Abstract
BACKGROUND: Community Health Workers (CHWs) play a vital role in improving health equity and patient outcomes in the United States (US). However, a systematic synthesis of their economic value remains limited. This review aimed to critically appraise the methodologies and consolidate the evidence on the return on investment (ROI) of CHW programmes in the US. METHODS: We conducted a systematic review of US-based economic evaluations that assessed the ROI of CHW programmes. We searched PubMed, EMBASE, Web of Science, EconLit, CEA Registry, and available grey literature from inception to April 2025. Two reviewers independently screened studies, extracted data, and assessed quality using the NICE CBA Compilers checklist. Programme costs and savings were annualized and inflated to 2024 US dollars. Narrative synthesis was performed to summarise the evidence. FINDINGS: Thirty-five studies (of 2155 records) representing 41 distinct CHW programmes across 23 states were included. The ROI analyses were commonly conducted in the Southern region, with 16 analyses (39%). Programmes most frequently targeted patients with diabetes and high admission risk (n = 8; 19.5%). Latino/Hispanic populations were the most frequently targeted (n = 8; 19.5%). The healthcare system perspective (n = 30; 73%) was predominantly adopted, with time horizons up to 20 years. Most ROI analyses (n = 37; 88%) used simple cost analysis, while 4 (9.7%) used Markov-modelling. The median inflation-adjusted annual programme cost was $155,275, yielding median annual savings of $403,298. The median ROI was $2.12 (interquartile range: 1.64-4.03) per dollar invested. Sensitivity and scenario analyses were conducted by 17 (48.5%) studies. INTERPRETATION: CHW programmes in the US demonstrate consistent, favourable financial returns. Future research should consider standardized methodologies integrating equity metrics. FUNDING: The study was funded by a cooperative agreement CDC-RFA-FT-23-0069 from the CDC's Centre for Forecasting and Outbreak Analytics. The funders had no role in the conduct of this study, data collection, management, analysis, and interpretation of the data. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.