COHORT STUDY

DR. SOURAB KUMAR DAS

COHORT

A GROUP OF PEOPLE WHO SHARE A COMMON EXPERIENCE

OR CONDITION WITHIN A DEFINED TIME PERIOD
COHORT STUDY
◦DEFINITIONS
A type of analytic study which groups of individuals
defined on the basis of their exposure status are followed to
assess the occurrence of disease
◦SYNONYMS: Follow-up study, Incidence study,
Longitudinal study, Prospective study
Cohort study is undertaken to support the existence
of association between suspected cause and disease

◦A major limitation of cross-sectional surveys

and case-control studies is difficulty in
determining if exposure or risk factor preceded
the disease or outcome.
◦Cohort Study:

Key Point:

◦ Presence or absence of risk factor is determined before outcome

occurs.
 Design of a Cohort Study
TIME

Direction of inquiry

Disease
EXPOSED
Non disease
POPULATIO People
without
N
the
Disease
disease
NON EXPOSED
Non disease
Cohort studies

 longitudinal
 Prospective studies
 Forward looking study
 Incidence study

 starts with people free of disease

 assesses exposure at “baseline”
 assesses disease status at “follow-up
◦INDICATION OF A COHORT STUDY

◦When there is good evidence of exposure and

disease.
◦When exposure is rare but incidence of disease
is higher among exposed
◦When follow-up is easy, cohort is stable
◦When ample funds are available
General consideration while selection of cohorts

 Both the cohorts are free of the disease.

 Both the groups should equally susceptible to disease
 Both the groups should be comparable
 Diagnostic and eligibility criteria for the disease should be defined
well in advance.
3 types of cohort study
(depending on the time frame)

1.Prospective cohort study(Concurrent cohort study)

-A prospective cohort study is one in which the outcome(eg-
disease) has not yet occurred at the time of the investigation
begins.
For example: The long term effects of exposure to uranium was
evaluated by identifying a group of uranium miners and a
comparison group of individuals not exposed to uranium mining
and assessing subsequent development of lung cancer in both
group.
The principal findings was that the uranium miners had an excess
frequency of lung cancer compared to non miners.
2.Retrospective Cohort Study ( Nonconcurrent cohort
study, Historical cohort study)
◦A retrospective cohort study is one in which the outcomes
have all occurred before the start of the investigation.
◦The investigator goes back in time, sometimes 10 to 30
years, to select his study group from existing records of
past-
 Employment
 Medical or other records
And traces them forward through time from a past date fixed
on the records, usually up to the present.
Example
The study was undertake 1978. The out come measured was neonatal
death. A cohort of 17,080 babies born between January 1,1969 and
December 31,1975 at Boston hospital were investigate the effects of
electronic foetal monitoring during labour. The study showed that the
neonatal death rate was 1.7 time higher in unmonitored infants.
 3.Combination of retrospective and prospective cohort
studies .
◦ In this type of study, both the retrospective and prospective elements are
combined. The cohort is identified from past records, and is assessed of
date for the outcome. The same cohort is followed up prospectively into
future for further assessment of outcome.
◦ Example: Court-Brown and Doll(1957) applied this approach to study the
effects of radiation. They assembled a cohort in1955 consisting of 13,352
patients who had received large doses of radiation therapy for ankylosing
spondylitis between 1934 and 1954.The outcome evaluated was death
from leukomia or aplastic anaemia between 1935 and 1954. they found
that the death rate from leukamia or aplastic amaemia was substantially
higher in their cohort than that of the general population.

◦ A prospective component was added to the study and the cohort was
followed, as established in 1955, to identify deaths occurring in
subsequent years.
Elements of cohort study
◦ Selection of study subjects
◦ Obtaining data on exposure
◦ Selection of comparison group
◦ Follow up
◦ Analysis
Selection of study subjects
◦General population
◦ Whole population in an area
◦ A representative sample

◦Special group of population

◦ Select group
◦ occupation group / professional group (Dolls study )
◦ Exposure groups
◦ Person having exposure to some physical, chemical or biological agent
◦ e.g. X-ray exposure to radiologists
Obtaining data on exposure

◦Personal interviews / mailed questionnaire

◦Reviews of records
◦ Dose of drug, radiation, type of surgery etc
◦Medical examination or special test
◦ Blood pressure, serum cholesterol
◦Environmental survey

◦By obtaining the data of exposure we can classify

cohorts as
◦ Exposed and non exposed and
◦ By degree exposure we can sub classify cohorts
Selection of comparison group

◦Internal comparison
◦ Only one cohort involved in study
◦ Sub classified and internal comparison done

◦External comparison
◦ More than one cohort in the study for the purpose of comparison
◦ e.g. Cohort of radiologist compared with ophthalmologists

◦Comparison with general population

rates
◦ If no comparison group is available we can compare the rates of
study cohort with general population.
◦ Cancer rate of uranium miners with cancer in general population
 Follow-up

◦To obtain data about outcome to be

determined (morbidity or death)
◦ Mailed questionnaire, telephone calls, personal interviews
◦ Periodic medical examination
◦ Reviewing records
◦ Surveillance of death records
◦ Follow up is the most critical part of the study
◦Some loss to follow up is inevitable due
to death change of address, migration,
change of occupation.
◦Loss to follow-up is one of the draw-back
of the cohort study.
ANALYSIS

◦Calculation of incidence rates among exposed

and non exposed groups

◦Estimation of risk
 Do Not
Develop Develop
Disease Disease

Exposed a b
Not Exposed c d

Incidence in exposed
R.R =
Incidence in non-exposed

= =
Strengths/Advantages

◦Correct temporal relationship between exposure and the

outcome of the disease
◦Disease rates can be calculated directly
◦Allows the evaluation of multiple effects from a single
exposure
◦Generally involved good information on exposure
Limitations/Disadvantage
◦Large number of subjects are required if the outcome of
interest is rare
◦Requires long follow-up, if latency period is long
◦Expensive
◦Investigator should consider several issue: availability of
study groups, records, and feasibility of complete follow-
up of subjects
Potential biases
◦Bias in assessment of the outcome
◦Information bias-most likely when historical cohort
was used
◦Bias from non-response and losses to follow-up