense and some in the future tense which makes it read a little disjointed. This is also the case in some other sections of the methods e.g. in the appraisal of quality.

Authors’ response: Thank you. We have revised the two sentences to:
“A search strategy will be devised with support from a librarian at Trinity College Dublin and the literature. This strategy will be applied across various databases including Embase, MEDLINE, and CINAHL (Supplementary Appendix 2). Our approach will include a manual search of reference sections in the identified studies and searches for cited references. Additionally, relevant databases specific to economic evaluations, such as the Tufts CEA Registry and NHS Economic Evaluation Database, will be explored. EndNote 21 will be used to import studies, and Covidence will be utilized to manage search results and remove duplicate records.”
“To enhance the interpretability of the reporting quality of papers, we will employ a traffic light color-coding system to visually represent the degree to which the key elements of the CHEERS checklist were addressed:”
Dear Reviewer,
We sincerely appreciate your thoughtful and constructive feedback, which has significantly enhanced the quality of our manuscript. In response, we have carefully considered each comment and revised the protocol to improve its clarity, methodological transparency, and adherence to reporting standards. Presented below is our detailed point-by-point response to your comments.

Abstract

I think the last sentence in the background of the abstract could mention that economic evaluations are being specifically looked at.

Authors’ response: We thank the reviewer for the comments. We have revised the section as: "This systematic review aims to identify, appraise, and synthesize economic evaluation studies on CGA across various care settings.”

In the first section of the methods and analysis in the abstract the average reader who is not familiar with economic evaluations might not understand the difference between full and partial.

Authors’ response: Thank you. We have revised the section as:
Full economic evaluation studies (comparing both the costs and the consequences of alternatives) on CGA will be searched for in the Embase, Medline, CINAHL, CEA registry, and NHSEED databases.

Main text

Suggest rewording the end of the second sentence for better clarity: "research is increasingly focused on identifying to improve that improve healthy ageing".

Authors’ response: Thank you. We have revised the sentence as:
With increasing life expectancy and changes in demography (1), the demand for healthcare is increasingly rapidly in line with the growth of the older population (2). The World Health Organization (WHO) defines "healthy ageing" as "the process of developing and maintaining the functional ability that enables well-being in older age" (3)”.To realize healthy aging, health and social care systems advocate a shift from acute management of cases to coordinated, longitudinal, and integrated care for older adults (4). As a result, researchers are increasingly focused on identifying interventions that improve healthy ageing.

I don't think "frailty" in the second paragraph needs to be in "".

Authors’ response: Thank you. We have revised the sentence as:
CGA is considered for older adults living with frailty or at risk of adverse outcomes.

The wording of the last sentence in paragraph three could be improved. I suggest to simplify it to make the point that costs can differ from study to study because of the different settings CGA is used in.

Authors’ response: Thank you. We have revised the sentence as follows:
The resource implications of CGA can vary between studies due to differences in the settings, the target population, or the intensity of the intervention, resulting in heterogeneity in treatment outcomes.

The last section of the last sentence in the background could be a bit clearer from a wording point of view - it is not immediately clear to me what 'explain plans to seek optimal configuration of CGA means'.

Authors’ response: Thank you. We have revised the sentence as follows:
Therefore, this protocol aims to appraise full economic evaluation studies on CGA and assess the cost-effectiveness of the intervention by focusing on various care settings, economic perspectives, and sub-group characteristics.

I think in the background you could include an explanation of what is the difference between model based or trial based economic evaluations.

Authors’ response: Thank you. We have included about model-based and trial based economic evaluations. With respect to design, economic evaluations can be classified into trial-based and model-based economic evaluations. Trial-based economic evaluation is conducted alongside a randomised controlled trial (RCT) by tracking relevant costs and effectiveness data of comparison groups throughout the trial. Model-based economic evaluations define a set of multiple factors within a single decision-analytic framework, generating expected costs and effects for comparison groups and facilitating decision-making under uncertainty

I think you could include in the methods section that you have it registered on PROSPERO and include what date you registered on PROPERO.

Authors’ response: Thank you. We have added the Prospero registration detail.
This review was registered in PROSPERO (registration number CRD42023492586) on December 11, 2023.

Population: For the frailty inclusion criteria does there need to be a standardised tool to measure frailty? I wonder about also including at risk of cognitive decline as one of the adverse outcomes.

Authors’ response: Thank you, we have included cognitive decline as an example of population at risk of adverse outcome.

Outcome: Is there one main primary outcome? Or is the primary outcome a composite of the "mean costs, mean effects, incremental costs, and incremental effectiveness".

Authors’ response: Thank you. We have used AND/OR to show it is either or combination of the lists.

Exclusion Criteria; could you explain a bit more what is meant by Geriatric expertise - is this that the explicit involvement of a Geriatric medicine physician? Or is it the members of the MDT must have specific geriatric medicine training? I know that some (not all) models of CGA do not include a geriatric medicine physician but the rest of a team might have extensive geriatric training which is why I suggest you make this a little clearer.

Authors’ response: Thank you. We have revised the criteria as “CGA delivered by personnel with no training or expertise in gerontology”.

In the search methods for identification of studies section there is some interspersing of tenses: some in the past tense and some in the future tense which makes it read a little disjointed. This is also the case in some other sections of the methods e.g. in the appraisal of quality.

Authors’ response: Thank you. We have revised the two sentences to:
“A search strategy will be devised with support from a librarian at Trinity College Dublin and the literature. This strategy will be applied across various databases including Embase, MEDLINE, and CINAHL (Supplementary Appendix 2). Our approach will include a manual search of reference sections in the identified studies and searches for cited references. Additionally, relevant databases specific to economic evaluations, such as the Tufts CEA Registry and NHS Economic Evaluation Database, will be explored. EndNote 21 will be used to import studies, and Covidence will be utilized to manage search results and remove duplicate records.”
“To enhance the interpretability of the reporting quality of papers, we will employ a traffic light color-coding system to visually represent the degree to which the key elements of the CHEERS checklist were addressed:”
Competing Interests: The authors declare that they have no competing interests related to this work. No financial, personal, or professional relationships influenced the design, conduct, or reporting of this study. Close
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COMMENTS ON THIS REPORT

Author Response 11 Nov 2025

Amanuel Yigezu, Trinity College Institute for Neuroscience, Trinity College Dublin, Dublin, Ireland

11 Nov 2025

Author Response
Dear Reviewer,
We sincerely appreciate your thoughtful and constructive feedback, which has significantly enhanced the quality of our manuscript. In response, we have carefully considered each comment and revised the ... Continue reading
Dear Reviewer,
We sincerely appreciate your thoughtful and constructive feedback, which has significantly enhanced the quality of our manuscript. In response, we have carefully considered each comment and revised the protocol to improve its clarity, methodological transparency, and adherence to reporting standards. Presented below is our detailed point-by-point response to your comments.

Abstract

I think the last sentence in the background of the abstract could mention that economic evaluations are being specifically looked at.

Authors’ response: We thank the reviewer for the comments. We have revised the section as: "This systematic review aims to identify, appraise, and synthesize economic evaluation studies on CGA across various care settings.”

In the first section of the methods and analysis in the abstract the average reader who is not familiar with economic evaluations might not understand the difference between full and partial.

Authors’ response: Thank you. We have revised the section as:
Full economic evaluation studies (comparing both the costs and the consequences of alternatives) on CGA will be searched for in the Embase, Medline, CINAHL, CEA registry, and NHSEED databases.

Main text

Suggest rewording the end of the second sentence for better clarity: "research is increasingly focused on identifying to improve that improve healthy ageing".

Authors’ response: Thank you. We have revised the sentence as:
With increasing life expectancy and changes in demography (1), the demand for healthcare is increasingly rapidly in line with the growth of the older population (2). The World Health Organization (WHO) defines "healthy ageing" as "the process of developing and maintaining the functional ability that enables well-being in older age" (3)”.To realize healthy aging, health and social care systems advocate a shift from acute management of cases to coordinated, longitudinal, and integrated care for older adults (4). As a result, researchers are increasingly focused on identifying interventions that improve healthy ageing.

I don't think "frailty" in the second paragraph needs to be in "".

Authors’ response: Thank you. We have revised the sentence as:
CGA is considered for older adults living with frailty or at risk of adverse outcomes.

The wording of the last sentence in paragraph three could be improved. I suggest to simplify it to make the point that costs can differ from study to study because of the different settings CGA is used in.

Authors’ response: Thank you. We have revised the sentence as follows:
The resource implications of CGA can vary between studies due to differences in the settings, the target population, or the intensity of the intervention, resulting in heterogeneity in treatment outcomes.

The last section of the last sentence in the background could be a bit clearer from a wording point of view - it is not immediately clear to me what 'explain plans to seek optimal configuration of CGA means'.

Authors’ response: Thank you. We have revised the sentence as follows:
Therefore, this protocol aims to appraise full economic evaluation studies on CGA and assess the cost-effectiveness of the intervention by focusing on various care settings, economic perspectives, and sub-group characteristics.

I think in the background you could include an explanation of what is the difference between model based or trial based economic evaluations.

Authors’ response: Thank you. We have included about model-based and trial based economic evaluations. With respect to design, economic evaluations can be classified into trial-based and model-based economic evaluations. Trial-based economic evaluation is conducted alongside a randomised controlled trial (RCT) by tracking relevant costs and effectiveness data of comparison groups throughout the trial. Model-based economic evaluations define a set of multiple factors within a single decision-analytic framework, generating expected costs and effects for comparison groups and facilitating decision-making under uncertainty

I think you could include in the methods section that you have it registered on PROSPERO and include what date you registered on PROPERO.

Authors’ response: Thank you. We have added the Prospero registration detail.
This review was registered in PROSPERO (registration number CRD42023492586) on December 11, 2023.

Population: For the frailty inclusion criteria does there need to be a standardised tool to measure frailty? I wonder about also including at risk of cognitive decline as one of the adverse outcomes.

Authors’ response: Thank you, we have included cognitive decline as an example of population at risk of adverse outcome.

Outcome: Is there one main primary outcome? Or is the primary outcome a composite of the "mean costs, mean effects, incremental costs, and incremental effectiveness".

Authors’ response: Thank you. We have used AND/OR to show it is either or combination of the lists.

Exclusion Criteria; could you explain a bit more what is meant by Geriatric expertise - is this that the explicit involvement of a Geriatric medicine physician? Or is it the members of the MDT must have specific geriatric medicine training? I know that some (not all) models of CGA do not include a geriatric medicine physician but the rest of a team might have extensive geriatric training which is why I suggest you make this a little clearer.

Authors’ response: Thank you. We have revised the criteria as “CGA delivered by personnel with no training or expertise in gerontology”.

In the search methods for identification of studies section there is some interspersing of tenses: some in the past tense and some in the future tense which makes it read a little disjointed. This is also the case in some other sections of the methods e.g. in the appraisal of quality.

Authors’ response: Thank you. We have revised the two sentences to:
“A search strategy will be devised with support from a librarian at Trinity College Dublin and the literature. This strategy will be applied across various databases including Embase, MEDLINE, and CINAHL (Supplementary Appendix 2). Our approach will include a manual search of reference sections in the identified studies and searches for cited references. Additionally, relevant databases specific to economic evaluations, such as the Tufts CEA Registry and NHS Economic Evaluation Database, will be explored. EndNote 21 will be used to import studies, and Covidence will be utilized to manage search results and remove duplicate records.”
“To enhance the interpretability of the reporting quality of papers, we will employ a traffic light color-coding system to visually represent the degree to which the key elements of the CHEERS checklist were addressed:”
Dear Reviewer,
We sincerely appreciate your thoughtful and constructive feedback, which has significantly enhanced the quality of our manuscript. In response, we have carefully considered each comment and revised the protocol to improve its clarity, methodological transparency, and adherence to reporting standards. Presented below is our detailed point-by-point response to your comments.

Abstract

I think the last sentence in the background of the abstract could mention that economic evaluations are being specifically looked at.

Authors’ response: We thank the reviewer for the comments. We have revised the section as: "This systematic review aims to identify, appraise, and synthesize economic evaluation studies on CGA across various care settings.”

In the first section of the methods and analysis in the abstract the average reader who is not familiar with economic evaluations might not understand the difference between full and partial.

Authors’ response: Thank you. We have revised the section as:
Full economic evaluation studies (comparing both the costs and the consequences of alternatives) on CGA will be searched for in the Embase, Medline, CINAHL, CEA registry, and NHSEED databases.

Main text

Suggest rewording the end of the second sentence for better clarity: "research is increasingly focused on identifying to improve that improve healthy ageing".

Authors’ response: Thank you. We have revised the sentence as:
With increasing life expectancy and changes in demography (1), the demand for healthcare is increasingly rapidly in line with the growth of the older population (2). The World Health Organization (WHO) defines "healthy ageing" as "the process of developing and maintaining the functional ability that enables well-being in older age" (3)”.To realize healthy aging, health and social care systems advocate a shift from acute management of cases to coordinated, longitudinal, and integrated care for older adults (4). As a result, researchers are increasingly focused on identifying interventions that improve healthy ageing.

I don't think "frailty" in the second paragraph needs to be in "".

Authors’ response: Thank you. We have revised the sentence as:
CGA is considered for older adults living with frailty or at risk of adverse outcomes.

The wording of the last sentence in paragraph three could be improved. I suggest to simplify it to make the point that costs can differ from study to study because of the different settings CGA is used in.

Authors’ response: Thank you. We have revised the sentence as follows:
The resource implications of CGA can vary between studies due to differences in the settings, the target population, or the intensity of the intervention, resulting in heterogeneity in treatment outcomes.

The last section of the last sentence in the background could be a bit clearer from a wording point of view - it is not immediately clear to me what 'explain plans to seek optimal configuration of CGA means'.

Authors’ response: Thank you. We have revised the sentence as follows:
Therefore, this protocol aims to appraise full economic evaluation studies on CGA and assess the cost-effectiveness of the intervention by focusing on various care settings, economic perspectives, and sub-group characteristics.

I think in the background you could include an explanation of what is the difference between model based or trial based economic evaluations.

Authors’ response: Thank you. We have included about model-based and trial based economic evaluations. With respect to design, economic evaluations can be classified into trial-based and model-based economic evaluations. Trial-based economic evaluation is conducted alongside a randomised controlled trial (RCT) by tracking relevant costs and effectiveness data of comparison groups throughout the trial. Model-based economic evaluations define a set of multiple factors within a single decision-analytic framework, generating expected costs and effects for comparison groups and facilitating decision-making under uncertainty

I think you could include in the methods section that you have it registered on PROSPERO and include what date you registered on PROPERO.

Authors’ response: Thank you. We have added the Prospero registration detail.
This review was registered in PROSPERO (registration number CRD42023492586) on December 11, 2023.

Population: For the frailty inclusion criteria does there need to be a standardised tool to measure frailty? I wonder about also including at risk of cognitive decline as one of the adverse outcomes.

Authors’ response: Thank you, we have included cognitive decline as an example of population at risk of adverse outcome.

Outcome: Is there one main primary outcome? Or is the primary outcome a composite of the "mean costs, mean effects, incremental costs, and incremental effectiveness".

Authors’ response: Thank you. We have used AND/OR to show it is either or combination of the lists.

Exclusion Criteria; could you explain a bit more what is meant by Geriatric expertise - is this that the explicit involvement of a Geriatric medicine physician? Or is it the members of the MDT must have specific geriatric medicine training? I know that some (not all) models of CGA do not include a geriatric medicine physician but the rest of a team might have extensive geriatric training which is why I suggest you make this a little clearer.

Authors’ response: Thank you. We have revised the criteria as “CGA delivered by personnel with no training or expertise in gerontology”.

In the search methods for identification of studies section there is some interspersing of tenses: some in the past tense and some in the future tense which makes it read a little disjointed. This is also the case in some other sections of the methods e.g. in the appraisal of quality.

Authors’ response: Thank you. We have revised the two sentences to:
“A search strategy will be devised with support from a librarian at Trinity College Dublin and the literature. This strategy will be applied across various databases including Embase, MEDLINE, and CINAHL (Supplementary Appendix 2). Our approach will include a manual search of reference sections in the identified studies and searches for cited references. Additionally, relevant databases specific to economic evaluations, such as the Tufts CEA Registry and NHS Economic Evaluation Database, will be explored. EndNote 21 will be used to import studies, and Covidence will be utilized to manage search results and remove duplicate records.”
“To enhance the interpretability of the reporting quality of papers, we will employ a traffic light color-coding system to visually represent the degree to which the key elements of the CHEERS checklist were addressed:”
Competing Interests: The authors declare that they have no competing interests related to this work. No financial, personal, or professional relationships influenced the design, conduct, or reporting of this study. Close
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Reviewer Report 14 Feb 2025

Jonas Ammundsen Ipsen, Lillebaelt Hospital, University Hospital of Southern Denmark,, Kolding, Denmark

Approved with Reservations

https://doi.org/10.21956/hrbopenres.15448.r45710

Dear Authors
Thank you for giving me the opportunity to review your protocol addressing the interesting subject of cost-effectiveness of comprehensive geriatric care assessment across varius health care setting. it is an relevant research question and I look forward to reading the review when completed.
The protocol is well-written, transparent, and easy to follow. I do, however, have some comments and suggestions for your consideration.

Is the rationale for, and objectives of, the study clearly described?
1. I believe the rationale and objectives are well argumented. I only have a minor comment regarding your aim. I believe this sentence are a bit broad: “and explain plans to seek optimal configurations of CGA” I would suggest you clearly state the aim of the review instead.
Is the study design appropriate for the research question?
1. Study design: the study design are appropriate, however I recommend defining how the synthesis of economic evaluations will be completed.
2. Inclusion criteria: I acknowledge that Briggs et al also used the six month criteria, but their focus was on community dwelling high risk patients. I understood from you aim that you focussed on a broader type of setting. Hence, you may need a bit wider inclusion criteria to reduce the risk of missing potentially relevant studies.
3. Population: I not sure what the argument are for potentially including 55 years old are. CGA are an intervention intended for the geriatric patients. so I would expect the mean age to reflect that.
4. Intervention: I believe the protocol would benefit from a more in-depth description of the intervention and in which settings it has found use.
5. Outcomes: I suggest defining one primary outcome for instance the incremental cost-effectiveness ratio and the remaining as secondary outcomes.
6. Setting: There are large differences in the health care setting around the world, providing some description or definition on the different healthcare settings may be helpful for readers: CGA provided at home, GP practice, emergency/acute care departments, outpatient departments, inpatient departments, and long-term care facilities.
7. This may be a discussion topic or something that’s needs to be addressed in the protocol. But how will you group and compare countries across health care systems. In Scandinavia and the commonwealth there are an publicly financed single payer system while the US operates with an insurance based system. This will affect costs.
8. Appraisal of Quality: The CHEERS guideline is designed to ensure reporting, however to my knowledge it is not intended for Risk of Bias assessment. Meaby you could look into the: Quality of Health Economic Studies (QHES) Instrument, Drummond checklists or another that is designed for quality assessment of economic evaluations. Philips et al. Model Assessment Criteria is designed for model based economic evaluation. Watts et al. published an article on the subject in 2019 that may be worth looking in to Use of Checklists in Reviews of Health Economic Evaluations, 2010 to 2018.
9. You may encounter publications of varying age will you be forward discounting costs?

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Cost-effectiveness, hip fracture, rehabilitiation

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Author Response 11 Nov 2025

Amanuel Yigezu, Trinity College Institute for Neuroscience, Trinity College Dublin, Dublin, Ireland

11 Nov 2025

Author Response

Dear reviewer,
We sincerely thank the reviewers for their thoughtful and constructive feedback, which has greatly strengthened our manuscript. We have carefully addressed all comments and revised the protocol to ... Continue reading Dear reviewer,
We sincerely thank the reviewers for their thoughtful and constructive feedback, which has greatly strengthened our manuscript. We have carefully addressed all comments and revised the protocol to improve clarity, methodological transparency, and alignment with reporting standards. Below is our detailed point-by-point response to the comments.
Title " Evaluating the Cost-Effectiveness of Comprehensive Geriatric Assessment: Protocol for a Systematic Review of Economic Evaluations.

1. I believe the rationale and objectives are well argumented. I only have a minor comment regarding your aim. I believe this sentence are a bit broad: “and explain plans to seek optimal configurations of CGA” I would suggest you clearly state the aim of the review instead. Authors’ response: Thank you. We have revised the sentence as follows:
Therefore, this protocol aims to appraise full economic evaluation studies on CGA and assess the cost-effectiveness of the intervention by focusing on various care settings, economic perspectives, and sub-group characteristics.

2. Study design: the study design are appropriate, however I recommend defining how the synthesis of economic evaluations will be completed.
Authors’ response :Thank you. We plan to change the price year of the costs to 2024 to compare cost-utility studies on cost-effectiveness plane. To allow comparability, all costs reported in the cost-effectiveness plane will be converted to and the price year of 2024 in Euro using the purchasing power parity and gross domestic product deflator index

3. Inclusion criteria: I acknowledge that Briggs et al also used the six month criteria, but their focus was on community dwelling high risk patients. I understood from you aim that you focussed on a broader type of setting. Hence, you may need a bit wider inclusion criteria to reduce the risk of missing potentially relevant studies.
Authors’ response: Thank you for your recommendations
We have now revised the exclusion criteria and included the studies with time horizon less than 6 months.

4. Population: I not sure what the argument are for potentially including 55 years old are. CGA are an intervention intended for the geriatric patients. so I would expect the mean age to reflect that.
Authors’ response: Thank you.
We acknowledge the comments of the reviewer. However, we have used similar inclusion criteria used by the Cochrane review by Briggs et al.

5. Intervention: I believe the protocol would benefit from a more in-depth description of the intervention and in which settings it has found use.
Authors’ response: We thank the author for the comment. We have tried to revise the description of CGA by stating, for which population it is indicated, its characteristics including multidimensional assessment, interdisciplinary team, and care planning with active engagement of the older adults.
“Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining an older person's medical, psychological, and functional capabilities to develop a coordinated and integrated care plan (5). CGA is often deployed considered for older adults living with frailty or at risk of adverse outcomes. when older people are identified as at risk of "frailty" (6). To improve the trajectory of aging, CGA considers various factors, including medical, psychological, and functional impairment, as well as environmental and social issues. CGA requires an interdisciplinary team that may include geriatric specialists, doctors, nurses, and allied health professionals, and aims to produce a coordinated and integrated care plan for treatment, rehabilitation, support, and long-term care with active engagement of the older adults in decision-making.”
We acknowledge the comments and believe that we have already addressed reviews on CGA that consider various settings and patient populations. However, we have not provided a detailed account of where CGA has been found useful, as it is beyond the scope of this review.

6. Outcomes: I suggest defining one primary outcome for instance the incremental cost-effectiveness ratio and the remaining as secondary outcomes.
Authors’ response: We thank the reviewer for the comment.
We have now improved it to reporting at least one of
    Average cost, average effectiveness,
                     AND/OR
            Incremental cost and incremental effect
                         AND/OR
            Incremental Cost Effectiveness Ratio.

7. Setting: There are large differences in the health care setting around the world, providing some description or definition on the different healthcare settings may be helpful for readers: CGA provided at home, GP practice, emergency/acute care departments, outpatient departments, inpatient departments, and long-term care facilities.
Authors’ response: We thank the reviewer for this helpful comment. Given the considerable variation in healthcare settings across countries, it may be challenging to provide a comprehensive global description. However, we plan to include detailed descriptions of how the intervention is delivered in each study, which will help clarify the specific settings in which CGA is implemented.

8. This may be a discussion topic or something that’s needs to be addressed in the protocol. But how will you group and compare countries across health care systems. In Scandinavia and the commonwealth there are an publicly financed single payer system while the US operates with an insurance based system. This will affect costs.
Authors’ response: We thank the reviewer for this important observation. We acknowledge that healthcare system differences can significantly influence costs. To improve the interpretation of our findings, we plan to include the country in which each study was conducted in the review.

9. Appraisal of Quality: The CHEERS guideline is designed to ensure reporting, however to my knowledge it is not intended for Risk of Bias assessment. Meaby you could look into the: Quality of Health Economic Studies (QHES) Instrument, Drummond checklists or another that is designed for quality assessment of economic evaluations. Philips et al. Model Assessment Criteria is designed for model based economic evaluation. Watts et al. published an article on the subject in 2019 that may be worth looking in to Use of Checklists in Reviews of Health Economic Evaluations, 2010 to 2018.
Authors’ response: We thank the reviewer for this valuable comment. We acknowledge that the CHEERS checklist is intended to assess the reporting quality of economic evaluations rather than risk of bias. At this stage, we do not plan to include a separate methodological quality assessment for the economic evaluations themselves and will use CHEERS solely to evaluate reporting quality. However, we have removed the ROB-1 assessment from our analysis. We will also acknowledge this limitation in the final review.

10. You may encounter publications of varying age will you be forward discounting costs? Authors’ response: We thank the reviewer for this comment. In our synthesis, we plan to adjust all reported costs to a common price year to facilitate comparison, particularly for visualizing cost-utility analyses on the cost-effectiveness plane. The remainder of the review will primarily involve a descriptive and narrative synthesis.
Dear reviewer,
We sincerely thank the reviewers for their thoughtful and constructive feedback, which has greatly strengthened our manuscript. We have carefully addressed all comments and revised the protocol to improve clarity, methodological transparency, and alignment with reporting standards. Below is our detailed point-by-point response to the comments.
Title " Evaluating the Cost-Effectiveness of Comprehensive Geriatric Assessment: Protocol for a Systematic Review of Economic Evaluations.

1. I believe the rationale and objectives are well argumented. I only have a minor comment regarding your aim. I believe this sentence are a bit broad: “and explain plans to seek optimal configurations of CGA” I would suggest you clearly state the aim of the review instead. Authors’ response: Thank you. We have revised the sentence as follows:
Therefore, this protocol aims to appraise full economic evaluation studies on CGA and assess the cost-effectiveness of the intervention by focusing on various care settings, economic perspectives, and sub-group characteristics.

2. Study design: the study design are appropriate, however I recommend defining how the synthesis of economic evaluations will be completed.
Authors’ response :Thank you. We plan to change the price year of the costs to 2024 to compare cost-utility studies on cost-effectiveness plane. To allow comparability, all costs reported in the cost-effectiveness plane will be converted to and the price year of 2024 in Euro using the purchasing power parity and gross domestic product deflator index

3. Inclusion criteria: I acknowledge that Briggs et al also used the six month criteria, but their focus was on community dwelling high risk patients. I understood from you aim that you focussed on a broader type of setting. Hence, you may need a bit wider inclusion criteria to reduce the risk of missing potentially relevant studies.
Authors’ response: Thank you for your recommendations
We have now revised the exclusion criteria and included the studies with time horizon less than 6 months.

4. Population: I not sure what the argument are for potentially including 55 years old are. CGA are an intervention intended for the geriatric patients. so I would expect the mean age to reflect that.
Authors’ response: Thank you.
We acknowledge the comments of the reviewer. However, we have used similar inclusion criteria used by the Cochrane review by Briggs et al.

5. Intervention: I believe the protocol would benefit from a more in-depth description of the intervention and in which settings it has found use.
Authors’ response: We thank the author for the comment. We have tried to revise the description of CGA by stating, for which population it is indicated, its characteristics including multidimensional assessment, interdisciplinary team, and care planning with active engagement of the older adults.
“Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining an older person's medical, psychological, and functional capabilities to develop a coordinated and integrated care plan (5). CGA is often deployed considered for older adults living with frailty or at risk of adverse outcomes. when older people are identified as at risk of "frailty" (6). To improve the trajectory of aging, CGA considers various factors, including medical, psychological, and functional impairment, as well as environmental and social issues. CGA requires an interdisciplinary team that may include geriatric specialists, doctors, nurses, and allied health professionals, and aims to produce a coordinated and integrated care plan for treatment, rehabilitation, support, and long-term care with active engagement of the older adults in decision-making.”
We acknowledge the comments and believe that we have already addressed reviews on CGA that consider various settings and patient populations. However, we have not provided a detailed account of where CGA has been found useful, as it is beyond the scope of this review.

6. Outcomes: I suggest defining one primary outcome for instance the incremental cost-effectiveness ratio and the remaining as secondary outcomes.
Authors’ response: We thank the reviewer for the comment.
We have now improved it to reporting at least one of
    Average cost, average effectiveness,
                     AND/OR
            Incremental cost and incremental effect
                         AND/OR
            Incremental Cost Effectiveness Ratio.

7. Setting: There are large differences in the health care setting around the world, providing some description or definition on the different healthcare settings may be helpful for readers: CGA provided at home, GP practice, emergency/acute care departments, outpatient departments, inpatient departments, and long-term care facilities.
Authors’ response: We thank the reviewer for this helpful comment. Given the considerable variation in healthcare settings across countries, it may be challenging to provide a comprehensive global description. However, we plan to include detailed descriptions of how the intervention is delivered in each study, which will help clarify the specific settings in which CGA is implemented.

8. This may be a discussion topic or something that’s needs to be addressed in the protocol. But how will you group and compare countries across health care systems. In Scandinavia and the commonwealth there are an publicly financed single payer system while the US operates with an insurance based system. This will affect costs.
Authors’ response: We thank the reviewer for this important observation. We acknowledge that healthcare system differences can significantly influence costs. To improve the interpretation of our findings, we plan to include the country in which each study was conducted in the review.

9. Appraisal of Quality: The CHEERS guideline is designed to ensure reporting, however to my knowledge it is not intended for Risk of Bias assessment. Meaby you could look into the: Quality of Health Economic Studies (QHES) Instrument, Drummond checklists or another that is designed for quality assessment of economic evaluations. Philips et al. Model Assessment Criteria is designed for model based economic evaluation. Watts et al. published an article on the subject in 2019 that may be worth looking in to Use of Checklists in Reviews of Health Economic Evaluations, 2010 to 2018.
Authors’ response: We thank the reviewer for this valuable comment. We acknowledge that the CHEERS checklist is intended to assess the reporting quality of economic evaluations rather than risk of bias. At this stage, we do not plan to include a separate methodological quality assessment for the economic evaluations themselves and will use CHEERS solely to evaluate reporting quality. However, we have removed the ROB-1 assessment from our analysis. We will also acknowledge this limitation in the final review.

10. You may encounter publications of varying age will you be forward discounting costs? Authors’ response: We thank the reviewer for this comment. In our synthesis, we plan to adjust all reported costs to a common price year to facilitate comparison, particularly for visualizing cost-utility analyses on the cost-effectiveness plane. The remainder of the review will primarily involve a descriptive and narrative synthesis.
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 11 Nov 2025

Amanuel Yigezu, Trinity College Institute for Neuroscience, Trinity College Dublin, Dublin, Ireland

11 Nov 2025

Author Response

Dear reviewer,
We sincerely thank the reviewers for their thoughtful and constructive feedback, which has greatly strengthened our manuscript. We have carefully addressed all comments and revised the protocol to ... Continue reading Dear reviewer,
We sincerely thank the reviewers for their thoughtful and constructive feedback, which has greatly strengthened our manuscript. We have carefully addressed all comments and revised the protocol to improve clarity, methodological transparency, and alignment with reporting standards. Below is our detailed point-by-point response to the comments.
Title " Evaluating the Cost-Effectiveness of Comprehensive Geriatric Assessment: Protocol for a Systematic Review of Economic Evaluations.

1. I believe the rationale and objectives are well argumented. I only have a minor comment regarding your aim. I believe this sentence are a bit broad: “and explain plans to seek optimal configurations of CGA” I would suggest you clearly state the aim of the review instead. Authors’ response: Thank you. We have revised the sentence as follows:
Therefore, this protocol aims to appraise full economic evaluation studies on CGA and assess the cost-effectiveness of the intervention by focusing on various care settings, economic perspectives, and sub-group characteristics.

2. Study design: the study design are appropriate, however I recommend defining how the synthesis of economic evaluations will be completed.
Authors’ response :Thank you. We plan to change the price year of the costs to 2024 to compare cost-utility studies on cost-effectiveness plane. To allow comparability, all costs reported in the cost-effectiveness plane will be converted to and the price year of 2024 in Euro using the purchasing power parity and gross domestic product deflator index

3. Inclusion criteria: I acknowledge that Briggs et al also used the six month criteria, but their focus was on community dwelling high risk patients. I understood from you aim that you focussed on a broader type of setting. Hence, you may need a bit wider inclusion criteria to reduce the risk of missing potentially relevant studies.
Authors’ response: Thank you for your recommendations
We have now revised the exclusion criteria and included the studies with time horizon less than 6 months.

4. Population: I not sure what the argument are for potentially including 55 years old are. CGA are an intervention intended for the geriatric patients. so I would expect the mean age to reflect that.
Authors’ response: Thank you.
We acknowledge the comments of the reviewer. However, we have used similar inclusion criteria used by the Cochrane review by Briggs et al.

5. Intervention: I believe the protocol would benefit from a more in-depth description of the intervention and in which settings it has found use.
Authors’ response: We thank the author for the comment. We have tried to revise the description of CGA by stating, for which population it is indicated, its characteristics including multidimensional assessment, interdisciplinary team, and care planning with active engagement of the older adults.
“Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining an older person's medical, psychological, and functional capabilities to develop a coordinated and integrated care plan (5). CGA is often deployed considered for older adults living with frailty or at risk of adverse outcomes. when older people are identified as at risk of "frailty" (6). To improve the trajectory of aging, CGA considers various factors, including medical, psychological, and functional impairment, as well as environmental and social issues. CGA requires an interdisciplinary team that may include geriatric specialists, doctors, nurses, and allied health professionals, and aims to produce a coordinated and integrated care plan for treatment, rehabilitation, support, and long-term care with active engagement of the older adults in decision-making.”
We acknowledge the comments and believe that we have already addressed reviews on CGA that consider various settings and patient populations. However, we have not provided a detailed account of where CGA has been found useful, as it is beyond the scope of this review.

6. Outcomes: I suggest defining one primary outcome for instance the incremental cost-effectiveness ratio and the remaining as secondary outcomes.
Authors’ response: We thank the reviewer for the comment.
We have now improved it to reporting at least one of
    Average cost, average effectiveness,
                     AND/OR
            Incremental cost and incremental effect
                         AND/OR
            Incremental Cost Effectiveness Ratio.

7. Setting: There are large differences in the health care setting around the world, providing some description or definition on the different healthcare settings may be helpful for readers: CGA provided at home, GP practice, emergency/acute care departments, outpatient departments, inpatient departments, and long-term care facilities.
Authors’ response: We thank the reviewer for this helpful comment. Given the considerable variation in healthcare settings across countries, it may be challenging to provide a comprehensive global description. However, we plan to include detailed descriptions of how the intervention is delivered in each study, which will help clarify the specific settings in which CGA is implemented.

8. This may be a discussion topic or something that’s needs to be addressed in the protocol. But how will you group and compare countries across health care systems. In Scandinavia and the commonwealth there are an publicly financed single payer system while the US operates with an insurance based system. This will affect costs.
Authors’ response: We thank the reviewer for this important observation. We acknowledge that healthcare system differences can significantly influence costs. To improve the interpretation of our findings, we plan to include the country in which each study was conducted in the review.

9. Appraisal of Quality: The CHEERS guideline is designed to ensure reporting, however to my knowledge it is not intended for Risk of Bias assessment. Meaby you could look into the: Quality of Health Economic Studies (QHES) Instrument, Drummond checklists or another that is designed for quality assessment of economic evaluations. Philips et al. Model Assessment Criteria is designed for model based economic evaluation. Watts et al. published an article on the subject in 2019 that may be worth looking in to Use of Checklists in Reviews of Health Economic Evaluations, 2010 to 2018.
Authors’ response: We thank the reviewer for this valuable comment. We acknowledge that the CHEERS checklist is intended to assess the reporting quality of economic evaluations rather than risk of bias. At this stage, we do not plan to include a separate methodological quality assessment for the economic evaluations themselves and will use CHEERS solely to evaluate reporting quality. However, we have removed the ROB-1 assessment from our analysis. We will also acknowledge this limitation in the final review.

10. You may encounter publications of varying age will you be forward discounting costs? Authors’ response: We thank the reviewer for this comment. In our synthesis, we plan to adjust all reported costs to a common price year to facilitate comparison, particularly for visualizing cost-utility analyses on the cost-effectiveness plane. The remainder of the review will primarily involve a descriptive and narrative synthesis.
Dear reviewer,
We sincerely thank the reviewers for their thoughtful and constructive feedback, which has greatly strengthened our manuscript. We have carefully addressed all comments and revised the protocol to improve clarity, methodological transparency, and alignment with reporting standards. Below is our detailed point-by-point response to the comments.
Title " Evaluating the Cost-Effectiveness of Comprehensive Geriatric Assessment: Protocol for a Systematic Review of Economic Evaluations.

1. I believe the rationale and objectives are well argumented. I only have a minor comment regarding your aim. I believe this sentence are a bit broad: “and explain plans to seek optimal configurations of CGA” I would suggest you clearly state the aim of the review instead. Authors’ response: Thank you. We have revised the sentence as follows:
Therefore, this protocol aims to appraise full economic evaluation studies on CGA and assess the cost-effectiveness of the intervention by focusing on various care settings, economic perspectives, and sub-group characteristics.

2. Study design: the study design are appropriate, however I recommend defining how the synthesis of economic evaluations will be completed.
Authors’ response :Thank you. We plan to change the price year of the costs to 2024 to compare cost-utility studies on cost-effectiveness plane. To allow comparability, all costs reported in the cost-effectiveness plane will be converted to and the price year of 2024 in Euro using the purchasing power parity and gross domestic product deflator index

3. Inclusion criteria: I acknowledge that Briggs et al also used the six month criteria, but their focus was on community dwelling high risk patients. I understood from you aim that you focussed on a broader type of setting. Hence, you may need a bit wider inclusion criteria to reduce the risk of missing potentially relevant studies.
Authors’ response: Thank you for your recommendations
We have now revised the exclusion criteria and included the studies with time horizon less than 6 months.

4. Population: I not sure what the argument are for potentially including 55 years old are. CGA are an intervention intended for the geriatric patients. so I would expect the mean age to reflect that.
Authors’ response: Thank you.
We acknowledge the comments of the reviewer. However, we have used similar inclusion criteria used by the Cochrane review by Briggs et al.

5. Intervention: I believe the protocol would benefit from a more in-depth description of the intervention and in which settings it has found use.
Authors’ response: We thank the author for the comment. We have tried to revise the description of CGA by stating, for which population it is indicated, its characteristics including multidimensional assessment, interdisciplinary team, and care planning with active engagement of the older adults.
“Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining an older person's medical, psychological, and functional capabilities to develop a coordinated and integrated care plan (5). CGA is often deployed considered for older adults living with frailty or at risk of adverse outcomes. when older people are identified as at risk of "frailty" (6). To improve the trajectory of aging, CGA considers various factors, including medical, psychological, and functional impairment, as well as environmental and social issues. CGA requires an interdisciplinary team that may include geriatric specialists, doctors, nurses, and allied health professionals, and aims to produce a coordinated and integrated care plan for treatment, rehabilitation, support, and long-term care with active engagement of the older adults in decision-making.”
We acknowledge the comments and believe that we have already addressed reviews on CGA that consider various settings and patient populations. However, we have not provided a detailed account of where CGA has been found useful, as it is beyond the scope of this review.

6. Outcomes: I suggest defining one primary outcome for instance the incremental cost-effectiveness ratio and the remaining as secondary outcomes.
Authors’ response: We thank the reviewer for the comment.
We have now improved it to reporting at least one of
    Average cost, average effectiveness,
                     AND/OR
            Incremental cost and incremental effect
                         AND/OR
            Incremental Cost Effectiveness Ratio.

7. Setting: There are large differences in the health care setting around the world, providing some description or definition on the different healthcare settings may be helpful for readers: CGA provided at home, GP practice, emergency/acute care departments, outpatient departments, inpatient departments, and long-term care facilities.
Authors’ response: We thank the reviewer for this helpful comment. Given the considerable variation in healthcare settings across countries, it may be challenging to provide a comprehensive global description. However, we plan to include detailed descriptions of how the intervention is delivered in each study, which will help clarify the specific settings in which CGA is implemented.

8. This may be a discussion topic or something that’s needs to be addressed in the protocol. But how will you group and compare countries across health care systems. In Scandinavia and the commonwealth there are an publicly financed single payer system while the US operates with an insurance based system. This will affect costs.
Authors’ response: We thank the reviewer for this important observation. We acknowledge that healthcare system differences can significantly influence costs. To improve the interpretation of our findings, we plan to include the country in which each study was conducted in the review.

9. Appraisal of Quality: The CHEERS guideline is designed to ensure reporting, however to my knowledge it is not intended for Risk of Bias assessment. Meaby you could look into the: Quality of Health Economic Studies (QHES) Instrument, Drummond checklists or another that is designed for quality assessment of economic evaluations. Philips et al. Model Assessment Criteria is designed for model based economic evaluation. Watts et al. published an article on the subject in 2019 that may be worth looking in to Use of Checklists in Reviews of Health Economic Evaluations, 2010 to 2018.
Authors’ response: We thank the reviewer for this valuable comment. We acknowledge that the CHEERS checklist is intended to assess the reporting quality of economic evaluations rather than risk of bias. At this stage, we do not plan to include a separate methodological quality assessment for the economic evaluations themselves and will use CHEERS solely to evaluate reporting quality. However, we have removed the ROB-1 assessment from our analysis. We will also acknowledge this limitation in the final review.

10. You may encounter publications of varying age will you be forward discounting costs? Authors’ response: We thank the reviewer for this comment. In our synthesis, we plan to adjust all reported costs to a common price year to facilitate comparison, particularly for visualizing cost-utility analyses on the cost-effectiveness plane. The remainder of the review will primarily involve a descriptive and narrative synthesis.
Competing Interests: No competing interests were disclosed. Close
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Version 2

VERSION 2 PUBLISHED 05 Feb 2025

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Version 2 (revision) 11 Nov 25	read
Version 1 05 Feb 25	read	read

Jonas Ammundsen Ipsen, Lillebaelt Hospital, University Hospital of Southern Denmark,, Kolding, Denmark
Robert Murphy, Galway University Hospital, Galway, Ireland

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Reviewer Report

2 Views

25 Nov 2025 | for Version 2

Jonas Ammundsen Ipsen, Lillebaelt Hospital, University Hospital of Southern Denmark,, Kolding, Denmark

2 Views Cite this report Responses(0)

Approved

I have read the comments and changes and the I believe the authors have clarified my remarks sufficiently.

Competing Interests

No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

16 Views

12 Mar 2025 | for Version 1

Robert Murphy, Galway University Hospital, Galway, Ireland

16 Views Cite this report Responses(1)

Approved With Reservations

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Geriatric Medidine

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Author Response

11 Nov 2025

Amanuel Yigezu, Trinity College Institute for Neuroscience, Trinity College Dublin, Dublin, Ireland

Dear Reviewer,
We sincerely appreciate your thoughtful and constructive feedback, which has significantly enhanced the quality of our manuscript. In response, we have carefully considered each comment and revised the protocol to improve its clarity, methodological transparency, and adherence to reporting standards. Presented below is our detailed point-by-point response to your comments.

Abstract

I think the last sentence in the background of the abstract could mention that economic evaluations are being specifically looked at.

Authors’ response: We thank the reviewer for the comments. We have revised the section as: "This systematic review aims to identify, appraise, and synthesize economic evaluation studies on CGA across various care settings.”

In the first section of the methods and analysis in the abstract the average reader who is not familiar with economic evaluations might not understand the difference between full and partial.

Authors’ response: Thank you. We have revised the section as:
Full economic evaluation studies (comparing both the costs and the consequences of alternatives) on CGA will be searched for in the Embase, Medline, CINAHL, CEA registry, and NHSEED databases.

Main text

Suggest rewording the end of the second sentence for better clarity: "research is increasingly focused on identifying to improve that improve healthy ageing".

Authors’ response: Thank you. We have revised the sentence as:
With increasing life expectancy and changes in demography (1), the demand for healthcare is increasingly rapidly in line with the growth of the older population (2). The World Health Organization (WHO) defines "healthy ageing" as "the process of developing and maintaining the functional ability that enables well-being in older age" (3)”.To realize healthy aging, health and social care systems advocate a shift from acute management of cases to coordinated, longitudinal, and integrated care for older adults (4). As a result, researchers are increasingly focused on identifying interventions that improve healthy ageing.

I don't think "frailty" in the second paragraph needs to be in "".

Authors’ response: Thank you. We have revised the sentence as:
CGA is considered for older adults living with frailty or at risk of adverse outcomes.

The wording of the last sentence in paragraph three could be improved. I suggest to simplify it to make the point that costs can differ from study to study because of the different settings CGA is used in.

Authors’ response: Thank you. We have revised the sentence as follows:
The resource implications of CGA can vary between studies due to differences in the settings, the target population, or the intensity of the intervention, resulting in heterogeneity in treatment outcomes.

The last section of the last sentence in the background could be a bit clearer from a wording point of view - it is not immediately clear to me what 'explain plans to seek optimal configuration of CGA means'.

Authors’ response: Thank you. We have revised the sentence as follows:
Therefore, this protocol aims to appraise full economic evaluation studies on CGA and assess the cost-effectiveness of the intervention by focusing on various care settings, economic perspectives, and sub-group characteristics.

I think in the background you could include an explanation of what is the difference between model based or trial based economic evaluations.

Authors’ response: Thank you. We have included about model-based and trial based economic evaluations. With respect to design, economic evaluations can be classified into trial-based and model-based economic evaluations. Trial-based economic evaluation is conducted alongside a randomised controlled trial (RCT) by tracking relevant costs and effectiveness data of comparison groups throughout the trial. Model-based economic evaluations define a set of multiple factors within a single decision-analytic framework, generating expected costs and effects for comparison groups and facilitating decision-making under uncertainty

I think you could include in the methods section that you have it registered on PROSPERO and include what date you registered on PROPERO.

Authors’ response: Thank you. We have added the Prospero registration detail.
This review was registered in PROSPERO (registration number CRD42023492586) on December 11, 2023.

Population: For the frailty inclusion criteria does there need to be a standardised tool to measure frailty? I wonder about also including at risk of cognitive decline as one of the adverse outcomes.

Authors’ response: Thank you, we have included cognitive decline as an example of population at risk of adverse outcome.

Outcome: Is there one main primary outcome? Or is the primary outcome a composite of the "mean costs, mean effects, incremental costs, and incremental effectiveness".

Authors’ response: Thank you. We have used AND/OR to show it is either or combination of the lists.

Exclusion Criteria; could you explain a bit more what is meant by Geriatric expertise - is this that the explicit involvement of a Geriatric medicine physician? Or is it the members of the MDT must have specific geriatric medicine training? I know that some (not all) models of CGA do not include a geriatric medicine physician but the rest of a team might have extensive geriatric training which is why I suggest you make this a little clearer.

Authors’ response: Thank you. We have revised the criteria as “CGA delivered by personnel with no training or expertise in gerontology”.

In the search methods for identification of studies section there is some interspersing of tenses: some in the past tense and some in the future tense which makes it read a little disjointed. This is also the case in some other sections of the methods e.g. in the appraisal of quality.

Authors’ response: Thank you. We have revised the two sentences to:
“A search strategy will be devised with support from a librarian at Trinity College Dublin and the literature. This strategy will be applied across various databases including Embase, MEDLINE, and CINAHL (Supplementary Appendix 2). Our approach will include a manual search of reference sections in the identified studies and searches for cited references. Additionally, relevant databases specific to economic evaluations, such as the Tufts CEA Registry and NHS Economic Evaluation Database, will be explored. EndNote 21 will be used to import studies, and Covidence will be utilized to manage search results and remove duplicate records.”
“To enhance the interpretability of the reporting quality of papers, we will employ a traffic light color-coding system to visually represent the degree to which the key elements of the CHEERS checklist were addressed:”

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Competing Interests

The authors declare that they have no competing interests related to this work. No financial, personal, or professional relationships influenced the design, conduct, or reporting of this study.

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Reviewer Report

15 Views

14 Feb 2025 | for Version 1

Jonas Ammundsen Ipsen, Lillebaelt Hospital, University Hospital of Southern Denmark,, Kolding, Denmark

15 Views Cite this report Responses(1)

Approved With Reservations

Is the rationale for, and objectives of, the study clearly described?
1. I believe the rationale and objectives are well argumented. I only have a minor comment regarding your aim. I believe this sentence are a bit broad: “and explain plans to seek optimal configurations of CGA” I would suggest you clearly state the aim of the review instead.
Is the study design appropriate for the research question?
1. Study design: the study design are appropriate, however I recommend defining how the synthesis of economic evaluations will be completed.
2. Inclusion criteria: I acknowledge that Briggs et al also used the six month criteria, but their focus was on community dwelling high risk patients. I understood from you aim that you focussed on a broader type of setting. Hence, you may need a bit wider inclusion criteria to reduce the risk of missing potentially relevant studies.
3. Population: I not sure what the argument are for potentially including 55 years old are. CGA are an intervention intended for the geriatric patients. so I would expect the mean age to reflect that.
4. Intervention: I believe the protocol would benefit from a more in-depth description of the intervention and in which settings it has found use.
5. Outcomes: I suggest defining one primary outcome for instance the incremental cost-effectiveness ratio and the remaining as secondary outcomes.
6. Setting: There are large differences in the health care setting around the world, providing some description or definition on the different healthcare settings may be helpful for readers: CGA provided at home, GP practice, emergency/acute care departments, outpatient departments, inpatient departments, and long-term care facilities.
7. This may be a discussion topic or something that’s needs to be addressed in the protocol. But how will you group and compare countries across health care systems. In Scandinavia and the commonwealth there are an publicly financed single payer system while the US operates with an insurance based system. This will affect costs.
8. Appraisal of Quality: The CHEERS guideline is designed to ensure reporting, however to my knowledge it is not intended for Risk of Bias assessment. Meaby you could look into the: Quality of Health Economic Studies (QHES) Instrument, Drummond checklists or another that is designed for quality assessment of economic evaluations. Philips et al. Model Assessment Criteria is designed for model based economic evaluation. Watts et al. published an article on the subject in 2019 that may be worth looking in to Use of Checklists in Reviews of Health Economic Evaluations, 2010 to 2018.
9. You may encounter publications of varying age will you be forward discounting costs?

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Cost-effectiveness, hip fracture, rehabilitiation

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Responses (1)

Author Response

11 Nov 2025

Amanuel Yigezu, Trinity College Institute for Neuroscience, Trinity College Dublin, Dublin, Ireland

Dear reviewer,
We sincerely thank the reviewers for their thoughtful and constructive feedback, which has greatly strengthened our manuscript. We have carefully addressed all comments and revised the protocol to improve clarity, methodological transparency, and alignment with reporting standards. Below is our detailed point-by-point response to the comments.
Title " Evaluating the Cost-Effectiveness of Comprehensive Geriatric Assessment: Protocol for a Systematic Review of Economic Evaluations.

1. I believe the rationale and objectives are well argumented. I only have a minor comment regarding your aim. I believe this sentence are a bit broad: “and explain plans to seek optimal configurations of CGA” I would suggest you clearly state the aim of the review instead. Authors’ response: Thank you. We have revised the sentence as follows:
Therefore, this protocol aims to appraise full economic evaluation studies on CGA and assess the cost-effectiveness of the intervention by focusing on various care settings, economic perspectives, and sub-group characteristics.

2. Study design: the study design are appropriate, however I recommend defining how the synthesis of economic evaluations will be completed.
Authors’ response :Thank you. We plan to change the price year of the costs to 2024 to compare cost-utility studies on cost-effectiveness plane. To allow comparability, all costs reported in the cost-effectiveness plane will be converted to and the price year of 2024 in Euro using the purchasing power parity and gross domestic product deflator index

3. Inclusion criteria: I acknowledge that Briggs et al also used the six month criteria, but their focus was on community dwelling high risk patients. I understood from you aim that you focussed on a broader type of setting. Hence, you may need a bit wider inclusion criteria to reduce the risk of missing potentially relevant studies.
Authors’ response: Thank you for your recommendations
We have now revised the exclusion criteria and included the studies with time horizon less than 6 months.

4. Population: I not sure what the argument are for potentially including 55 years old are. CGA are an intervention intended for the geriatric patients. so I would expect the mean age to reflect that.
Authors’ response: Thank you.
We acknowledge the comments of the reviewer. However, we have used similar inclusion criteria used by the Cochrane review by Briggs et al.

5. Intervention: I believe the protocol would benefit from a more in-depth description of the intervention and in which settings it has found use.
Authors’ response: We thank the author for the comment. We have tried to revise the description of CGA by stating, for which population it is indicated, its characteristics including multidimensional assessment, interdisciplinary team, and care planning with active engagement of the older adults.
“Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining an older person's medical, psychological, and functional capabilities to develop a coordinated and integrated care plan (5). CGA is often deployed considered for older adults living with frailty or at risk of adverse outcomes. when older people are identified as at risk of "frailty" (6). To improve the trajectory of aging, CGA considers various factors, including medical, psychological, and functional impairment, as well as environmental and social issues. CGA requires an interdisciplinary team that may include geriatric specialists, doctors, nurses, and allied health professionals, and aims to produce a coordinated and integrated care plan for treatment, rehabilitation, support, and long-term care with active engagement of the older adults in decision-making.”
We acknowledge the comments and believe that we have already addressed reviews on CGA that consider various settings and patient populations. However, we have not provided a detailed account of where CGA has been found useful, as it is beyond the scope of this review.

6. Outcomes: I suggest defining one primary outcome for instance the incremental cost-effectiveness ratio and the remaining as secondary outcomes.
Authors’ response: We thank the reviewer for the comment.
We have now improved it to reporting at least one of
    Average cost, average effectiveness,
                     AND/OR
            Incremental cost and incremental effect
                         AND/OR
            Incremental Cost Effectiveness Ratio.

7. Setting: There are large differences in the health care setting around the world, providing some description or definition on the different healthcare settings may be helpful for readers: CGA provided at home, GP practice, emergency/acute care departments, outpatient departments, inpatient departments, and long-term care facilities.
Authors’ response: We thank the reviewer for this helpful comment. Given the considerable variation in healthcare settings across countries, it may be challenging to provide a comprehensive global description. However, we plan to include detailed descriptions of how the intervention is delivered in each study, which will help clarify the specific settings in which CGA is implemented.

8. This may be a discussion topic or something that’s needs to be addressed in the protocol. But how will you group and compare countries across health care systems. In Scandinavia and the commonwealth there are an publicly financed single payer system while the US operates with an insurance based system. This will affect costs.
Authors’ response: We thank the reviewer for this important observation. We acknowledge that healthcare system differences can significantly influence costs. To improve the interpretation of our findings, we plan to include the country in which each study was conducted in the review.

9. Appraisal of Quality: The CHEERS guideline is designed to ensure reporting, however to my knowledge it is not intended for Risk of Bias assessment. Meaby you could look into the: Quality of Health Economic Studies (QHES) Instrument, Drummond checklists or another that is designed for quality assessment of economic evaluations. Philips et al. Model Assessment Criteria is designed for model based economic evaluation. Watts et al. published an article on the subject in 2019 that may be worth looking in to Use of Checklists in Reviews of Health Economic Evaluations, 2010 to 2018.
Authors’ response: We thank the reviewer for this valuable comment. We acknowledge that the CHEERS checklist is intended to assess the reporting quality of economic evaluations rather than risk of bias. At this stage, we do not plan to include a separate methodological quality assessment for the economic evaluations themselves and will use CHEERS solely to evaluate reporting quality. However, we have removed the ROB-1 assessment from our analysis. We will also acknowledge this limitation in the final review.

10. You may encounter publications of varying age will you be forward discounting costs? Authors’ response: We thank the reviewer for this comment. In our synthesis, we plan to adjust all reported costs to a common price year to facilitate comparison, particularly for visualizing cost-utility analyses on the cost-effectiveness plane. The remainder of the review will primarily involve a descriptive and narrative synthesis.

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Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Evaluating the Cost-Effectiveness of Comprehensive Geriatric Assessment: Protocol for a Systematic Review of Economic Evaluations

Abstract

Background

Methods and analysis

Ethics and dissemination

Keywords

Revised Amendments from Version 1

Background

Methods

Criteria for eligibility of studies

Table 1. Inclusion and exclusion criteria.

Search methods for identification of studies

Selection of studies

Figure 1. PRISMA flow diagram for the identification of studies.

Data extraction and management

Appraisal of quality

Figure 2. Traffic light system of the reporting quality of the studies.

Data analysis and synthesis

Table 2. General characteristics of the studies.

Figure 3. Description of characteristics of interventions.

Figure 4. Measurements of health service utilisation for comparison groups.

Table 3. Description of characteristics of the studies.

Figure 5. Cost-effectiveness plane for reporting cost-utility studies.

Table 4. Description of results of from the studies.

Patient and public involvement

Discussion

Ethics and dissemination plan

Abbreviations

Data availability

Underlying data

Extended data

Reporting guidelines

Acknowledgements

References

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Open Peer Review

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Reviewer Reports

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