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Table 2 Illustrative example: mixed-method cost-effectiveness evaluation of problematic sexual behavior-cognitive behavioral therapy

From: Mixed-method approaches to strengthen economic evaluations in implementation research



CHEERS guideline

How met in illustrative example studyb

Title and abstract



Identify the study as an economic evaluation.

Title: Economic value of community-based services for problematic sexual behaviors in youth: A mixed-method cost-effectiveness analysis.



Provide a structured summary of the study.

We note that design, interpretation of quantitative analyses were informed by qualitative themes; both themes, quantitative threshold indicated that results represented cost-effective values.


 Background and objectives


Provide an explicit statement of the broader context for the study. Present the study question and its relevance for health policy or practice.

Ability of treatments to reduce social, economic impacts of problematic sexual behavior is poorly understood. We used mixed-method cost-effectiveness analysis to compare costs of implementing PSB-CBT with clinical outcomes.


 Target population and subgroups


Describe characteristics of the base case population and subgroups analyzed.

413 youth who received PSB-CBT at 1 of 6 provider agencies that implemented a PSB-CBT program between 2011 and 2015. We compared agencies that did vs. did not provide intensive individual services, did vs. did not incur indirect costs of implementation.

 Setting and location


State relevant aspects of the system(s) in which the decision(s) need(s) to be made.

Agencies received grants from U.S. OJJDP to implement PSB-CBT, achieved adequate fidelity.

 Study perspective


Describe the perspective of the study.

Perspective of agencies implementing PSB-CBT.



Describe the interventions or strategies being compared and state why they were chosen.

PSB-CBT: cognitive-behavioral treatment model, with concurrent groups for youth and caregivers.

 Time horizon


State and justify the time horizon(s) over which costs and consequences are evaluated.

Costs were measured for 6-month period. Outcomes were measured from 2011 to 2015.

 Discount rate


Report and justify the choice of discount rate(s) used for costs and outcomes.

N/A—all costs were measured within a period of less than one year (i.e., 6 months).

 Choice of health outcomes


Describe what outcomes were used as the measure(s) of benefit in the evaluation and their relevance for the study.

Caregiver-report measures of problematic sexual behaviors, nonsexual emotional and behavior problems (also self-reported), and traumatic stress symptoms.

 Measurement of effectiveness


Describe fully the design features of the effectiveness study.

Estimated pre-post changes in health outcome measures, expressed using effect size Cohen’s d.

 Estimating resources and costs


Describe approaches and data sources used to estimate and value resource use associated with the alternative interventions.

Collected quantitative cost surveys from participating agencies, covering costs related to running a PSB-CBT program. Cost survey was designed based on themes from qualitative interviews.

 Currency, price date, and conversion


Describe methods for adjusting estimated unit costs to a common currency and price date.

Converted all monetary values to 2017 U.S. dollars (national average).

 Analytic methods


Describe all analytical methods supporting the evaluation, including methods for handling population heterogeneity and uncertainty.

Calculated CERs as the per-youth cost of PSB-CBT divided by observed effect size for each health outcome. Compared CERs to a cost-effectiveness threshold of $8333. Used expertise plus qualitative themes to identify plausible range of values for key sources of uncertainty, variability; for sensitivity analyses, calculated CERs across those ranges of values.


 Study parameters


Report the values, ranges, references, and, if used, probability distributions for all parameters. Report reasons or sources for distributions used to represent uncertainty where appropriate.

Median cost of $3527. Large to moderate (ds = 0.72–1.99) improvements on health outcome measures. We conducted four sensitivity analyses (described under 20a and 21).

 Incremental costs and outcomes


For each intervention, report mean values for estimated costs and outcomes, as well as mean differences between the groups. If applicable, report incremental cost-effectiveness ratios.

CERs ranged from $1772 to $4899, indicating cost-effectiveness. Qualitative themes also indicated that PSB-CBT has valuable impact on families, society that is worth the cost.

 Characterizing uncertainty


Describe the effects of sampling uncertainty and methodological assumptions for the estimated incremental cost and effectiveness parameters.

Calculated CERs across plausible range for improvements on health outcome measures (95% CIs) and training costs (including vs. excluding initial training). All cost-effective except minimum improvement for traumatic stress.

 Characterizing heterogeneity


If applicable, report differences in costs, outcomes, or cost effectiveness explained by variations between subgroups.

Calculated CERs for agencies that did vs. did not provide intensive individual services, indirect costs. All cost-effective except for agency with regular supplemental individual services.




Summarize key study findings. Discuss limitations and generalizability of the findings; how the findings fit with current knowledge.

We note that the results of our qualitative interviews informed and supported the validity of our quantitative analyses.

  1. CER cost-effectiveness ratio, CHEERS Consolidated Health Economic Evaluation Reporting Standards [30], PSB-CBT Problematic Sexual Behavior–Cognitive-Behavioral Therapy, OJJDP Office of Juvenile Justice and Delinquency Prevention. All monetary values are reported in 2017 U.S. dollars
  2. aWe omitted items 11b (synthesis-based measurement of effectiveness), 12 (preference-based outcomes), 13b (model-based evaluation), 15 and 16 (decision-analytic model and its assumptions), and 20b (characterizing uncertainty for model-based evaluation) because they were not applicable to the illustrative example study, and items 23 (source of funding) and 24 (conflicts of interest) because they are not methodological
  3. bThe illustrative example study (Dopp A, Mundey P, Silovsky J, Hunter M, Slemaker A.: Economic value of community-based services for problematic sexual behaviors in youth: a mixed-method cost-effectiveness analysis, under review)