Challenges and Stimulating Factors for the Incorporation of Economic Considerations in Clinical Practice Guidelines: A Scoping Review

ABSTRACT

Rationale, Aims and Objectives

The incorporation of economic considerations in clinical practice guidelines (CPGs) could help promote cost‐conscious decision‐making in healthcare. Though healthcare expenditures increase, and resources are becoming scarcer, the extent to which economic considerations are incorporated into CPGs remains limited. This scoping review aims to identify the challenges and potential stimulating factors to incorporate economic considerations in CPGs.

Method

This scoping review was conducted following the Joanna Briggs Institute Methodology and findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA‐ScR) guidelines. A systematic search was conducted in eight databases considering literature published from July 2017 and onwards. Data extraction was conducted via an iterative and inductive approach to identify challenges and potential stimulating factors from the included reports. Included documents focused on the (para)medical field and reported on CPG development and economic considerations.

Results

The search identified 2445 documents from which 33 documents were included for analysis. The analysis identified five challenges: discourse surrounding economic considerations in CPGs, methodological ambiguities, scarcity of (high‐quality) economic evidence, transferability of evidence, and resource constraints. Additionally, three potential stimulating factors were identified: acceptance, economic evidence knowledge, and guidance on incorporating economic considerations.

Conclusion

These findings reflect the complexity of incorporating economic considerations in CPGs. The identified challenges highlight the need for clearer guidance (i.e. by training) and standardised methodologies for incorporating economic considerations in CPGs. The potential stimulating factors provide a roadmap for future efforts to enhance the integration of economic evidence in CPGs. Collaborative initiatives between health economists, CPG developers, and other stakeholders are essential to drive progress in this area and promote cost‐conscious decision‐making in healthcare.

1. Introduction

The provision of healthcare is under pressure due to a scarcity of resources (financial, human, and material) [1]. Worldwide, healthcare expenditures have more than doubled in the last two decades, reaching US$8.5 trillion in 2019. In 29 high‐income countries, healthcare costs grew more rapidly than the gross domestic product (GDP) [2]. Therefore, it is imperative to make well‐informed and cost‐conscious healthcare decisions to ensure affordable healthcare, for example regarding expensive innovations and long‐term conditions [3, 4]. One potential avenue to support cost‐conscious decision‐making in healthcare is to enhance the (limited) incorporation of economic) economic evidence in clinical practice guidelines (CPG) [5, 6, 7]. Economic evidence in CPGs is often referred to by various terms, such as costs and resource use. This scoping review categorises these under ‘economic considerations’, encompassing all related economic analysis methods (e.g. budget impact analysis and economic evaluations).

CPGs contain recommendations to support decision‐making by healthcare professionals [8, 9] and patients. These recommendations are based on scientific evidence and the experiences/expertise of healthcare professionals and patients [10]. They are formed by a multidisciplinary CPG panel, consisting of guideline methodologists, patient representatives and healthcare professionals [11]. Addressing economic considerations in CPGs could improve the CPG's practical feasibility and implementation success [12]. Additionally, economic considerations in CPGs can enhance healthcare professionals' awareness of limited resources. Subsequently, this can encourage more thoughtful consideration of healthcare resource usage when making healthcare decisions [13, 14].

The formulation of CPG recommendations is guided by the strength of clinical evidence, incorporating several contextual factors such as equity and patient values and preferences [15, 16, 17]. Resource use is a contextual factor within the most common CPG development methodology, the GRADE Evidence to Decision framework [18]. In the Appraisal of Guidelines for REsearch and Evaluation II (AGREE‐II) tool, a CPG quality appraisal tool, cost implication is one of the quality criteria for the applicability domain [17]. The incorporation of economic considerations in CPGs is still limited despite its importance and the explicit requirement for incorporation [19].

The limited incorporation of economic considerations in CPGs indicates barriers at play [5]. A review assessing the incorporation of economic considerations in CPG development handbooks and documents from different CPG development organisations showed that CPG development handbooks and documents often lacked explicit guidance on how to incorporate economic considerations in CPGs [6]. Possible challenges to incorporating economic considerations in CPGs were lack of guidance, transferability of economic evidence, lack of expertise and added resources needed [6]. However, a comprehensive understanding of all the challenges hindering the uptake of economic consideration in CPG development is lacking. Moreover, an understanding of stimulating factors is unknown. To bridge this gap, this scoping review aimed to create a comprehensive overview of current challenges and potential stimulating factors for incorporating economic considerations when developing CPGs.

2. Method

2.1. Protocol & Registration

The scoping review approach allows a broad investigation to help identify key characteristics or factors related to a concept, in this case determining the challenges and potential stimulating factors to incorporating economic considerations in CPGs [20]. A scoping review iteratively narrows the focus in response to the found evidence [20]. This scoping review has been guided by the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis [21], an advancement on Arskey and O'Malley's original work [22]. This approach consists of nine steps: (1) defining the research question, (2) developing the inclusion criteria, (3) creating a research protocol, (4–7) searching, selecting, extracting and analysing the evidence, and (8–9) presenting and summarising the results. A scoping review has an iterative nature, allowing researchers to adjust the search strategy, inclusion criteria, and analysis in response to emerging evidence. As a result, the carried‐out method slightly deviates from the protocol, prospectively registered with Open Science Framework in July 2022 [23]. Changes are explicitly addressed in method section 2.5. The findings are reported according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA‐ScR) [24].

2.2. Eligibility Criteria and Search Strategy

The inclusion of relevant documents was determined with the help of the Population‐Concept‐Context (PCC) framework in Table 1.

Table 1.

Description of the Population‐Concept‐Context (PCC) criteria applied for evidence selection.

PCC framework item	Inclusion criteria
Population	Documents devoted to CPG development
Concept	Documents that reported on challenges or stimulating factors for the incorporation of economic considerations in CPGs
Context	English or Dutch documents focused on CPG development for the (para)medical field, without any geographical limitation, that have been published since 2017

2.2.1. Population

Documents reporting on the development of CPGs for the (para)medical field were included. Document on the endorsement of CPGs, CPG development handbooks, studies in progress, (conference) abstracts, CPGs, and CPG appraisals were excluded.

2.2.2. Concept

Economic evidence considered in CPGs tends to be referred to by different terms, such as (monetary) costs, resource use, and evidence from economic evaluations or health technology assessments (HTA). Whilst these terms have different meanings [25, 26], they are used interchangeably in the literature making it an elusive subject. This scoping review considered every term related to (health) economic evidence as used or suggested by the authors of the included studies. Additionally, this scoping review included all economic analysis methods as suggested by the authors, such as cost‐effectiveness analysis and budget impact analysis. See Appendix 2 for an overview of (health) economic evidence terms and economic analysis methods referred to under the term ‘economic considerations.’

2.2.3. Context

This scoping review considered documents related to the CPG development phase. Documents related to the implementation phase were excluded. The review considered documents worldwide, limited to English and Dutch. Additionally, to capture the current challenges and potential stimulating factors, this review only considered literature published from July 2017 and onwards.

2.2.4. Search

An initial search in PubMed and OVID, NHS EED and EMBASE was conducted to determine index terms and keywords to develop search strings. In collaboration with a literature specialist, full search strings were designed for MEDLINE (PubMed & OVID), Cochrane Library, National Health Service Economic Evaluation Database (NHS EED), Google Scholar, Web of Science, International HTA Database (INAHTA), Embase (Elsevier) (Appendix 1). The initial search was conducted in July 2022 and repeated in November 2023.

2.3. Screening and Selection of Data

Evidence selection was conducted via an iterative process by CdM and JY [21]. First, identified records were collated into the Clarivate reference manager EndNote and de‐duplicated by the Bramer Method [27]. Next, records were imported into Rayyan [28] for the title and abstract screening. A pilot on 5% of randomly selected records was conducted by researchers CdM and JY. Pilot results were discussed amongst researchers CdM and JY, resulting in refined eligibility criteria to reflect the aim of the study. When consensus could not be reached a third researcher (AP or DD) was consulted. Once 90% agreement was achieved, all remaining records were screened for inclusion. The same method was used to complete the full‐text screening.

2.4. Data Items and Extraction

The data extraction format was developed through an iterative and inductive approach in Microsoft Excel. The extracted data included bibliographic information (e.g. year, journal) and study characteristics (e.g. research approach). All segments relating to economic considerations were extracted from the included documents by the main researcher (CdM), and 10% by the second researcher (JY).

2.5. Synthesis of Evidence

The primary researchers (CdM and JY) thematically analysed 10% of the extracted data segments and categorised them inductively into challenges and potential stimulating factors [29]. The third researcher (AP) was consulted when consensus could not be reached. The main researcher categorised the remaining extracted segments and consulted the second researcher (JY) and third researcher (AP) when there were uncertainties regarding the categorisation or inclusion of segments. The final data extraction format can be found in Appendix 3.

2.6. Deviation From Protocol

Due to the explorative and iterative nature of the scoping review, some deviations from the study's protocol were made [23]. The initial aim of the review was to explore the barriers and facilitators to incorporating economic evaluations during CPG development. However, the results did not yield any proven facilitators for increasing the incorporation of economic considerations. Consequently, the focus shifted to examining potential stimulating factors, which are suggestions to improve the incorporation but have not been proven effective (yet). Endorsements of CPGs, originally intended for inclusion, were excluded due to their limited content related to the CPG development process. Additionally, CPG development handbooks were excluded, as we felt the most valuable new information would be derived from different types of resources next to the CPG development handbook review from Sanabria et al. (2019) [6].

3. Results

This scoping review consulted eight databases to map challenges and potential stimulating factors for incorporating economic considerations into CPGs. Figure 1 shows the identification of 3617 records, of which 86 documents were fully screened. The scoping review process was iterative, with the research team refining the selection criteria as the review progressed and ultimately data were extracted from 33 documents. The study characteristics are described in Table 2. The included records were published between 2017 and 2023 originating from five continents. Most articles were conducted in geographically unspecified areas (38%), then Europe (23%) and North America (21%). Documents from geographically unspecified areas often included methodological‐oriented studies and their first authors were often from high‐income countries. Various research designs are represented in the included articles, with most articles using a qualitative research design (91%). Appendix 2 shows an overview of all the terms authors used to refer to economic evidence and methods, referred to as economic considerations in this scoping review. Authors refer most often to costs, cost of and cost‐effectiveness.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta‐analyses extension for Scoping Reviews (PRISMA‐ScR) flowchart of included reports [24].

Table 2.

Characteristics of the included reports.

Author, reference	Origin	Study designa		Challenges to the incorporation of economic considerations					Potential stimulating factors to the incorporation of economic considerations
		Qualitative	Quantitative	Discourse surrounding economic considerations	Methodological ambiguities	Scarcity of economic evidence	Transferability of evidence	Resource constraints	Acceptance and intent	Knowing what evidence to consider	Guidance
Alderson and Maconachie, [30]	Europe	Unspecified journal article								x
Alper, et al., [31]	n.a.	Communication			x		x				x
Antioch, et al., [32]	Oceania	Review		x	x	x	x		x		x
Barkham, Moller and Pybis, [33]	Europe	Original article			x					x
Bettmann and Hunink, [34]	n.a.	Book chapter					x
Braun, et al., [35]	North America	Roundtable discussion			x		x		x
Briggs, et al., [36]	Europe	Commentary		x	x						x
Capone, et al., [37]	North America	Research review				x
Chou, Easterbrook and Hellard, [38]	n.a.	Method				x
Garbi, [39]	Europe	Review		x
Hurtado, et al., [40]	Europe	Original research				x
Kahale, et al., [41]	North Africa	Research				x	x
Knies, Severens and Brouwer, [42]	n.a.	Brief report							x		x
Li, et al., [43]	Europe, North America, South America	Original research							x		x
Maaløe, et al., [44]	n.a. (Low‐ or Middle‐Income countries)	Viewpoint									x
Marcucci, et al., [45]	n.a.	Correspondence				x	x
Marx, et al., [46]	n.a.	Meeting report									x
Mercuri, Baigrie and Upshur, [47]	n.a.	Original article			x
Murano, et al., [48]	n.a.	Research				x	x	x
Norlin, et al., [49]	Europe	Original article			x	x	x
Ostrominski, et al., [50]	n.a.		Clinical research		x	x	x		x	x	x
Powell, et al., [51]	North America	Special contributions				x
Qaseem, et al., [52]	North America	Update of methods			x				x
Richter Sundberg, Garvare and Nystrom, [53]	Europe	Research article						x	x		x
Riva, et al., [54]	n.a.		Review		x	x		x	x		x
Riva, et al., [55]	n.a.	(Systematic) review			x		x	x		x	x
Scott, Mogga and Harstall., [56]	n.a.	Conference presentation									x
Shaker, et al., [57]	n.a.	Special series journal article						x
Tuck, Little and Aspray, [58]	n.a.	Journal article				x		x	x
Wiercioch, et al., [59]	North America		Original article					x
Wilson, [60]	n.a.	Commentary		x	x	x	x	x		x
Xie, et al., [61]	n.a.	Original article				x	x			x	x
Yao, Brignardello‐Peterson and Guyatt, [62]	n.a.	Editorial									x
Total (33)		91% (30/33)	9% (3/33)	12% (4/33)	36% (12/33)	42% (14//33)	36% (12/33)	24% (8/33)	27% (9/33)	18% (6/33)	42% (14/33)

^aStudy design as reported by the authors themselves.

Five challenges and three potential stimulating factors for the incorporation of economic considerations in CPGs were identified (Table 2). The five challenges include (1) discourse surrounding economic evidence incorporation in CPGs, (2) methodological ambiguities, (3) scarcity of (high‐quality) economic evidence, (4) challenges regarding the transferability of evidence, and (5) resource constraints. The three potential stimulating factors entail (1) acceptance and intent to incorporate economic considerations in CPGs, (2) knowing what evidence to consider and what evidence is missing, and (3) guidance.

3.1. Challenges for the Incorporation of Economic Considerations in CPGs

3.1.1. Challenge 1: Discourse Surrounding Incorporation of Economic Considerations in CPGs

A lack of consensus on whether to incorporate economic considerations into CPGs represents the first challenge. This partly stems from a debate on whether CPGs should describe the best patient care or best value‐based care [60]. Resistance from healthcare professionals to incorporate economic considerations in CPGs was noted [32]. Furthermore, Garbi et al., noted that healthcare professional societies seem less concerned with resource availability or costs, and are often not directly responsible for CPG implementation [39]. Lastly, some plead that CPG's recommendations must be in line with the global healthcare professional societies' CPG recommendations, even in cases where economic evidence might give rise to a different recommendation [36].

3.1.2. Challenge 2: Methodological Ambiguities

When guideline panels decide to include economic considerations in their CPGs, they are faced with a new challenge: methodological ambiguities. There is a lack of clarity about how economic evidence should be incorporated into the CPG (development), as well as some limitations to economic evaluation methods. In general, the literature mentioned a lack of explicit guidance and clear or agreed‐upon methodologies for various aspects of incorporating economic considerations in CPGs [47, 54]. More specifically, some studies noted that there is no clear guidance on how to integrate different concepts such as costs, benefits, and harms into the recommendations [47, 54]. Integrating these concepts is difficult because they use different outcome measures [47]. The interpretation of cost‐effectiveness modelling is stated to be complex and attention might be paid to how economic evidence data might be presented to a CPG panel [31]. For example, Briggs et al., presented their cost‐effectiveness results in a ranked manner to the CPG panel. They suspected that the ranking order might have influenced the panel's initial recommendations [36]. However, the panel must balance the cost‐effectiveness concept with the other concepts that could affect the decision‐making, e.g. patient values [36, 47]. When guideline panels incorporate economic evidence, implicitly and/or explicitly, this information is often limited and poorly described [54].

Furthermore, the literature highlighted some limitations of economic evaluation methods indicated by the authors. First, incremental cost‐effectiveness ratio (ICER) analyses, can only be performed when the long‐term outcomes are positive [35]. Secondly, it is thought cost‐effectiveness acceptability curves may give misleading views on the strength of evidence as they use ordinal measuring [36]. Thirdly, cost‐effectiveness analyses often use non‐standardised methods [60] and a clear systematic review methodology for economic evaluations is believed to be lacking [54]. Lastly, it is stated that various assumptions must be made to conduct economic evaluations, large sample sizes are required, and the results may be paired with uncertainty [33, 36, 49, 50, 52]. These assumed limitations might partly be attributed to the finding that available economic evidence frequently fell short of the desired quality standards [36, 47, 50, 52, 60]. The quality of economic evidence studies can be determined with the help of study reporting checklists. However, it is noteworthy that cost‐effectiveness study reporting checklists are not infallible. Sometimes, a well‐reported but poorly conducted cost‐effectiveness study can receive a high score on a checklist [55]. Lastly, there exists controversy concerning the usage of quality‐adjusted life year measures, cost‐effectiveness thresholds, and methods used to determine weights for decision criteria [32, 60].

3.1.3. Challenge 3: Scarcity of Economic Evidence

Economic evidence must be available or developed to realise the incorporation of economic considerations during CPG development. The literature described a lack of available local data and (high‐quality) economic evidence [37, 38, 40, 41, 48, 50, 54, 61]. Additionally, it was described that economic evidence becomes outdated quickly and could already be so before a CPG is published [58, 60].

3.1.4. Challenge 4: Transferability of Evidence

Given the limited availability of (high‐quality) economic evidence, Kahale et al. sought economic information from panel members or investigated economic evidence from similar contexts [41]. However, if the economic evidence does not completely align with the context of the CPG, e.g. if it pertains to a different population or geographical region, a new challenge arises. This challenge is not solely recognised in economic literature, where it is referred to as the ‘transferability of evidence,’ but also in clinical studies. Within the CPG development community, in which there is also a focus on clinical studies, the challenge is known as the “indirectness of evidence” [55, 60].

Several factors that could constrain the transferability of economic evidence were mentioned [48]. For instance, disparities in the characteristics of populations in the economic study and target population of the CPG [31, 49, 61]. Additionally, the use of different perspectives in the CPG and the economic analyses [32, 34, 61], as well as the omission of elements in the economic analyses that were relevant to the CPG [45, 49]. Disparities in drug prices between countries were also mentioned to add to the transferability challenge [35, 50].

Whilst some researchers suggested that economic models could never be transferred from their original setting, it seems common to extrapolate effectiveness data from other contexts [55]. According to Riva et al., assessing the indirectness of certain transferability characteristics was easier than others, such as perspective, discount rate, cost approach, and comparable life expectancies. While, similar practice norms, health status (utilities), absolute and relative prices, technology availability, and acceptability are characteristics that were more challenging to transfer [50, 55].

3.1.5. Challenge 5: Resource Constraints

The last challenge noted the increase in resource requirements to incorporate economic considerations in CPGs. The main additional resources mentioned were time [48, 53, 54, 55, 58, 59, 60], financial resources [54, 55, 60], and the need for specialised expertise to enable incorporating economic considerations in CPG development [55, 57].

3.2. Potential Stimulating Factors to Incorporating Economic Considerations in CPGs

3.2.1. Potential Stimulating Factor 1: Acceptance and Intent

The first stimulating factor described in the literature is a wider acceptance and intent towards the incorporation of economic considerations in CPGs. Richter Sundberg et al., highlighted that in the last few decades, more emphasis had been put on CPG recommendations being informed by cost‐effectiveness studies [53]. Some organisations have been incorporating economic considerations in their CPGs, for example, the National Institute for Care and Excellence (NICE) in England and the National Board of Health and Welfare in Sweden [32, 35, 42, 50, 52, 53, 58]. Three studies indicated that economic considerations are a topic of interest to CPG panel members [32, 43, 54] and other stakeholders (e.g., healthcare providers, manufacturers, patients/families, and insurers) [32]. Knies et al. (2018) mentioned that national decision‐making bodies ideally set boundaries and principles for economic considerations in CPGs, after which clinicians and health economists together specify the guidance [42]. The governments of Sweden and Australia required the incorporation of health economics evidence to inform decision‐making [32, 53].

3.2.2. Potential Stimulating Factor 2: Enhancing Knowledge of What Evidence to Consider for Economic Considerations in CPGs

When CPG developers embrace the idea of incorporating economic considerations in CPGs, they can consider various types of economic evidence. The literature proposed to describe in each CPG what economic evidence might have been able to enhance the CPG recommendations. Consequently, showing where economic evidence could be expanded, CPG developers and health economists can prioritise the generation of high‐quality economic evidence [50, 60].

Additionally, some researchers have proposed broadening the range of economic evidence beyond randomised control trial (RCT) study results and considering evidence from different geographical areas [33, 55, 61]. Furthermore, to mitigate time and expertise constraints in conducting new economic evaluations for a CPG, it has been suggested to utilise previously published (high‐quality) economic evaluations relevant to the CPG [30].

3.2.3. Potential Stimulating Factor 3: Guidance on How to Incorporate Economic Considerations in CPGs

The scoping review revealed that CPG developers are in need of guidance on how to incorporate economic considerations during CPG development. Although no ‘perfect’ method for including economic considerations in CPGs was described [56], several potential avenues were suggested in the literature. Firstly, CPG developers could look towards the approaches taken by organisations that already incorporate economic considerations within their CPGs [32, 35, 42, 50, 52, 53].

Furthermore, some literature suggested (international and broad stakeholders) that consensus upon a well‐defined grading of evidence framework might help to incorporate economic considerations in CPGs [32, 46, 50]. For example, Riva et al., suggested a framework that includes an explicit step for prioritisation of research questions most benefiting from economic evidence [55]. The most mentioned framework in the literature was the GRADE evidence‐to‐decision (EtD) framework [31, 43, 54, 61, 62]. The GRADE methodology, which the EtD is part of, focuses on assessing and grading evidence for CPG recommendations and helps determine the strength of the recommendations [31]. The GRADE EtD framework explicitly requires consideration of resource use (cost) when determining the strength and direction of a recommendation [31, 61]. This framework employs predefined “Likert‐type” questions for judgement, integrates research evidence and allows for the inclusion of additional cost‐related information through free text fields [54]. Recently, the GRADE working group published an article on how economic evidence could be considered to inform CPG recommendations using the GRADE EtD framework [61].

The GRADE EtD framework is widely recognised and applied. However, Riva et al., proposed three simplified criteria to help apply the conventional GRADE criteria to economic evidence: (1) the transferability of economic evidence to the decision context, (2) identifying limitations of economic evaluations, and (3) assessing the consistency of findings across multiple cost‐effectiveness models [54]. Hence, addressing their concern that the “Likert‐type” judgements might become a “check box exercise” when the EtD framework was completed without supporting research evidence or additional considerations [54].

Next to the GRADE EtD framework, other frameworks and methods were mentioned in the literature, such as the WHO‐INTEGRATE framework [44], the Swedish NBHW guideline development model [53] and the Australian National Health and Medical Research Council (NHMRC) methodologies [32].

Another suggested approach to guide the incorporation of economic considerations was including a health economist on the CPG panel or collaborating with one [32, 42, 50, 55, 56]. The literature proposed that it would be beneficial that economic evidence was presented in a simplified and understandable manner to panel members, who often have no economic background. For example, using a graphical representation of the economic evidence, such as forest plots [36], and keeping economic models simple and transparent [56]. An additional suggestion to support the incorporation of economic consideration in CPGs was to develop an economic evidence indirectness tool to help determine the suitability of economic evidence for the CPG [54, 55]. Until the development of such a tool, it was recommended to use the GRADE indirectness criteria to determine the level of indirectness/transferability of the economic evidence [55].

4. Discussion

4.1. Overall Review Results

The incorporation of economic considerations in CPGs is still limited, even though CPGs could support cost‐conscious decision‐making in healthcare [5, 6]. This study is one of the first to provide a comprehensive overview of the challenges and potential stimulating factors to the incorporation of economic evidence in CPGs within the (para)medical field. The five identified challenges were: discourse, methodological ambiguity, scarcity of data, transferability of data, and resource constraints. The three potential stimulating factors were: acceptance, economic evidence knowledge, and guidance on incorporating economic considerations. The identified challenges and potential stimulating factors reflect the complexity of incorporating economic considerations in CPGs and may explain the limited extent to which this is undertaken [5, 6].

This extensive literature search identified a broad range of literature related to CPG development, but a narrower subset addressed the incorporation of economic considerations. This observation reflects the evolving nature of this topic in the field of CPG development. The included 33 documents were predominantly qualitative and originated from high‐income countries or were from non‐specified areas, of which the first author was often from a high‐income country.

4.2. Main Results and Implications

Previous literature documented the challenges of methodological ambiguity, transferability of economic evidence, and requirement for added resources [6]. However, the broad scope of this review allowed the identification of an additional challenge: the discourse between prioritising best patient healthcare or value‐based healthcare. There are various definitions of value‐based healthcare, but they have in common that they place the patient centrally and define value ‘as health outcomes for patients in relation to costs of the whole process of care’. CPG‐developing healthcare profession societies might feel it is their responsibility to describe the best patient care and not to address economic considerations within their CPGs. Additionally, healthcare professionals may not be trained to consider resource impact in healthcare [63]. However, recognition of the need to effectively allocate resources in healthcare is seen as necessary due to growing resource strains [2, 64]. Various organisations address the importance of economic considerations in CPGs in their vision and guidance tools [17, 39, 61]. It has been shown that workplace culture and regional practice patterns can influence the attitudes of healthcare professionals regarding value‐based healthcare [65, 66]. Thus, training CPG developers and guideline panel members regarding the importance of value‐based healthcare might positively affect their attitudes on the incorporation of economic considerations in CPGs [12, 52].

Another novel challenge mentioned in more than half of the included studies was the scarcity of suitable economic evidence for CPG development. Reasons for this limited use of economic evidence included outdated data, relevance to different contexts (e.g. low‐ or high‐income countries), and issues with data quality. Interestingly, this finding is contradicted by other researchers who argue there is ample economic evidence available, citing cost‐effectiveness studies from clinical trials [6, 67]. An explanation for these contradictory views may be that there is no clear definition of what should be considered under these economic considerations. This is reflected in the interchangeable terminology used when discussing economic concepts and the lack of a clear methodological approach to the incorporation of economic considerations in CPGs [6]. Additionally, most CPG developers lack training in health economics or related fields. Consequently, they might be unaware of what economic data could be considered during CPG development or where to locate such data. This lack of awareness is also reflected in the authors’ perceived limitations of economic evaluations which are not always recognised as such in health economics. For instance, it was noted that a large sample size is necessary, though, like randomised‐control trials (RCTs), smaller sample sizes can be used, albeit with greater uncertainty. They also noted a lack of systematic review methods for economic evaluations, yet van Mastrigt et al., [68] and the ISPOR taskforce (2021) [69] have provided such guidance to conduct such reviews [70, 71]. These inaccurate assumptions reflect the importance of informing and educating CPG developers in basic health economics. Additionally, Wilkinson et al., suggested training health economists in the implementation and relevance of economic considerations for CPGs could be beneficial [64].

While the above‐mentioned challenges pose hurdles, this scoping review identified three novel potential stimulating factors to guide the incorporation of economic considerations in CPGs. These factors were acceptance and intent, economic evidence knowledge, and guidance on incorporating economic considerations. Building on these factors, an initial step could be to define a shared concept of economic considerations in CPGs [64]. This may include consensus on the appropriate economic evaluation(s) and perspective(s) to utilise for CPGs. To develop such communal concepts, it would be beneficial to have acceptance and support on the micro (healthcare professionals and patients), meso (CPG development organisations and healthcare professional societies) and macro level (governments) [42]. There are several implementation strategies one could consider to stimulate acceptance and support [72]. One implementation strategy is education: educating stakeholders on the importance of economic considerations in healthcare decision‐making might positively stimulate efforts to prioritise economic considerations in CPGs [64, 72].

Once these communal concepts are established a methodological approach to incorporate economic considerations in CPGs could be developed. This would guide CPG developers on what economic evidence they could consider for their CPG and how. The new approach might be an extension or adaptation of a current approach, for example, the GRADE EtD framework. Both developments should preferably be realised through interdisciplinary collaboration between CPG developers and health economists. This collaboration would help align their different methodological approaches and enhance practical feasibility.

When a new methodological approach is co‐created, CPG developers would benefit from guidance on how to incorporate this approach into their CPG development. To support CPG developers the GRADE working group published a guidance paper on the incorporation of economic considerations in CPGs [61]. Other forms of guidance could entail training on basic economic concepts [64] and incorporation of economic considerations in CPGs or collaboration with a health economist or a CPG developer who specialises in this topic.

4.3. Strengths and Limitations

This scoping review focused on publications from 2017 onwards, creating a comprehensive up‐to‐date portrayal of challenges and potential stimulating factors. Including previous reviews in this scoping review, potential earlier relevant literature was aimed to be included as well as all experiences and opinions concerning economic consideration incorporation into CPGs. When considering the results, it is important to realise different contexts may present distinct challenges and potential stimulating factors. Most literature originated from high‐income countries within North America and Europe, thereby creating a possible bias. Valuable insight might be found by understanding how middle‐ and low‐income countries approach CPG development and economic considerations. These countries face more and different resource constraints and might heed resource use and implications more when creating clinical guidance.

There is much ambiguity surrounding the terminology for economic considerations. Differing terms were used in the literature to address economic considerations. These terms do not have the same meaning and are often used interchangeably. This scoping review covered the various terms under economic considerations, thereby recognising that this may introduce some level of generalisation of the results. However, singling out a specific term would have resulted in an incomplete picture of the current practice in CPG development. Despite the limitation, the broad scope of this scoping review allowed a comprehensive overview of the currently known challenges and potential stimulating factors to incorporate economic evidence in CPGs. Giving direction to future efforts to stimulate this endeavour.

5. Conclusion

The incorporation of economic evidence in CPG is complex and faces challenges on various levels, ranging from methodological ambiguities to acceptance. Consequently, the incorporation of economic considerations in CPGs is limited. Agreement on communal concepts and baseline terminology of economic considerations could be helpful. Future research could then focus on the development of practical methodologies and guidance tools for the incorporation of economic considerations in CPGs. Interdisciplinary collaboration between health economists and CPG developers could be beneficial to developing such approaches and tools. Furthermore, CPG (development) training programs addressing the importance of value‐based healthcare could enhance the awareness and acceptance of economic considerations in CPGs, which is needed at the micro, meso and macro level. Additionally, specific training on economic basic concepts and how economic evidence could be considered during CPG development might help CPG developers realise the incorporation of economic considerations in CPGs.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supporting information.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.