Systematic error (Bias)

Types of Bias
Non- response High unresponse rate to surveys/ questionnaires
bias can cause errors if unresponders differ in some way
from unresponders
Healthy worker Study populations are healthier than general
effect populations
Berkson bias Disease studied using only hospital based patients
may lead to results not applicable to target
population.
(the researcher parked in the hospital and never
came out)
Prevalence Exposures that happen long before disease
(Neyman) bias assessment can cause study to miss diseased
patients that die early or recover
Ascertainment Study population differs from target population
(sampling) bias duo to nonrandom selection methods. Ex. Severely
ill patients are the most likely to enroll on cancer
trials leading to results that are not applicable to
patients with less advanced cancer.
Selective survival occurs in case-control studies when cases are
bias selected from the entire disease population instead
if just those who are newly diagnosed. Ex. Study on
cancer survival that is not limited to newly
diagnosed patients will contain a higher proportion
Referral When the case and control populations differ duo
(admission rate to admission or referral practices. Ex. Study
bias) involving cancer risk factors performed at a
hospital specializing in cancer research may enroll
cases referred from all over the nation. However,
hospitalized control subjects without cancer may
come from only local area.
Attrition bias Significant loss of study participants may cause
(loss of follow- bias if those lost to follow-up differ significantly
up) from remaining subjects.

Allocation bias Can result from the way that treatment and control
groups are assembled. It may occur if subjects are
assigned to the study groups in a nonrandom
fashion. Ex. In a study comparing oral NSAIDs and
intra-articular corticosteroids for OA ttt, obese
patients may be preferentially assigned to the
corticosteroid group.
Recall bias Results from inaccurate recall of past exposure by
people in the study and applies mostly to
retrospective studies such as case control studies.
People who have suffered and adverse event (such
as having child with congenital abnormalities) are
more likely to recall previous risk factors that are
people who have not experienced a poor outcome.
The risk in known at the time of enrollment in
prospective studies, so recall bias is eliminated.
FA, reduce bias by decreasing time from exposure
to follow-up
Becker: Also if people dont remember clearly what
happened, so they make things up or distorts the
past based on perspective of the present.
Procedure bias Subjects in different groups are not treated the
same.
Reduce by blinding and use of placebo.
Detection bias The risk factor itself may lead to extensive
diagnostic investigation and increase the
probability that a disease is identified. Ex. Patients
who smoke may undergo increased imaging
surveillance duo to their smoking status, which
would detect more cases of cancer in general.
Lead time bias When a screening test diagnoses a disease earlier
than it would have appeared by natural history so
that the time from diagnosis until death is
prolonged. Affected studies may not accurately
reflect an improvement in survival or alteration of
 the natural history.
To reduce this bias, Measure back-end survival
(adjust survival according to
the severity of disease at the time of diagnosis)
Measurement Information is gathered in a way that distorts it.
bias Ex. Miscalibrated scale consistently overstates
weights of subjects. Reduce by using standardized
methods of data collection.
Hawthorne effect Tendency of a study population to affect outcome
duo to knowledge of being studied. It occurs
commonly in studies concerning behavioral
outcomes or outcomes that can be influenced by
behavioral changes. To minimize, studied subjects
can be kept unaware that they are being studied
but pose ethical problems
Observer bias When observer misclassifies data secondary to
individual differences in interpretation or
preconceived expectations regarding the study
(Pygmalion effect, Belief in efficacy of a ttt
changes the outcome). It can be reduced by
performing a double blind study and by having
multiple observers encode and verify the recorded
data.
Becker: Researchers see things based on prior
knowledge.
Confounding When a factor is related to both the exposure and
bias outcome, but not on the causal pathway factor
distorts or confuses effect of exposure on outcome.
To reduce, do multiple/ repeated studies, cross
over studies and matching
Effect Results when an external variable positively or
modification negatively impacts the observed effect of a risk
(NOT a bias) factor on a disease status. When this occurs,
stratified analysis will reveal a significant
difference between the stratified groups.
Proficiency bias Ex. New surgical technique is done by most expert
 surgeon so there is inflated estimate of benefits of
the technique.

Reporting bias Subjects over or under-report exposure history duo

to perceived social stigmatization
When outcome is obtained by the patient's
response, and not by objective diagnostic method
(e.g. Migraine headache)
Respondent bias: When outcome is obtained by the patient's
response, and not by objective diagnostic method
(e.g. Migraine headache)

UW Classification for Biases:

1- Selection Biases: Inappropriate selection or poor
retention of study subjects.
Include: Ascertainment (sampling), Nonresponse, Berkson,
Prevalence, Attrition biases.
2- Observational Biases: Inaccurate measurement or
classification of disease, exposure, or other variable.
Include: Recall, Observer, Reporting, Surveillance
(detection) Biases.

FA Classification for biases:

Bias in recruiting participants selection bias
Bias in performing study: Recall, measurement, procedure,
observer-expectancy bias.
Bias in Interpreting results: Confounding, lead time.
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References: UW for step 1, UW for step 2 CK, FA for step1,
Becker step 1.