Case-Control Study

Concept Map

Descriptive Analytical
Epidemiology Hypothesis Epidemiology

RCT
Cohort
Judging
Causality

Prevention
Strategies
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 Concept Map

Descriptive Analytical
Epidemiology Hypothesis Epidemiology

RCT
Cohort
Judging
Causality Case-Control

Prevention
Strategies
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 Case-Control Study

A type of observational analytical epidemiological investigation

in which the subjects are selected on the basis of whether they
do (cases) or do not (controls) have a particular disease under
study. The groups are compared with respect to the proportion
having a history of an exposure or characteristic of interest.
 
(Epidemiology in Medicine)
 Case-Control Study

Persons with a given disease (cases) and persons without the

given disease (controls) are selected; the proportion of cases and
controls who have certain background characteristics or who
have been exposed to possible risk factors are then determined
and compared.
 
(?)
 Case-Control Study

That method of epidemiological investigation in which the

frequency of an attribute or exposure to an environmental factor
in cases (individuals with the disease or another defined adverse
health outcome) is compared to that in the non-cases or controls.
The difference in the two frequencies is quantified statistically to
rule out chance of occurrence and to estimate the magnitude of
the effect of the attribute or exposure on the disease.
 
(“The Case-Control Study: The Problem and the Prospect”)
 Case-Control Study

Also called:

• Case-comparison study
• Case-referent study
• Retrospective study
• Trohoc study
• “Fishing expedition”
 Case-Control Study
QQuick

Carried out in a short period of time

Does not require large samples

Less expensive
 Case-Control Study
DDirty
May not be able to get accurate information
concerning potential risk factors
May not be able to get accurate information
concerning potential confounding variables
Recall bias
Unable to determine with certainty whether
exposure
came before disease or disease came before exposure
Difficult to assemble a representative case group
and
control group
 Case-Control Study

Selection of Cases
 
 Newly diagnosed cases are preferred
 
Considered incidence at time of diagnosis
 
Diagnostic criteria
 Case-Control Study
Methods of Selecting Cases
 

All incidence cases in defined population over specific

time period
All incidence cases seen at certain hospital over specific
time period
Cases seeking care from office-based physician
Patients seen at pre-paid health plan
Schools, places of employment, military service
 Case-Control Study
Selection of Controls
 
Most difficult and most controversial aspect of study
design
  
The control series is intended to provide an estimate of the
exposure rate that would be expected to occur in the cases if
there was no association between the study disease and
exposure.
 

Individuals selected as controls should not only be free of the

disease, but should be similar to the cases in regard to the
possibility of having past exposure during the time period of
risk.
 Case-Control Study

MMethods of Selecting Controls

 
PProbability sample of population from which cases come
SSchool rosters, selective service lists, insurance company lists
 
NNeighbors of cases
 
FFriends, schoolmates, siblings, fellow-workers
 
PPersons seeking medical care at the same institution as cases
for condition not related to cases’ disease
 Case-Control Study

EExclusions
 
SSame criteria must be applied to cases and controls
 
·      Sex and age
 
·      Organ removal
 
·      Having disease more than a certain time
 
·      Does not speak English
 Case-Control Study

AAscertainment of Exposure
  
·    Personal interviews
 
·      Existing records
 
·      Physical measurements and lab tests
 Case-Control Study

EExposure
  
·      Yes / No
 
·      Intensity
 
·      Length of exposure
 
 Case-Control Study

Estimates Made from Case-Control Studies

 
Proportion of cases exposed
 
Proportion of controls exposed
 Case-Control Study

Measure of Effect
  
Odds ratio,
ratio of 2 odds
 
Ratio of odds in favor of exposure among cases to
odds in favor of exposure among controls.
 Case-Control Study
Measure of Effect
 

Odds in favor of exposure among cases

(a / c)
Odds in favor of exposure among controls
(b / d)
 

Odds ratio,
ratio of 2 odds
  

a/c
____________
 

b/d
 Case-Control Study

SStrengths
Can examine multiple etiologic factors for a single disease

Is optimal for the study of rare disease

Is particularly well-suited to the evaluation of diseases with

long latent period

Is relatively quick and inexpensive compared with other

analytical designs
 Case-Control Study

LLimitations

Is inefficient for the evaluation of rare exposures, unless

the attributable-risk percent is high
Cannot directly compute incidence rates of disease in
exposed and non-exposed individuals, unless study is
population based
In some situations, the temporal relationship between
exposure and disease may be difficult to establish
Is particularly prone to bias compared with other analytical
designs, in particular selection and recall bias
 Concept Map

Descriptive Analytical
Epidemiology Hypothesis Epidemiology

RCT
Cohort
Judging
Causality Case-Control
X-Sectional

Prevention
Strategies
 Flow
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Review
 What’s the Design?

Define treatment and control groups.

Administer exposure to treatment group, but not controls.

Follow through time and compare rate of disease in

treatment group with rate of disease in control group.

Epidemiologist is involved during the entire time from

exposure and disease.

Randomized Trial
 What’s the Design?

Select a healthy study sample.

Observe who is exposed and who is not exposed.

Follow through time and compare rate of disease in
exposed group to rate of disease in unexposed group.
Epidemiologist is involved during the entire time from
exposure and disease.

Cohort Study
 What’s the Design?

Select a group of people with disease and a similar group

of people without the disease.
Ask both groups about their exposures in the past.
Compare proportion of exposure in diseased group to
proportion of exposure in non-diseased group.
Epidemiologist is involved after disease has occurred
and relies on subjects’ memories to gather information
about exposure.
Case-Control Study
 What’s the Design?
Select a study sample.

Ask each person about both exposure and disease at that

point in time.

Disease rate in exposed group is compared to disease rate

in unexposed group.

Epidemiologist gathers data only at that one point in time.

Cross-Sectional Study
 Study Design Exercise

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Case-Control Study
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Cross-Sectional Study
 Study Design Exercise

Select a healthy study sample.

Observe who is exposed and who is not exposed.

Follow through time and compare rate of disease in
exposed group to rate of disease in unexposed group.
Epidemiologist is involved during the entire time from
exposure and disease.
 Study Design Exercise

Select a group of people with disease and a similar group

of people without the disease.
Ask both groups about their exposures in the past.
Compare proportion of exposure in diseased group to
proportion of exposure in non-diseased group.
Epidemiologist is involved after disease has occurred
and relies on subjects’ memories to gather information
about exposure.
 Study Design Exercise

Define treatment and control groups.

Administer exposure to treatment group, but not controls.

Follow through time and compare rate of disease in

treatment group with rate of disease in control group.

Epidemiologist is involved during the entire time from

exposure and disease.
 Study Design Exercise

Select a study sample.

Ask each person about both exposure and disease at that

point in time.

Disease rate in exposed group is compared to disease rate

in unexposed group.

Epidemiologist gathers data only at that one point in time.

Chapter Questions
DES Study
 Case-Control Study

Bias
  
“... systematic error introduced into sampling or testing by
selecting or encouraging one outcome or answer over others.”
 
(Webster’s New Collegiate Dictionary)
 Case-Control Study

Selection Bias
 
·      Prevalence / incidence
 
·      Detection
 
·      Non-Response
 Case-Control Study

Information Bias
 
·      Limitations of human recall
 
·      Recall bias
 Case-Control Study

Confounders
 
Factors known to be associated with exposure of interest
and causally with disease under study
Variables Used in Study of Smoking and Lung
Variables Used Cancer
in Study of Smoking and Lung Cancer
Subject Selection Control Selection

 Males and/or females  Age matched

 Occupational groups  Healthy individuals
 Hospitalized cases  Patients hospitalized for other cancers
 Autopsy series  Patients hospitalized for other diseases
 Total lung cancer deaths in an area  Deaths from other causes than cancer
 National sampling lung cancer deaths  Sampling of general population

Methods of Interviewing Other Variables Concurrently Studied

 Mailed questionnaires  Geographic distribution

 Personal interviews subjects/relatives  Occupation
 Personal interviews controls: professional  Marital status
 Personal interviews controls  Coffee and alcohol consumption
 Other nutritional factors
Tobacco-Use History  Parity
 War gas exposure
 Type of smoking  Other pathologic conditions
 Amount and type  Hereditary factors
 Amount, type and duration  Air pollution
 Inhalation practices  Previous respiratory conditions