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    BIOSTAT & EPID AMBOSS

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    29 views81 pages

    Biostat & Epid Amboss

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    kajanylogan

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    © All Rights Reserved
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    High Vietd Highgne Statistical analysis of data updated: Dec 02,2019 P cnanxsrsson CGUNICALSCENCES) © LEARNED ‘Summary Statist anaisisis ore ofthe principal tools employed in epidemiology. which is primary concemed wit the study of hesth ane cizears in populations Statics ete sience ot ellecting,anhyaing. snd interpreting cata anda g20d epidenlogical study depends on statistical methods being employed coecty. At the sare Gime, Naw in study design can affect statistics ane lead toincoret conchisions.Qesritve statis measure describe, and summarize features of 2 colecton of dta/sarple without making inferences that go beyond the scope ofthat collector/samce. Common measure of decerpive statics are thoce of central tendency and dispersion Measures of central tendency deccribe the cents dztrbution or data and include the mode, median, and mea. Measures of dispersion decribe how data ic ciotibuted and inchde range, aril. vance. and deviation. The counterpart of cessive statistic. ferential stabi, relies on dts to make inference: that dogo beyond the coe ofthe data calected andthe ample from which ‘twas ebtsine. inferential tatetce mvolves pararntere such ae senetty.specinety,pentve/negstve aesitive values, confdence intervals, nd hypothesis testing, “Thevalues used to describe features of sample or data et are called variables, Variables can be independent, inthe 2ense that they are not dependent on other variable: and can thus be manipulated by the researcher for the purpoce of & ‘study (eg. edminitration ofa certain drug or dependent in the sence that tei value Gepende on another variable anc thus, cannot be manipulted by the researcher (ag, 2 condition cause bya certzin dug) Variables can tuthermore be categorize cuaitaively in categorical terms (ez. eye cob, se, race) anc quantitatively in numerical terms fea. a2 eis. teraerature ‘The evaluation of dagrostic tects betere approval for cinical practice is ancther important area of epiderilogical stu, It reson inferential statistics to drow conclusions rom comple groups that can be apie tothe general population, See ako types of epideriolgicalstucies. (2NOTES FEEDBACK Descriptive and inferential statistics 1+ Descriptive statistics: anaysc ofa sample group conducted inorder to meature, describe, and summarize the data callected but nt to make inferences that ga beyand the :cope af that sample group; employs measures of central tendency (ade. median ane mean) anc meaner of sspernion erines range quarts. variance. and deviston) + Inferential statistics: analysis of a ample group conducted in orerto make inferences that go beyond the samcle sop. NOTES — FEEDBACK Measures of central tendency and outliers Measures of central tendency + Defnition: mestures to describe a comimon typical vale ofa data et fe cluntering of data at pec vale) © +The type oF messure used depends onthe sample see 7 MAMIMIZE TABLE Q TABLE QUIZ Meme | efeiton Femle Mean + Tastes een of theta 1 Theol cata ide te rer of alsin tnt Gatti) | rns ene by enone wes ones) (eg sosideresussetat 25 236 09 The meamvabe sii cos Mes + Temisassis ot enacesatarhse een arene rr + Unsuemumefsias 36,14 8.39 Taman ate tne (Gattis) |” Srrngmnce tanta te cqper tae cs arom re de oe = rng ated yours Aenea ere ofthe two nl aes «72 Mote = Themestcommanvaus nats cet + Ina itatnththe aes 8 661. temace 12 (eats) Measures of central tendency and outliers Measures of central tendency + Definition: measures to describe common, typical value ofa data at fg, chetaring of data a a space vale The type of messure used depends onthe sample size 7 maxmize TABLE TABLE QUIZ Mewxe | Defablon Mean + Theartvnic erent he cates (satis). eats fete iy scree votes ote) Metin + Theme ae ot ect that ac aan emgeé in orcer (satis) ” Sprograse cs ne perv ate sence he 1 not stongy act by utes or howe Mode + Themactcammanvabe ne (sats). stctestartspnnctoites Outlier + Definition a data pointlabeavaton that tan ram other datapoints /ebeervatons in a dat et Problem eagle 1 Theses ct dey the rune of asin eta ai oes "lee aveageotthe two rides 272-0. © ic important toidenty cuties because cuties can indicate errorsin measurement or sttitical anomalies ©The meaniz ess nfvenced by ctiers © Approach Outlier ‘+ Defrition: «data point/obrervaton that is distant from other cata ponts/observations in a data set © + Problem © tisimoortant to ientiy others, because xe can indicate eros in mesturement or statistical ancmalies, ‘© Themeanis easyinfuenced by outers © + Aoproach (© Usinga trimmed mear: clelate the mean by discard values otreme values in a data set and using the emsiing ‘© Use the mecin or mode: uetul for aymmetrical cota: there mearures are not sfacted by entreme valuse because they are based on ook of data (medizn| othe most commonly occuring value ode) rather than the average score fall values ‘© Removing outlets can ak distort the nteroretaton of cata should be dane with caution and with view to reflecting the respective data zet 2 NOTES FEEDBACK Measures of dispersion “+ Defritin: mescures the eitne to which the sisributon ie tretched out ie” MAXIMIZE TABLE TABLE QUIZ Defrien Deszipton ange + Teamraencetenvem se egstare:matet + Inthe nat 37. 890 ne a (sate) Vateinssenee 1 sete rece cena ee eety Measures of dispersion + Definition: measures the extent ta which the dstibution ic tetched 7 maximize taste TABLE Quiz efi Desaon ange + Thecifeese beeen he lestendaratist + Inthe dea se 27, 24.9 the anes 24279 (satis) * alma sve oxen dat vate hes ier lenge so sneter sy popaton Interguarle + Therrgetomineceondtoshemidenain + Catach citar acne 728 an 2° pace spe 7 ad 25 eect (sts) a “ ~ sbsenstione| " + Reprcenisdby) + Coeuasy nteseing nerean om een papuoion setae Eth (Sheree san sanesana nas topeoer fins hatte isc aeaby Sande + Thescunmrontof ernst + Catlins he sane ok of um ogee evo rm hep deiton | acer versity open fete Geddy ta rumor of atone) (so) + Theta sition caleseed by fetal te nen The mea + emmy Sane) ‘beomasiron ech penuston tat los Sot sffvetee sue ne Teicd together Tete ss cvced byte tcl urberef st aes ete rorctusvabe ste nance ceraeon + Inaromatdeiouion Measures of dispersion + Defntion rmeasues the extent to which the distribution stretched out © ange (sats) Interuarile ‘lance eta) deat 0 & mane quiz + Sentient di eho ier ange sa ameter pono + Lerinereesty etna ct vate outers) ed by CM + esrber evoran orazpeconctcte est Cetus: the france nine the 75 and 2° omc Pacumetenan atused by strange meg to cn poptn data ceva ach Caterers en sane afd sce epee Fay thet sa eed DY Coady to nunoarstaoeavasen) + meqncaaseyauenecaesses byt aleuseng te pean The nese sesestogener (patina tm seas by ates mumbo tat ae “hese oct vache Zana garon oh acer ition sandr deviation isp) uate Standard ror ofthe Thedevatono the sense pi om the Inference vin pene {Dns the poe fers othe Scope ee scmstersangie soe lnc the + Coeds thezevseeatatne sum ofsnnedcevitsen rm here Coded ts nunoerstansevaten) + Theanascevatenecsesbes ys cease tn nea The nese Sesestsgenar Yates scab tata mmner ott ae nara tn 2 Top eeeeoroe cacet #250 es3 ote easet + Serene suzy castes aust cnlenne ranch sgcin te 28 percarele techs average the cles neti heparan eet aurenatne some age group ove perm Sh eran cine ne ope up Forsanae aSqacare o/lcosune) eat aie se atarnen meee + 20PRancni SOOO tA ae eer eae ‘oan, Fence 97 0D RR 7 fal eae rai he ti ‘SEM = sna deviton Moroes) 2 NOTES FEEDBACK Variables + Definition: measured values of population atrbutes or 2 value subject to change + Tes © Independent variable: 2 variable that ic not dependent on other variables and can thus be manipulate by the researcher forthe purpose ofa study © 1 Dependent variable: variable with a vale thet depends on another variable and therefore manipulated bythe researcher + Types of quantitative variables © Discrete variable: variables that can only assume whale rumber values note ‘Continuous variable inon-dcrete varie? variables that can azcume any real number value + Categorical variable (nominal variable: variables that hae afte numberof etezores that may nc have an intrinsic logis ordar + Variable scales © Definition: ypc ot measurement sealer: categorized as categorical scaler and metic © Categorical scale uateative) sme ictance inter between two categories is undefined. neice the natin zee sod orinl eels 1 Met cal quanttatve) sme nce between two categories is defined Gard the dats canbe ankes 1 incusee the interval eae ane ato eee 7 MAXIMIZE TABLE TABLE QUIZ Tees harceiscs ssa als Nominal wale | + oxtncamarte mint 4 Sengurmane tee ag annem te a Types of quantitative variables: © Discrete variable variables that can only assume hale rumber vases © Continuous variable gon-scete variable) variables that can assume any eal pumber value + Categorical variable romina variable variables thot have a finite numberof eategeries that may not have an intrinsic lozesl onder + Variahle scales © Detwrition types of measurement esos catezorined ar catngorea ales and mete sles © Categorical scale cusittive) 1 The distance interval between two categories is undefnes 1 nluces the nominal scale snd erinlsele © Metric scale (cuanttative! 1 The distance between two categories is defined Wand the data canbe ranked + ncluces the inter cae ane ratio sele WP MAXIMZETABLE TABLE QUIZ To Ohccscn Statin Nominlsaie + Ostacnmatbe anes + Nan puanaric tents lg Men hing ( cuddle + oxncanernias Imendlsale | + Thee bronetaal arovort © + Prentice ea Tet eee + The emt ao port © Reterencan 07 NOTES FEEDBACK Distribution and graphical representation of data Normal distribution (Bell curve, Gaussian distribution) 1+ Normal ictiouton: dite according to their mean and variance. but share the folowine characterise: pe: the follow 168% ofthe eat tll within 2.50 of he mean > thesame tae mmptors about the data ditrbuton con be mace: + 95% ote eat tll within 25 et he mes, 1+ 90.7% ot the cata alle within SSD of tne mean. © Symmetry (le, asymmetries ball curve) > Totelaresunserthe cue =2 ‘© Almeacure: of central tendency ae equal mean = med + Standard normal distubution iz cetibuton)& nocra wibution with 2 mean of © ane stancard deviston ot mode) Nonnormal distributions WP MAXIMETABLE — Q TABLE QUIZ Desrson Meanie redaldsebatn + Se derbuten nin Me psi apask~mocepensegy) = ‘Tacubgiupe wate ue popution Poitey skewed tribution + Ova set mut deweoio eet + Men resin» nae Negatively stewoddstrbtion —- + Mean emecin TABLE QUIZ Descipon eaing ‘Binal dstibaton + Ses anrnusen wt pals apeae=mocepieminegy) + Docibiope wenn ey population Postncty sewed Gstibuion + Sea et thntitewes tte et + Mean>mecin > mode DNegatly skewed ditrbuten + Ox srttedewactonelet = Meanemecin «ode ‘Standard normal value (Z-score; Z-value; standard normalized score) 1+ enables the comparison at populations with dttevent means and standard deviations © standae normal value= (value - population ean) vied by standaed deviation (© Ameancct expecting data score (eg, height in centimeters or meters) in the same metic specially in tanne of ints of standare deviation forthe population) 1 Determines how many standard deviations an cbservation is above or below the mean © Recommended measures according to distribution (7 MAMIMIZE TABLE > TABLE QUIZ isuibton Meat cet dency Mess of stead Normal ymca Mews. rman ce Stand dein sowed asmetica) econ sang or necunie rng Data illustration Categorical data Standard normal value (Z-score; Z-value; standard normalized score) ‘enables the comparizon ot populations with erent means and standard deviations © ‘standard normal value= (value - population mean) divides by standard deviston © Ameanet sireztng dts ecore (eg, neghtin centimeters ormeters|in th sme metic epscifelly in tame fot unite of andar deviation tor the popultin) © Determines how many standard devitins an abservtion is above o blow the mean Recommended measures according to distribution WP MARIMZETABLE > TABLE QUIZ Disumuton measure oem eency Measurotspead Neue re etn ce sana eraren Swed bomen win en) Data illustration Categorical data + Frequency table © resents data value french eateporyin 2 table © tater which value ina dota st ape trequenty + Phechart © Describe the requency of categories in a cular graph cided into ces, with exch sce reprecenting 2 catesaical proparion © Usetl for depicting 2 sll manber of categovies and large dtterences between then + Borgraph © Describes the reequency of categories in hars separated trom each other; the height/length ofeach bar represents Recommended measures according to distribution 7 MaxiZE TABLE G TABLE QUIZ subon ease of cel tendency Measueotsread Nowa omnia een rein. ce seandescerecon Stewed syne) eson fang crnerquae nse Data illustration Categorical data + Frequency table ©. resents data values for exch category ina table © thesates which values ina data set pea trequently + Piechart © Describes the requency of categories in a icular graph divided into ices, with each sce representing 2 categorical proporbon © Useful for depicting @ small ner of categories ad large ferences between ther + Bargraph © Describes the Fequeney of categories in bars sep=rted from each other the heigh/lenth of ech bar epresents ‘estezoical proportion © Usetul for depicting many categorie of information (comaaredto a pie char) © Frequency can be expresed in abzolite or relative torm. Continuous data + Histogram © Ahistogram is similor to a bar graph but displays data on 2 metric scale. Continuous data = Histogram © Abistopram is simlar toa bar gragh but splays data on # metric sale © The detais roupedinta intervals that ae ote onthe wax © Useful for desiting continuous dete © © ‘Similar toa bar chat but citfersin the folowing ways 1 Used for continuous data 1 Thebars canbe shown touching eachother to lustre continucus data, 1 bars cnnct be reordered © + Boxplot 1 Quarles ard metdan ae ured to dislay numerical data the form of 2 box. © Useful for desicting continuous dete 1 Shows the following important characteristics of date: = Minnum an maxnum values ct ana tie quartiles = Mecisn cof central tendency, ange, symmetry. and outers ta glance + Scatterplot © Agraph ured to dcsay values fr (tyricaly two variable of data plotted onthe horizontal xa) and vertical Ive) axes using cateian coordinate, which eprecene individual cots values © Halpeto ectabich covteltions between dependent nd independent variables © Helps to determine whether relationship between tases i ina’ or nonlinear Frequency -3SD -2SD -1SD mean +1SD +2 SD +3 SD opigetblveshittc Mode Mode Mode Median Median Mean Median Mean S\ Mean 1 I \ : AN \ \ I distribution Negative skew Positive skew Symmet Frequency table Mean arterial pressure (mm Hg) Number of patients <60 3 60-69 12 70-79 13 80-89 17 Independent risk factors Risk factor 3 71% Risk factor 1 18,2% Risk factor 5 12,1% Improvement in MMSE performance after treatment 10 low dose Una. Druga Drug B Drug C Drug D Drug E Placebo © “ o B Body height among underage females Average height in inches 80 70 60 30 20 2.3 4 5 6 7 8 9 10 11 12 13 14 15 1€ “7 Comparison of USMLE Step II test results between two universities USMLE Step II scores 300 150 University A WEB. Swhisker* and maximum interquartile range and median (dark line) “whisker and minimum Mean childhood BMI at 4- year follow-up Mean maternal BMI before pregnancy 0.45,p<0.01 (2 NOTES” FEEDBACK Hypothesis testing and probability Hypothesis testing 1+ To mutually elusive hypotheresrtered 1025 null ypothes and aemative hypotheses) 2 tomate. ‘> Null hypothesis Hg: the sesumprion that here eno rlationchip between te measures vorstlee e.,the ‘expceure andthe outcome) or na significant dfaence between two studed populations; ttl teste ae used to ether ejector acept the hypothesis ‘© Aterative hypothesis (Ha) the assumption that there is a elstionship between tro measured variable ‘expccure ar the outcome) or significant ctterence between tno tucied populatn. This hypothe: ormulsted 352 counterpart tothe nll ypothesc;satistical tects are ured to ether ejector acept thie hypothesis ete + nterprtation 1 Type J amr. The ul hypothesis is ected hen t= actually tr, and consesuenly, the alternate hypoth is accepted, although the chserved eect is actually cue to chance + Signicance evel type 4 eror ate 1 The erababliy of ste dexrom dencted with“ 1 The sgnficance levels determined by the crincial investigator © before the study is conducted. © 1 Formedica/eicemilogtal studies. the significance level aisusualy sett 0.05 ‘© Type errr: The mull hypothesis is accented hen it actually fase. and, consequent the altemative hypothesis is rejecta eventhough an cbcerved effect didnot occur due to chance, + Type 2 errr rate: the prabablity of a type 2 ero: cenoted by" > Statscal power 1-6) 1 The probability of correctly rejecting the null hpothe groups when there uly ica dimerence 2. the ability te detect a aterence between to bnyaothesie + Interpretation © Type terror: The mull hypothesis is telected wen tis ectually true. and consequent the alerative hypothesis is accepts, although the observed eects actully duet chance. 1 Significance eval (ype 1 eror at) 1 The probsbiftyor2 type eran: denoted with at 1 The sarifcance level determined by the principalinvestigstr (3 before the study is conducted.) 1 For macica’epidemioogical tuces, the significance level ic uualy et t2 003, © Type 2ertr: The null hypothesis is accepted when te actualy tales, 2nd, concecuenthy the alternative hypothesis i reacted even thovgh an observed eect didnot occur ci to chance 1 Tyne 2 error rte: the obablty of tyne 2 ror: denoted by 2" © Statistical power (1-8) 1 Theorchailty of corel ceectine the nll hypothesis. i. the abity to detec «ference between wo groups when there trlyic a diterence 1 Reciprocal tothe tne 2eror‘ate sively comeletes with the comple size and the magnitude of the accocation of terest (eg Increasing the sample siz ot a tuey would increases statistical power 1 sy convention, most studies sim to achieve 80% statstsl poner. ©. Pealue:the probably that a statisti tet lacs tothe flee conclusion that there 2 relationship between 100 measured vaables leg. the exronite and the outcome) or that there isa sinfican ference between two studed populations 1 Calelates with stata! teste 1 lf the ervalueis equal to orless than a predetermined sgnicanc level usualy stat 0.05), the asociaton considered ctaisicalysianifcar. 7 maximize taste — TABLE Quiz ul hypochess iste ud hypoches ig) ase Sn EEE TW RET U7 MANIMIZETABLE — G TABLE QUIZ Nulhypthess Hediste sexta tet das notre Hg te Sexi et et Thor Leer) Probability + Description © Probability of an occuring evant (F) * Deserts the degree of certainty that a particular event wll take place ( 1 mumber ot averable outcomes/total unter et possible outcomes © robabity of an evant not occuring (Q) 1 the degree ot censinty cht a particular event wl ot tke pace Nulhypthesis iste estenere 1+ Q=numberat untovouable outcomas/toal nunbarot sosebe outcomes GRL-P + Use ©. Probablities canbe combined tor individual, unrelated event: by muting them by one anther.) ©. Probablitie cn be combined or muitple, unrelated (2, exclusive) events by adition © Probablitie cn be combined tor multiple events tha re related (ie, NOT excucve) by adding he probability ot each event and then berating the probabil of the combined events isnot the same arth obzerved frequency ofan event! + Conditional probabilty (rae) the probebity of event’ cecuring sven that event ha accuree: AS) © PIals) = P(eand s/s) = PtS)= probobaity or events" + Conditional probably Pe) the probabity of event’ cecum sven that event” haz eccuree: A/S) © PIAS) = P(Aand 5) / 8) + P(G) probability of evert “2” + PtRand 8) - probability of events ‘A’ and 8" curring simutaneausy 2 -NOTES — FeeDEAcK Confidence interval + Overview: Confidence intervals provide a way to determine 2 population measurement ora value that izubiet to change tom 2 sample measurement. + Definition: the range or values that are highly Hkly to contain the tue sample measurement + Foumula:sny eamole measurement e.g, een +/-Z-ecore andar enor ot the mean) > rauirs the tllowing © Confidence level (usualy fed 8 955% 5) © Sample messurement © Standard evar ofthe mean, which requves the 1 Sample size 1 standard deviations + Interpretation ©. Overlapping confidence intervals benween two groups signi that there no statistically significant difference ©. Nom-overlappng confulence intervals between two groups sigity that there a statistical significant sitterence © the confidence interval incites the rull hypothesis. the result not sgificant ard the null hypothesis cannot be reectee, “a. ifthe 58 copmdlonce interval ef relatwe rick ov ede ratio weludee 4.0 the reel. Confidence interval 1+ Overview: Confidence intervals provide 2 woy te determine 3 popultion mesrurement ora value tht icutject to change tom a sample measureinent 4 Defnition: the ange of values that ate highly Bkaly to contain the tue sample measurement ecuies the following 4+ Formula: ary ample measurement fe, mean) +/-Z-score (standard error ofthe meso) 1» Confidence evel ualy heed st 9595) 1» Sample mesturement 1 Standate erorof the mean. which resus the 1 Sample see S Standard deviation © + Interpretation ‘© Overlappine confidence intervals between two groups sient thet tere ino statistically significant dference. ‘© Non-overapping confidence intervals ketveen tw groups sient thet there isa statistically significant cifrence, > nthe connence intel inclase the nul hysethen, the result ienctsgnincant re the null hypothete canst be reectes 1 ithe 99% conficence incl eave rick or ad ratio includes 1.0, the result not significant and the rll bhypothets cannot be rejected + the 95% confidence interval of ference between the means of hwo variables nce theres not "lenfcan end the rll ypothess cannot bereectd © 49556 confderce interval that does notinclude the null hypothesis coresponds to a p-value of 005 > 9956 confderce interval that does notinclude the null hypothesis coresponds to a p-value of 002 Statistical tests ‘Statistical significance vs. clinical significance + Significance epidemiology: the statistical rabbit that a recut cid not occur by chance alone © © ‘Statistical sieniicance: describes a tre statistical outcome fe, that is determined by static tests that has nt ‘curred by chance © Clinical significance epidemiology: decenbes an important change in patents clinical coreiton, which may or sway ret be due tan intervention iocuess curing cinco usy 1 statistical and cine cigniicance donot necessary correlate.) Correlation and regression Comeation + Definition: 2 messure of the linear statics corelation between continuous variables © + Interpretation A correlation coefficient measures the strength ie, the degree) and dection ie, 2 postive or negative reetionshis) of neat relatonchin oes nt recite cau’) ented by alas’ "minus" respectively © Direction or relationship: canbe positive © or negative © Strength of lationship 1 erfectrelatonchip:two vanishes are perfect ine and the corelationcoefcent ie #2 9r-2 1 No ines lationship: correlation coefficient is > See oesrman's coreltin coetiient and Pearson's conelation coetcent. Regession epidemiology) ‘ot ceveloping a mathematical relationship between the dependant variable (the outcome "V) + Definition: he pre and one of mere indenenvent variables the exposute;) «© Linear regression: a type of regression in which the dependent variable is continuous Correlation and regression Coneation + Dafnton » mescurs tthe Inesrstatticlconelatonbetwesn contnuove variables + lIerpretaton: a comletion costfcient measures the strength (2. the degree) and direction (Le apostive or negative elationshi) ofa neat elationchip (ose nat requve covey!) © Direction of elationship: canbe positive G or negative cent by 2 “lus” or"minus expectivay © suength ofretionship 1 Pestect relationship two variables ate partecty liner and the correlation coetcent is +1 0-1 1 No nea relationship: oveation coctficient is 0 ©. See Spenan’s couelaton coefficient and Peatsonscoreation coefficient Regression epidemiology) Definition: the process of developing a mathematical rlatorchip between the dependent variable the outcome: '") he expocure:") and ore or more indepencert varie + Linearregrssion:2 typeof regression inwhich the cependent variable i continucus ©. Simpie near regression ¢ + incependent variable: ana 1 IV" toe linear restionshi with an independant variable 2 eroph pling tis relationship take the form ofa suaight ine (called regression fe) 1 inthe cue of simple near egression, the equation ofthe regrecton ine y= mix =, with" eepresenting the slope ofthe regression lin. "y' the dependent varia” the idaperen vtable. and“ the \intercep the value oFy where the line crosses the ya) © Multlelincar repression 2 incecencentvanabl « anayzee + Logistic ragresson: a type of repression in whch the dependent vrisbl is categorical ©. Simple lost repression: & independent vere ic analyzed © Multiple loisticremression: »1 independent variable is anshyzec Se ae eT ee Regression epidemiology) + Defition: the proces of develoing a mathematical lationship betwean the dependant vale (the outcome") and one or mere indesendent variables the excosure:"«) ‘+ Linear restesion: 2 type cfreresscn in which the dependent verieble i continucus © Simple ines restession ©) 1 Lindeperdect variables analyzed * FY’ hasa near relationship with an indegendent vanable ‘xa grach plotting this lationship takes the fom of ctraight line calles regression ine) = +b. with “representing 1 tn te caze of simple linear regression, the equation ofthe regression lie the slope of the regression line," the dependent variable" theindependent vata, and" the scot y where the line crosses the yea) yrintereeot the ‘© Multilinear rearession: 1 independent variable is anahzed itl i categorical + losisticregression «type of egiesion in hich the devendentv ‘© Mulfiole losstic regression: 1 independent varsbe is analyzed Parametric tests ifcantctterences between groups when the study sample hes 2 * Definition: tert: used to evaluate statically normal dstibuton and the sample ee arge + Types © Pearson correlation cosfcent = Compares incerval level variables © Cleubtes the estimated strength and diction of rebsticnship between two variables + Interpretation 1 rig always avalue between 2 and Parametric tests + Definition: tert: used to evlute statictical significant ferences between group: when the study cample he 2 normal ieributon and th sample cite ic age + Types > Peasson correlation cosfclnt 1 compores interval level variable 3 1 leustes the eximated strength and diction ot reticnship between two varisbles + Interpretation 1 rig always avalue between -2 nd 2 1 A postve eave tion © postive cone 1 negative isle = negative coraaton &) 1 Theclocer the ruck ico 2, the ewonger the coralation between the compared variablee 1 the coeticient =? the coeticient may be amected by extreme value) o Trest 1 leustes the derence between the means ot two comple: or between a sample ard popuston oa value subject to change when samples ate small andar the population or» subject to change, =p riovton cnet known 1 Use to deternine the confidence intense oft ztnbution + T-lstrbution: collection of eztbutions in which the stance devon ipunkronn anelorthe sale szeieare + Twosample test 1 Caeustes whether the meanc of two group iter from ane anether + Tyes + Unpaired-test ndasendent sampler ttt) 1 Two diferent groups are sampled a the same te EE EE eee 2 Trest + Coeusts the diference between the means of two samples or between a same ard population o value subject to change: especial subject change Aisriution coat known hen samples ote small anc/orthe population or 2 val + Used to determine the confidence itera of» stbuton + T-isribution.» collection of dstsibutions in ich the standard deviation fsunkrann anor the sample + Twosample test 1 Calculates whether the means of two groups diferfrom ane ancther + Twes 1 Unpaived test indecendentsameles test) 1 Two diferent aoups are sampled at the same tie 1 Thecitfrence betwean the means ofa continucus outcome variable of thece 2 groupie compares 1 Thenull hypothesis ic thatthe mean ofthese wo groupe i equa 2 statically ciaificart Aitferencereiects the nll hvpsthexs 1 Paired est Geoendent same test) 1 Thesame groups sampled at to ditferent times 1 Theitference between the means ofa continuous outcome vrai ofthis group fs compared 1 Thenul hypothesis is that the sroup mene ecual at these to dterent times statistically ‘enicant étference rejects the nul hmathesi: © Analysis of variance ANOVA) + Coeustes the tatetialysiniicant dtference between = Sindepencent groups by comparing their mean (on extension ofthe ree) 1 One-way analysis of valance 1 Accesses 1 variable (eg, the mean height of women in cies, 8 and C ata given point in time the variable is height) © Analysis of variance (ANOVA) 1 Coleulte the tatieically sanificant dteence between 2incependent group by comparing thir means len extension ofthe Hest) + One-way analysis of variance 1 Assenes I vatsile (eg. the mean height of women in chics A.B and variable height ven pointin ime: the 1 The zim iste determine whether there isan effect of diferent indeverdent variables ona danencent wore 1 Two-nay analysis of valance: scesrec 2 variable @. themean height of women and themesn height ot ren a cnics 8 and C ata point in ins; the vrabes are gender and height) (DB Trost - 2elabes ~ ditorencestetwesn 2 soups: ANOVA ~ 3 sylbles ~ erences betwoon 23 soups Non-parametric tests 4+ Denton: tests used to evaluate the statistically significant diterence between groups when the sample has ribution and the sample size small + wes Spearman conelation coefficient 1 Calculates the elationship between two vaiales according to thei + Compares ordinal eve! variables + Interretation 1 Extreme values have a minimal effet on Spearman’ coeficient 1 Not precise because not allinformation from the dat et is usec, 1 See conelstion © Mann-Whitney U test Non-parametric tests ‘+ Defition: texts used to eveluate the statically nica difernce between groups when the sample has nen-nerlcztbution andthe sample aie zm + Tyes © Spearman cortlation coefficient *Caeustes the estonship betwean two variable: according to thei rank + Compares ordinal level variables + Interpretation ‘Extreme values have a minimal effect on Spearman’ coeficent 1 Not precce becouse net allinformstion fom the dats cet ic ure. 1 Sse ceneistion ‘© Mann-Whitney U rast + Compares ordinal, intel or tio sealer + Cleuates whether two incependentychozen samples originate from the me population and have ental erioutione ane/er cane (© Wilcoxon test (rank sum and signed rank) 1 Ronk corn est compote the means batwaan groupe ot eimetent einer 1 signed rank tect compares the means between pis of scree tht cn be matched: subettte forthe ure ar the nll ‘one-samale-tet when 2 pre-terveion measure compared with a port-testmen me hypothesis is that the treatment hasmno effect Categorical tests ‘+ Defnidon: ert used o evaluate the stateticllysgnifcatcierence between groups with categorical variables + Twes © Chisquare test 222: Interpretation 1 Bctreme values have 2 minimal ettect on Spearman's cstficiant. 1 Not precise because nat al infomation trom the dat sets used 1 see conlation © Mann-Whitney U test 1 Compares orinal interval or tio zal: 1 Calculates whether twoncdevencenty chosen irate from the same populetion and have identical sietobutone end/armnediane > «© Wcoxon test ark sum and signed rank) Rank sum tert: compares the means between groups of diferent sizes 1 Sioned rank test compares the means between ait of score: tat can be matched: substitute fer the cone-comple ect when a pre-intervencion mestureic compared witha por-reatment mescure andthe null hypothesis that the treatment has no effect, Categorical tests + Definition: tects uses to evaluate the stately cgniicant deference between groupe with categoria variables + Typos © Chsquare rst x ert) + Calculates the cterence between the frequencies ina sample 1 ime to determne how likely outcomes are to occur cue to chance used in cross-sectional tues) © Fishers enact test 1 alc cocustes the erence Between the equencies na cample but, unk a Ch-cquore tect, cused when the stady sample 1 Alco sins ta cetermine how key it was the outcomes ocurred due to chance NOTES FeEDERcK. High iets Higgs Epidemiology Last updated: Mar:20, 2020 Dana srsson} CGUNICALSCENCES) © LEARNED ‘Summary {latsial epidemiology isthe study ofthe ditioution and determinants of dzescein populations. Clinica epidemiclogy apples the principles af escemiology to improve the prevention, detection, and teatment of dseate inpatient. Descriptive epdericlogcalstuesimvestigate individual characters, paces, and/or the tne af events in lation to {an outcome. They may take the form of ace reports, care caries. or ecological tudes. Araytical epidemiological studies ‘seek to determine the infuence ofan exposure onan outcome 2nd canbe Turther divided ito experimental (22, tendomind conto statis) and abe jal (eg, cohort oreaze-conta tudes typer There ates number af factors that influence the amour of cna evidence eidemialegca studies contribute. Conclusions drawn from these studies ‘an be made more reliable by imitig bie, confounding, and effect modification In epidemiological studies, the strength o the relationship between tuo events is measured using ratios rates, 2rd broportion tests. This relationship canbe presented inthe form ofa two-bytwo table which helos to visualize the umber of false ccsitive and true gositivecizgnoctc test results, aswell asthe umber of catiens who actually Rave the Giceaze and thece who donot (ected with ago ctandor test) isgrostic tet conciered precie ithe recut it viel ore eprecucibe under smi condiian (ible) and iit maura what twa developed ta meszure (vali). The highers tests lability anc yay the lowerthe amount of apd evors twill eenerate Alco 200 stabetcal analyse of dts NOTES FeEDEACK Introduction to epidemiology co ee Introduction to epidemiology + Classical epidemiology: tre: + Clinical epidemiology: the study and application o principles of epidemiology to improve the prevention detection, sd treatment sce inpatients 1 of determinants snd dlstrbution ot izes in populations + Population (pdesclogy:the total number of pzope or inhabitants in 2 country oregon tem which 2 sample is drawn for statistical neasierent © Population pyramid. 2 way of ilustratng the age and sex lstributon of» sceciic population 1 Stetonary pyar rearezents «population in which age and sex dntotionremsin conetant over tie: eal bicthane dats rates + Sipancivepyramic present a population which thers 2 erator percentage ct young pacple ie vyouthnl population high birth ces and iow Bre expectancy <3 + Consrctive pyramid: epresente a popUstion in which ther a greater parcentageof elderly people low bith and death rates + Data epidemiology factual information. collect curing observation and/or experimentation, thats ured as & basis for analysis and discussion + Sample epidemiology 2 small erous ct pele that are representative of a population + Control group: A group n a study that does ot recelvetheintorvention (eg. a drue or di nc develop the outcome leg. 2 Gicease) which recruits rom the ome source population athe rudy group. itis matched tor baaline chafaceristics wit the study popdaton 1 reduce confounding facts. 7 Maximize TABLE TABLE QUIZ ‘efeiton Time en ames Posie tans Endemic Acienetutafectsiniviautsatercaiay crstre—Unimies Lines Midinin Ace + Local guna: Iireves ane egress ——_—_—E—_—_—_— ———_—_—_—_—e" an tm [Aen Bm = Takin | Advtatocinatsratyouot | Unt | Unt + + Locum Sano Viaicee |" lomeaasue mane Sree = 5 + Sap 1» lungesnanene demic Aszenuemrstecsindvialsstonurunalyfster inated Slater, + teres nec ofa Gropessartsutnnsspeunepopustonrasen sadenennWet |” pees) Bees 3083) + thingcontion ag + secon bong sovassess ‘wus + spradrmeaaictonst epanegenta anew formic ae Pandemic Won epic United | Uninind + Seehis + Gebel onde ender oie : _ + cous i (Conner cose (de de LAL Reterences: 812151 ZNOTES — FEEDERCK feteences: ETS] Epidemiological studies Principles of study design ‘+ stuay derigne shouldbe talored tothe question that needs tobe answered. © ZNOUS — Feeneac 1+ goed etucy design with igh levee ot evidence incraces the etrength ot conclusions sown tram therzulte. ‘Types of epidemiological studies 7 MAXIMIZE TABLE TABLE QUIZ Deszigtion Desaiptie + starsat ey tlcentynaaialenrctenees ages acim pce sales + Sue hs cetarin the enc ernean an ages are SACS + Aways he a Compaison group ample 1+ Gropesetnal sv + Boerner tudes + Tre indpenéonsaable:s rete anomie cone a + obser tes Sects wihat mineerton 1 Treintpenent arte ot Interpretation + Enidemistogicalctucior uggs elatonchip: between twe events (22. posure and disease, + Thie comparzon can be measured using © Ratio: comparcon of to related or unelsted values © Proportion: cormparson of one partof the population t the whole © Rates: mescure af the frequency ofan event ina populabon over a cpecifc period of tie 1 These measures cetermine the strength of characteristic (eg, detect population: at sk) and quantity morbicity/moraty. tion betvcen So event nd alow 0 describe popuistion + Furthermore, researchers con eventually develop hypotheses about why these groups ate 2 ck 2 NOTES — FeEDBack Descriptive studies Case report *+ Descioton: = reper of cicease precentatin, treatment, ané outcome in single subject or event 1+ Brample: report of a sini cace of cervical concer m2 25-year-old female subject, Case series report + Descipton-2 report of cisease couse/resporse to treatment coiled by aggregating several similar patient cases Descriptive studies Case report + Descriptions report ot cease arezentston, trestmant, ane outcome in single subject or event + Brample: report of a single cace of eves concer m2 25-year-old female subject (Case series report + Descinton: recor of iease coure/resporse to treatment compiled by aggregating Several similar patient cases + Example: callecting and reporting several cases ef pericarditis ats local hospital Ecological study 1 to dentiy an exposure a:cocinted with an outcome eg, csease) especialy it the outcomes rae + Study method: acesces agpragatd data where t lactone variable fe 2 outcome is at 2 population lve and not srindivical level + Example: determining the inevleneeofchoersclesthe bates on specif lnctions eg. diferent parts of city to identity the expecure eg. water rom a singe contaminated pure) © Reterencer: 12151 2NOTES — FeEDEACK. Analytical studies Z.NOTES FEEDBACK Analytical studies Experimental studies Randomized controlled tals (RCT; Interventional stules) 1 lm: determines the possible effec of specific intervention on a population of interest Study method: patients ae randomly allocated 2s ether treatment or control subjects ©) ater which they are monitored ana evelustes tor the outcome ot nterat Spoctal variants © Blinding: the practice ot not informing an nciviual or aroup bout which individuals are 2 control or westment candidate; weed to minimize big 1 Single-blind study: Only resetchers know whois 2 contra or treatment candidate 1 Double-blind study iether the researcher nor the study participants know whois 2 contador weatment cancidte inle-blind study: The researcher the study participant, andthe pezon who analyzes the data do rot know wre ea contol a testment consists © Custer andomized contoled thas 1 bimeran partiinanes ore srouped tozetharinte clusters ane than randomly a2igned to the contol or intervention groupe 1 Acheter RET i easirtapertounthan a classical RCT but may have less vali than 2 caesicl RCT linia rug rts + Definition: tudes invelving human subjects to a:ce:s new heath intervention t provide safe and eHective medical linia cag trials + Definition TABLE QUIZ Leading cous of enh by age rs wd xd sae coree se 15-94" ste Heme aye sccdens corer Hen deem ose at doe cree a References E2181 2NOTES — Feeonac, Measures of risk at increase the probabilty of developing a dseareoriniry + Risk factors: variables or attnbute 1+ Types of rik actors are typically calculated with the help ofa two-by-two table which compere twa vargbles: precence/abeence of ccease and history or exposure 0a rk actor © a= eceare in those experse © benccicese in those exposed © = dcesrein those unexposed © d=nocicese i thove unaxpozed J? MAXIMIZE TABLE G TABLE QUIZ ieee No dese Fee * Absolute risk + weidence tate 4+ steasurs the probsbifty of acquiting diceaceijury ina gven study population + Used cohort stuies + Formula (oumberof new cares) / otal incviuale 2 rik of developing dseare|=(at cia +b +e+4) Relative risk (RR; risk ratio) + Therik ot an outcome (2. cizea:6) among one group compared tothe rsk among another soup + Meacureshow strongly isk factor (es. eathvinjuydceace) in excoredindividuss ic associated with an outcome + ured cohort studies Absolute risk + idence rate * Measures the probabity of acquring diseaze/injury ina given study population + seein cohort stucies + Formula (rumber of new cares} otal incnicuals at rik of developing cccace)= (2+ c/a +b+e+d) Relative risk (RR; risk ratio) 1 Therisk ofan outcome fg. cisease) among one group cormpared tothe sk among another group + Measures ow strongly sk factr fg, dasth/injry/dicesc) in expoced individual associated with an outcome + Usedin cohort sties 1 Considered statistical significant ithe comespanding pale ic < 005, + Formula Gncidence of dceace in expaced group incidence of disease in urexposes group) = (ala + Bee +) Interpretation Expocure neither inceaces or decreas the sdk of weaching the defined outcome © RR» 4: Exponureincranes there of aching the outcome © RR <3 Exponure decreas the rick of eaching the outcame Attributable risk (AR) '+ The proportion ot czsesin exoosedlincivicuals tht can be atibuted to the exposure + Uses in cohort stucies + Formula © Population AR (incidence rate entire study population = reidence rte in unevpaced soup) =(geevlesb=c+d)-(ole=d) a+ b)-clle+ d) © exposure incidence rte in exposed group) - incidence atin unexposed group) Attributable risk percent (ARP) © RR < 1 Exposure decreases the risk of reaching the outcome. ‘Attributable risk (AR) ‘+The proportion t aces in expeced individuals tht cn be atributed to the exposure + Used in cohort studies + Formula © Population Af ineidence rte entre study population -Greisence rate in unexposed group) slie-/a+ec+a)- eile+a)) (© exposure (incidence rain expozed group) -Gncicence rate in unexpored group) = ala +b)- ce + a) Attributable risk percent (ARP) +The percentage of incidence of disease among exoo:edinival that canbe atribute tothe exposure + Formula © ARP (RR 1/RR. © Alternative RE A licidence of disease in exoosed grow) * 100 (Odds ratio (OR) 1 The ode rato ia measure ot the ods ofan invicual developing ais raetee on exposure tos ick actor agsint the od of the + Compares the occ ot 2 ceese/inurycccurng in those expoves iesoeinjuy occuning in thove nat expoced tothe same vik factor + Odes: the probability of 2 ccease/event occuring svi by the probabil ofthis ciceace/event not occu © Odds of ciceate in thoce expoced= diceate in thoce expocadlina ase in thoce exposed a0) © Cede of cceate in thoce unexposed =cieate in those unesposed/ no dceae in thace unexposed eb 4 Formula: calculated using the 242 table (ee above) © Odds to = ode of cseasein those exposed/oddic af disease in those unaxpaced 1) dors ‘© Alternatively, ARP = AR/lincidence of disease in exposed group] * 100° (Odds ratio (OR) + The odds ratio isa measure of the odds ofan individual develoning a tceate on exposure to a ick factor. + Comeares the odds o « diceae/iiur occurring thaze excosed to ac factor agsinat the od ofthe dczacefinury occurring in thoce not expoced tote same rk actor + Odds: the probability of a ciceace/event occuting cided bythe probability oti iceaa/event not occutng © Odds ot disasce in thore expoced = diceace in thore excoredino cieateinthoce exposes a/b) © Odeeot dices in thove naxcozed = cleave in those unexposed) no dleeae in thace unaxpoces (6) + Formula cokeusted using the 202 table (ee above) © Odds rato = ocd ot dzesce in those expoced/ocds of cieateinthoe unexpared © OR=|[2b|/(e/9 oraavte + Interpretation © OR = Lmeanethe event ic equally aly in bot arouse. © OR» Lmeans the event ic moe kel to accu inthe group exposed to the sk facto. © OR < 1 means the event ss They to occur in the group exposed tothe rik actoe + Usetin case-control studies to measures the suength of the association between 2 sk factor and 2 disease/njury + Rare disease assumption © Sincecace contol suds donot tac patients overtime, relative rick cannot be caleulated © However, the asumption con be mace that fan autcam irate (2g, the prevalence a clase, the fidence lof tht outsome it ow ar the od ratio (OR) anprowmates the rlative nek RR). Relative risk reduction (RRR) + the proportion et decrescd ri due to an lnterventon compared othe conte! group + Formula: 1-RR Absolute risk reduction (ARR: tisk difference) © OR = [a0}/ (ear adbe + Interpretation © OR= means the event ic equally kl in bth sours. © OR» Lmeans the event ic mere likely to occur inthe group exposed to the rck factor. © OR < Amasne the eventie Waly to occurin te up expored tothe rk factor. in cae-contalstudles to mescures the strength o theo + Rare disease assumption ston betaen sek actor and a dizeae/injury © Since cate contro tucies donot track patiants overtime, relative rc cannot be ealeatec, © Honever,the azumption con be mac that tan outcomes irate (2g. the prevalence ot clsazs), she inecence lor that outcome i ow ard the odd ratio (OR) approimates the rlstive rick} Relative risk reduction (RRR) +The propotion of decreased risk de to an intervention compared tothe control group + Formula: 1-RR Absolute risk reduction (ARR: risk difference) 1 the differencein tsk 3c 3 rere of exposure compares to nonexcosure (eg. fk ot eath) + Formula abcolute risk in unexpoced (contr group minus absoite rick in exocec (ote) group =(efle+ d= [ala +b) Number needed to treat (NNT) + Themumber of individuals thet must be treated i 2 particular te perie, for one person to eet trom treatment {not cevelop clseaee injury + Fonmula 4/absolute sk reduction ARR) Number needed to harm (NNH) +The numberof inelvidusls who need to be exposed to = certain ssk factor before one person develops disease inury Absolute risk reduction (ARR; risk difference) 4 Thedifferenceinrsk s 3 result of exposure compared to nonexposure eg. sk of death) + Formula: absolute risk in unexposed (contr group minus absolute rick in exposed (ate) group e+ dalla Number needed to treat (NNT) + Thenumber or naviule that must be trated, ina perticer tne period for one person to benefit rom treatment (ie, nt devon iceaserijury) 1+ Ferrula/absolute isk reduction (ARR) Number needed to harm (NNH) + Thenumber of revicuals who need to be exDosed t certain risk actor before one person develoosdlsease/iiury + Formula: /eruibutable risk (AR) Hazard ratio 4 Themeasute ofan effect ofan intervention en an outcome death cure) over a petid a time 1+ Used in survival analysis. + Ferrata © (incidence a eutcome in exposed group) (incidence of outcome in unexposed grou) = [ale + bIVeN~ A) + HR= 1: no lationship 1 HR > 1 the event (the cutcome ofinterest eg, death cure) more ike to occur the exposed group HR <1 the event icles ely to occur the exposed grou Dose-response relationship (epidemiology) *+ One ofthe entra require to establish causal in epidemiological studies ‘+ Refers tothe presence of a doce-responce curve eg. the precence of ciseate incresces/decreaces in direct + Formula ‘attributable risk (AR) Hazard ratio 1+ The measure tan effect an Intervention en an outcome death/cure) over a period o time 1+ Used in survival analysis + Formula © (incidence or outcome in excozed group) (incidence ot outcome in unexposed grou) = [als “BVM A) + R= 1: no lationship 1 HR> 1: the event (the cutcome orinterest 2 cath cure mote key to occurin the expoted group 1 rR 1 the event i es ely co occur in the exposed group Dose-response relationship (epidemiology) ‘+ One ofthe entra require to establish causality in epidemiological studies 1+ Refers tothe presence of dose-resconce curveeg. the precence of cease incresces/decresesin direct proporien th the level ot pers) 1+ causal dose response elatlonshipaesumes that the grester the excozure, the sreater the ck ot diceace + conde infuerced by conrcunsing (] Therelave rk dds rato. and hazard ratio are usually é=played with acoresponding p-value. Per convention they are considered statisticalysignicant tthe rested p-value is < 005! References EES, 2 NOTES FEEDBACK Bias, confounding, effect modification, and latent period Blas * Definition: an erorin the study desin or way in which tic conductes that causes systematic dviation of Andines tromthe trum 7 MAKIMIZE TABLE TABLE QUIZ ypesotbis a Pre Feample ‘soho Selection + Theccunsinasemsie + Heathyneier ete The worn scpuions + ‘Randomization as fpouperenstepeserstve " hasbharonayerapethn‘hegneelpopoion =)” 6 Sabjesaeendonlysbgedtoche rhe ponuston fer nich enh nosing ives Senenian and eons peunet Getic cream coer notopeare tegen papasion reuststecn ous or) rhontas compe grape ran rom a hoe Scneunde Nonespuniasnrersanderctrcenee [Steragensnny women chaeermee ecto ronespontar dort em neon os cota Gorctinpond ie awransatey spose ceroarchis fori hor re Volartoerbi vst ho vane eee ces ihe gereslponlosse + Exarethe angle rou zrepecesie Steep bia: oe Scams precetine afte ein fie Elstner torte ttre ttn + Coc 2rmch tan orca of Uepatc nite mesposngticerormecstand shpareegursrperab + Attion bias sume shinee nc 58 ely see te vein hw be “wacsotias Be Problem Schein | + Thelen acer ies Youp rena epesentte fhe ponds tor nich example Healy mokerefet Te wort pensions rete nae thane gente popdton & They serle conan fern nothing icons Geernotrepeer the pene pondeon Brion ia: Sonse raves ean rom 9 hosp No espons Bas Nnrersander tracer (Sreragensnay wonesponrchoerrsce Sees onerpnaa doe termaon Vokrri sia wa vite to setionine uy hareciferen creer Steep bia ce Saaz seeing foster presipoest thescendane a Semmertortenetacsce mien avitonbi pein psecve ses ‘ernie ripest ieee sunivatbiae stutin + Reonizaton Sc ae anny are tothe courte tot route uty aisle sessine races ater cove) ‘cotcundre 6 sucess poeie conan ‘emogrghic teniy Nene scorn aval enue + Enarethe uma ro Srepeceiatve peporsepens arsenic + Ineton ty teat nasser nto ‘iy ates he ty rc Sepsis arineusesn tears ot ‘pubycoshelao sue secs Nocation ben eal ormton hae + Auareessf conn oy ater chnges there orem invebesnectve idee + eorasey atese es ‘ion bie suviatiae + Ato lrown x pelenceintenee ie or Nemes + Tycay oc tow cts wth the same consi Intrrason iste sary sameen he | ie ereerperrhemrriserdnietreieel + memo ozest als aters ate lneiy nates ney ean Sop srineusese ears ‘uy cats tap trace sect + Tino folowapinveorpectve uses Alcan tee Recline tae opine tie ‘peep erosrcpert ne Bape + Araenes of onion by suet changes te ec connor nrebepectve shee + reoranycalectes ts eeu o personales order ‘sina eal carta excite ater ring ut ‘out cr wit he cane conan rooontegaretes saan bcneen ne ‘ease anon goa epoing in: aac cin opin oftnorraton osusy res ere Interviewer is. iret rer ening spoons espa bi cy partpns do ated nih custo ae preg. eng eestor (Pelee the pointy 2 maroc cesabe (Obserrebias owtrenterenecary ct ot DPygroton cfc: manners of svarale hosfuten ofeubeessnfuenes bye (Seermentarsinevseps or spesstene Confenatonbis-ne ener othe menor ‘ince ony oseremsvmch prema he ‘oes arsigrare ne ret Mawthome eect: utjcr: change tet behavior Tinetofolowepinrevspacive ss eet pao Bled Coritve wer lead tne er Lene fine tie Saretnce as een ofperaralbetes code + any scion stance iter sree ‘eval + Aeapoaretingrovenetin Sterile chs lege ous. Response bis. ty pines do not earord ‘rah areca beau fthe manner> whch seston paced eg. ng urs Ober bin osname epee) eet or Pygiaion elects mane remave ots varsnie st este ue bueeas Oe Soetnene brovieag oxen: Confirmation bias ne ence ote estar othess end irre the est Hontbome cfc jects charge ts beavor cree tyre area ty eben nee Phat ad noc etc: tect he jst: a Siac wo een the esa ‘nontered mare Fest) se a placebo andes erie he bce sil sFectvenessists use meriltyatss seme ones wcorcne:o soeti Congarng 1 an neweces co lead ine as Lene tines a ie + Led tne hese eng afte enn Getcion secu ne lsrtereted sr incesed vid + Anapasetinprveret in ‘tein dase wih © lorgeines euros. eel poien eae + tess tottyen Inodenc na reece Confounding perso cone scening Lasting is our whe saline re ‘womieec more ery) Meme the bce sl Ffectvenesis tous moralerates range pater xcorong9 sve Canarngt sn nepal ge + Defrition: avy tir variable that has ot been conscered in the sty but that corelates withthe exposure and the outcome + Example: A contourder can be rezpenable for the observed relsbonchip between the desendnt ane indepencent \vorsbes Forinetnes, while expocure to aol can rutin ung concern neviduale 2 2 mining eampony, many siners smoke cgpretits, hich acte a 2 thie variable that can lead to hing cancer. + Solution ‘erfoommutike studies with diferent populations ‘¢ Randomization Confounding + Definition any thir variable that hos ot heen conscee!in the stu but dat comets withthe expasue andthe outcome [Brample: A confourder canbe responsi forthe obzerved relationship between the decendent and independent ‘vaiales For instance, while exposure t> coal con recutinlung cance in ndvidule at a mining company, many miner erika cigoerer, which 2ete 22 ti variable that con laa te hng cancer. + Solution © erormmultipl studies wit dierent popustions > Randomization © Crossover study © Restrction epidemiology) 1 Therecearcher only stuces 2 part ofthe popuistion that mest certain citer (ag. only mols with particular Baesee at ncladesin a tly to avai the influence of gender cn exposure and outcome) Problems 1 Linitseeneracbilty 1 Makes cbtzining a large sample group dificult © Matching (enidemiotogy) + Commonly wed in case-control studies + Ceses and contls are grouped into pais with similar atibutes to avd confounein Problems 1 Matching oes not completely eliminate confourding + Can introduce confounding ithe investigators match by factors that ae nt matched in the source posulation 1 Cenintroduce bie > Standardaston of dite see Zor) ‘© Stratified analysis © Standardization of data (see Z-scare). © Stratified analysis 1 study groups ae divided into subgroups according to the thd variable 1 Messure of azsocistion fog, the ods aie) can be calculated fr each subgroup fog, traturspeife ode + lnconfounding: 1 Statfing participants into subgroups according othe third variable wil eliminate the confounder ‘+The measures of association between subgroups wl be smi. but the trated measure of szzocistioni eran ram the whole population measure or aeezcotin 2, erode od ab) + inaracemocifeston 1 stating partcpanes into subgroups according othe thie variable wil result in 2 ctronger relationship in fone subgroup 1 The measures of association wil dite between subgroups (ie, there is 2 strong association nthe -albroup in which the effect medias present. whle therein association inthe subgroup in wich the ctteet mosiner aban Effect modincation + Defniton third variable that positively ornezstivelynfuences study outcome: occurs when the exposure has a Uiferent effect between groups: rot considera a tyse of bas initelt + Example: certain rue worksin children but does not have any effect on adults + Solution: -tratited ares ©. Effect moifeation canbe dferentated tom confounding by serforminga stratifed analy: When the population i strated according to 2 factor, dierent rzuke willbe seen tit ic a confounder ori tic an erect, odie Latency period + Definition: 4 ceernely inactive period between the exposure to a rick medinerto the bmeits effet becoming lirica apparent Evaluation of diagnostic tests Sensitivity and specinity + Sensitivity epidemiology) true postive rte) © The proportion offnsivduals that comrectiyregisteras postive in a ciical test desgnes to identity ses ‘© Atest with high sensitivity wilyiel low false negative rte 1 Atest with hh sensitivity Ge. few false negative) but low specifeity fora disease with ow prevalence wil Yielé ahh false postive rate © Can be used for sreening purposes © See two_by-twe table below fr the formula, Specificity true nesative at) © The proprtn ofincivcuals without citeace thet correctly test negate ina cincal test ceigned to identty ‘hot cesote Le, tus negative ele civdes by total rue nepotive an tle poitve ecu ypcaly expressed percentage © highly specifi test wil viel = ow false positive rate © Canbe used to confirm the diaeresis fllowinga postive screening test © © See tno-by-two table below forthe formula |) &| Aa! Predictive values + Positive predictive value (PPv) ©The proporten otincivicuals who test postive fora dieace that actualy have that seas + onthe other hand the probably that an indvidl whe tected postive actually Goes not have te diceas “coleulatac! ae fellows 4+ positive precictve vale Test cutoft Number of t patients Healthy With disease Test result Test cutoff Number of patients With disease Test result Test cutoff Number of i patients Healthy With disease Test result a Useless test True-positive rate (sensitivity) bs: Test with moderate discrimination G Test with good discrimination poy oF 0S 07 08 OF False-positive rate (1 - specificity) Predictive values + Positive predictive value (PPV) © The proportion oFinivduas who test postive Fora eave that actualy have that disease © *Onthe other and: the probability that an indvidal who tested postive actually doesnot have the dizeare is Calculated a5 follow: postive predictive value © The postive predictive value incteases with increasing prevalence of diseace inthe poculation ©. See two-bytwo table below forthe formal. + Negative predictive value (ev) © The probsbity that an individual who tested negative ic actual dseas-free + Onthe ctherhand the probably that an individual who tected regatve actualy her the 2 tolows: 1 - negative preictive value © The nestive predictive value decreases with increasing prevalence ofthe disease inthe populton ee caleustes ©. See twosby-twe table below forthe formals Liketinood ratio ©. Determines the utlity of adagnostictestin clinical practice: thethood rata snot influenced by disease prevalence © Reflects how mach more lel the diseases ina person with 2 postive (positive Ineo ris) or negative (nezatve tketncos rato) tect rezut compared to the pretest probability 1 te Mlehood rote», ten iti secccatac with the dzesce 1 ene ratio ie +2, then te sesocistes vith sbeence tte es 1 fe ietnood ratio ic 3 then the post-test probabil i ilar tthe pretect probsbiity, and therefore the ‘ethos poor cinial uty. © Positive encod ratio 1 Rall othe senstvty rate tue postive at) to the aloe postive rate 1 Sensitvity/t- specificity) © © Negative likelihood ratio ‘© Positive likelintood ratio: Ratio he ce + Sensitity/(t- specifiy), © Negative Beltvod ratio 1 Ratio between the fle negstive rote andthe specificity (rue negative ote) nity at true postive ate) t the fake postive rate 1 (Lsensithitysecticty = + Pre-test probability © The probsbifty that 2 patent with 2 poriuler manitectton ha a specifeaeescebefows the result ofthe iagrostic testis known. 1 The pretest probally of» dsesce is eflectad by ts pravalence in» particular gion © Negative and postive predictive values depend on the est subect’ pretest probabilty of seas (one enatity nd specify) 1 Abiche- pretest probability will decrease the NPY and increase the PPV ofa text 1 lower ertestprobbiitywilncresze the NPV and decreaze the PPV of atest Cutoff values © Every eisgnostic tect involves a trade-off between cerciwty and speci © Ina ROC cune, for example, the cenctnty plotted agnnct specifiy for diferent cutof values and iealy, the cuter point on a curve inthe upper ler corner, where cencivity and epecifcity are 100% © Sensitivity, specincty, positive predictive values, and negative predictive values very accorcing to the criterion or uo values of data © het happens when a cuto value rise or lowered deperds on whether 2 dagrostctestrecires high value (eg. tumormerker for cancer. ince for cancreatits| or low value ee. hyponetremia, granuioytos) 1 Lowering or raising 2cutot value forshigh value test = Leutof vale ie. brosdering the inclusion enter lower specificity, higher sensitivity lower postive precio value, nigher nesoivepraictve value = Teutor vale Ge, narowing te inclusion crits higher spect, lower ceritivity, higher positive recive value, loner nezative predictive value Cutoff values © Every iognoetic ect invelvee 2 ade between sancisvty and epecty © ina ROC cue for example, the censtity ie pltted agsnetspecicity tor direrentcutor values ardiealy, the ‘utof points on a curve in the upper lef corner, where sensitvty anc apecicity are 100% ©. Senitvity, specificity. pose predictive values. and negative predictive values vary accrsing to the ritetion oF cuto values of date © Wt happens when acuta value is rise or lowered depends on whether a dagnoste test recuires high value (eg, tumor marker tor concer, pce tor cancreatits or low value eg, hyponatremia, granuiocytoz:) 1 Lowering or tsicng 2 cutor value ror sigh value test 1 cutor value Ge, broadening the ncuron crite Iower specifiy, higher sensitivity lower positive precictive value higher negative predictive value 1 cute value Ge, narowing the inclusion criteria) higher spect, lower sensitivity, higher positive recive value loner negative presictvevaloe 1 Lowering or raising 2cutot value for low value test cases opposite results) cutoff value ie narowing the inclusion criteria higher spect. lower sensitivity, higher postive recive value (Seeracein rake poste» decrease in rus gostve) lower negative predictive value (increasein talez negatives > increscein wue negatives) 1 eutatr vale Ge, broadening the inclusion criteria} wer specifiy, higher sensitivity lower postive recive value incest in tre postves > increase in fale poriives). higher negative predictive value (cecresce in flee negatives» dareaze in true rezsbves) ©] Unive sensitivity ard spesifgity. which rey solely onthe Giagnosic testis predictive values are so influenced by isease relence! Verifying the presence or absence of a disease + Screening test, © Used to identity disease in asymnptor Verifying the presence or absence of a disease + Screening test © Used toidentityczease in asymotomati indvituals, * Ex, mammogram fo breast cancer ora Pap smear for cervical cancer 1 Should haves high sensitivity + Confrmatory test © Confirms dseace in individuals with sensor symotoms of dicease 1, bionsy for breast cancer or cervical cancer Usually performed after a screening test te confirm a diagnosis, 1 Should have high speccity © Receiving operating characteristic curve (ROC curve) ‘+ Agraph that compares the sensitivity and specificity ora diagnostic test 1+ Used to show the trade-ctt between circa sensitivity and specificity fc every possible cto vale to evaluate the ability ofthe test to adequately dzenose subnets lez, diseased vs nondiseased) “The y-axis represents the sensitivity Ge. the eo rate] and the vans corespond to 4 - specificity Ge. fase ostve rate, 1 A testis conseres more accurate if the curve follows the y-axis.) © Atestis considered les accurateifthe curve isclser tothe dagonal. © “The area under the curve ak allows the usefulness of tests to be comoarec: The larger the area unde the ROC curve the higher the validity of te text “Two-by-two table a: Useless test True-positive rate (sensitivity) bs: Test with moderate discrimination : Test with good discrimination eo | 1 oof 02 03 04 05 06 08 OF 1 False-positive rate (1 - specificity) Two-by-two table + Definition: type of cantingency table that eepays the Frequency oftwo categorical variables, ofen exposure and outcome ot sicaaee 7 maximize taste & taste quiz Postvetest + Tue pote TR, reat Negative test = Fabengstve(FN) ret ee 1 aimee nen acca Interetton + Senitvty ive tive Example of a two-by-two table Diagnostic est for tuberculosis 72) + Torna TN) + Specie reaive eet merpretton + Poste prin aie + Negative predetvevalue aMENTN) (The tale below ican srnatated 2 tle, with sdsitons columns dataing totel amount nd thairinterpretation) <7 maximize Taste TABLE QUIZ sens wih Poste test too te pst Negave estou 20 te enn N mel 10007 +) Pare witht 12 2400 ene) “TN Tora Example of a two-by-two table Diagnostic test for tuberculosis (7B) (The tae belew ean arctatee 2 tle with zelonsl clue dating tote aunt and theirinerpretation, SF maximize Taste Q TABLE QUIZ Pate with Pant how 3 rat Poste etresut $00 ener = FP 1200 Negsive est rest 0 fee reg 20 pape) = TN 00 Tal 1x0 TF +N s200(f8+) 3000 + Sensithity (wus postive rate) = TP/TE + FN) © £00//800 - 200) 20% + Specifity (wwe negative ate|= TWINEP + TID 2 2400400 + 3400) = 30% + False positive ate PEP = TH) 1 False negative rate = FRUIT +10) + Positive predictive ylue= TPT? + FP) 2 0/800 = 00) = 46 55 © Random error, precision, and validity Random error + Definition: on erorthat occurs due to chance and/or precision Imitation ofa ect + Can be reduced by cnested measurements and aversping over alarge numberof cbsonations Precision (reliability) + Definition te repreducbity of test eats on te same sample unde snd cordtions 1 test ith high precison wil hae minima random ror + Pracion ingoves with 1 standard deviation and ower a static est + Matha of etimating recon © Intenater eat: the test id simi raulte when pertrmed by ditterant examiners: fo Testreteat elisbliy the tat yields the sane raulte when repeated onthe ame subjects Validity (accuracy) + Definition: the cvrespondence between test mescurements/tesults and what the test was developes to measure 1a test with high ality (accuracy wl have minimal systematic error and bie. + Sensithity and specifiy are mearures of vali Le. a hil val testis high specie and sensitive + There ae mio forms ovals © Internal validity 1 Theextent to which study free of eor mast often inthe form of bias nd the resus therefore true fr the sample ot incivicusebaine toes 1 igh interna vay con be achieved by: matching study groupe according to age, sex, and other chaacteritice “e Obse-ving mentures to recluce systemic errors (bias) to 2 minimurn: ‘+ Precision improves with 21 standard deviation and * power of 2 statistical rest 4 Methods of estimating precision © ert calaity the test ies smi reste whan pected by ditteran examiners, Testretect elit the tat yields the came results whan repeatd on the me subjects. ‘Validity (accuracy) *+ Definition: the correspondence between te:t mescurements/recuit and what the test wae developed to measure ‘tect with high vat [acurac? wil have minimal systematic errr and bse. 1+ Sensitty ane spacficty are meacures of vality (Le, a highly vale testis hight

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