Clinical Epidemiology

Community Health and Environmental Medicine 3

Joko Mulyanto
Department of Public Health & Community Medicine
Jenderal Soedirman University School of Medicine
Introduction
• Epidemiology is basic science
concerned with the pattern of disease in
human population.
• Distribution of disease by person, place,
and time.
• Assumptions
- Disease does not occur randomly
- Disease has identifiable cause
> can be altered
> prevent from development
Epidemiology is defined as…

The study of the distribution and

determinants of health-related
states or events in specified
population, and the application of
this study to control of health
problems.
Epidemiology is defined as…
(cont’d)
• Study
surveillance, observation, hypothesis testing,
analytic research, and experiments.
• Distribution
analysis by time, place, and person.
• Determinants
physical, biological, social, cultural, and
behavioral factors that influence health.
• Health-related states or events
diseases, causes of death, behavior, reactions
to preventive regimens, and provision and use
of health services.
Epidemiology is defined as…
(cont’d)
• Specified populations
those groups of people with identifiable
characteristics
• Application to control
refers to the goal of epidemiology, that is to
assess the public health importance of
diseases, identify the population at risk, identify
the causes of disease, describe the natural
history of disease, and evaluate the prevention
and control of disease
Clinical Epidemiology

• Applying population-based
information to optimize patient care.
• Use epidemiological methods in
clinical setting.
• The basis of evidence-based
medicine.
How is epidemiology used in
clinical medicine ?
• Describe the natural history of disease.
• Discuss the causality of disease.
• Provide disease surveillance.
• Evaluate diagnostic testing.
• Evaluate therapy of disease
• Evaluate prognosis of disease.
• Economic evaluation and decision
analysis.
Observational & Analytical
Epidemiology
• Descriptive epidemiology
- The occurrence of disease
• Etiological epidemiology
- Cause of disease
• Experimental epidemiology
- Assessment of therapy
Epidemiological analysis

• Measure of disease frequency.

• Magnitude of association.
• Statistical association.
• Regard to bias, confounding, and
chance.
Research Designs Used in
Epidemiology
• Case reports / case series
• Case control
• Cross-sectional
• Cohort : Prospective and
Retrospective.
• Randomized Clinical Trial (RCT)
• Secondary analysis
Epidemiologic Terms

• Chance
• Bias
• Confounding
• Frequency measure
• Measure of association.
• Causal inference.
Chance

• “Luck of the draw”

• Concept of inference
• Hypothesis testing (p – value)
• Confidence interval
Bias

• Systematic errors in collecting or

interpreting data such that there is
deviation of results or inferences
from the truth.
• Bias results from systematic flaws
in study design, data collection, or
the analysis or interpretation of
results.
Type of Bias

• Selection Bias.
Non-comparable criteria used to enroll
participants.
• Information Bias.
Non-comparable information is obtained from
the study groups due to interviewer bias or due
to recall bias.
Confounding
• a mixing of effects between the exposure and
the disease
- by other factors associated with both the exposure
and the disease
- the effects of the two processes are not separated

• Confounding results when the effect of an

exposure on the disease (or outcome) is
distorted because of the association of
exposure with other factor(s) that influence the
outcome under study.
Confounding (cont’d)
observed association, presumed causation

Gambling Cancer

unobserved association true association

Smoking,
Alcohol
Frequency Measurement

• General measurement of frequency

- Ratio
- Proportion
- Rate
• Frequency measurement in
epidemiology
- Prevalence
- Incidence
Prevalence

• the number of existing cases in the

population; the proportion of the
population at a given time that have
the factor of interest.
Type of Prevalence

• Point Prevalence; specific point of

time

• Period prevalence; specific period

of time
Incidence

• the probability (risk) of an individual

developing the disease (outcome)
during a specific period of time.
Type of Incidence

• Cumulative incidence
a measure of the occurrence of new cases in a
population

• Incidence density
the rapidity with which new cases develop; one person
year of experience (PYOE)
Measure of Association
• frequency measurements are
compared and summarized
• to determine the magnitude of the
observed association between risk
factor and outcome
• useful in judging the likelihood that
the exposure is a significant
clinically factor in the development
of the outcome of interest.
Type of Measures of
Association
• Ratio
- Relative Risk
> Risk Ratio
> Rate Ratio
- Odd Ratio
• Difference
- Attributable Risk
> Attributable Risk Fraction
> Population Attributable Risk Fraction
Relative Risk

• Ratio of occurrence of disease in

exposed to non-exposed
populations.
• Risk Ratio: comparison of
prevalence or cumulative incidence.
• Rate Ratio: comparison of
incidence density.
Odd Ratio

• Ratio of odds of being exposed if

having disease, to those of being
exposed if disease free.
Attributable Risk

• Difference in risk between exposed

and non-exposed population.
• Attributable risk fraction
attributable risk as proportion of total risk in
exposed group.
• Population attributable risk fraction.
the proportion of the population risk that is
attributable to the exposure.
Causal Inference

• Natural history of disease; agent,

host, environment, vector.
• Koch’s postulate of infectious
disease.
• Bradford Hills postulates for multi-
causal diseases
Choice of Study Design

• Disease surveillance
> cross-sectional
• Natural history of disease, causality
of disease
> cohort study, case-control
• Diagnostic testing
> SR, RCT, cohort study, case-control
Choice of Study Design

• Therapy evaluation
> SR,RCT, cohort study, case control, case-
series
• Prognostic evaluation
> cohort study, survival analysis, case-series
Cross Sectional Study

CURRENT

Exposed Disease

No Exposed No Disease
Case - Control
PAST CURRENT

Exposed

Disease
No exposed

Exposed
No Disease

No Exposed
Cohort Study (Prospective)
CURRENT Follow-Up FUTURE

Disease

Exposed

No disease

Subject
Disease

No Exposed

No disease
Cohort Study (Retrospective)
PAST CURRENT

Disease

Exposed

No disease

Subject
Disease

No Exposed

No disease
Clinical Trial

Effect (+)

Treatment

Effect ( - )

Subject R
Effect (+)

Control

Effect ( - )
Diagnostic Test
Disease

Yes No

Positive TP FP
Diagnostic
Result
Negative FN TN
Survival Analysis
CURRENT Follow Up FUTURE
Time Interval

Death

Disease
Censored
Death

Survive Censored

Survive
References
MacMahon, B., Pugh, T.F. (1970). Epidemiology:
Principles and Methods. Little Brown & Co.:
Boston
Risser, W., Risser, J. (1999). Introduction to
clinical epidemiology.
Rothman, K.J. (1986). Modern Epidemiology. Little
Brown & Co: Boston.
Sastroasmoro, S., Ismael, S. ( 2002). Dasar-dasar
Metodologi Penelitian Klinis. Sagung Seto:
Jakarta.
Silman, A.J.Epidemiological studies: A practical
guide. Cambridge University Press: London.
THANK YOU

djokomoeljanto©2006