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Observational Study
A nonexperimental analytic study in which the investigator monitors, but does not influence, the exposure status of individual subjects and their subsequent disease status
Experimental Study
A study in which the investigator influences the exposure status of individual subjects (independent variable) and then monitors the subjects outcome (dependent variable)
Cohort = ancient Roman term = a group of soldiers that marched together into battle In clinical study = a group of person followed up together over time
Cohort studies
Descriptive: To describe incidence of certain outcome over time (absolute risk) Analytic: To analyze association between risk factors and outcomes (relative risk)
Prospective cohort
Select a sample from the population Measure predictor variable (present of absent) Follow-up the cohort Measure outcome (present or absent)
Retrospective cohort
Basically the same with prospective Basic measures, follow up, outcome all in the past Only possible if all data are complete and prepared for other purpose
Retrospective cohort
Assemble cohort in the past Measure risk factors Follow-up Measure outcomes Analyze
Malnutrition in chronic diarrhea may be the result rather than a cause Avoiding survivor bias
Selecting subjects
Define group of subjects at the beginning of the study (inception cohort), e.g., cervical cancer, stage 1-2 Select samples with rapidly occurring outcomes, e.g., hip fracture elderly woman Adequate sample size Control in double cohort should be selected by random sampling
Following subjects
Important: minimize loss to follow up!!! Strategies:
During design:
Restriction: exclude those likely to loss
Moving Unwilling to return
During follow-up
Periodic contact
Phone, visits, etc
Analyzing results
Descriptive: Incidence rate, mean, proportions, SD, etc Analytic: Relative risk Other analysis:
Cohort study
Analysis Incidence Relative/incidence risk Relative risk (RR) = the ratio between the incidence of an effect in the exposed group to that in the non-exposed
Disease -
Exp +
20
30
50
Exp -
45
50
RR = 20/50 : 5/50 = 4
RR = 4
The probability of developing the disease in exposed group is 4 x the probability of developing the disease in non-exposed group Exposed individuals are 4 x more likely to develop the disease compared with nonexposed CI is recommended; if CI include 1, then statistically not significant (the probability that the result is caused by chance is high)
1. Cardiovascular disease
Framingham, Ma Tecumseh, Mi Evans county, Ga (biracial) Muscatine, IA Bogalusa, LA (children)
2. Child health
National birthday trust studies
One week of births in England and Wales in 1946, 1958 and 1970
The national childrens study http://www.Nichd.Nih.Gov/about/despr/despr.H tm A study in Jakarta of 100,000 pregnancies with offspring followed to age 21?
3. Special exposures
Atomic Bomb Casualty Commission (ABCC): Hiroshima and Nagasaki survivors (effects of radiation) Dutch famine survivors (effects of starvation)
Seveso (effects of dioxin exposure)
5. Analysis is like a cohort study. Since the sampling fraction is known, and the entire population is sampled for caseness, true incidences and relative risks can be calculated.
Case-Control Studies
(Adapted from slides by Schenker M)
Objectives
After this session, you will be familiar with: The basic design features of a casecontrol study Rationale for applying case-control designs Limitations of case-control studies Example applications applying casecontrol designs
50
(Disease Yes)
Exp. Yes
Control 50
Exp. No 48
(Disease No)
Exp +
10
12
Exp -
40 50
48 50
88 100
20
OR = 6
Originally: The probability exposure in cases is 6 times than the probability of exposure in controls Mathematically similar to:
The probability of developing the disease in exposed group is 6 x the probability of developing the disease in non-exposed group Exposed individuals are 6 x more likely to develop the disease compared with nonexposed
E + E -
Contr ol b d
2. Case ascertainment system in place: The conduct of a case-control study may be facilitated by the availability of a case-ascertainment system. a) Population-based cancer registry b) Hospital-based surveillance systems c) Mandated disease reporting systems 3.When funding and time constraints are not compatible with a cohort study.
Total Population
Reference Population
Cases
Controls
b) Practical Questions (i) Is the approach selected for control selection feasible? (ii) Can this approach be used given the funds available?
Sources of controls
a) b) c) d) Population of defined area Hospital patients Probability sample of total population Neighbors
i. walk (door to door) ii. phone (random digit dialing) iii. letter carrier routes
Methodologic Issues
1. Handling potential confounding factors a) In the process of selecting controls: Matching The process of selecting controls so that they are similar to the cases in regard to certain characteristics such as age, sex and race. (i) Group matching (frequency matching, stratification) (ii) Individual matching (matched pairs)
C. Methodologic Issues
Handling potential confounding factors in matching: (iii) Problems with matching: - Matching on many variables may make it difficult or impossible to find an appropriate control. - Cannot explore possible association of disease with any variable on which cases and controls have been matched.
Methodologic Issues
Handling potential confounding factors in matching: b) In the process of selecting controls: Restriction c) In the data analysis: (i) Stratification (ii) Adjustment
Methodologic Issues
2. Evaluating Information on Exposure a) Problems of recall in case-control studies (i) Limitations in human ability to recall (ii) Recall bias (cases may remember their exposure with a higher or lower accuracy than controls do)
b) Avoiding other biases (i) Selection bias (ii) Information bias (iii) Non-response bias (iv) Analysis bias c) Validity testing (reliability, sensitivity and specificity)
Using Multiple Controls in Case-Control tudies a) Multiple controls of a similar type (e.g. 2 controls per case) b) Different types of controls (e.g. hospital and neighborhood controls)