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

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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. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://hrbopenresearch.org/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://hrbopenresearch.org/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://hrbopenresearch.org/articles/8-26/v1", "name": "Evaluating the Cost-Effectiveness of Comprehensive Geriatric Assessment:..." } } ] } Home Browse Evaluating the Cost-Effectiveness of Comprehensive Geriatric Assessment:... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article 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 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ 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 https://orcid.org/0000-0003-2792-2163 1,2 , Rose Galvin https://orcid.org/0000-0002-8171-224X 3 , Dominic Trépel https://orcid.org/0000-0002-1421-2966 1,2 Amanuel Yigezu https://orcid.org/0000-0003-2792-2163 1,2 , Rose Galvin https://orcid.org/0000-0002-8171-224X 3 , Dominic Trépel https://orcid.org/0000-0002-1421-2966 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 DETAILS 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. READ ALL READ LESS Keywords Comprehensive geriatric assessment, Economic evaluation, systematic review Corresponding Author(s) Amanuel Yigezu ( [email protected] ) Close 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: 11 Nov 2025, 8 :26 ( https://doi.org/10.12688/hrbopenres.14066.2 )  There is a newer version of this article available. Suppress this message for one day. Background 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 , “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 adults 4 . 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 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 facilities 17 . Similarly, the effectiveness of CGA in certain population groups, such as surgical patients 18 – 20 , cancer patients 21 , 22 , and in the prevention of delirium 23 , has been reviewed. Although CGA can be provided in multiple settings 24 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 outcomes 5 . 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 full 27 . 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 quality 10 . 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 protocol 30 . 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 guidelines 32 . 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 condition 10 . 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 literature 5 . 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 evaluations 29 . 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 evaluations 33 . 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 index 34 . 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 country 35 . 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.28239149 36 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.28239149 36 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. 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Yigezu A, Galvin R, Trépel D: PRISMA-P checklist and search strategies. figshare. 2025. http://www.doi.org/10.6084/m9.figshare.28239149.v2 Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 05 Feb 2025 ADD YOUR COMMENT Comment 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 (2) version 2 Revised Published: 11 Nov 2025, 8:26 https://doi.org/10.12688/hrbopenres.14066.2 version 1 Published: 05 Feb 2025, 8:26 https://doi.org/10.12688/hrbopenres.14066.1 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. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics VIEWS $counts.viewCount downloads Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article 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 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE 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 Version 1 VERSION 1 PUBLISHED 05 Feb 2025 Views 0 Cite How to cite this report: Murphy R. Reviewer Report For: 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/10.21956/hrbopenres.15448.r45708 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-26/v1#referee-response-45708 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 12 Mar 2025 Robert Murphy , Galway University Hospital, Galway, Ireland Approved with Reservations VIEWS 0 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 READ ALL 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. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Murphy R. Reviewer Report For: 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/10.21956/hrbopenres.15448.r45708 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-26/v1#referee-response-45708 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern 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 Report a concern Respond or Comment 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 Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Ipsen JA. Reviewer Report For: 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/10.21956/hrbopenres.15448.r45710 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-26/v1#referee-response-45710 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 14 Feb 2025 Jonas Ammundsen Ipsen , Lillebaelt Hospital, University Hospital of Southern Denmark,, Kolding, Denmark Approved with Reservations VIEWS 0 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 READ ALL 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? 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? Study design: the study design are appropriate, however I recommend defining how the synthesis of economic evaluations will be completed. 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. 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. Intervention: I believe the protocol would benefit from a more in-depth description of the intervention and in which settings it has found use. Outcomes: I suggest defining one primary outcome for instance the incremental cost-effectiveness ratio and the remaining as secondary outcomes. 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. 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. 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 . 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. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Ipsen JA. Reviewer Report For: 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/10.21956/hrbopenres.15448.r45710 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-26/v1#referee-response-45710 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern 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 Report a concern Respond or Comment 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 Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 05 Feb 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline 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 Reviewer Reports Invited Reviewers 1 2 3 Version 2 (revision) 11 Nov 25 read 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 Clarabelle T Pham , Flinders University, Bedford Park, Australia Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Pham C. This is an open access peer review report 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. 12 Mar 2026 | for Version 2 Clarabelle T Pham , Flinders University, Bedford Park, Australia 0 Views copyright © 2026 Pham C. This is an open access peer review report 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. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline 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 Thank you for the opportunity to review this protocol. The protocol is clear and well described. I have 3 comments regarding the methods. 1. Methods > Exclusion criteria : I am unclear why you need to state the exclusion of studies that do not define population groups as "at risk". My understanding is that an individual had to be at risk of frailty or other adverse outcomes to be eligible for CGA. Unless there are countries where they routinely undertake CGA in older adults. 2. Methods > Exclusion criteria : The exclusion of studies with less than 6 months of follow-up is still in this paragraph but the amendment statement describes that you have no longer excluded based on this criterion. 3. Methods > Appraisal of quality : Please provide justification for assessing the quality of reporting instead of the quality of methods. The CHEERS checklist is guidance for the reporting of EE but it is not a tool to assess the quality and methodological rigour of an EE, such as the CHEC checklist or Drummond's checklist. For example, CHEERS asks whether an item was reported but CHEC will ask whether the item reported is appropriate. Using just the CHEERS checklist will only allow you to make conclusions regarding how well studies have reported EE but you will not be able to make any assessments regarding the "appraisal of approaches to the identification, measurement, and valuation of costs and outcomes which will support proper interpretation" that you state in your discussion. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Partly 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 I am a health economist with expertise in systematic reviews and economic evaluation methods. 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. reply Respond to this report Responses (0) Pham CT. Peer Review Report For: 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/10.21956/hrbopenres.15710.r53783) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-26/v2#referee-response-53783 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Ipsen J. This is an open access peer review report 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. 25 Nov 2025 | for Version 2 Jonas Ammundsen Ipsen , Lillebaelt Hospital, University Hospital of Southern Denmark,, Kolding, Denmark 0 Views copyright © 2025 Ipsen J. This is an open access peer review report 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. format_quote Cite this report speaker_notes Responses (0) Approved info_outline 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 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. reply Respond to this report Responses (0) Ipsen JA. Peer Review Report For: 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/10.21956/hrbopenres.15710.r51374) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-26/v2#referee-response-51374 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Murphy R. This is an open access peer review report 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. 12 Mar 2025 | for Version 1 Robert Murphy , Galway University Hospital, Galway, Ireland 0 Views copyright © 2025 Murphy R. This is an open access peer review report 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. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline 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 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. reply Respond to this report Responses (1) 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:” View more View less 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. reply Respond Report a concern Murphy R. Peer Review Report For: 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/10.21956/hrbopenres.15448.r45708) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-26/v1#referee-response-45708 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Ipsen J. This is an open access peer review report 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. 14 Feb 2025 | for Version 1 Jonas Ammundsen Ipsen , Lillebaelt Hospital, University Hospital of Southern Denmark,, Kolding, Denmark 0 Views copyright © 2025 Ipsen J. This is an open access peer review report 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. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline 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 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? 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? Study design: the study design are appropriate, however I recommend defining how the synthesis of economic evaluations will be completed. 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. 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. Intervention: I believe the protocol would benefit from a more in-depth description of the intervention and in which settings it has found use. Outcomes: I suggest defining one primary outcome for instance the incremental cost-effectiveness ratio and the remaining as secondary outcomes. 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. 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. 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 . 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. reply Respond to this report 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. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Ipsen JA. Peer Review Report For: 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/10.21956/hrbopenres.15448.r45710) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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