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The key difference between choosing and deciding in pharmacotherapy

Among health care providers, in addition to primary rational considerations to choose a pharmacotherapy - such as effectiveness and safety - other, often less rational factors also play a role in the selection process. These may include such things as emotional, financial and unconscious selection criteria. These non-rational selection criteria largely explain the considerable differences that exist between choosing and deciding in pharmacotherapy. These derive from the difference between ‘evidence-based medicine’ and ‘experience-based medicine’.

The considerable difference between ‘choosing’ and ‘deciding’ in pharmacotherapy becomes more important once the selection process requires a more policy-based approach from the point of view of effectiveness and safety. This demands a broad assessment within the framework of the disorder and the patient population, while the actual decision takes place in the individual context of the patient. Nevertheless, it is inevitable that - however rationally the formulary choice or therapy agreement is determined - there is always room for a deviating, individual assessment at the patient level.

But it would be preferable to base the routine aspects of pharmacotherapeutic policies on rational selection criteria. In the Netherlands, a great deal of experience has been gained in this field using selection models based on decision matrix techniques, such as InforMatrix and SOJA. These methods are used interactively in groups in order to rationalise the selection process, to promote consensus about therapy agreements, and - naturally following from this - to facilitate ‘the routine decision-making process' in prescription practice. This is without detracting from a broader assessment process at the level of the patient.

Matrix methods such as SOJA and InforMatrix are not intended for pharmacotherapeutic decisions during surgery hours or at the patient's bedside. What they are suitable for, is to be used in a hospital medication committee or in pharmacotherapeutic consultations (PTC). The matrix method is deployed by Digitalis in Northern Ireland under the name ’STEPSelect’ (Safe, Therapeutic, Economic, Pharmaceutical Selection) to support the purchasing of medication.

Matrix is Latin for 'womb'. The concept is also synonymous with 'a substance in which something develops'. This combination of meanings is aptly reflected in a Russian 'Matryoshka'. This is a female wooden figure that can be opened to reveal a similar, smaller doll, which can also be opened and contains another smaller doll, et cetera. The matrix as a womb can be seen as a representation of the guaranteed reproducibility of decision-making and change processes.

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