Dr. Maher D.

Fuad Fuad Lecturer Faculty of Medicine Department of Community Medicine

Definition
Observational epidemiologic study Persons with the disease & a suitable control

(comparison, reference) group of persons without the disease. The relationship of an attribute to the disease is examined by comparing the diseased and nondiseased with regard to how frequently the attribute is present

Def. continue
It is a retrospective or backward looking study as the

study commences with the cases in which disease in question had already appeared.

Purpose
Establish the cause and effect relationship (causal

association) Testing causal hypothesis for rare diseases When results are expected less expensively and in short time

TIME

EXPOSED

NOT EXPOSED

EXPOSED

NOT EXPOSED

Direction of inquiry

STEPS OF CASE CONTROL STUDY

Selection of cases
Selection of controls Matching Enquiry and records verification for amount of

exposure in both groups Comparison analysis and risk measurement If exposure is more in cases than in controls causal association suspected

Selection of Cases
Study begins with CASES

- Patients in whom the disease has already occurred - were enquired for all the details of their exposure to the suspected cause Do the cases need to represent all patients with the disease? No Restricted to a specific type or severity Usually new cases (incidence) is chosen not prevalent cases? Similar clinical, histological, pathological. Duration of exposure Selected independent of exposure. (very important recap XS)

Continue..
Time of admission and duration of hospital stay

has also to be considered while selecting the cases. Hospital cases will be usually of advanced stage of disease and this factor should be kept in mind while selecting the cases otherwise it will lead to selection bias (error). If possible, it is always advisable to select all cases from similar environmental exposure. Sources Hospital Community

Selection of Controls
Carefully chosen otherwise validity of the study will be

defective Should be obtained from same population Hospital-based. Community-based. Friends, relatives, Neighbors.

Hospital-based
ADVANTAGES
Efficiency in obtaining

DISADVANTAGES
Unknown potential

subjects. Can carry out Diagnostic test. Less recall bias Willingness to participate. Less likely to drop out. Cost saving

confounders drugs. Exclusion criteria=case Without exclusion risk underestimate

Community-based
ADVANTAGES
Prevalence of exposure can be

DISADVANTAGES
Sampling frame Cost contacting lists of

used as an estimate of exposure

potential controls Interviewing subjects

Friends, Relatives, Neighbors

ADVANTAGES
Cooperation Predominantly healthy Can adjust confounders by

DISADVANTAGES
Over matching

underestimate true effect

cultural or geographical

Selection of Controlscontinue..
Number of controls taken may be

four times Twice even equal to that of cases the ratio depends upon the availability of suitable matched controls, available time and finances. Equal number, if they are better matched, are enough to conduct the study.

MATCHING
Is a comparative technique of neutralizing all other

variables present in cases and control EXCEPT the variable under study Known confounding variable eg. age, gender, occupation etc. Unknown confounding variable playing a role in causation

 Cases are made identical with controls i.e. all the

known variables of the cases (like age, sex, occupation, social status,..etc) are (eliminated) with those of controls except the factor (disease) under study. Cases and controls of same age, same sex, same occupation and living same village may be selected for better comparison, if feasible.

 When selected from hospitals, it is essential to choose

patients with other diseases, not with the disease under question and if possible, preferably from same hospital from where the cases were selected Study on the association between lung cancer and smoking if lung cancer cases were selected as study group thyroid cancer patients can be taken as controls from the same hospital. This improves the efficiency of comparison and also the validity of the study by avoiding error

 Both the groups were made identical in all their other

characteristics except for the presence of lung cancer, which will be present only in cases. This can be done by proper selection and by matching the known variables in both groups. Then, we measure the proportion of smoking in cases and controls and compare. If it is significantly more in cases than in control group, causal association is suspected

Design of case-control studies

First select Then measure past exposure Exposed Cases with disease Control without disease b

Not exposed

c
a+c

d
b+d P E/D- = [b/(b+d)]

Proportions Exposed

P E/D+ = [a/(a+c)]

Ratio between above 2 proportions is mathematically possible but conceptually wrong because they are not true prevalences

Hypothetical example of case control study of CHD and Cigarette Smoking

CHD CONTROL

SMOKE DO NOT SMOKE TOTAL

OR = ??????

112 88 200

176 224 400

What should be always true for a case-control study?

1.
2. 3. 4.

5.

Cases and controls are randomly selected. Cases are a representative sample of all cases in the general population Controls are a representative sample of the general population Cases and controls have the same population of origin Always start with some cases, then identify their valid controls

RR & AR in case-control study?

Recall WHAT is Relative Risk & Attributable Risk?
RRduration = Risk (E+)/ Risk (E-) ARduration= Risk (E+) Risk (E-) Since risk cannot be computed directly from a case-

control study (why?), RR and AR cannot be computed.

Answer: because we can not calculate incidence.

Advantages of Case-Control Studies

1.
2. 3. 4. 5. 6.

Less expensive and simpler Require smaller sample sizes Shorter duration than prospective study Study multiple risk factors for 1 disease. Easily reproduced in different populations by different investigators. Used for rare diseases.

Disadvantages of Case-Control Studies

1.
2. 3. 4. 5.

Liable for selection and recall bias. Population of origin for cases is difficult to define precisely. Difficult to identify appropriate control group Does not provide estimate of risks and attributable risk. not suitable for rare exposures

 Thank you