Essential Epidemiology observational studies

Robert Scragg School of Population Health University of Auckland

Definition of Epidemiology
Epidemiology is the study of the distribution & determinants of health-related states or events in specified populations & the application of this study to the control of health problems Last, Dictionary of Epidemiology, 1988.

Differences between a Rate, Ratio & Proportion

! Ratio = a / b ! Proportion = a / (a + b) ! Rate = !a / !b ie. change in a per unit change in b eg. acceleration is change in speed per unit change in time.

Measures of Disease Frequency

! Incidence rate ! Cumulative incidence ! Prevalence

What is the difference between these cohorts? - years to death shown for each person
Cohort A
5 7

Cohort B
9 11

12 8

Incidence Rate

number of new disease events " person time

Calculation of Person-Years

Example of incidence rate

(Skegg & Cox, Lancet 1991; 338: 1436)

Cumulative Incidence
Number of persons who get the disease during a specified time period Number of persons free of the disease in the population at risk at the beginning of the time period

Incidence measures: examples

! Newly developed disease ! Death in the total population (mortality) ! Death in patients (case fatality) ! Recurrence of a disease ! Development of a side effect of a drug

Prevalence
Number of persons with (new & old) disease at a specified time Number of persons in the population at risk at the specified time

Summary of Measures of Disease Frequency

! Incidence rate
! Measure of the new cases of disease occurrence per unit of person-time

! Cumulative incidence
! Proportion of people who convert from nondiseased to diseased, in a specified period of time

! Prevalence
! Proportion of people who have a disease at a specific instant in time

Types of Studies
Observational 1.! Ecological study (group measures) 2.! Cohort study 3.! Cross-sectional study 4.! Case control study Experimental 1.! Randomised clinical trial (patients) 2.! Field trial (healthy) 3.! Community trials
(group randomisation)

Cohort study
Exposed at baseline
Yes

Disease at follow-up
Yes : A

No : B Healthy population Yes : C No No : D

Time

Risk ratio incidences rates (IR)

distribution after X years of follow-up Exposed Yes Yes No Total a c a+c Disease Personyears PYE PYNE PYT

IR ratio = a / PYE c / PYNE

Example Risk ratio incidences rates (IR)

distribution after X years of follow-up

Exposed Yes Yes No Total 200 100 300

Disease -

Personyears 20,000 20,000 40,000

IR ratio = 200 / 20,000 100 / 20,000 = 2.0

Risk ratio cumulative incidence (CI)

distribution after X years of follow-up

Exposed Yes Yes No Total CI risk ratio Odds ratio a c

Disease No b d b+d

Total a+b c+d N

a+c

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

Example Risk ratio cumulative incidence (CI)

distribution after 10 years of follow-up

Exposed Yes Yes No Total 200 100 300

Disease No 800 900 1700

Total 1000 1000 2000

CI risk ratio = 200 / 1000 100 / 1000 = 2.00 Odds ratio = 200 / 800 100 / 900 = 2.25

Tokelau Island Migrant Study

! 1966 cyclone migration to NZ ! 1968 census of those still in Tokelau ! 1970 register of those who had migrated to NZ ! Examinations:
! Tokelau: 1968, 1971, 1976 ! NZ: 1972-74, 1975-77

! Variables: weight, BP, serum lipids, blood glucose, smoking

Cross-sectional study
Time

Population

Exposure & disease measured at same time in each person

Cross-sectional Surveys in the Pacific

Most common type of epidemiological study

Examples ! National census ! National health surveys ! STEPs surveys for cardiovascular risk factors
! Step 1: questionnaire ! Step 2: physical measurement ! Step 3: blood sample

! Clinical audits: % with complication ! Prevalence of birth defects

Risk ratio prevalence

distribution at a point in time Exposed Yes Yes No Total a c a+c Disease No b d b+d a+b c+d N Total

Prevalence risk ratio = a / (a + b) c / (c + d) Odds ratio = a / b c / d

Example Risk ratio prevalence

distribution at a point in time

Exposed Yes Yes No Total 300 100 400

Disease No 700 900 1600

Total 1000 1000 2000

Prevalence risk ratio = 300 / 1000 100 / 1000 = 3.00 Odds ratio = 300 / 700 100 / 900 = 3.86

Auckland Diabetes Heart & Health Study

Obesity Prevention In Community (OPIC) Study:

data collection with PDAs by Students

OPIC Study Overweight & obesity (%): 4 countries

Females Males

OPIC Study Overweight & obesity (%): NZ Pacific v. Tonga

NZ Pacific Tonga

OPIC Study Overweight & obesity (%): New Zealand

Females Males

Case Control Study

Exposed
Yes : A

Cases
No : C

(disease)

Yes : B No : D

Controls
(no disease)

Time

Odds ratio
from case control study Exposed Yes No Total Case a c a+c Control b d b+d

Odds ratio = a / c b / d =a/bc/d = a*d b*c

NZ Cot Death Study

Cases: infants dying 28 days to 12 months age, suddenly, without obvious cause (98% autopsy) Controls
! Unmatched, randomly selected from hospital births ! Randomly allocated an interview age, collectively similar to expected age distribution of cases ! Included also as cases if they subsequently died of SIDS

! Inclusion criteria
! Born in study area November 1987 to October 1990 ! Mother domiciled in study area at interview or infant death

! Home interviews (cases & controls)

! 81% of cases within 7 weeks after death, 70% of controls within 4 days of nominated date

! Response rate
! cases 81% (393 / 485), controls 88% (1592 / 1800)

Disease measures by study design

! Cohort, experimental studies
! Incidence rate, cumulative incidence ! Risk ratio (relative risk), odds ratio

! Cross-sectional
! Prevalence ! Prevalence ratio (relative risk), odds ratio

! Case control study

! Odds ratio (estimate of relative risk)