Nur Aisyah Jamil

z
BIAS AND
CONFOUNDING
z
z
 z
Perhatikan hasil pengukuran 5
sampel berikut :

Valid, random
Reliabel, errorr sistem besa
error besar

Hulley S.B,et al.,2001

Valid, reliabel, errorr sistem dan random error minimal

 z
INTERNAL VALIDITY
§ Bias

§ Confounding

§ Random errorr/chance

BIAS dan CONFOUNDING akan mempengaruhi

hasil penelitian seberapapun besar sampel

Random errorr akan berkurang dengan

penambahan sampel
 z
Random Error
Per Cent

14
12
10
8
6
4
2
0
0 5 10 15 20 25 30 35

Size of induration (mm)

WHO (www)
 z
Systematic Error
Per Cent

14
12
10
8
6
4
2
0
0 5 10 15 20 25 30

Size of induration (mm)

WHO (www)
 z

Chance vs Bias

Chance is caused by random error

Bias is caused by systematic error

Errors from chance will cancel each other out in the long run (large
sample size)
Errors from bias will not cancel each other out whatever the sample
size

Chance leads to imprecise results

Bias leads to inaccurate results
 BIAS?
Any trend in the collection, analysis, interpretation, publication or
review of data that can lead to conclusions that are
systematically different from the truth (Last, 2001)
A process at any state of inference tending to produce results that
depart systematically from the true values (Fletcher et al, 1988)
z
Systematic error in design or conduct of a study (Szklo et al, 2000)
 z
Jenis Bias, menurut Sacket

§ Literature Review § Study Design

Selection bias
§ Foreign §

§ Sampling frame bias

language
§ access bias
exclusion bias
§ Diagnostic purity bias
§ Literature § Hospital access bias
search bias § Migrator Berkson (admission rate) bias

§ Centripetal bias
§ One-sided
§ Diagnostic bias
reference bias
§ Prevalence-incidence (Neyman /
§ Rhetoric bias selective survival; attrition) bias
§ Telephone sampling bias
z
§ Nonrandom sampling bias
§ Autopsy series bias
§ Detection bias
§ Diagnostic work-up bias
§ Door-to-door solicitation
bias
§ Previous opinion bias
§ Referral filter bias
§ Sampling bias
§ Self-selection bias
§ Unmasking bias
§ Noncoverage bias
§ Early-comer bias
§ Ilegal immigrant bias
§ Loss to follow-up (attrition) bias
§ Response bias
§ Withdrawal bias
§ Noncomparability bias
§ Ecological (aggregation) bias
§ Healthy worker effect (HWE)
§ Lead-time bias
§ Length bias
§ Membership bias
§ Mimicry bias
§ Nonsimultaneous comparison bias
§ Sample size bias
 § Data Collection
z
§ Instrument bias
§ Case definition bias
§ Study § Diagnostic vogue bias
Execution § Forced choice bias
§ Framing bias
§ Bogus control § Insensitive measure bias
bias § Juxtaposed scale bias

§ Contamination § Laboratory data bias

bias § Questionnaire bias

§ Scale format bias
§ Compliance § Sensitive question bias
bias
§ Stage bias
§ Unacceptability bias
§ Underlying/contributing cause of death
bias
§ Voluntary reporting bias
z
§ Data source bias
§ Competing death bias
§ Family history bias
§ Hospital discharge bias
§ Spatial bias
§ Observer bias
§ Diagnostic suspicion bias
§ Exposure suspicion bias
§ Expectation bias
§ Interviewer bias
§ Therapeutic personality bias
§ Subject bias
§ Apprehension bias
§ Attention bias (Hawthorne
effect) (Wickström, 2000)
§ Culture bias
§ End-aversion bias (end-of-
scale or central tendency bias)
§ Faking bad bias
§ Faking good bias
§ Family information bias
§ Interview setting bias
§ Obsequiousness bias
§ Positive satisfaction bias
§ Proxy respondent bias
z

§ Recall bias § Data handling bias

§ Reporting bias § Data capture error

§ Response fatigue bias § Data entry bias

§ Unacceptable disease § Data merging error

bias
§ Digit preference bias
§ Unacceptable
§ Record linkage bias
exposure bias
§ Underlying cause
(rumination bias)

§ Yes-saying bias
§ Analysis
§ Interpretation of
z Results
§ Cultiple exposure bias
§ Nonfounding bias § Assumption bias

§ Latency bias § Cognitive

§ Monrandom sampling bias dissonance bias
§ Standard population bias § Correlation bias
§ Spectrum bias § Generalization bias
§ Analysis strategy bias
§ Magnitude bias
§ Distribution assumption bias
§ Significance bias
§ Enquiry unit bias
§ Underexhaustion
§ Estimator bias
bias
§ Missing data handling bias
§ Outlier handling bias
§ Overmatching bias § Publication
§ Scale degradation bias
§ All's well literature
§ Post hoc analysis bias bias
§ Data dredging bias
§ Positive result bias
§ Post hoc significance bias
§ Hot topic bias
§ Repeated peeks bias
 z
BIAS

Selection Information/ Confoundin

Bias Missclassified g Bias
Diagnosti Bias
Self c/ Loss to Prevalenc
selection Workup follow up / e-
bias bias withdrawal incidence Recall Reporting bias /
bias bias bias Hawthorne effect

Publicity Health
bias y
worker
bias

Most simplistically, there are three types of bias: (1) selection bias, (2) information /
misclassification bias, (3) confounding bias. This basic classification derived from
the studies by Miettinen in the 1970s (see for example Miettinen & Cook, 1981)
z
BIAS
SELEKSI....
 z
Bias Publicity

§ Subjek didapat dari relawan (self-referral) yang datang karena publikasi

penelitian

§ Contoh : 18% responden penelitian atom dan leukimia merupakan self

referral setelah di publish penelitian.

(www)
z
Bias non respons/bias relawan

§ Subyek menolak ikut

§ Latar belakang relawan ikut

§ Pasien alergi berat, resisten, kronis akan ikut obat

alergi namun yang alergi ringan merasa tidak perlu
z
Healthy Worker Effect

§ Kelompok yang bekerja (lebih sehat, lebih rendah

mortality rateny)

§ Menggunakan darah dari donor darahà lebih sehat

lyfstyle

§ àgunakan kontrol dari kelompok pekerjaan lain

(bukan populasi)
z
Admission Bias/Berksonian

§ Memilih subjek (kasus dan kontrol) dari rumah

sakit.àindikasi rawat bisa berbeda, kesetaraan
berbeda

§ 500 kasus PJK ( RS), kontrol 500 pasien RS bukan

PJK, thd minum kopi

§ Pasien RS lebih sedikit yang minum kopi

§ Pasien RS lebih sedikit yang merokok

§ àmenghimpun kelompok (subyek sehat, sakit ringan,

sedang, berat) atau kelompok kontrol lebih dari satu.
Atau kontrol dari tetangga (neighbourhood)
z
BIAS PREVALEN/INSIDEN
(Neyman’s bias)
§ Mortalitas tinggi di awal kehidupan

§ Misal Faktor Risiko PJB, subjek direkrut pada usia 1

thn

§ àstudi insiden : merekrut sejak lahir

§ You want to determine the prevalence of HIV infection

§ - You ask for volunteers for testing

§ - You find no HIV

§ - Is it correct to conclude that there is no HIV in this

location?
 z
Loss to follow up/ withdrawal bias

§ Subjects in follow-up study of multiple sclerosis may differentially drop out due
to disease severity
z
BIAS
INFORMASI...
z
RECALL BIAS

§ Bias umumnya pada case-control

§ Ibu yang memiliki bayi dengan kelainan lebih

mengingat suatu exposure dibanding yang tidak
z
REPORTING BIAS (Hawthorne
effect)

§ Responden dengan penyakit kronis berat lebih

komplit laporan terhadap paparanàhubungan lebih
kuat

§ Responden yang sadar sedang diteliti akan

mengubah perilaku menjadi sehat sehingga
laporan/informasi berbeda
z
BIAS PENGUKURAN lainnya...
Pemeriksa,subjek, alat ukur

§ Bias Prosedur : ada yg lebih mendapat perhatian,

lebih sering diukur.., dsb

§ Bias insensitive meassurement : alat ukur tidak baik

§ Bias deteksi : kemampuan deteksi dini, vs masuk

studi sdh sakit

§ Bias ketaatan(compliance): beda perlakuan, beda

ketaatan
 z
Controlling for Information Bias

• Blinding
Form of survey
mail may impose less “white coat tension”
than a phone or face-to-face interview
•Questionnaire
use multiple questions that ask same
information
acts as a built in double-check
•Accuracy
multiple checks in medical records
gathering diagnosis data from multiple
sources
z
CONFOUNDIN
G....
z
CONFOUNDING

§ the confusion,

§ or mixing,

§ of effects
z
CONFOUNDING
z
VARIABEL ANTARA
 Syarat Confounding
z

§ It is a risk factor for the disease, independent of the putative risk factor.

§ It is associated with putative risk factor.

§ It is not in the causal pathway between exposure and disease.

§ The first two of these conditions can be tested with data. The third is
more biological and conceptual.
z
Hubungan sebab akibat

§ Hubungan waktu(temporal relationship)

§ Kuatnya assosiasi (p,CI,OR,RR)

§ Dose dependent/biologically gradient

§ Konsistensi, pada kelompok usia,jenis kelamin, ras

lain

§ Koherensiàsampel ke populasi

§ Biological plausibility

§ Kesamaan dengan penelitian lain dengan design

beda, populasi beda,dsb
z

Minum Penyakit
Kopi Jantung

Merokok
z

Makan Carries
Permen Dentis

Sikat
Gigi
z
Extraneous variable dapat menjadi
Confounding, jika :

§ Merupakan faktor risiko sebuah penyakit

§ Memiliki hubungan dengan paparan yang diteliti

§ Bukan merupakan tahap antara dalam hubungan

kausal dua variabel

Hendrik Vermooten
z
Confounding by indication

§ Hati-hati pada penarikan kesimpulan data case-

control

§ Misal penelitian pemberian plasma dan prognosis

DSS, maka renjatan berat, perdarahan,renjatan
lama, renjatan berulang yang merupakan indikasi
pemberian plasma dapat menjadi confounder.

§ àskor propensity (log regresion)

z
Confounding...

§ Identifikasi confounding variabel àpustaka,

common sense

§ Menyingkirkan

§ Menganalisis
 z
HOW TO CONTROL FOR
CONFOUNDERS?

§ IN STUDY DESIGN…

§ RESTRICTION of subjects according to potential confounders

(i.e. simply don’t include confounder in study)

§ RANDOM ALLOCATION of subjects to study groups to

attempt to even out unknown confounders

§ MATCHING subjects on potential confounder thus assuring

even distribution among study groups
 z
HOW TO CONTROL FOR
CONFOUNDERS?

§ IN DATA ANALYSIS…

§ STRATIFIED ANALYSIS using the Mantel Haenszel method to adjust

for confounders

§ IMPLEMENT A MATCHED-DESIGN after you have collected data

(frequency or group)

§ RESTRICTION is still possible at the analysis stage but it means

throwing away data

§ MODEL FITTING using regression techniques

z
DM dan CHD, apakah hipertensi
menjadi confounding?
z
z
 Perhatikan : analisis stratified....
z
z
Bacaan lebih lanjut

§ Epidemiology Research Method from

https://onlinecourses.science.psu.edu/stat507/node/28

§ Joe L. Hsu, MD, MPH, Dipanjan Banerjee, MD, and Ware G. Kuschner, M,
Understanding and Identifying Bias and Confounding in the Medical Literature, 2008
the Southern Medical Association

§ Hulley S.B, Cummings,S.R., Browner,W.S.Grady,D.G., Newman,T.B.,2001,

Designing Clinical Research, 3rd ed, philadelphia : Lippincot William and Wilkin.

§ Rothman KJ. (2002). Epidemiology: An Introduction. New York, Oxford University

Press.

§ Rothman KJ, Greenland S. (1998). Modern Epidemiology, 2nd ed. Philadelphia PA,
Lippincott-Raven Publishers.

§ Sackett DL. Bias in analytic research. J Chronic Dis 1979;32:51-63

§ Sastroasmoro S, Ismael S, 2011, Dasar-Dasar Metodologi Penelitian Klinis, ed 4,

Jakarta : Sagung Seto.
z

§ Pertanyaan?