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.14066.1

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Study Protocol

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

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

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

PUBLISHED 05 Feb 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 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 1; peer review: 2 approved with reservations]. HRB Open Res 2025, 8:26 (https://doi.org/10.12688/hrbopenres.14066.1) First published: 05 Feb 2025, 8:26 (https://doi.org/10.12688/hrbopenres.14066.1) Latest published: 05 Feb 2025, 8:26 (https://doi.org/10.12688/hrbopenres.14066.1)

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, “and research is increasingly focused on identifying to improve that improve healthy ageing. To realize healthy aging, health and social care systems advocate a shift from acute management of cases to efficient configurations of coordinated, longitudinal, and integrated care for older adults⁴.

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 often deployed 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.

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. Although CGA can be provided in multiple settings²⁴ and in multiple populations, this will vary the types and amounts of healthcare resources that are utilized (resulting in variable costs of CGA), and varying levels of intensity may explain the observed 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 or deaths averted and improvement in frailty.

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. The aim of this protocol is to describe a plan to conduct a systematic review of the economic evaluation of CGA, critically appraise studies reporting quality, describe what data will be extracted, subgroup by various care settings and other characteristics, and explain plans to seek optimal configurations of CGA.

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.

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.

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. Then, a meticulous search strategy was devised with support from a librarian at Trinity College Dublin and the literature⁵. This strategy was applied across various databases including Embase, MEDLINE, and CINAHL (Supplementary Appendix 2)³¹. Our approach included 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 summarizes 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 employed 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. Amber: 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.

NA: Not applicable.

In addition, we will assess the risk of bias using ROB-1 for studies that conducted trial-based economic evaluations. Two authors will independently assess the methodological quality, and third and fourth authors will be involved if there is any disagreement between the two reviewers.

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 1.

Table 1. General characteristics of the studies.

Characteristics	Description of characteristics	Number	Reference
Year of publication
Country of study
Target population
Study design
Type of economic evaluation
Perspective of the study
Time horizon
Base year cost
Discount rate
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). Table 2 shows a description of the characteristics of the interventions being compared.

Table 2. Description of characteristics of interventions.

Personnel conducting CGA

Author, Year

Screened for frailty

Training of experts

Comprehensive assessment

MDT meeting

Goal Setting

Assessment Tools

Protocol

Home or ward environment

Follow-up

Patient involvement In treatment plan

Consultant Geriatrician

General Practitioner

Geriatrics specialist Trainee

Trained Nursing

Social work

Physiotherapy

Occupational Therapy

Dietetics

Pharmacy

Speech and Language

Audiology

Care manager

Old age psychiatrist

Psychologist

Physician

Trained care co-ordinator

Study 1

Study 2

Study 3

Study 4

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 Table 3.

Table 3. Measurements of health service utilisation for comparison groups.

Author, year, country

Intervention

Inpatient care

Outpatient care

Accident and emergency care

Ambulance or transports

Medication

General practice

Home visit

Paramedical care

Permanent residence

Temporary residence

Nursing home

Mobility aids

Meal delivery

Informal care

Patient's out of pocket (OOP)

Study 1

Study 2

Study 3

Study 4

Study 5

A description of the presentation of study characteristics is shown in Table 4.

Table 4. 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
1
2
3
4
5
6
7

The study findings will be presented for each type of measured outcome, including the currency, base year for costs, mean cost and effectiveness of both intervention and control groups, incremental cost, and incremental effectiveness. A description of the results will be presented in Table 5 and Table 6, respectively.

Table 5. Mean costs and effectiveness classified by control and intervention group.

			Intervention				Control
Study ID	Setting	Perspective	Mean cost	SD of cost	Mean effectiveness	SD of effectiveness	Mean cost	SD of cost	Mean effectiveness	SD of effectiveness
1
2
3
4
5
6

Table 6. Description of results of from the studies.

Author, year	Care Setting	Perspective_ cost	Incremental cost (95% CI)	Effectiveness measure	Incremental effect (95% CI)
Study
Study 2
Study 3
Study 4
Study 5
Study 6

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. Figure 3 illustrates the cost-effectiveness plane that will be used to report the incremental costs and QALYs by care setting.

Figure 3. Cost-effectiveness plane for reporting cost-utility studies.

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. Table 5 and Table 6 present the overall results to be reported in the review.

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. Our objective is to support policy decision-making by synthesizing and critically appraising existing studies on CGA to inform policy decision-making. Reporting summary findings with attention to intervention characteristics, study characteristics, and results will facilitate a robust interpretation of the findings. For example, the number of health professionals involved and the healthcare setting may influence the cost-effectiveness of interventions, as these factors can impact both cost and effectiveness. Similarly, approaches to the identification, measurement, and valuation of costs and outcomes, as well as the discounting and time horizon of the study, will impact the analysis output. However, some variations could be due to differences in countries' health technology assessment guidelines. For example, the thresholds and discount rates differ from country to country³⁵. Therefore, a complete report that considers the factors affecting cost-effectiveness estimates will support proper interpretation of the results.

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 1

VERSION 1 PUBLISHED 05 Feb 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

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.

Article Versions (1)

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Published: 05 Feb 2025, 8:26

https://doi.org/10.12688/hrbopenres.14066.1

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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 1; peer review: 2 approved with reservations]. HRB Open Res 2025, 8:26 (https://doi.org/10.12688/hrbopenres.14066.1)

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Reviewer Report 12 Mar 2025

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 ... Continue reading

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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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 ... Continue reading

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

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.

CITE

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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

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12 Mar 2025 | for Version 1

Robert Murphy, Galway University Hospital, Galway, Ireland

11 Views Cite this report Responses(0)

Approved With Reservations

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.

Respond to this report

Responses (0)

Back to all reports

Reviewer Report

11 Views

14 Feb 2025 | for Version 1

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

11 Views Cite this report Responses(0)

Approved With Reservations

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

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.

Respond to this report

Responses (0)

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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

Background

Methods

Criteria for eligibility of studies

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 1. General characteristics of the studies.

Table 2. Description of characteristics of interventions.

Table 3. Measurements of health service utilisation for comparison groups.

Table 4. Description of characteristics of the studies.

Table 5. Mean costs and effectiveness classified by control and intervention group.

Table 6. Description of results of from the studies.

Figure 3. Cost-effectiveness plane for reporting cost-utility 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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