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.