Guidelines that use the GRADE approach often fail to provide complete economic information for recommendations: A systematic survey

J Clin Epidemiol. 2021 Aug;136:203-215. doi: 10.1016/j.jclinepi.2021.04.018. Epub 2021 May 11.


Objective: Little is known about how developers and panel members report cost and cost effectiveness considerations in GRADE guideline Evidence-to-Decision (EtD) frameworks. A systematic survey was conducted to explore approaches and factors contributing to variability in economic information reporting.

Study design and setting: Guideline organization websites were systematically searched to create a convenience sample of guidelines. Reviewers screened published EtD frameworks and generated frequencies of reporting approaches. We used thematic analysis to summarize factors related to variability of economic information reporting.

Results: We included 142 guidelines. The overall rate of reporting economic information was high (91%); however, there was variability across completion of predefined EtD Likert-type judgments (70%), noting information as not identified across EtD framework domains (57%), and providing remarks to justify recommendations (38%). Six themes contributing to variability emerged, related to: intervention, population, payor, provider, healthcare resource use, and economic model building factors. Only 2 guidelines performed a GRADE certainty appraisal of economic outcomes.

Conclusion: Completing predefined EtD Likert-type judgments, specifically reporting a literature review approach, study selection criteria and economic model building limitations, as well as linking these to recommendation justification remarks are potential areas for improved use, adoption and adaptation of recommendation, and transparency of GRADE EtD frameworks.

Keywords: Cost-benefit analysis; Economics; Epidemiological research design; Evidence-based medicine; Health care costs; Practice guidelines.

Publication types

  • Research Support, Non-U.S. Gov't
  • Systematic Review

MeSH terms

  • Biomedical Research / economics*
  • Biomedical Research / standards*
  • Biomedical Research / statistics & numerical data
  • Cost-Benefit Analysis / statistics & numerical data
  • Epidemiologic Research Design*
  • Evidence-Based Medicine / economics*
  • Evidence-Based Medicine / statistics & numerical data*
  • GRADE Approach / standards
  • GRADE Approach / statistics & numerical data
  • Guidelines as Topic*
  • Humans
  • Research Design / standards*
  • Research Design / statistics & numerical data