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A Decision Analysis Approach to the Swine Influenza Vaccination Decision for an Individual (2001)

A Decision Analysis Approach to the Swine Influenza Vaccination Decision for an Individual (2001)

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A Decision Analysis Approach to the Swine Influenza Vaccination Decision for an IndividualAuthor(s): David L. Zalkind and Richard H. ShachtmanSource:
Medical Care,
Vol. 18, No. 1 (Jan., 1980), pp. 59-72Published by: Lippincott Williams & WilkinsStable URL:
Accessed: 26/07/2009 04:37
Your use of the JSTOR archive indicates your acceptance of JSTOR's Terms and Conditions of Use, available athttp://www.jstor.org/page/info/about/policies/terms.jsp. JSTOR's Terms and Conditions of Use provides, in part, that unlessyou have obtained prior permission, you may not download an entire issue of a journal or multiple copies of articles, and youmay use content in the JSTOR archive only for your personal, non-commercial use.Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained athttp://www.jstor.org/action/showPublisher?publisherCode=lww.Each copy of any part of a JSTOR transmission must contain the same copyright notice that appears on the screen or printedpage of such transmission.JSTOR is a not-for-profit organization founded in 1995 to build trusted digital archives for scholarship. We work with thescholarly community to preserve their work and the materials they rely upon, and to build a common research platform thatpromotes the discovery and use of these resources. For more information about JSTOR, please contact support@jstor.org.
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MEDICAL CAREJanuary1980,Vol.XVIII,No.1
ADecisionAnalysis Approachto theSwineInfluenza VaccinationDecisionfor anIndividual
DAVID L. ZALKIND* ANDRICHARD H.SHACHTMANfWepresenta methodtoanalyzethe decisionbyanindividual whethertoreceive theswine influenza(A/NewJersey)vaccine,includinganapproachforhealth carepersonnelto useininformingan individual about thepersonalcosts,benefits andprobabilities,as well asindicated choicesofactions,associatedwithsuch decisions. Thisanalysisisaprototypefor cases whereinformedconsentrequirementshavepromptedincreasedpatientinvolvementinper-sonalmedical decisions. Probabilities andpersonallyassessedvaluesthataffectthedecision are: reaction to theinjection,attackrates,vaccineefficacy,chancesfor anepidemicandconcomitantprobabilitiesofcontractinginfluenza,andmortality.Wespecifyapreferenceorderingforconsequencesofreceivingthevaccine. Theanalysis yieldsapreferenceorderingforpossibleactionsbecauserelativevaluesreflectingpreferencesarecomparedon a fixed consistentscale.Thesolutionexhibited,determinedinthe fall of1976,indicatesconditionswhenselection ofthe actionto receivethe vaccine is automatic.Incaseswherethe decision isnotautomatic,anindividual needs additional informationaboutthepersonalvalueof death(life),relativetootherpossibleoutcomes. Weprevi-ouslyhavedevelopedanoneconomicapproachto thedetermination of thevalue ofdeath15 andtheresults,brieflydescribed in thispaper,are used toconstructadecisionregionfor thechoice ofreceivingthevaccine thatdependson boththeprobabilityof anepidemicand thevalueofdeath.Surprisingly,inclusion ofinformation abouttheGuillain-Barresyndromedoesnotnecessar-ilyalter thedecision toreceive thevaccine,eventhough recognitionoftheincreasedincidence ofthesyndromecausedbythevaccinecausedcancellationofthe federalprogram.THEFEDERALLY-SPONSOREDswine in-fluenzavaccinationcampaignthat was un-
*Faculty Fellow,OfficeofAssistantSecretaryfor
PlanningandEvaluation,U.S.DepartmentofHealth,Education,andWelfare,Washington,D.C.and DukeUniversity,Durham,NorthCarolina.
i
AssociateProfessor,Director ofSENICProject,DepartmentofBiostatisticsandCurriculumnOpera-tionsResearchandSystemsAnalysis,UniversityofNorthCarolina,Chapel Hill,NorthCarolina.Thisprojectwaspartially supportedbyGrant #HS-01971-2romthe NationalCenter forHealthSer-vicesResearch,HealthResourcesAdministration,andContract#200-77-0705,CenterforDisease Con-trol,Atlanta,Georgia.
expectedlyandabruptlyabortedhigh-lightsthecurrentethicalandlegal prob-lemsattendant toinformedconsentbymedicalpatients.Thereisa needformechanismsthatprovidepatientswiththeinformationandtools tobeactivedecisionmakersin themedicalcareprocess.Decisionanalysisprovidesasystematicframeworkforrationaldecisionmakingthatcanbeutilizedbyknowledgeablehealthcarepersonneltoinformapatientaboutpotentialconsequencesofmedicalactions,andthatcan beusedwiththepa-tient'sownvalues tohelpmake adecision
0025-7079/80/0100/0059/$01.20?J.B.LippincottCo.59
 
ZALKINDANDSCHACHTMAN
that isbest for him. Inotherwords,indi-viduals canusethetoolofdecisionanalysis,perhapsunder theguidanceofspeciallytrainedhealthtechnicians,toeducatethemselvestomakemorerationaldecisions intheface ofharddata,softdata,nonexistentdata andpersonalpreferences.Equallyimportant,publichealthanalystscan usedecisionanalysistohelpdeter-minewhether adviceaboutwhat actionsindividualsshouldtakeis rational fromtheviewpointofeachindividualbeingad-vised totake the action.Suchan under-standingmaybeof use indevisingbothone-on-one andmassmediaeducationalefforts forpreventivehealthmeasures.There are at leastfourdifferentview-pointsfor thedecision,orfour differentdecisions. Thefirst is thefederalgovern-mentdecision ofwhetherto havesuch aprogramand,ifso,whoshould fund it.Schoenbaum et al.10havediscussed thefirstpartof thisdecision froman economicviewpoint.Thesecondisthat of alocalhealthadministratorwhomustdecidehowtopayfortheprogram.Wedo notconsidertheseproblemshere. Ahealthprofessionalwhomust advise individualswhether ornot to receive thevaccinehas athirdview-point.Theindividuals whowould receivethe vaccinehasthefourthviewpoint.Forthelatter twoviewpoints,certainparame-terscharacterizingtheindividual'svaluesforconsequencesandprobabilitiesfor out-comesmayaffectthe decision. Factors totakeintoconsiderationinclude theproba-bilityof anepidemic,reactiontoreceivingthevaccine,etc.Thus,this articleproposesarationalprocedurefor anindividualtofollowindecidingwhether to obtainaswineinfluenza vaccination.ManyAmeri-cans madethis decisionduringthefall of1976 andsimilardecisionswillbemadeyearafteryearasnewor altered viralstrainsthreatento cause nationalepidemics,jfor whichacceptanceof thevaccineisnot mandatedbylaw.
t
As thisisbeingwritten,theupcomingexampleappearstobe the"Russian Influenza"(A/USSR).
Themethodologydevelopedhere canbe used inseveralcontexts.First,with theaid ofaneasy-to-use computer packageorprogrammablecalculator,apatientincon-junctionwithmedicalpersonnelcan useinformed consentto its fullest extent. Sec-ond,thesystematic approachtoproblemsolvinginherentindecisionanalysismakesitan excellenttoolfortrainingofhealth carepersonnel.Wewill notreviewthe use ofdecisionanalysisin medicalcarehere. The interestedreader canfindanex-tensivebibliographyin Albert.1Anexam-pleofatypicalapplicationin theliteratureisthat of Plisken and Beck7describinghowaphysicianandapatientincorporatesomeoftheirsubjective feelingsandvaluejudgmentsinadecisionanalysismodelused to determinethetreatmentofend-stagerenalfailure.Anindividual is facedwitha choice-receive thevaccine,ordecline toreceivethevaccine. Inlargepart,theconsequenceofsuchachoicedependson whethertheindividualinquestionisexposedto swineinfluenzavirus,or is neverexposedtoswineinfluenzavirus.Intheterminologyofclassicalstatistics,onemightsaythatreceivingthevaccine andnotbeingex-posedtothevirus is aTypeIerrorand thatnotreceivingthevaccineandbeingex-posedto thevirusisaTypeIIerror.Al-thoughclassical statisticsdevelopstrade-offsbetweenprobabilitiesofcommittingTypeIandTypeIIerrors,themethodol-ogyofdecisionanalysis,describedinthispaper,goesfurther,because itallowstheindividual decisionmakertoincorporatehis ownvalues(andprobabilities)forthepotentialconsequencesofhis actionsandthe truestate ofnature thatis unknownatthe time thedecisionismade. For exam-ple,atthetime theimmunization decisionismade,theindividual does notknowwhether hewillbeexposedto the virus.Furthermore,thistechnique providestheopportunityfor the decisionmakerto ex-plorethesensitivityof hisdecision to al-ternativeprobabilityestimates and valueassessments.60
MEDICALCARE

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