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UKURAN ASOSIASI
DALAM EPIDEMIOLOGI
Agus Handito

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UKURAN DALAM KESEHATAN MASYARAKAT

Tipe Kuantitas matematis


1.

Jumlah (enumerasi, counts)

2.

Rasio

3.

Proporsi

4.

Rate (angka, laju)

Tipe Ukuran epid


1.

Frekuensi: insidens, prevalens, mortalitas

2.

Asosiasi: Relative Risk (Risk dan Rate Ratio), Odds Ratio,


Prevalens Odds Ratio

3.

Dampak: Attributable Risk, % Attributable Risk, Prevented Fraction

Ukuran Asosiasi
(Ukuran dari akibat
pemaparan)
Mengukur

keeratan hubungan statistik


antara faktor tertentu dengan kejadian
penyakit yang diduga merupakan akibat
pemaparan tersebut. Hubungan antara
pemaparan dan akibatnya diukur dengan
menggunakan Relative Risk atau Odds
Ratio atau Prevalens Ratio

UKURAN ASOSIASI
Relative

:
RR (relative risk) Studi Cohort
Risk ratio
Rate ratio
Odds Ratio (OR), Prevalence Odds Ratio (POR) studi case
control
Prevalence Ratio (PR) studi cross sectional

Absolute

:
RD (risk difference) Studi cohort

Ukuran asosiasi dalam


epidemiologi

Ukuran asosiasi
Merefleksikan kekuatan atau besar asosiasi
antara suatu eksposur/faktor risiko dan
kejadian suatu penyakit
Memasukkan suatu perbandingan frekuensi
penyakit antara dua atau lebih kelompok
dengan berbagai derajat eksposur
Beberapa ukuran assosiasi digunakan untuk
mengestimasi efek

Basic Question in Analytic


Epidemiology
Are

exposure and disease linked?

Exposure

Disease

Ukuran-ukuran asosiasi

Ukuran rasio (perbandingan relatif)

rasio dua frekuensi penyakit


membandingkan kelompok terpajan
dengan kelompok tidak terpajan

Ukuran perbedaan efek (perbandingan


absolut)

perbedaan antara ukuran frekuensi


penyakit suatu kelompok terpajan dan
kelompok yang tidak terpajan

Two-By-Two Table
Disease
Yes
Yes
Exposure

No

Total

a+b

c+d

No
Total
b+d

a+c

a+b+c+d

Hypothetical Two-By-Two Table


Lung
cancer
Yes

Yes
Smoking

No

Total

70

300

370

15

700

715

No
Total
1,000

85

1,085

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Relative Risk (RR)


Measures

how likely the exposed


group will develop a disease
compared to the unexposed group.

RR =

incidence in the exposed

incidence in the unexposed

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

Example: Hypothetical Study

Lung cancer
Yes

Smoking

No

Total

Yes 70

300

370

No 15

700

715

1,000

1,085

Total 85

Relative Risk (RR)

Relative Risk =

12

70/(70+300) = 9.0
15/(15+700)

Which means participants who smoked


were 9 times more likely to develop lung
cancer than those who did not smoke.

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Relative Risk (RR)


RR of 1.0 indicates that the
occurrence of disease in the exposed
an unexposed groups are identical:
No

association observed between


exposed and unexposed groups.

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Relative Risk (RR)

RR

greater than 1.0 indicates a


positive association, or an
increased risk among the exposed.

RR

less than 1.0 means that there


is a decreased risk among the
exposed group.

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Ukuran-ukuran asosiasi
Ukuran
Rasio

rasio

risiko atau risiko relatif (RR)

RR

Risiko pada kelompok terpajan


Risiko pada kelompok tidak terpajan

Rasio Insidens Kumulatif (RIK)


RIK

Insidens kumulatif pada kelompok terpajan


Insidens kumulatif pada kelompok tidak terpajan

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Perhitungan RR untuk CI
Outcome (+)
E (exposed)

Outcome (-)

a+b

NE (unexposed) c

c+d

Total

a+c

b+d

Total

N
(a + b + c + d)

CI pada populasi exposed (E) --- a/(a + b)


RR=
CI pada populasi unexposed (NE) --- c/(c + d)

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THEN,

FOLLOW TO SEE
WHETHER
Disease
Develo
ps

Disease
Does Not
Develop

Tota
ls

FIRST,
SELECT Expose
d

a+
b

Not
c+
Expose c
d
d a
d
Relative Risk ( RR ) = incidence in exposed
a+b
=
incidence in non-exposed c

c+d

Inciden
ce
rates
of
Disease
a
Incidence
=
a+b
in
exposed
c
= Incidence
c+d
in nonexposed

Example A Prospective Study of 3,000 Smokers and


:
5,000 Non-smokers to Investigate Smoking and
Coronary Heart Disease (CHD)

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THEN FOLLOW UP TO
SEE HOW MANY

FIRST,
SELECT

Do
Inciden
Develo Not
ce per
p
Develo Tota 1,000
l
p
per
CHD
year
CHD
Healthy
Smokers

84

2,916

3,00
28.0
0

Healthy NonSmokers

87

4,913

5,00
17.4
0

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Contoh 5.

Tabel 1. Kaitan antara merokok dan angka insidens


stroke dalam suatu kohort.
Kategori
merokok

Tidak pernah
merokok
Mantan perokok
Perokok

Total

Jumlah kasus
stroke

Orang-tahun
observasi
(lebih dari 8
tahun)

Tingkat
insidens stroke
(per 100.000
orang tahun)

70

395.594

17,7

65
139

232.712
280.141

27,9
49,6

274

908.447

30,2

Sumber: diterjemahkan dari:Beaglehole et al. Basic Epidemiology. WHO. 1993. 18.

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Postmenopausal Hormone Supplement and CHD
CHD
Ever use
Past use
Current
Never use

Person-years
30
19
11
60

54,308.7
24,386.7
29,922.0
51,477.5

RR ever use vs never use = (30/54,308.7) / ( 60/51477.5) = 0.5


RR past use vs never use = (19/24386.7) / (60/51477.5)

= 0.7

RR current use vs never use = (11/29922.0) / (60/51477.5) = 0.3

Prevalence Ratio (PR)

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Prevalence Ratio (PR)


RP

Prevalens pada kelompok terpajan


Prevalens pada kelompok tidak terpajan

Untuk kasus prevalens pada studi cross


sectional survey
Sama seperti perhitungan RR,

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THEN,

FOLLOW TO SEE
WHETHER
Disease
Develo
ps

Disease
Does Not
Develop

Tota
ls

FIRST,
SELECT

Expose
d

a+
b

Prevale
nce
rates
of
Disease
a
a+b =
c
c+d

Not
c+
Expose c
d
d a
d
Prevalence Ratio ( PR ) = Prevelence in exposed
= a+b
Prevelance in non-exposed
c
c+d

Prevalenc
e in
exposed
Prevalenc
e in nonexposed

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Rasio odds (Odds ratio = OR)

Ukuran rasio

Rasio odds (Odds ratio = OR)

Nama lain: Odds relative; rasio krosproduk

rasio dua odds yang digunakan


dalam studi kasus-kontrol untuk
mengestimasi ratio rate atau rasio
risiko

Rasio odds (Odds ratio =


OR)

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Ukuran rasio

Rasio odds (Odds ratio = OR)

odds untuk satu kelompok dibagi


dengan odds untuk kelompok yang
lain

Mempunyai interpretasi yang sama


seperti risiko relatif

Rasio odds (Odds ratio =


OR)

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Odds suatu kejadian

rasio probabilitas bahwa kejadian terjadi


terhadap probabilitas kejadian tidak terjadi

P
Odds suatu peristiwa
1 P
P = Probabilitas suatu kejadian terjadi
1P
= Probabilitas suatu kejadian tidak terjadi

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Figure 11-5 A, Odds ratio (OR) in a cohort study. B, Odds ratio (OR) in a case-control study.

Downloaded from: StudentConsult (on 8 October 2009 11:44 AM)


2005 Elsevier

Prevalence Odds Ratio (POR) = Cross


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Product Ratio bila data didasarkan pada
kasus-kasus prevalens
650 x 350
Prevalence Odds Ratio
4,8
950 x 50
650 / 1600 0,40625
Prevalence ( proportion ) Ratio

3,25
50 / 400
0,125

Faktor
Perokok

Kasus
650 (a)

Kontrol
950 (b)

Total
1600

Bukan
perokok
Total

50 (c)

350 (d)

400

700

1300

2000

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The odds ratio (relative odds)


is a good approximation of the
relative risk when :

1.The cases are


representative of all cases
with regard to exposure;

2.The controls are


representative of all control
with regard to exposure;
=

Odds Ratio & Risk Ratio


The odds ratio will provide a good
estimate of the risk ratio when:

The outcome (disease) is rare


E+
E-

D+
a
c

Db
d

a / (a +b )
RR = -----------c / (c +d)

If the disease is rare, then


cells (a) and (c) will be small

OR = (a / c) / (b / d)
a / (a +b ) a / b ad
OR = (ad) / (bc) RR = ------------ = ------ =-- =___ OR
c / (c +d) c / d
bc
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Figure 11-6 Example: The odds ratio is a good


estimate of the relative risk when a disease is
infrequent.
Downloaded from: StudentConsult (on 8 October 2009 11:44 AM)
2005 Elsevier

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Figure 11-7 Example: The odds ratio is


not a good estimate of the relative risk
when a disease is not infrequent.
Downloaded from: StudentConsult (on 8 October 2009 11:44 AM)
2005 Elsevier

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In a prospective study/cohort study,
the Relative Risk can be calculated
directly

In a retrospective study /case


control study, the RR cannot
be calculated directly, so that
the Relative Odds or ODDS
RATIO ( Cross Products Ratio
) is used as an estimate of the
RR, when the risk of the

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OR & RR

Pada

penyakit yang jarang terjadi, nilai


Odds Ratio hampir sama dengan nilai
Relative Risk (Risk Ratio). Nilai Prevalence
Odds Ratio hampir sama dengan nilai
Prevalence Proportion Ratio.

Pada

penyakit yang umum terjadi, nilai


Odds Ratio lebih ekstrim dari pada Risk
Ratio.

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Interpretation of Odds Ratio


Relative

odds associated with exposure

OR = 1 no association
OR > 1 positive association
OR < 1 negative association
Size of OR indicates strength of association
OR RR when disease rare (i.e., risk < 5%);
when disease not rare, OR still a valid
measure of association

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Thank You