A qualitative systematic review and quality assessment of pharmacoeconomic evaluations on Chinese Herbal Medicine from 2020 to 2025

Objective: This systematic review evaluated the status quo and quality of pharmacoeconomic (PE) evaluations of Chinese Herbal Medicine (CHM) published between 2020 and 2025, aiming to identify common quality flaws, compare the performance of different quality assessment tools, and formulate targeted recommendations for improving study quality. Methods: A comprehensive literature search was conducted across six databases to retrieve studies published in six years. Included studies were assessed using three validated tools: Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022), the British Medical Journal guidelines, and the Quality of Health Economics Studies (QHES) scales. Data regarding study characteristics were systematically extracted and assessed. Descriptive statistics were employed to analyze the study characteristics, while Intraclass Correlation Coefficients (ICC) and Bland-Altman analysis were applied to assess the differences in scores among the three tools. Results: A total of 198 studies were included. Of these, 58 studies (29.29%) failed to report the study perspectives, 148 studies (74.75%) adopted short-term time horizons (< 6 months), 2 studies with time horizons exceeding 1 year did not report discounting rates. 160 studies (80.81%) measured direct medical cost only. Outcome measures predominantly relied on conventional clinical efficacy rates (119 studies, 60.10%) rather than Traditional Chinese Medicine (TCM) syndrome indicators (25 studies, 12.63%). Incremental analyses was conducted in 155 studies (78.28%), and sensitivity analyses was performed in 161 studies (81.31%). Mean quality scores were 54.14% ± 9.16% for CHEERS 2022, 71.08% ± 9.41% for BMJ guidelines, and 68.83 ± 14.69 points for QHES scale. The overall ICC among the three tools was 0.580. Limits of agreement were as follows: CHEERS vs. BMJ were (-32.61%, -1.27%), CHEERS vs. QHES were (-39.12%, 9.75%), and BMJ vs. QHES were (-18.37%, 22.87%). Conclusion: While the quality of CHM PE evaluations has improved, substantial gaps remain in reporting transparency and methodological rigor, particularly regarding study protocols and CHM-specific outcome measures. The discrepancy in scores across assessment tools suggests that reporting quality does not always align with methodological soundness. Future research should strictly adhere to international guidelines (e.g., CHEERS), pre-register protocols, and adopt a multi-tool strategy for quality assessment to enhance the evidence base for decision-making. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD420251117386.