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Ukuran Ukuran

Epidemiology

1.

2.

JUMLAH atau ANGKA adalah cara sederhana untuk menunjukkan derajat


dari suatu penyakit atau problem kesehatan dalam segi kuantitas. Jumlah dari
suatu penyakit tertentu harus ditunjukkan dalam periode waktu tempat
tertentu
sesuai referensi.
x
Rasio = -------- x K
Y
X = jumlah orang dengan angka kejadian
Y = jumlah seluruh orang pada kejadian yang lain
K = Konstanta, umumnya 1 atau 100
Jumlah Pddk < 15 Tahun + Pnddk > 65 Tahun
Dependency Ratio = ------------------------------------------------------------Jumlah Seluruh Penduduk umur 15 64 tahun

3. PROPORSI : Suatu proporsi menunjukkan bahwa pembilang selalu


termasuk dalam penyebut. Ini digunakan untuk mencari kuantitas relatif
dari kejadian tertentu, dibandingkan terhadap jumlah seluruh
kejadian
yang ada. Rentang dari proporsi adalah 0-1. Bagaimanapun jika
pengali, 100, digunakan sehingga rentang
proporsi menjadi 0-100, ini
disebut persentase

Cause Specifics Death Ratio


Jumlah kematian karena sebab spesifik dalam satu tahun
Jumlah seluruh kematian (seluruh kasus) periode yang sama

Proporsi kematian oleh PJK


Jumlah kematian karena PJK
Jumlah seluruh kematian pada periode yang sama

120/450 = 0,27

1.
2.
3.

INDEKS
Kata indeks secara umum digunakan terbatas dalam kesehatan
masyarakat.
Biasanya sebagian besar indeks adalah indeks vital
Pada kenyataan, angka, rasio, proporsi, adalah seluruh indeks
kesehatan, karena seluruhnya dapat menunjukkan tingkat
kesehatan, dalam aspek yang berbeda.

Ukuran Ukuran Epidemiologi


1.
Ukuran mortalitas (angka kematian)
2.
Ukuran morbiditas (angka kesakitan)
3.
Ukuran kekuatan kelompok (Resiko Relatif)
4.
Ukuran hubungan potensial (Fraksi atributabel
populasi)

Ukuran Morbiditas

1. Prevalence Rate
2. Specifics Prevalence Rate
3. Incidence Rate: jumlah kasus2 baru dari suatu penyakit
tertentu dalam kurun waktu tertentu dibagi dengan populasi.

4. Specifics Incidence Rate

Ukuran Mortalitas
1. Crude Mortality Rate
2. Specifics Mortality Rate

Ukuran Ukuran Resiko

Absolute Risk
Risk Difference : perbedaaan resiko antar paparan
Relative Risk
Adjusted Relative Risk
Attributable Risk
Population Attributable Risk
Absolute Risk Reduction (ARR)
Relative Risk Reduction (RRR)
Numbers Needed to Treat (NNT)
Numbers Needed to Harm (NNH)

Apakah A berhubugan dengan B?

Exposure
Treatment
Program
Process
Characteristic
Behavior

Effect
Death
Outcome
Cost
Disease

Absolute Risk
Insiden penyakit didalam populasi dalam
ukuran Absolute
Menunjukan derajat resiko suatu group
populasi dengan karakteristik
Tidak dapat dibandingkan
Tidak ada hubungan dengan intervensi ataupun
paparan
Contoh Resiko : resiko fraktur pangkal paha
pada wanita yang diterapi dengan alendronate

Perbandingan Resiko
Harus dibandingkan antara kelompok
yang terpapar dengan kelompok yang
tidak terpapar)
Dua bentuk pendekatan yang biasa
dipakai
Risk difference = Perbedaan Resiko
Risk Ratio = Ratio dari kedua resiko

Risk Difference
Perbedaan Resiko
Risk difference= IE IC (control)
(incidence terpapar) - (incidence tidak terpapar)

Contoh

Intervensi : Fosamax; Controls: Placebo


Outcome: Fraktur Klinis
IE = 11.9 per 100; IC = 14.7 per 100
Risk difference = 11.9-14.7 = -2.8 per 100

Attributable Risk
Terpapar

Tidak terpapar

Attributable risk
Kalkulasi:
Perbedaan dari absolut risk =risk difference = ARD
= (incidence terpapar) - (incidence tidak terpapar) = A.R

Relative Risk (RR)


RR = IE/IC
(incidence in exposed) / (incidence in nonexposed)

Contoh:

Intervensi: Fosamax; Controls: Placebo


Outcome: Fraktur Klinis
IE = 11.9 per 100; IC = 14.7 per 100
RR = 11.9/14.7 = 0.81

Relative Risk/Resiko Relatif


Terpapar
Tidak terpapar

Interpretasi dari Relative Risk


RR = 1

RR > 1

RR < 1

Insiden kelompok terpapar


dan tidak terpapar(Tidak
ada Hubungan)
Insiden kelompok terpapar
lebih besar dari kelompok
tidak terpapar.
Insiden kelompok terpapar
lebih kecil dari kelompok
tidak terpapar.(Protektif)

Rumus Relatif Risk


Outcome
Yes

No

Total

Yes

a+b

No

c+d

Exposure

Relative risk = incidence in exposed


incidence in nonexposed

Hitunglah Resiko relatif


Heart Disease
Yes

No

Yes

40

360

400

No

200

1400

1600

Regular
Exercise

RR

= I(e)
I(ne)

Interpretation:

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

Hitunglah resiko Relatif


Any MH Visits No MH Visits
MH benefit

600

400
a

No MH
benefit
Relative risk =

1000
b

300

700
c

1000
d

Interpretation:

Legend: MH Visit -- any use of mental health services


MH Benefit - person has a health insurance
that provides coverage for MH visits

Penelitian Kasus Kontrol

Hip Fracture
(cases)

Received
Health
Promo
a

Did Not
Receive
Health
Promo
c

No
Hip Fracture
(controls)

Received
Health
Promo
b

Did Not
Receive
Health
Promo
d

Penelitian Kasus Kontrol


Hip Fx
(cases)

No Hip Fx
(controls)

Promo

No Promo

Total

a+c

b+d

Odds Ratio (OR) or Relative Odds (RO) =


Odds that a case was exposed
Odds that a control was exposed

ad
bc

Promo -- Person has participated in injury prevention program


Hip Fx -- Person has a hip fracture

Hitunglah Odd Ratio


Hip Fx

No
Hip Fx

Promo

100

200

No Promo

900

800

Odds Ratio =

Interpretation:

Promo -- Person has participated in injury prevention program


Hip Fx -- Person has a hip fracture

Hitunglah Odd Ratio


CHD

Smokers
Non-Smokers
Total
Odds Ratio

Cases

Controls

120

170

80

230

200

400

Interpretation:

CHD -- Coronary heart disease

Adjusted Risk
Resiko yang disesuaikan
Kegunaan
Untuk dapat dibandingkan
Memperhitungan perbedaan Co-Variate
yang ada
dalam group yang diteliti

Metoda Penyesuaian/Adjustment
Standarisasi
Mantel Haenszel
Log-linear models

risk models
odds models
rate models
incidence-time models

Adjusted RR
Myocardial Infarction
Yes
No

Total

Education
High School

100

1700

1800

College

60

1140

1200

130

2570

2700

1-4 years

105

110

5-9 years

10

120

130

10 + years

15

45

60

160

2840

3000

Oral Contraception
Never

Total

Adjusted RR
Myocardial Infarction
Crude
Adjusted*
95% C.I.
RR
RR
Education
High School

1.11

--

--

--

--

--

1-4 years

0.98

1.0

(0.9-1.1)

5-9 years

1.60

1.3

(0.9-1.7)

10 + years

5.20

4.1

(2.1-6.1)

College
Oral Contraception
Never

*Adjusted for educational status

Absolute Risk Reduction (ARR)


Absolute Risk Reduction (ARR) adalah
perbedaan angka kejadian antara kelompok
kontrol dan kelompok perlakuan(control group
(CER) dan exposure group (EER): ARR = CER EER.
Example:

Perlakuan: Fosamax; Controls: Placebo


Outcome: Fraktur Klinis
CER = 14.7 per 100; EER = 11.9 per 100
ARR = 14.7-11.9 = 2.8 per 100

Hitunglah
Absolute Reduction Risk
ARR (Fosamax vs Placebo) untuk fraktur pangkal
paha for hip fracture risk in the study reported in
the article:
Black DM; Cummings SR; Karpf DB; Cauley JA;
Thompson DE; Nevitt MC et al. Randomised trial of
effect of alendronate on risk of fracture in women
with existing vertebral fractures. Fracture
Intervention Trial Research Group. Lancet 1996;
348:1535-41

Number needed to treat


NNT Adalah penderita yang harus diobati untuk
mengurangi 1 tambahan outcome yang jelek
(death, stroke, etc.).
Perhitungan: NNT = 1/ARR
NNHs Adalah jumlah penderita yang harus
ditambahkan untuk menimbulkan 1 effek buruk
(side effect, etc.)

For more information: http://cebm.jr2.ox.ac.uk/docs/nnt.html

CONTOH- NNT

ARR =(18.2-13.6) /100 = 0.046


NNT = 22

HITUNGLAH NNT
Hitunglah NNT untuk Hip Fraktur
Dari artikel
Black DM; Cummings SR; Karpf DB; Cauley
JA; Thompson DE; Nevitt MC et al.
Randomised trial of effect of alendronate on
risk of fracture in women with existing
vertebral fractures. Fracture Intervention Trial
Research Group. Lancet 1996; 348:1535-41

Population attributable risk


Proporsi populasi dengan penyakit
tertentu dan paparan tertentu
Perhitungan:
(incidence in total population) - (incidence in non-exposed
group)

Relative Risk Reduction (RRR)


Relative Risk Reduction (RRR)
RRR = (CER - EER) / CER * 100
Cara Kalkulasi lainnya:

RRR = (1-RR) * 100

CONTOH - RRR

RRR = ((CER-EER)/ CER) * 100


=((0.182-0.136)/0.182) * 100 = 35%

Population Attributable Risk


Risk in Total Population-Background Risk
e.g. (12/1,000) - (9/1,000) = 3/1,000

Due to Exposure

Incidence Non-exposed

Incidence Exposed

Levine equation/Formula
(pe(RR-1))/(pe(RR-1)+1)
Example:
RR=2; pe= 33%
(0.33(2-1))/(0.33(2-1)+1)=0.33/1.33=25%
25% of 12/1,000 = 3/1,000

PAR - example

Cut point in bone density of 1 SD below age adjusted mean


associated with three different lifetime incidences of hip
fracture. Relative risk of hip fracture is assumed to be 2.6 per
1 SD decrease in bone density.
From: Marshall: BMJ, vol. 312(7041), May 18, 1996, pp. 12541259.

Epidemiologic Study Design


Cohort study
Case-control studies
Nested case-control study
Case-cohort study
Case-crossover study

Miscellaneous studies

Clinical trial
Intervention study
Cross-sectional study
Other (e.g., ecological study, case study and case series)

Design of a Cohort Study


R1

A1
A0

R0
Incidence rate among exposed IR1 = A1 (no. exposed cases) / R1 (total person-time exposed)
Incidence rate among unexposed IR0 = A0 (no. unexposed cases) / R0 (total person-time unexposed)
Incidence rate ratio (exposed vs. unexposed) = IR1 / IR0 = (A1/A0) / (R1/R0)
Source: partially adapted from WHO, 1993

Worksheet for Using an Article About Prognosis

Design of a Case-Control Study


a
b
c
d
note that c and d should be appropriate
representation of R1 and R0 as shown for cohort study

should be representative of source population

Exposure odds among cases D1 = a (no. exposed cases) / b (no. unexposed cases)
Exposure odds among controls D0 = c (no. exposed controls) / d (no. unexposed controls)
Exposure odds ratio (cases vs. controls) = (a/b) / (c/d) where a/b = A1/A0 as shown for cohort study
Source: partially adapted from WHO, 1993

Nested Case-Control Study (1)


Consider the following hypothetical cohort:
X

X = lung cancer case


O = loss to follow-up

O
O

X
t1

t2
Time

t3

Nested Case-Control Study (2)


At time t1 the first case occurs for which 8 eligible controls
are identified
Similarly, there are 5 eligible controls for the case at time t2,
and 4 eligible controls for the case occurring at time t3
A control can become a case at a later time (e.g., cases at t2
and t3 serve as control for case at t1)
Controls can be selected randomly from all eligible controls
(i.e., 1 or more controls for each case)
Number of eligible controls decreases with increasing
number of matching factors

Case-Cohort Study (1)


Consider the following hypothetical cohort:
X

X = lung cancer case


O = loss to follow-up

O
O

X
t0
Time

Case-Cohort Study (2)


In closed cohort (in this case, when everybody enters cohort
at t0), a sample of control subjects (sub-cohort) is randomly
selected from cohort members at start of follow-up t 0
In open cohort (i.e., when time of entry into cohort is
variable), a sample of control subjects (sub-cohort) is
randomly selected from members of entire cohort (i.e.,
regardless of when subjects entered the cohort)
Case-cohort study population consists of all cases of any
disease of interest, and members of sub-cohort(can use
same control group for many different outcomes)
A subject can be both case and member of sub-cohort

Case-Crossover Study
Study of triggers within an individual
Case" and "control" component, but information of both
components will come from the same individual
Case component" = hazard period which is the time period
right before the disease or event onset
Control component" = control period which is a specified
time interval other than the hazard period
Exposure must vary from time to time within person
Disease must have abrupt onset, and effect of exposure must
be brief

Final Remarks on Cohort and Case-control Studies


Cohort and case-control studies can be either prospective or
retrospective, or both
Prospective: Exposure information is collected during follow-up, and
period of time at risk occurs during conduct of the study
Retrospective: Cohorts (cohort study) or cases (case-control study) are
identified from recorded information, and period of time at risk has already
occurred before the study has begun

Measures of effect (ratios)


Cohort study: Incidence rate ratio (open cohort) or risk ratio (closed cohort)
Case-control study: Exposure odds ratio as estimate of incidence rate ratio
(e.g., incidence density sampling) or risk ratio (e.g., cumulative incidence
sampling)

Miscellaneous Study Designs


Clinical trials
randomization of individuals to a treatment or reference
group

Cross-sectional studies
measures prevalence of health outcomes or
determinants of health (e.g., biomarkers) at a point in
time or over a short period

Intervention studies
intervention usually on community level rather than
individual level