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Medical Epidemiology=study of the factors affecting the occurrence and

distribution of disease in human pops

Incidence rate=ratio of the number of new cases of a disorder to the number of
potential new cases
# new of cases/# of people in pop set
Prevalence rate=ratio of number of present cases of disorder to the number of
potential cases
# of total cases/# of people in pop set
Point Prevalence=# of people that have an illness at a specific point (like
on a specific date) divided by the people that could have it on that date ie the
population of the sample
# ill at point in time / # of people in pop set
Period Prevalence=# of people that have an illness during a specific time
period (like during a specific year)/# of people that could have it during that period
(the pop of the sample)
# ill during time period / # of people in pop set
Prevalence=incidence rate * average duration of the disease process
If disease lasts long time then Prevalence>Incidence (ex. HIV) (Influenza
Prevalence = Incidence)
Health intervention that prevent disease dec incidence and thus prevalence
In case of HIV if new drug inc live expectancy the prevalence will inc
Relative Risk (RR)=compares incidence rate of a disorder among people exposed
to risk factor with the incidence rate of those not exposed
Data collected via cohort study
((#exposed + disease)/pop) / ((#not exposed + disease)/pop)
Example the risk of lung cancer is X times higher for smokers than
Attributable risk=incidence rate of illness in exposed incidence rate of not
Data collected via cohort study
Used to determine how many cases can be attributed to the exposure
((#expose + disease):pop) ((#not exposed + disease):pop)
Example X cases of lung cancer can be attributed to smoking

Odds Ratio= Tells the risk of a disease for those exposed as compared to those not
Data collected via case-control study
Can estimate the relative risk in this type of study
(Exposed + disease * not exposed disease) / (not exposed + disease *
exposed disease)
Example the risk of lung cancer is X times higher for smokers than
Number Needed to Harm= # of people that must be exposed to a risk factor for
one person to be harmed that wouldnt have otherwise been harmed
1 / attributable risk (inverse of attributable risk)
Number needed to treat (NNT)= # of people who need to be treated for one
person to benefit from a treatment
1 / absolute risk reduction
Absolute risk= # w/ disease / pop
Absolute risk reduction= absolute risk of placebo group absolute risk of
treatment group
Biased test/study= constructed so one outcome is more likely that the other to
Selection Bias=if subjects or investigator allowed to choose group assignments
Sampling Bias= subjects to not represent the population being studied- results
may not be generalizable
Recall Bias= knowledge of the presence of a disorder alters the way the subject
remembers his/her history (ex mothers of children w/ cleft palate ay over estimate
how much meds they took during preg..can lead to false finding that certain meds
related to cleft palate)
Lead-time Bias=early detection of disease is confused with inc survival or inc
incidence rate
Surveillance bias=people that are aware they are being followed for the
development of a disease are more likely to seek testing and thus be identified
Late-look Bias=people who already died from the disease are not included in the
sample. symptoms of disease seem less severe
Single blind=subject doesnt know if getting treatment or not
Double Blind=neither subject nor evaluator knows the assignments

Crossover study= in beginning group 1 no treatment group 2 treatment, then

Each person can act as their own control
Reliability= reproducibility / dependability of results
Interrater reliability=are the results the same when administered by
different rater/examiner
Test-retest reliability=are results same when person tested repeatedly
Validity=does the test what is was designed to assess
Sensitivity=ability of test to id people that have disorder
#TP / total disease positives
Total disease positives = #TP + #FN (TP= + result + w/ disease FN= result w/ disease)
Specificity=can test id people that do not have the disorder
#TN / total disease negatives
Total disease negatives= #TN +#FP (TN= - result no disease FP= + result no
Predictive value=measure of % of results that match the actual diagnosis
Positive predictive value=likelihood that + test = actually diseased
TP / (TP + FP) = TP / Total positives
Negative predictive value=likelihood that test = actually well
TN / (TN + FN) = TN / total negatives
Receiver operating characteristic curve= graphic of the relationship of
sensitivity and specificity
Plotted as true positive rate (sensitivity) as a function of the false positive
rate (1-specificity)
Each point corresponds to a sensitivity/specificity pair at a certain decision
Perfect discrimination between ill and well has curve that hugs the Y axis
(100% sensitivity, 100% specificity)
Curve closer to the diagonal has less discriminating ability

Clinical probability=# times event

occurs / # times event can occur
Attack Rate= incidence rate used to
describe disease outbreaks
# that become ill during study period /
# at risk during study period
Cohort Study= begin with id ppl w/out
disease of interestassess exposure to
risk factorassess incidence rates btwn
exposed and not look at how health
changes over time as result of exposure
or not
Prospective (concurrent)
cohort study= taking place now
Historical (no concurrent) cohort study= happened in the past
Clinical Treatment trial= some members in cohort given treatment others
given other treatment or placebo
Case-control study=begin with group of people that have illness and group that is
Look at prior exposure to risk factors in both groups
Cross-Sectional study= provides a snapshot in time of the disease
Provide info on relationship btwn risk factors and health status at a specific
Can be used to calc the prevalence of a disease in a pop
Standard Deviation= average distance of observations from their mean

Square each value not the mean value (deviations)

Add all squared deviations together
Divide that number by the total number of scores -1
Take the square root of this value

z Score (standard normal value)= difference btwn individual score and the pop
mean in units of standard deviation
Standard Error= estimate of the quality of the sample
standard deviation / sqrt of # of scores in the sample
Confidence Interval= specifies the limits btwn which a given % of the pop should

For example with a CI = 95% if conduct the clinical trail 100 times 95% of
results will fall within the calculated range
Narrower intervals give greater preision
Limits calc by mean of sample +/- z score * standard error
@ 95% CI z score=2
@99% CI z score =2.5
@99.7% CI z score=3
Normal distribution= bell curve/ Gaussian curve theoretical distribution of
scores in which the mean, median and mode are equal. ~68% of pop falls w/in 2 SD
of the mean; ~95% of scores w/in 2 SD of mean; ~99.7% of scores w/in 3 SD of
Highest pt in distribution of scores is the modal peak
Precision=degree to which the mean is resistant to random variation
Accuracy=likelihood of bias
Skewed distribution=model peak shifts to one side

Positive skew(right skew)= tail towards right, peak towards left=scores cluster
at lower end

Negative skew(left skew)=tail towards

left, peak towards right=scores cluster at high end
Bimodal= 2 peaks=2 distinct populations
Hypothesis=statement based on inference,
existing lit, or preliminary studies that suggests
diff btwn 2 groups
Null Hypothesis=says no difference exists btwn
2 groups
Rejected or not rejected after stat analysis
Type 1 () error=null hypoth rejected
when true
Type 2 () error=null hypoth not rejected
when false
Probability=chance of at type 1 error occurring
P .05, reject null
IE of 100 outcomes 5 happened by chance
(type 1 error)
Considered stat significant
Power=(1-) the ability to detect a difference
btwn groups if there truly is one
Larger sample size gives more power to
detect difference
Statistically significant doesnt always mean clinically significant

Statistical Tests=used to analyze medical data, indicate whether to reject or not

reject the null
Parametric Statistical test=used to id presence of statistically sig diff
btwn groups when distribution of scores in pop is normal and sample size large
Ex) t-tests-difference between means of 2 samples
Independent (nonpaired) test=test mean diff of 2 groups on
one occasion
Dependent (paired) test=test mean diff of same people
sampled on 2 occasions
Ex)ANOVA (Analysis of variance)=diff btwn means of more than 2
One way analysis=tests diff in mean of 1 variable taken in 3 or
more groups
Two way analysis=examines the influence of 2 different
categorical independent variables on 1 continuous dep variables
Ex)Linear correlation=degree of
relationship btwn 2 contiuous variables
Assessed using linear correlation
coefficients (r) ranging btwn -1 and +1
If 2 variables move in the same
direction r = + ex) height inc weight inc
If 2 variables move in opposite
direction r = - ex) time exercising inc weight dec
Non parametric statistical tests=evaluate
the presence of stat sig diff btwn groups then
distribution of scores isnt normal or sample size is
Ex) Wilcoxons (rank sum & signed-rank),
Mann-Whitney and Kruskal-Wallis tests
Chi-square=diff btwn frequencies in a samples
Fishers Exact tests=diff btwn frequencies in a small sample

Evidence-Based Practice/Medicine=integration of individual clinical expertise

with the best available external clinical evidence, patient values
EBM Process
1) Assess the patient


Ask the question

Acquire the evidence
Appraise the evidence
Apply/talk with the patient

PICO=how to ask a good clinical question

P=Patient problem
I=intervention, prognostic factor or exposure
C=Comparison (alternatives to the treatment)
Type of clinical question
Diagnosis-how to select and interpret
diagnostic tests
Therapy-how to select treatment that
does more good than harm and worth
effort and cost
Prognosis-how to estimate patients
likely clinical course over time (based
on factors other than intervention) and
anticipate likely complications of the
Harm/Etiology-how to id causes for

Type of study to use

Prospective, blind comparison to a gold
standard or cross-sectional
Randomized controlled trial>cohort
Cohort study> case control> case

Cohort> case control> case series

Study designs from least rigorous and most bias to most rigorous and
least bias
Case series and Case reports-made of collection of reports on treatment of
individual patients or report on a single patient.
No control group
Little statistical validity
Case Control Studies-patients that already have a specific condition are
compared with people that do not have the condition
Look back to identify risk factors and exposures
Rely on records and/or patient recall
Statistical relationship doesnt mean 1 factor caused the other
Cohort Studies- use group of patients already taking a particular treatment or
have an exposurefollow them over timecompare their outcomes with similar
group not affected by the treatment or exposure

Observational and 2 groups may differ in more ways then independent

Randomized controlled clinical trials-introduce treatment or exposure to study
effect in real patients
Control who receives treatment or exposure
Use methods to minimize bias
Use control and treatment group
Can provide cause and effect data
Systemic Reviews=extensive literature search to identify studies with sound
methodologyresults summarized according to the criteria of the review question
Studies reviewed and assessed for quality
Goal is to answer a specific clinical question
Meta-analysis=examines many valid studies on a topic and mathematically
combine the results
Cross-sectional studies= describe the relationship btwn disease and other
factors at one point in time in defined pop
No info on timing of exposure or outcome relationships
Only include prevalent cases
Often used to compare diagnostic tests (prospective, blind
comparison to the gold standard)
Sensitivity and specificity of the new test are compared to that of the gold
standard to determine potential usefulness
Qualitative research=used to describe, explore and explain health related
phenomena being studies
Answers wide variety of questions related to human responses to actual or
potential health problems
Retrospective Cohort (historical)-same direction as cohort. Subjects being w/ or
w/out exposure or risk factor and are followed until outcome of interest is observed.
PubMed/MEDLINE give access to primary lit
ACP Journal Club, Essentail Evidence, FRIN Clinical Inquireies and Clinical
Evidence give assessment of original studies
Cochrane Library gives systematic reviews that help summarize results from
many studies
Evaluating Validity

1) Where patients randomized?

2) Was group allocation concealed?
3) Were patients in the study groups similar with respect to known prognostic
4) To what extent was the study blinded
5) Was follow-up complete?
6) Were patients analyzed in the groups to which they were fist allocated?
7) Aside from the experimental intervention, were the groups treated equally
Experimental Event Rate(EER)= Outcome present/total in experimental group
Control Event Rate(CER)= outcome present/total in control group
Absolute Benefit Increase(ABI)= inc of a good even as a result of the
Absolute Risk Reduction(ARR)=decrease of a bad event as a result of the
Relative Risk= with treatment vs no treatment
Relative Benefit increase= proportional inc in benefits btwn rates of events in
control and experimental group
Likelihood Ratios(LR)=
(+)=positive test in patients with disease/positive test in patient without
(-)=negative test in patients with disease / negative test in patients without
10 < LR < .1 cause large changes
LR 5-10 or .1-.2 cause moderate changes
LR 2-5 or .2-.5 cause small changes
LR<2 or LR>.5 cause tiny changes
LR = 1 cause not change
Relative Risk for Random Control Trials and Cohort Studies=how much more
often does the outcome occur in those exposed vs those not exposed
( exposed + disease / all exposed) / (not exposed + disease / all not exposed)

Odds Ratio=those with the outcome are X times more likely to have been exposed
than where those in the control group
(exposed + disease / not exposed + disease) / (exposed disease/ not
exposed disease)