Furthermore, in countries with fewer resources, the cost per
capita of healthcare may limit statin use, and healthcare-related
decisions may not that of resource-rich countries. Thus, identified gaps
in equity necessitate suitable plans: the decision for higher-risk
patients might be high-intensity statin while for lower-risk patients,
counselling him/her about positive family history and his/her
preferences regarding his/her ability to change and health priorities.
In this situation, in which a patient reflects on his/her values of what
he/she sees as a gain or loss and the consideration of acceptability of
lifestyle modifications versus commitment to lifelong statin treatment
with an emphasis on the long-term benefits, harms and costs are
determinants in the bargaining process, adding to the physician’s
rationality of determining value. Preferably, the patient will be
informed about their options and will contribute to the decision by
weighing options with the physician. In the end, the shared best
judgement between the physician and patient is selected. However, when
identifying any need to change or any new opportunity to improve a
patient’s life, this new identified need or opportunity is followed by
the development of and search for new possible options, after which
re-evaluation occurs and multiple meta-decision cycles may be needed to
reach the best decision.
Example (2). Validating decisions for a national genetic
screening program will require information on the budget and resources
needed along with local data on genetic diseases’ epidemiology,
socio-economic status, and health literacy—essential to inform
decision consequences. Careful analysis of each decision developed
previously is to be validated through bargaining and weighing options
against each other. For example, while genetic testing has the long-term
benefit of avoiding genetic diseases in children, a short-term outcome
may be test anxiety due to results of uncertain significance or any
immediate decisions the couple may take to avoid children with possible
diseases. Another long-term harm is exposing the couple and their
children to explicit genetic data with possible employment or treatment
disadvantages. The freedom to make choices might be affected due to the
influence of others, such as the government or their community, on
decision-making.
The process appraisal and feedback on the success or failure of
meta-decisions’ processes contribute to improving future meta-decisions.
Research using local data is crucial for making informed validated
decisions for special populations in all settings. The approach of
meta-decisions will also prevent unstructured decision-making and
accommodate differences.
It is worth noting that clinical practice guidelines and protocols
provide choices, facts, and ideas that can be used in the meta-decision
process and its steps. Therefore, meta-decision is the junction to
deliver the right evidence to the right patient. This is true for
clinical decision support tools as well, which are increasingly
available at the point of decision-making. It was found to reduce costs,
improve quality, and reduce medical errors in clinical settings.23 Nevertheless, it provides mainly clinical
knowledge, but is not relevant to other domains considered important in
medical decision-making as a social determinant of health and patient
preferences. 24 However, the question remains of does
it facilitate accessibility to data and ideas on expenses of limiting
search and design. This needs to be better studied through its use with
the meta-decision approach. Table 1 shows the concept applied on more
examples.