Standardisasi

Rate

• rate mengukur frekwensi suatu kejadian

• terdiri dari :
• numerator
• denominator
• waktu

• numerator: menunjukkan jumlah kejadian selama periode

waktu tertentu

• denominator: menunjukkan jumlah populasi dimana kejadian

terjadi

• waktu : menunjukkan periode waktu kejadian terjadi

2
Kalkulasi dari rate :

number of occurence of event in specifief time

rate = ------------------------------------------------------------------- x konstanta
average or mid-interval population

• data surveilens sering

• hanya memberi informasi tentang data numerator saja
• dalam bentuk angka kasar

• angka kasar
• hanya menggambarkan jumlah kejadian
• tidak memperhatikan:
• jumlah populasi dari mana kejadian terjadi
• distribusi karakteristik demografis di populasi
dari mana kejadian terjadi

3
Rate memberi informasi yang lebih lengkap :
• karena mengandung informasi tetang :
• jumlah kejadian
• jumlah populasi dari mana kejadian terjadi
• periode waktu kejadian terjadi

Rate memberi kondisi yang komperabel :

• dapat untuk membandingkan frekwensi kejadian
secara lebih komperabel :
• frekwensi kejadian penyakit di populasi dari
waktu ke waktu
• frekwensi kejadian penyakit diantara satu populasi
dengan populasi lain
• frekwensi kejadian penyakit diantara sub populasi

4
Kegunaan rate dalam epidemiologi :

• menghitung rate kejadian merupakan suatu hal yang yang

paling penting dalam peneilitian epidemiologi
• dengan menghitung rate, informasi tadi dapat digunakan
untuk :
• memformulasikan dan membuktikan hipotesis
• mengidentifikasikan faktor risiko dan penyebab
• membandingkan secara komperabel frekwensi
kejadian diantara populasi

5
Crude, Specific, and Standardized Rates

Rate dapat dihitung dari

• seluruh populasi atau
• subpopulasi yang ada di populasi besar

Crude rate :
• dihitung dari seluruh populasi
• contoh : crude death rate
• numerator = jumlah seluruh kematian selama interval
waktu tertentu
• denominator = jumlah populasi rata-rata selama
interval waktu yang sama

6
7
8
CDR (angka kematian kasar)
populasi A dan B

9
Specific rate :
• dihitung dari subpopulasi
• contoh : age specific death rate :
• numerator : jumlah kematian pada kelompok usia
tertentu selama interval waktu tertentu
• denominator: jumlah populasi rata-rata kelompok
usia tertentu selama interval waktu yang sama

• contoh lain :
• sex specific death rate
• numerator : jumlah kematian pada kelompok sex
tertentu selama interval waktu tertentu
• denominator : jumlah populasi rata-rata kelompok
sex tertentu selama interval waktu yang sama

10
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 Numerical Illustrations
Table 7.2 (p. 144)

Population A Population B
Rate Rate
Age Cases Persons Cases Persons
per 100,000 per 100,000

Young 99 99,000 100 1 1,000 100

Old 10 1,000 1,000 990 99,000 1,000

All 109 100,000 109 991 100,000 991

Rate in Population B is 9× that of Population A

15
 Illustrative Example (Table 7.2, cont.)

Population A Population B
Age Cases Persons Rate Cases Persons Rate

Young 99 99,000 100* 1 1,000 100

Old 10 1,000 1,000 990 99,000 1,000

All 109 100,000 109 991 100,000 991

Within young, rates are identical

* Rates are per 100,000. Example of calculation: R = 99 ÷ 99,000 × 100,000 = 16
100
 Illustrative Example (Table 7.2 cont.)

Population A Population B
Age Cases Persons Rate Cases Persons Rate

Young 99 99,000 100 1 1,000 100

Old 10 1,000 1,000 990 99,000 1,000

All 109 100,000 109 991 100,000 991

Within old, rates are identical

17
 Why the apparent paradox?
Population A Population B
Age Cases Persons Rate Cases Persons Rate

Young 99 99,000 100 1 1,000 100

Old 10 1,000 1,000 990 99,000 1,000

All 109 100,000 109 991 100,000 991

Pop. A mostly young, Pop. B mostly old

18
 And rates are age-related

Population A Population B
Age Cases Persons Rate Cases Persons Rate

Young 99 99,000 100 1 1,000 100

Old 10 1,000 1,000 990 99,000 1,000

All 109 100,000 109 991 100,000 991

You’re OK as long as you compare like-to-like

19
 Confounding
• Explanatory factor
associated with age
• Extraneous factor
associated with confounder
disease rate Age
• Extraneous factor
confounds relation
between
explanatory factor Population Rate
and disease rate explanatory disease
factor

20
 REASONS FOR STANDARDIZATION
1. To REMOVE THE EFFECT ON CRUDE RATES WHICH
ARE DUE TO DIFFERENCES IN THE COMPOSITION OF
POPULATIONS BEING COMPARED

2. TO ARRIVE AT SIMPLE SUMMARY MEASURES WHICH

ARE MORE READILY COMPARED THAN A SERIES OF
RATES

3. IF THE SPECIFIC RATES ARE IMPERCISE BECAUSE OF

SMALL NUMBERS OF THE NUMERATOR AND
DENOMINATOR, THEN THEY ARE UNRELIABLE TO
BE USED FOR COMPARISON

4. THE SPECIFIC RATES FOR ONE OR MORE OF THE

POPULATIONS UNDER STUDY ARE NOT AVAILABLE
Standardized Rate

• jika crude rate dibandingkan diantara populasi atau

untuk populasi yang sama pada waktu yang berbeda
• maka perbadingan rate tadi tidak komperabel jika :
• distribusi frekwensi faktor-faktor yang mempengaruhi
kejadian kematian tidak mirip/sama diantara populasi
yang dibandingkan
• faktor-faktor yang dapat mempengaruhi kejadian
kematian antara lain:
• umur
• ras
• sex
• status sosial ekonomi
• faktor risiko lainnya (mis. status kesehatan dll)

22
Agar perbandingan rate diantara populasi dapat komperabel
maka crude rate harus distandarisisasi dengan faktor-
faktor konfounding tadi

Metode standarisasi :
• Direct standardization (standarisasi langsung)
• Indirect standardization (standarisasi tak langsung)

23
Standardisasi
■ Kapan Standardisasi?
◻ Membandingkan rate penyakit pada populasi yg
mempunyai distribusi karakteristik populasi yg
berbeda dan karakteristik tersebut berhubungan
dengan penyakit
■ 2 cara membandingkan:
◻ Menggunakan category-specific rate
◻ Menggunakan adjusted rate

24
 AGE SPECIFIC DEATH RATES PER 1000
PERSONS IN TWO FLORIDA COUNTIES (1960)
I I
AGE GROUP MX MX
PINELLAS COUNTY DADE COUNTY
0-1 28.2 28.8
2-4 1.4 1.2
5-14 0.6 0.4
15-24 0.8 1.2
25-34 1.4 1.7
35-44 3.0 3.3
45-54 7.7 8.2
55-64 15.9 16.7
65-74 28.9 31.1
75+ 82.8 84.2
CRUDE DEATH RATE
Total 15.3 8.9 25
 AGE DISTRIBUTION OF TWO FLORIDA
COUNTIES (1960)
AGE % OF POPULATION IN EACH AGE
GROUP GROUPS
PINELLAS COUNTY DADE COUNTY
0-1 1.5 2.0
2-4 5.9 8.0
5-14 13.9 17.4
15-24 8.7 11.6
25-34 9.0 13.3
35-44 11.1 15.0
45-54 11.1 12.6
55-64 13.9 10.0
65-74 17.6 7.3
75+ 7.3 2.8

26
Metode standarisasi langsung

• cara kalkulasi
• menggunakan specific rate berdasarkan variabel yang
akan dikontrol (misal umur, sex dll) pada populasi studi
• specific rate tadi diaplikasikan pada populasi standard
berdasarkan variabel yang akan dikontrol (umur, sex dll)

• standarisasi ini menggambarkan :

• apa yang akan terjadi dengan crude rate pada populasi
studi jika distribusi dari variabel yang dikontrol
(misal umur, sex) sama dengan populasi standard

27
METODA STANDARDISASI
LANGSUNG
DATA YANG HARUS TERSEDIA :
• SPECIFIC RATE DARI VARIABEL
POPULASI STUDI /POPULASI YANG
AKAN DIKONTROL
• DISTRIBUSI VARIABEL YANG AKAN
DI KONTROL PADA POPULASI
STANDARD

28
 DATA NECESSARY
FOR DIRECT METHOD
1. Specific rates for each category of
populations being studied.

2. The distribution (frequencies) across the

various strata of a selected
standard/reference population
 AGE SPECIFIC DEATH RATES PER 1000
PERSONS IN TWO FLORIDA COUNTIES (1960)
I I
AGE GROUP MX MX
PINELLAS COUNTY DADE COUNTY
0-1 28.2 28.8
2-4 1.4 1.2
5-14 0.6 0.4
15-24 0.8 1.2
25-34 1.4 1.7
35-44 3.0 3.3
45-54 7.7 8.2
55-64 15.9 16.7
65-74 28.9 31.1
75+ 82.8 84.2
CRUDE DEATH RATE
Total 15.3 8.9 30
 AGE ADJUSTED DEATH RATES
(Direct Method)

AGE I
MX I
MX Standard Expected death: sEX = IMX . spX
GROUP PINELLAS DADE population PINELLAS DADE
COUNTY COUNTY structure (spX) COUNTY COUNTY
0-1 28.2 28.8 23000 649 662
2-4 1.4 1.2 90000 126 108
5-14 0.6 0.4 199000 119 80
15-24 0.8 1.2 134000 107 161
25-34 1.4 1.7 127000 179 216
35-44 3.0 3.3 134000 402 442
45-54 7.7 8.2 114000 878 935
55-64 15.9 16.7 87000 1383 1453
65-74 28.9 31.1 61000 1763 1897
75+ 82.8 84.2 31000 2558 2613

All ages 15.3 8.9 1000000 8164 8567

31
 AGE ADJUSTED DEATH RATES
(Direct Method)

Expected
Age Adjusted Death Rate (MDIR)=
Std. population
Pinellas County:
8164
MDIR = x 1000 = 8.2 per 1000 1000000
Dade County:
8567
MDIR = x 1000 = 8.6 per 1000 1000000

32
CDR (angka kematian kasar)
populasi A dan B

33
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35
Hillsborough 1995 (top) Pinellas 1995 (bottom)
Age Popul. # Deaths % of Popul. Death Rate
0 to 14 190,703 174 21.4% 0.0009
15 to 24 115,928 115 13.0% 0.0010
25 to 44 289,441 620 32.4% 0.0021
45 to 64 180,396 1,435 20.2% 0.0080
65 + 116,406 5,657 13.0% 0.0486
TOTAL 892,874 8,001 100.0% 0.0090

Age Popul. # Deaths % of Popul. Death Rate

0 to 14 138,986 116 15.9% 0.0008
15 to 24 83,815 63 9.6% 0.0008
25 to 44 239,396 498 27.3% 0.0021
45 to 64 190,427 1,421 21.7% 0.0075
65 + 223,576 10,326 25.5% 0.0462
TOTAL 876,200 12,424 100.0% 0.0142
 STANDARDIZATION
Direct Standardization:

One way to select the standard population is to

combine population counts from the
populations.

We can then apply the category-specific death

rates to the standard population to calculate
and compare the expected number of deaths in
each population.
 STANDARDIZATION
H+P Death Rate Expected Deaths
Age Popul. H P H P
0 to 14 329,689 .0009 .0008 296 263
15 to 24 199,743 .0010 .0008 199 159
25 to 44 528,837 .0021 .0021 1,110 1,110
45 to 64 370,823 .0080 .0075 2,966 2,781
65 + 339,982 .0486 .0462 16,523 15,707
TOTAL 1,769,074 ----- ----- 21,094 20,020

Adjusted Death Rate (H) = 21094 / 1,769,074 = 1,192 per 100K

Adjusted Death Rate (P) = 20020 / 1,769,074 = 1,132 per 100K
 STANDARDIZATION
Adjusted Death Rate (H) = 21094 / 1,769,074 = 1,192 per
100K
Adjusted Death Rate (P) = 20020 / 1,769,074 = 1,132 per
100K

Age-adjusted rate ratio = 1,192 / 1,132 = 1.05

Using Hillsborough + Pinellas county as the

standard population:

The age-adjusted 1995 death rate appears to be

approximately 5% higher in Hillsborough county
compared to Pinellas county.
 STANDARDIZATION

Direct Standardization:

Another way to select the standard population

is to use an external standard population,
such as the United States population.

As before, we can then apply the

category-specific death rates to the standard
population to calculate and compare the
expected number of deaths in each
population.
 STANDARDIZATION
U.S. Death Rate Expected Deaths
Age Popul. H P H P
0 to 14 55,961,000 .0009 .0008
15 to 24 36,124,000 .0010 .0008
25 to 44 82,366,000 .0021 .0021
45 to 64 48,345,000 .0080 .0075
65 + 32,283,000 .0486 .0462
Total 255,079,000 ----- -----

Adjusted Death Rate (H) =

Adjusted Death Rate (P) =

 STANDARDIZATION
U.S. Death Rate Expected Deaths
Age Popul. H P H P
0 to 14 55,961,000 .0009 .0008 50,364 44,768
15 to 24 36,124,000 .0010 .0008 36,124 28,899
25 to 44 82,366,000 .0021 .0021 172,968 172,968
45 to 64 48,345,000 .0080 .0075 386,760 362,587
65 + 32,283,000 .0486 .0462 1,568,953 1,491,474
Total 255,079,000 ----- ----- 2,215,169 2,100,696

Adj. Death Rate (H) = 2,215,169 / 255,079,000 = 868 per 100K

Adj. Death Rate (P) = 2,100,696 / 255,079,000 = 824 per 100K

 STANDARDIZATION
Adj. Death Rate (H) = 2,215,169 / 255,079,000 = 868 per 100K
Adj. Death Rate (P) = 2,100,696 / 255,079,000 = 824 per 100K

Age-adjusted rate ratio = 868 / 824 = 1.05

Using the United States as the standard

population:

The age-adjusted 1995 death rate appears to be

approximately 5% higher in Hillsborough county
compared to Pinellas county.
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52
Prosedur Perhitungan: Direct
■ Dapatkan category-specific rates populasi
yang dibandingkan
■ Tentukan standard populasi
■ Hitung jumlah “expexted deaths/cases”
■ Hitung rate yang distandardisasi:
Total “expected deaths/cases”
Total populasi standard

53
Metode standarisasi tidak langsung

• cara kalkulasi
• menggunakan specific rate berdasarkan variabel yang
akan dikontrol (misal umur, sex dll) pada standard populasi
• standard spesific rate tadi diaplikasikan pada populasi studi
berdasarkan variabel yang akan dikontrol (umur, sex dii)
konfounder lain)

• standarisasi ini menggambarkan :

• apa yang akan terjadi dengan crude rate pada populasi
studi jika distribusi dari specific rate nya sama dengan
populasi standard

54
 METODA STANDARDISASI
TIDAK LANGSUNG

DATA YANG HARUS TERSEDIA :

1. DISTRIBUSI VARIABEL YANG AKAN

DIKONTROL PADA POPULASI STUDI (distribusi
umur ,sex)
2. DISTRIBUSI SPECIFIC RATE BERDASARKAN
VARIABEL YANG DIKONTROL PADA POPULASI
STANDARD.
3. CDR POPULASI STUDI
4. CDR POPULASI STANDARD
 AGE ADJUSTED DEATH RATES
(Indirect Method)
AGE I
PX I
PX Death rates per Expected death: IEX = sMX . ipX
GROUP 1000 in std.pop PINELLAS DADE
PINELLAS DADE
COUNTY COUNTY (s M X ) COUNTY COUNTY
0-1 5674 18819 27.0 153 508
2-4 22167 74554 1.1 24 82
5-14 51932 162633 0.5 26 81
15-24 32565 108310 1.1 36 119
25-34 33877 126938 1.5 51 187
35-44 41633 140768 3.0 125 422
45-54 41670 118013 7.6 317 897
55-64 51985 93058 17.4 905 1619
65-74 65783 67994 38.2 2513 2597
75+ 27379 25960 106 2902 2752

All ages 374665 935047 9.5 7052 9264

Observed 5732 8245
56
death IDX
 AGE ADJUSTED DEATH RATES
(Indirect Method)

obs. death
Adjusted Death Rate (MInd)= CDR x
Expected death
Pinellas County:
SMR = (obs/expec) = 5732/7052 = 0.82
Mind = (9.5 x (5732/7052)
= 7.8 per 1000
Dade County:
SMR = 8245/9264 = 0.90
Mind = (9.5 x (8245/9264)
= 8.5 per 1000

57
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SMRT & IAR (Indirect Adjusted Rate)

59
60
Prosedur Perhitungan: Indirect
■ Tentukan category-specific rates populasi
standard
■ Dapatkan distribusi populasi yang dibandingkan
■ Hitung jumlah “expexted deaths/cases”
■ Hitung SMR :
Jumlah kematian yang diobservasi
Jumlah “expected deaths”
■ Hitung rate yang distandardisasi:
SMR x Crude Death Rate populasi standard

61
 ADJUSTED RATES
•statistically constructed summary rates
that account for the difference between
population with respect to these other
variable
The use for comparison:

■ Indirect method : relative comparison (population

of interest with population standard)

■ Direct method: direct comparison (population of

interest with other population of interest)
 Standard population

1. Distribution of one of the

population of interest
2. Combining the two population
of interest
3. Other population (outside
standard of interest)
 ADVANTAGES AND DISADVANTAGES
CRUDE, SPECIFIC, ADJUSTED RATES
Rates Advantages Disadvantages

Crude 1. Actual summary rates 1. Difference crude

2. Readily calculable for rates difficult to
international comparison interpret (vary in
widely used composition)
Specific 1. Comparison is made 1. Cumbersome to
between homogens compare subgroup
sub-group (more several subgroups
accurate) of two or more
2. Detailed rates are useful populations
for epidemiologic and
public health purpose 65
 ADVANTAGES AND DISADVANTAGES
CRUDE, SPECIFIC, ADJUSTED RATES

Rates Advantages Disadvantages

Adjusted 1. Summary statement 1. Fictional rates

2. Differences in 2. Absolute
composition of magnitudes depend
groups are removed on standard
permitting unbiased population chosen
comparisons 3. Actual value of
adjusted is
meaningless

66
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