Example (2). Decision-makers at the policy level for premarital
genetic disease screening may/ may not have sufficient guidelines to
detail all target conditions. If available evidence is not organized in
recommendations for specific conditions, but rather for the most common
ones, such as hemoglobinopathies, solutions will have to be developed.
Options are conducting selective screening for certain population
subgroups such as certain ethnicities, patients with family or
suggestive history, or all populations, to conduct screening for
selective diseases found to have stronger evidence, or not screening at
all.
Evaluation
In the evaluation step, alternative decisions are evaluated, the optimum
decision is selected, and resources are allocated for implementation. It
is a critical phase involving analysis, bargaining, and judgement.
Mintzberg et al 11 mentioned that in the evaluation or
selection phase, analysis can distinguish between facts and value.
Bargaining, on the other hand, is dependent on the context and
decision-maker/end user perception of value and in judgment, the
end-user values are determinant to balance options against each other
and should be considered in rationalizing optimum shared
decision-making.
Figure 1-b shows the suggested criteria to rationalize and judge value
in the evaluation step based on the triple aim domains where achieving
optimal target outcomes in each domain is dependent on considering the
context, population difference, and short- and long-term outcomes, all
of which would collectively converge at the bullseye. The bullseye
represents “the ideal target/outcome,” that is, the outcome that
results in maximum benefit and optimal safety with minimal costs and
maximal care experiences for both individual patients and the
population.
Example (1). The physician might consider that although statin can
be used for high-risk and low-risk patients, for the former, the benefit
far outweighs the potential harm. Harmful side effects, could include
short-term muscular pain and a long-term risk of diabetes. However, harm
occurrence depends on harm rarity in different age groups. Moreover,
ethnicity is a determinant of diabetes, therefore, its occurrence
probability will vary accordingly. The target population’s vulnerability
regarding comorbidities—liver or kidney diseases—is to be
considered, and patients’ tolerance of the drug is also unpredictable.