Public Health Sciences   PUBLIC HEALTH SCIENCES—Epidemiology and Biostatistics SECTION II 263

Precision vs accuracy
Precision (reliability)
Accuracy (validity)
The consistency and reproducibility of a test.
The absence of random variation in a test.
The closeness of test results to the true values.
The absence of systematic error or bias in a test.
Random error  precision in a test.
 precision Ž  standard deviation.
 precision Ž  statistical power (1 − β).
Systematic error  accuracy in a test.

Accuracy Accuracy
High Low High Low

High High Low Low

Precision Precision

Incidence vs # of new cases Incidence looks at new cases (incidents).

Incidence = (per unit of time)
prevalence # of people at risk
# of existing cases (at a point in Prevalence looks at all current cases.
Recurrence Prevalence =
Total # of people    time)
Incidence
in a population
Prevalence Prevalence
= Incidence rate × average duration
1 – prevalence of disease
Mortality Cure
Prevalence ≈ incidence for short duration disease Prevalence ∼ pretest probability.
(eg, common cold).  prevalence Ž  PPV and  NPV.
Prevalence > incidence for chronic diseases, due to
large # of existing cases (eg, diabetes).
SITUATION INCIDENCE PREVALENCE

 survival time — 
 mortality — 
Faster recovery time — 
Extensive vaccine administration  
 risk factors  
 diagnostic sensitivity  
New effective treatment started — 
 contact between patients with and — —
without noninfectious disease
 contact between infected and  
noninfected patients with airborne
infectious disease

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 264 SECTION II Public Health Sciences   PUBLIC HEALTH SCIENCES—Epidemiology and Biostatistics
Bias and study errors
TYPE DEFINITION
Recruiting participants
Selection bias Nonrandom sampling
or treatment allocation
of subjects such that
study population is not
representative of target
population
Most commonly a sampling
bias
Performing study
Recall bias Awareness of disorder alters
recall by subjects; common in
retrospective studies
Measurement bias Information is gathered in a
systemically distorted manner
Procedure bias Subjects in different groups are
not treated the same
Observer-expectancy Researcher’s belief in the
bias efficacy of a treatment changes treatment group to show signs
the outcome of that treatment
(also called Pygmalion effect)
Interpreting results
Confounding bias Factor related to both exposure
and outcome (but not on
causal path) distorts effect
of exposure on outcome (vs
effect modification, in which
the exposure leads to different
outcomes in subgroups
stratified by the factor)
Lead-time bias Early detection interpreted as
 survival, but the disease
course has not changed
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EXAMPLES
Berkson bias—cases and/
or controls selected from
hospitals (bedside bias) are
less healthy and have different variables)
exposures
Attrition bias—participants lost comparison/reference group
to follow up have a different
prognosis than those who
complete the study
Patients with disease recall
exposure after learning of
similar cases
Using a faulty automatic
sphygmomanometer
Hawthorne effect—participants
change behavior upon
awareness of being observed
Patients in treatment group
spend more time in highly
specialized hospital units
An observer expecting
of recovery is more likely to
document positive outcomes
An uncontrolled study shows
an association between
drinking coffee and lung
cancer; however, people who
drink coffee may smoke more,
which could account for the
association
Breast cancer diagnosed early
by mammography may
appear to exaggerate survival
time because patients are
known to have the cancer for
longer
STRATEGIES TO REDUCE BIAS
Randomization (creates groups
with similar distributions
of known and unknown
Ensure the choice of the right
Decrease time from exposure
to follow-up; use medical
records as sources
Use objective, standardized,
and previously tested methods
of data collection that are
planned ahead of time
Use placebo group
Blinding (masking) and
use of placebo reduce
influence of participants and
researchers on procedures and
interpretation of outcomes
as neither are aware of group
assignments
Multiple/repeated studies
Crossover studies (subjects act
as their own controls)
Matching (patients with
similar characteristics in both
treatment and control groups)
Effect modification—
association is shown
differently in individual
subgroups due to stratification
by given factor even when
there is association between
exposure and outcome
Measure “back-end” survival
(adjust survival according to
the severity of disease at the
time of diagnosis)
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