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The Relative Merits of Risk Ratios and Odds Ratios

# The Relative Merits of Risk Ratios and Odds Ratios

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04/08/2012

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REVIEW ARTICLE
The Relative Merits of Risk Ratios and Odds Ratios
Peter Cummings, MD, MPH
W
hen a study outcome is rare in all strata used for an analysis, the odds ratio es-timateofcausaleffectswillapproximatetheriskratio;therefore,oddsratiosfrommost case-control studies can be interpreted as risk ratios. However, if a studyoutcome is common, the odds ratio will be further from 1 than the risk ratio.There is debate regarding the merits of risk ratios compared with odds ratios for the analysis of trials and cohort and cross-sectional studies with common outcomes. Odds ratios are conve-niently symmetrical with regard to the outcome definition; the odds ratio for outcome
is the in-verse of the odds ratio for the outcome not
. Risk ratios lack this symmetry, so it may be neces-sary to present 1 risk ratio for outcome
and another for outcome not
. Risk ratios, but not oddsratios, have a mathematical property called collapsibility; this means that the size of the risk ratiowillnotchangeifadjustmentismadeforavariablethatisnotaconfounder.Becauseofcollapsibil-ity, the risk ratio, assuming no confounding, has a useful interpretation as the ratio change in av-erage risk due to exposure among the exposed. Because odds ratios are not collapsible, they usu-allylackanyinterpretationeitherasthechangeinaverageoddsortheaveragechangeinodds(theaverage odds ratio).
Formorethan20years,therehasbeende-bate about the relative merits of risk ratioscompared with odds ratios as estimates of causal associations between an exposure(such as smoking or medication for highbloodpressure)andabinaryoutcome(suchasdeathvslife).Inthisarticle,Idiscusshowthese measures differ and review argu-ments for each. To limit my discussion, Iwill ignore other useful measures of asso-ciation,suchastherateratio,hazardratio,risk difference, and rate difference.
AGREEMENTS REGARDING RISKRATIOS AND ODDS RATIOS
Inaclinicaltrialorcohortstudyinwhichall subjects are followed up for the sametime, the cumulative incidence (averagerisk) of the outcome is
A
/(
A
B
) amongthose exposed (
Table 1
) and
C
/(
C
D
)amongthosenotexposed;thecorrespond-ingoddsare
A
/
B
and
C
/
D
,respectively.Therisk ratio is therefore [
A
/(
A
B
)]/[
C
/ (
C
D
)] and the odds ratio is (
A
/
B
)/(
C
/
D
). In the literature about these ratios,there are 2 areas where there is generalagreement:iftheoutcomeisrare,theoddsratio will approximate the risk ratio; andin most case-control studies, odds ratioswill approximate risk ratios.
Approximation of Risk Ratios by OddsRatios When Outcomes Are Rare
If the study outcome is rare among thoseexposed (Table 1), then
A
will be smallrelative to
B
, so the risk (
A
/[
A
B
]) willbeclosetotheodds(
A
/
B
).Similarly,iftheoutcome is rare among those not ex-posed, then
C
will be small relative to
D
and [
C
/(
C
D
)] will be close to (
C
/
D
). If
Author Affiliations:
Department of Epidemiology, School of Public Health andCommunity Medicine, and Harborview Injury Prevention and Research Center,University of Washington, Seattle.
(REPRINTED) ARCH PEDIATR ADOLESC MED/VOL 163 (NO. 5), MAY 2009 WWW.ARCHPEDIATRICS.COM