Epidemiology quiz

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Estimating Risk

Sukon Kanchanaraksa, PhD Johns Hopkins University

Section A

Relative Risk

4

Incidence of Disease Absolute Risk= (Attack Rate)

Risk

5

Attack Rates from Food-Borne Outbreak Exercise

Attack Rate (%)

Food (1) Ate

(2) Not Ate

Egg salad 83 30

Macaroni 76 67

Cottage cheese 71 69

Tuna salad 78 50

Ice cream 78 64

Other 72 50

6

Attack Rates from Food-Borne Outbreak Exercise

Attack Rate (%)

Difference of Attack

Rates

Food (1) Ate

(2) Not Ate (1)–(2)

Egg salad 83 30 53

Macaroni 76 67 9

Cottage cheese 71 69 2

Tuna salad 78 50 28

Ice cream 78 64 14

Other 72 50 22

7

Attack Rates from Food-Borne Outbreak Exercise

Attack Rate (%)

Difference of Attack

Rates

Ratio of Attack Rates

Food (1) Ate

(2) Not Ate (1)–(2) (1)/(2)

Egg salad 83 30 53 2.77

Macaroni 76 67 9 1.13

Cottage cheese 71 69 2 1.03

Tuna salad 78 50 28 1.56

Ice cream 78 64 14 1.21

Other 72 50 22 1.44

8

Approaches to the Measurement of Excess Risk

Ratio of risks

Differences in risks

(Risk in exposed) – (Risk in non-exposed)

Risk in exposed Risk in non−exposed

9

Relative Risk or Risk Ratio

Relative risk (RR) = Risk in exposed

Risk in non-exposed

10

Cohort Study

Then follow to see whether Calculate

and compare

Disease develops

Disease does not develop Totals

Incidence of disease

First, identify

Exposed a b a+b

Not exposed

c d c+d

a a + b

= Incidence in exposed

c c + d

= Incidence in not exposed

a a + b

c c + d

11

Cohort Study

Then follow to see whether Calculate

and compare

Disease develops

Disease does not develop Totals

Incidence of disease

First, identify

Exposed a b a+b

Not exposed

c d c+d

a a + b

= Incidence in exposed

c c + d

= Incidence in not exposed

a a + b

c c + d

Relative Risk =

a a + b

c c + d

12

Cohort Study

Then follow to see whether calculate

Develop CHD

Do not develop

CHD Totals Incidence of disease

First select

Smoke cigarettes

84 2916 3000

Do not smoke cigarettes

87 4913 5000

84 3000

87 5000

Relative Risk =

84 3000

87 5000

= 28.0 17.4

= 1.61

13

Interpreting Relative Risk of a Disease

If RR = 1 −

Risk in exposed = Risk in non-exposed

−

No association If RR > 1 −

Risk in exposed > Risk in non-exposed

−

Positive association; ? causal If RR < 1 −

Risk in exposed < Risk in non-exposed

−

Negative association; ? protective

14

Cross-Tabulation Table (Food-Borne Outbreak Exercise)

Attack Rates of Sore Throat Egg Salad

Ate Did not

eat

Tuna Salad

Ate 46/53

(87%) 3/10

(30%)

Did not eat

8/12

(67%) 3/10

(30%)

15

Cross-Tabulation Table (Food-Borne Outbreak Exercise)

Relative Risk of Sore Throat Egg Salad

Ate Did not

eat

Tuna Salad

Ate 2.9 1.0

Did not eat

2.2 1.0

The baseline group for comparison is the no exposure group—

i.e., those who did not eat tuna salad and did not eat egg salad

16

Exposure-Disease Tables Expanded from the Cross- Tabulation Table (Food-Borne Outbreak Exercise)

Sore Throat

Yes No Total

Tuna Salad

Only

Ate 3 7 10

Did not eat either

3 7 10

Sore Throat

Both Tuna Salad and Egg Salad

Yes No Total

Ate 46 7 53

Did not eat either

3 7 10

Sore Throat

Yes No Total

Egg Salad

Only

Ate 8 4 12

Did not eat either

3 7 10

RR = (46/53)/(3/10) =2.9 RR = (3/10)/(3/10) =1.0

RR = (8/12)/(3/10) =2.2

17

Relative Risk by Food Items

No tuna salad

Ate tuna salad

0

1

2

No Egg Salad Ate Egg Salad

R el

at iv

e R

is k

+Tuna

+Egg

1 2 3 4

18

Relative Risk for MI and CHD Death in Men Aged 30–62 in Relation to Cigarette Smoking

0

1

2

3

4

5 Cholesterol Levels

Low

High*

0

1

2

3

4

5 Blood Pressure

Non-Smoker Smoker SmokerNon-Smoker * High > 220 mg/100 cc

R el

at iv

e R

is k

< 130 mmHg

130+ mmHg

Source: Doyle et al, 1964

19

Relationship between Serum Cholesterol Levels and Risk of Coronary Heart Disease by Age and Sex

Men Women Serum Cholesterol

mg/dL Aged 30–49 Aged 50–62 Aged 30–49 Aged 50–62

Incidence Rates (per 1,000)

< 190 38.2 105.7 11.1 155.2

190–219 44.1 187.5 9.1 88.9

220–249 95.0 201.1 24.3 96.3

250+ 157.5 267.8 50.4 121.5

Source: Doyle et al, 1964

20

Incidence Rates and RR of CHD in Relation to Serum Cholesterol Levels by Age and Sex

Men Women Serum Cholesterol

mg/dL Aged 30–49 Aged 50–62 Aged 30–49 Aged 50–62

Incidence Rates (per 1,000)

< 190 38.2 105.7 11.1 155.2

190–219 44.1 187.5 9.1 88.9

220–249 95.0 201.1 24.3 96.3

250+ 157.5 267.8 50.4 121.5

Relative Risk*

< 190 1.0 2.8 0.3 4.1

190–219 1.2 4.9 0.2 2.3

220–249 2.5 5.3 0.6 2.5

250+ 4.1 7.0 1.3 3.2 * RR of 1.0 set at level for males 30–49 yrs of age with cholesterol level < 190 mg/dL.

21

Incidence Rates and RR of CHD in Relation to Serum Cholesterol Levels by Age and Sex

Men Women Serum Cholesterol

mg/dL Aged 30–49 Aged 50–62 Aged 30–49 Aged 50–62

Incidence Rates (per 1,000)

< 190 38.2 105.7 11.1 155.2

190–219 44.1 187.5 9.1 88.9

220–249 95.0 201.1 24.3 96.3

250+ 157.5 267.8 50.4 121.5

Relative Risk*

< 190 1.0 2.8 0.3 4.1

190–219 1.2 4.9 0.2 2.3

220–249 2.5 5.3 0.6 2.5

250+ 4.1 7.0 1.3 3.2 * RR of 1.0 set at level for males 30–49 yrs of age with cholesterol level < 190 mg/dL.

Section B

Odds Ratio

23

Interpreting Odds

“Odds” is often known as the ratio of money that may be won versus the amount of money bet In statistics, an odds of an event is the ratio of: −

The

probability that the event WILL occur to the

probability that the event will NOT occur For example, in 100 births, the probability of a delivery being a boy is 51% and being a girl is 49% The odds of a delivery being a boy is 51/49 = 1.04

In simpler term, an odds of an event can be calculated as: −

Number of events divided by number of non-events

24

The probability

that an exposed person develops disease

The probability

that a non-exposed person develops disease

=

a a + b

Develop Disease

Do Not Develop Disease

Exposed a b

Non-exposed c d

=

c c + d

Calculating Risk in a Cohort Study

25

Applying Concept of Odds

Let’s borrow the concept of odds and apply it to disease and non-disease So, the odds of having the disease is the ratio of the probability that the disease will occur to the probability that the disease will not occur Or, the odds of having the disease can be calculated as the number of people with the disease divided by the number of people without the disease [Note: in the exposure-disease 2x2 table, the odds of having a disease in the exposed group is the same as the odds that an exposed person develops the disease]

26

The odds

that an exposed person develops disease

The odds

that a non-exposed person develops disease

Develop Disease

Do Not Develop Disease

Exposed a b

Non-exposed c d

=

a b

=

c d

Calculating Odds in a Cohort Study

27

Odds ratio

is the ratio of the odds of disease in the

exposed to the odds of disease in the non-exposed

Odds ratio

is the ratio of the odds of disease in the

exposed to the odds of disease in the non-exposed

Calculating Odds in a Cohort Study

Develop Disease

Do Not Develop Disease

Exposed a b

Non-exposed c d

OR = odds that an exposed person develops the disease

odds that a non - exposed person develops the disease =

a b c d

28

Disease Odds Ratio in a Cohort Study

OR =

a b c d

= a b

x d c

= ad bc

29

Calculating Odds Ratio in a Case-Control Study

Case Control History of Exposure

a b

No History of Exposure

c d

a c

b d

The odds that a control was exposed =

The odds that a case was exposed =

30

Odds ratio (OR)

is the ratio of the odds that a case was

exposed to the odds that a control was exposed

Odds ratio (OR)

is the ratio of the odds that a case was

exposed to the odds that a control was exposed

Calculating Odds Ratio in a Case-Control Study

Case Control History of Exposure

a b

No History of Exposure

c d

OR = odds that a case was exposed

odds that a control was exposed =

a c b d

31

Exposure Odds Ratio in a Case-Control Study

OR =

a c b d

= a c

x d b

= ad bc

32

Odds Ratio versus Relative Risk

Odds ratio can be calculated in a cohort study and in a case- control study −

The exposure odds ratio is equal to the disease odds ratio

Relative risk can only be calculated in a cohort study

33

When Is Odds Ratio a Good Estimate of Relative Risk?

When the “cases” studied are representative of all people with the disease in the population from which the cases were drawn, with regards to history of the exposure When the “controls” studied are representative of all people without the disease in the population from which the cases were drawn, with regards to history of exposure When the disease being studied is not a frequent one

34

When Is Odds Ratio a Good Estimate of Relative Risk?

If the incidence of the disease is low, then:

a+b ~ b c+d ~ d

Therefore:

a/(a+b) c/(c+d)

a/b c/ d

= ad bc

= OR

RR

=

~

35

Comparing OR to RR: Disease Is Infrequent

Develop Disease

Do not Develop Disease

Exposed 200 9800 10,000

Non-

Exposed 100 9900 10,000

Relative Risk =

200/10, 000 100/10, 000

= 2

Odds Ratio =

200 x 9900 100 x 9800

= 2.02

36

Comparing OR to RR: Disease Is NOT Infrequent

Develop Disease

Do not Develop Disease

Exposed 50 50 100

Non-

Exposed 25 75 100

Relative Risk =

50/75 50/25

= 2

Odds Ratio =

50 x 75 50 x 25

= 3

37

Interpreting Odds Ratio of a Disease

If OR = 1 −

Exposure is not related to disease

−

No association; independent If OR > 1 −

Exposure is positively related to disease

−

Positive association; ? causal If OR < 1 −

Exposure is negatively related to disease

−

Negative association; ? protective

Section C

Odds Ratio in Unmatched and Matched Case-Control

39

E = Exposed

N = Not exposed

Unmatched Case-Control Study: Example

Assume a study of 10 cases and 10 unmatched controls, with these findings

Assume a study of 10 cases and 10 unmatched controls, with these findings

CASE CONTROL

E N

E E

N N

E N

N E

N N

E N

E E

E N

N N

40

Unmatched Case-Control Study: Example

CASE CONTROL

E N

E E

N N

E N

N E

N N

E N

E E

E N

N N

Thus, 6 of 10 cases were exposed, and 3 of 10 controls were exposed. In a 2x2 table, we have the following:

Thus, 6 of 10 cases were exposed, and 3 of 10 controls were exposed. In a 2x2 table, we have the following:

Case Control

Exposed 6 3

Not Exposed

4 7

E = Exposed

N = Not exposed

41

Unmatched Case-Control Study: Example

CASE CONTROL

E N

E E

N N

E N

N E

N N

E N

E E

E N

N N

Case Control

Exposed 6 3

Not Exposed

4 7

OR =

ad bc

= 6 x 7 3 x 4

= 3.5

E = Exposed

N = Not exposed

42

Quick Pause

OR =

ad bc

= 8 x 7 3 x 4

= 4.7

In a hypothetical 2x2 table with the following rows and columns, is the OR calculated correctly?

In a hypothetical 2x2 table with the following rows and columns, is the OR calculated correctly?

Control Case

Exposed 8 3

Not Exposed

4 7

43

Quick Pause

OR =

ad bc

= 8 x 7 3 x 4

= 4.7

Incorrect!Incorrect!

Control Case

Exposed 8 3

Not Exposed

4 7

Why?Why?

44

Odds Ratio in a Case-Control Study

OR =

a c b d

= a c

x d b

= ad bc

=

(# cases exposed) x (# controls not exposed) (# cases not exposed) x (# controls exposed)

The numerator is the product of cases exposed and controls not exposed.

The numerator is the product of cases exposed and controls not exposed.

45

Case-Control Study: Example

Cases

CHD Controls

(without disease)

Smoked cigarettes 112 176

Did not smoke cigarettes

88 224

Total 200 400

% Smoking cigarettes

112 200

= 56% 176 400

= 44%

OR =

ad bc

= 112 x 224 176 x 88

= 1.62

46

Matched Case-Control Study

In a matched case-control study, one or more controls are selected to match to a case on certain characteristics, such as age, race, and gender When one control is matched to a case, the case and the matched control form a matched pair

47

Concordant and Discordant Pairs

We can define two types of matched pairs by the similarity or difference of the exposure of the case and control in each pair Concordant pairs are: 1.

Pairs in which both the case and the control were exposed, and

2.

Pairs in which neither the case nor the control was exposed

Discordant pairs are: 3.

Pairs in which the case was exposed but the control was not, and

4.

Pairs in which the control was exposed and the case was not

48

2x2 Table in a Matched Case-Control Study

Controls

Exposed Not

Exposed

Cases Exposed

Not Exposed

Discordant

Concordant

49 Total number of subjects = 2 x (aa+bb+cc+dd)

2x2 Table in a Matched Case-Control Study

Controls

Exposed Not

Exposed

Cases Exposed aa bb

Not Exposed

cc dd

“aa”

= number of matched pairs

2 x aa

subjects in this cell “aa”

= number of matched pairs

2 x aa

subjects in this cell

50

OR from 2x2 Table in a Matched Case-Control Study

Controls

Exposed Not

Exposed

Cases Exposed aa bb

Not Exposed

cc dd

Odds ratio (matched) =

bb cc

Note: bb is not the product of b and b (not b x b);

it is the number of pairs

51

Matched Case-Control Study: Example

Assume a study of 10 cases and 10 controls in which each control was matched to a case resulting in 10 pairs.

Assume a study of 10 cases and 10 controls in which each control was matched to a case resulting in 10 pairs.

CASE CONTROL

E N

E E

N N

E N

N E

N N

E N

E E

E N

N N

E = Exposed

N = Not exposed

52

Matched Case-Control Study: Example

Controls

Exposed Not

Exposed

Cases

Exposed 2 4

Not Exposed

1 3

Matched OR =

4 1

= 4

CASE CONTROL

E N

E E

N N

E N

N E

N N

E N

E E

E N

N N

E = Exposed

N = Not exposed

53

Review: Matched Case-Control Study

Controls

Exposed Not

Exposed

Cases

Exposed 2 4

Not Exposed

1 3

Q1. How many pairs?

Q2. How many

subjects?

Q3. What are the discordant

pairs?

Q4. Which is the “bb”

cell?

Q5. What is the “bb”

cell?

Q1. How many pairs?

Q2. How many

subjects?

Q3. What are the discordant

pairs?

Q4. Which is the “bb”

cell?

Q5. What is the “bb”

cell?

54

Review: Unmatching a Matched 2x2 Table

Matched CC Controls

Exposed Not

Exposed

Cases

Exposed 2 4

Not Exposed

1 3 Disease

Unmatched

2x2 Yes No

Exposure

Exposed

Not Exposed

Section D

Attributable Risk

56

Attributable Risk

Attributable risk (AR) is a measure of excess risk that is attributed to the exposure Attributable risk in the exposed group equals the difference between the incidence in the exposed group and the incidence in the non-exposed (baseline) group

57

Attack Rates from Food-Borne Outbreak Exercise

Attack Rate (%)

Difference of Attack

Rates

Food (1) Ate

(2) Not Ate (1)–(2)

Egg salad 83 30 53

Macaroni 76 67 9

Cottage cheese 71 69 2

Tuna salad 78 50 28

Ice cream 78 64 14

Other 72 50 22

58

Exposed group Non-exposed group

Risk in Exposed and Non-Exposed Groups

Background

Risk

59

Exposed group Non-exposed group

Risk in Exposed and Non-Exposed Groups

Background

Risk

Attributable risk

Incidence due to

exposure

Incidence not due to

exposure

60

Incidence in exposed group

Incidence in non-exposed group( ) ( )–=

Risk in Exposed and Non-Exposed Groups

1.

Incidence attributable to exposure (attributable risk)

61

Incidence in exposed group

Incidence in non-exposed group( ) ( )–=

Risk in Exposed and Non-Exposed Groups

1.

Incidence attributable to exposure (attributable risk)

2.

Proportion of incidence attributable to exposure (proportional attributable risk)

Incidence in exposed group

Incidence in non-exposed group( ) ( )–=

Incidence in exposed group

62

Example: Cohort Study

Develop CHD

Do not develop

CHD Totals Incidence of disease

Smoke cigarettes

84 2916 3000 28.0 per

1,000

Do not smoke cigarettes

87 4913 5000 17.4 per

1,000

63

= 28.0 –

17.4 = 10.6/1,000/year

Attributable Risk in Smokers

1.

The incidence in smokers which is attributable to their smoking

Incidence in smokers

Incidence in non-smokers( ) ( )–=

64

Incidence in smokers

Proportion Attributable Risk in Smokers

2.

The proportion of the total incidence in the smokers which is attributable

to their smoking

= 0.379 = 37.9%= 28.0 – 17.4

28.0 10.6 28.0=

Incidence in smokers

Incidence in non-smokers( ) ( )–=

65

Risk in the Total Population

Population is a mix of exposed and non-exposed groups

66

Incidence in total population

Incidence in non-exposed group) ( )–=

Attributable Risk in the Total Population

3.

Incidence attributable to exposure

(

67

Incidence in total population

Incidence in non-exposed group) ( )–= (

Attributable Risk in the Total Population

3.

Incidence attributable to exposure

4.

Proportion

of incidence attributable to exposure

( ) ( )Incidence in total population Incidence in non-exposed group–= Incidence in total population

68

Incidence in total population

Incidence in non-exposed group) ( )–=

Attributable Risk in the Total Population

3.

Incidence attributable to smoking in the total population

(

69

Attributable Risk in the Total Population

If the incidence in the total population is unknown, it can be calculated if we know: −

Incidence among smokers

−

Incidence among nonsmokers −

Proportion of the total population that smokes

70

Attributable Risk in the Total Population

We know that: −

The incidence in smokers = 28.0/1,000/year

−

The incidence in nonsmokers = 17.4/1,000/year From another source, we learn that: −

The proportion of smokers in the population is 44%

So, we know that: −

The proportion of nonsmokers in the population is 56%

71

Attributable Risk in the Total Population

Incidence in total population =

Incidence

in smokers( ) Percent

smokers in population

( )+ Incidence in non- smokers

( ) Percent non-smokers in population

( ) (28.0/1000) (.44) + (17.4/1000) (.56)

= 22.1/1000/year

72

) ( )Incidence in total population Incidence in non-smokers–=

Attributable Risk in the Total Population

3.

Incidence attributable to smoking

( (22.1/1000/year) –

(17.4/1000/year)

= 4.7/1000/year

73

22.1–17.4

= 21.3%

Attributable Risk in the Total Population

4.

Proportion of incidence attributable to exposure

Incidence in total population

Incidence in non-smokers) ( )–= (

Incidence in total population

22.1

74

Lung Cancer, CHD Mortality in Male British Physicians

Age-Adjusted Death Rates/100,000

Smokers Non-Smokers RR AR %AR

Lung cancer 140 10 14.0 130 92%

CHD 669 413 1.6 256 38%

%AR = Proportion attributable risk

Source: Doll and Peto

(1976). BMJ, 2:1525.

75

Lung Cancer, CHD Mortality in Male British Physicians

Age-Adjusted Death Rates/100,000

Smokers Non-Smokers RR AR %AR

Lung cancer 140 10 14.0 130 92%

CHD 669 413 1.6 256 38%

%AR = Proportion attributable risk

Source: Doll and Peto

(1976). BMJ, 2:1525.