Introduction to Clinical Biostatistics

Research Methodology Terminology, Data,

Measurement, Error
SCIENCE;

It is a set of information that is accepted to be accurate by

means of the the current knowledge, tools and methods and
generalizations derived from this information and methods to
obtain these informations.
The aim is to isolate and classify objects and events and to find
out the relationships between and within these classes in order
to provide an insight into the universe of infinite number and
perplexed objects and events. For this reason, the subject is not
an object and an event, but subject and event societies.
 Scientific work: Studies to obtain scientific information. Science
develops with the help of scientific studies. In order to obtain
scientific information, the obtained information should be
obtained by the methods called scientific method.
Scientific research is a systematic endeavor designed to achieve
information appropriate for the purpose of science.
SCIENTIFIC METHOD; understanding the formation in
nature, objectivity in the production of scientific knowledge,
planned systematic study and ways of implementing logic
rules. Identifying the features that occur in units with a
logical approach, to examine the reasons, to solve the
structure of the formation by getting rid of personal
judgments while acquiring information about the events
around us is called scientific method.
- Deductive Method
It goes to conclusion with the analogies between the
concepts and the phenomena based on the dogmas coming
from philosophy and religions.
- Inductive Method
- Generalizations are made from the events and the
observations. The results from the small parts of the whole
are generalized to the whole.
- Modern Scientific Method
- It is a synthesis of deductive and inductive approaches.
The results are evaluated by statistical techniques.
 Modern scientific method is a four-step procedure
for information production :
1. Observation
2. Establishment of assumptions
3. Verification
4. Generalization
Generalization is a phase of putting forward general
rules and determining the real scientific behavior
(law) which can be valid in all places at any time
when the result is cleared from random conditions
based on the results achieved during the verification
phase
 RESEARCH DESIGN
Scientific research is a systematic endeavor designed to achieve
information appropriate for the purpose of science.
Science consists of three consecutive stages :
1- Defines the events related to the subject
2- Explains the causal relationship between events,
3- Makes suggestions by generalizing the determined relations.
No matter what level of research is done, it should be based on a
plan to achieve its purpose. This plan, which regulates the road to
be followed and the procedures to be carried out in a research, is
called Research Design.
Issues to be considered in a research design:
1-Determination of research problem and population; research problem
must be sufficiently explained (The question we are wondering),
2-Determination of research type; There are two types depending on the
purpose of the research:
a-) Descriptive : They are made to determine how often certain
characteristics are observed in a population
b-) Analytical: They aim to establish a cause-effect relationship
between observation methods and events based on an assumption
3-Determination of observation technique; They are applications to
provide the information required by the research subject.
O We can classify research in different
ways according to their purpose, time
and how it is made:

Descriptive/Analytical:

Observational / Experimental

Retrospective/Prospective
Descriptive/Analytical (According to their purposes)
O Datas are tried to be collected, in order to identify individuals in
descriptive researches and to determine cause - effect relationships
in analytical researches. In descriptive research, answers to
questions of ”who“, “where“ and ”when” are sought. In analytical
research answers to the question ”why“ is sought. Hypotheses are
established based on data obtained from descriptive research
O Testing of these hypotheses and investigating whether there is a
relationship between the suspected etiological cause and the
disease is performed through analytical research.
Observational/Experimental (How they are made)

OIn observational studies, individuals (subjects) do not undergo

any procedure or intervention. In such studies, only the
individual characteristics of the observation result are recorded.
OIn experimental studies, some or all of the individuals undergo
an intervention (treatment, …) and the changes that occur in
individuals before and after the intervention are recorded.
Retrospective / Prospective (according to time )
OThe data examined in the retrospective studies is
about the period before the start of the study.
Comparing historical information of healthy people
with diseased people, the causes of disease are
investigated. Here, the content and quality of
patient files kept in the clinic is very important.
OIn prospective studies, individuals are followed up
prospectively and the changes resulting from such
follow-up are recorded.
BIOSTATISTICS
It is a science of mathematical and statistical
techniques which includes practices in health sciences,
makes new adaptations specific to this area, produces
new methods.
Biostatistics; can also be defined as a branch of science
that deals with the detection, counting, regulation and
evaluation of the characteristics of living beings and all
other factors affecting these characteristics..
 Why Biostatistics is Necessary?
O In all fields of science, scientific research must be sufficiently utilized
from biostatistics science to gain scientific value.
O Nowadays, as the importance given to human health increases, the
use and contribution of biostatistics has gained importance with the
developments in the field of diagnosis, imaging and treatment.
O Physicians need more skill in evaluating new knowledge and
technologies than ever before.
O A good understanding of biostatistics; improves clinical decision-
making and the ability to evaluate treatment programs and
improves the quality of medical research
O With the availability of statistical softwares, the statistics are seen to
be easily applicable to non-professionals.
O The lack of knowledge of underlying mathematical and statistical
concepts leads to significant problems
O Biostatistics can also be defined as a methodology applied from the
planning stage to the end of the research
O However, in most studies, biostatistics counseling is taken in the
stages after the planning (evaluation / analysis).
O In this case, the correction of the methodological and statistical
errors in the early stages of the research may be difficult or
impossible.
O These efforts are very important for increasing the health level.
O Scientific people use the numbers and ratios based on a
statistical analysis in the definition of their findings, in the
decisions they make.
O Example: The medical doctor evaluates the ‘’diagnostic test’’
that is used when making a decision in the context of
SENSITIVITY, SPECIFITY and ACCURACY.
O Explains the success rate of the treatment to be applied and
the risk of a surgical operation to the patient at first .
O Therefore, researchers try to present their experiences or
medical facts with the help of statistics science as simple,
objective and safer.
 Normality limit and p probability
According to community norms, the supervised
difference is evaluated as normal or abnormal
(significantly different), based on the initially accepted
confidence level (95%). The probability outside the
confidence level is the error (α= %5).

The result of all statistical tests is interpreted by reducing

it to the probability of ‘’p’’ probability.
 SUPERVİSİON: HYPOTHESIS CREATION
H0 hypothesis (null hypothesis, indifference hypothesis, absence hypothesis)
-It is the hypothesis that is proposed in a test and is to be tested. Express a
simple sentence about society.
This assumption suggests that the difference between the values we want to
compare is actually (zero), and if the implementation is nonzero, this
difference is only due to random reasons.
H1 hypothesis (Alternative hypothesis, option hypothesis)
-It is set up against the zero hypothesis and includes an inverse expression of
the null hypothesis.

H0 : HDL levels of MI patients are not different from healthy

individuals.
H1 : HDL levels of MI patients are different from healthy
individuals.
 STATISTICAL EVALUATION
It is decided which assumption is correct.
When at the end of the statistical evaluation,

p≤ 0.05 was found, H1 is considered CORRECT.

The difference will be proven to be significant.

p > 0.05 was found, H0 is considered CORRECT

The difference is not significant
 “p” value (Significance level)

p is between ”0 to 1’’.
Definition p; while the H0 hypothesis is true, it
is the probability of accidental rejection.
It allows us to decide whether the observed
difference depends on chance.
It not the possibility to be true of H0 hypothesis
- Levels smaller than limit indicate that the null
hypothesis is not correct.
Statistical decision and ‘’p’’ probability

ACCEPTANCE

REJECTION REJECTION

Difference is not there is a significant difference

significant
there is a highly significant difference

there ileri
is a very highly significant difference
düzeyde
 Decision Errors

UNIVERSAL FACT
TRUE TRUE

RIGHT Type-2
RESEARCH ERROR
TRUE DECISIO
RESULT N
DECISION
RIGHT
Type- DECISIO
TRUE
1 N
ERROR

TYPE-1 To say there is a difference, when there is no difference

ERROR

TYPE-2 To say there is no difference, when there is a difference

ERROR
 • They are errors that
İncreasing
İncreasing the
the number
number of
of samples
samples occur due to
coincidences
Error-free
Error-free measurement
measurement method
method Random • They depend on
unknown reasons
Errors • Random errors take
Selecting
Selecting the
the appropriate
appropriate variable
variable type
type away each other
and do not affect the
result

• They occur due to a

methodological
disruption
Systemati • It is done consciously
c Errors or unconsciously, so
the result really causes
significant
(BİAS) differentiation of
information
 MAJOR BIAS TYPES (Defined in the process and stages of research)
1-SELECTION BIAS: Selection of cases in sampling
2-MANEUVER BiAS: The realization of the research
3-DATA OBTAINMENT, MEASUREMENT BIAS: Data collection
and measurement
4-EVALUATION BiAS: Evaluation, interpretation
5-PUBLICATION BiAS: At the stages of publication of research
results
 SELECTION BIAS Types

Insufficient Number BiAS : Due to lack of sample, the result is not reliable.
67% of our patients were discharged with cure... (Only 2 out of 3 patients!!!)
Popularity BiAS : Some unique operations may misrepresent the frequency of
specific results...
Unfortunately, 60% of our causes of death were firearm (According to the forensic autopsy
results!)
Centripetal Bias : Recognition of certain experts or institutions may lead to case
condensation and assessment stereotyping.
Turkey's most commonly found in schizophrenia district is Bakirkoy district!!!
Referral Filter Bias : The concentration of very severe cases in certain foci upon the
recommendation of the patients who could be treated...
He healed my pimples instantly, you must go to him for your chest pains...
Diagnostic Access Bias: Economic, geographical, etc. reasons can make access to
healthy diagnostic facilities difficult..
Who will go to the Cancer hospital?! it can be expensive, we can show our dispenser..
Diagnostic Suspicion Bias: Preliminary assumptions about case characteristics are
misleading in diagnosis...
The suspected disease is mostly found in South America, yours is something simpler...
ADMISSION RATE BIAS(Berkson Bias) : In some diseases, patients are in a state
of secondary trait, and lead to false frequency evaluations..
The frequency of depression in children aged 8-12 years was found to be higher than
expected...(We searched the children's clinic in our hospital so that we could find easy
cases.!!)
PREVALANCE- INCIDENCE BiAS (Neyman Bias) : Diagnosis errors can be made in
early cases due to monitoring error.” The Start Point Bias also has a similar
concept.
In our patients treated with this method, we have achieved remarkable success in
survival follow-up!!!(We've only been watching for 15 days...)
METHODOLOGICAL SELECTION BIAS: Not taking into account the risks brought
by the method of different treatment methods applied to the same disease.
5-year survival in medical approach is 80%, but 60% in surgery..(The risk of surgery is so
high that 30% of operated cases are lost in post-op intensive care!!!)
SPECIAL CLUSTER BIAS ( Membership - Healty Worker – Volunteer - Migrator
Bias ) :Study cases which have common characteristics that can differentiate the
result
The atmosphere conditions of this factory are not as horrible as it is shown at all1%
morbidity was observed...(60% of workers retired because of disability in 2 years..)
 “MANEUVER” PERIOD(Process) BiAS TYPES
Withdrawall BiAS : Excessive number of missing cases -sometimes due to
insufficient attention- in follow-up studies -. ....
Phone and ask their status, if they are not at home, we count them as lost?!!
Missing Data BiASI : Uncertainty of the status of unhandled or unprocessed
data..
Type «130/75» in all of the «normal« written places....
Compliance BiASI : When people with certain types of features shows
incompatibility to the study, both the losses increase and the remaining
ones become a special cluster type.
This medicine makes a lot of headaches over the age of 65, almost all such cases
have left the study , thankfully young people appeared durable !!
Bogus Control BiASI : Transfer of Incompatible «Experiment Cluster» to
«Control Cluster»....
These elderly people with headaches...we let them stop using the drug and make
plasebo , at least we do not lose the cases!!!
 DATA OBTAINMENT,MEASUREMENT STAGE
(Information) BiAS
ROUGH-BAD MEASUREMENT BiASI : Sloppy readings, rough roundings,
unadjusted tools (instrument bias) , insufficient staff taking measurements,
etc..
The nurse Ayşe should measure blood pressure.... she doesn't hear well but it doesn’t
matter ??
EXAMINATION TENSION–White coat (Apprehension Bias) BiAS : It should be
kept in mind that just living the examination environment can make
physiological and psychological changes..
That woman's got allergy to doctors, I guess, her blood pressure rises as she sees me!!.
UNACCEPTABILITY BiAS : Data obtained by methods that disturbs, hurts or
enters private life changes..
Aylin's test scores are high in everyone's test... She also has lots of problems these
days , Does she affects patients by yelling???
EXPECTATION BiAS: Recording of the Observer unintentionally by rounding in
the direction of his / her job..
Slightly higher than 170 mmHg.... 3-5mmHg does not matter much?!! Let's write 170,
we made so much effort for this drug!!
RECALL BiAS : Asking the existence of an investigative
factor in a way that causes a false recall...
You’ve surely had measles in your childhood.?!!
FAMILY INFORMATION BiAS : Mistakes when getting
information not from the case but from his/her relatives-
Did your son start smoking after college?
- Later, my son is a very well-mannered person!!
(The boy actually smokes 1 pack a day since he went to
secondary school!!)
IN ATTENTION BiAS : Some cases, especially their
psychological state, may change when they know they are
under observation...
Mr.Mehmet says” You treat me like a guinea pig” and his
depression is increasing rather than decreasing!!
 BiAS AT THE EVALUATION-ANALYSIS STAGE
POST-HOC SIGNIFICANCE BIAS: Determination of alpha level after statistical
results...
Look,here is also p =0.06...., if we think α = 0.10, it will be significant!!??
RESULT SELECTION (Looking for the pony) BİAS : Without at first making
assumptions, making possible all the comparisons and bringing forward some
meaningful results..
50 mg dose set is also significant in terms of cholesterol.. let's not give point to the results of
other doses
TIDYING UP BİAS : After the statistical results are obtained , observing excess and
uncertainty in data, exclusion and re-evalution ..
Here is also p =0.06....Because of the fat man in the control group whose cholesterol level is
405. It’s an extreme value , it expands the variance, let’s exclude it, you’ll see , it will be
significant.
CHANGING DEFINITION LIMITS OF CLUSTER BIAS: After the statistical results are
obtained, changing the definition of some clusters and re-evaluating....
They've compared people over the age of 70 to those below, but it isn’t significant when we
do so, of course this is not USA, we should compare people over the age of 65 to those below
so it can be significant.
 PUBLICATION BIAS
AVOIDING PUBLISHING RESULTS WHICH ARE NOT
SIGNIFICANT (PUBLICATION BIAS):
When zero assumption is found valid , the idea that the result
will not attract attention , the anxiety to contradict with the
results that found significant before
No, no..it’s not significant.. We are unable to show a so researched
and known feature, let’s never try to publish, anyway nobody accepts
for publication..
(How many people didn't attempt to publish it, so that significant
result remained as a false information!!)
 REMOVAL OF ERRORS AND PROVIDING VALIDITY

Appropriate sampling method should be used, RANDOMIZED–STRATIFIED

Unbiased data acquisition method – SINGLE BLIND, DOUBLE BLIND
Appropriate experiment design and appropriate α and β selection Process
control- MONİTORİNG , AUDİT
Be aware of Bias types and take precautions
Supervision of secondary factors
Selection of appropriate statistical methods
Correct interpretation
 SAMPLING METHODS
If the research subject is composed of a limited number of
individuals and the units are easy to observe, measure or
count, research can be sustained on all of these community
units. This type of compilation is called a COMPLETE
(Full Compilation).

Compilation: It is the process of counting, observing and

collecting the units examined.
Sampling (Partial Compilation):
In this case, instead of all units of the society, the units that are divided according
to some principles are considered. When the results obtained in the evaluation of
these units are generalized to the society (population), the process of selecting a
certain part of the society is called ‘’sampling’’.

POPULATION SAMPLE
Advantages and disadvantages of sampling:
- Sampling technique saves time, money, staff and
materials by freeing up an investigation from a large and
unnecessary information burden.
-In addition to the difficulty of full-count control, the study
also loses its actuality.
- Sampling is a highly risky method and it is very
inconvenient to use it indiscriminately.
The sample group obtained at the end of a sampling must
have the ability to represent and qualification :
 Sampling
Örnekleme

Rastlantısal örnekleme
Random Sampling Judicial örnekleme
Sampling
Yargısal
(olasılıklı örnekleme)
(Probability Sampling)

Basit rastlantısal
Simple Randomörnekleme
Sampling

Lottery Method
Kura Yöntemi

Rastlantısal
Random sayılar yöntemi
Numbers Method

Sistematik örnekleme
Systhematic yöntemi
Sampling Method

Stratified
Katmanlı Sampling
örnekleme

Proportional
Orantılı katmanlıStratified
örnekleme Sampling

Nonproportional
Orantısız Stratified Sampling
katmanlı örnekleme

Cluster Sampling
Küme örnekleme

Probabilistic
Olasılıklı alan Field Sampling
örnekleme
 SAMPLING
METHODS

A-Random Sampling B-Judicial Sampling

(probable) (nonprobable)
a) Single Random Sampling
1. Random Sampling
LOTTERY METHOD
2. Snow-ball Sampling
RANDOM NUMBERS METHOD
3. Quota Sampling
SYSTHEMATIC SAMPLING
4. Homogeneous Sampling
5. Outlier or Extreme Case Sampling
b) Stratiified sampling
6. Easy-to-reach Status Sampling
PROPORTIONAL STRATIFIED
7. Maximum Variety Sampling
SAMPLING
8. Criterion Sampling
NONPROPORTIONAL STRATIFIED
9. Verification or Falsification
SAMPLING
Sampling
10. Judgement (or Purposive) Sampling
c) Cluster Sampling
11. Sampling of Politically Important
Events
d) Probablistic Field Sampling
12. Critical Status Sampling
Example: The researcher is planning an experiment to test the success of a new
proposed treatment method according to the classical treatment method. What
is the minimum sample size required by the study?

Sample Size Calculating QUESTIONS ANSWERS

What is the experiment layout and criteria? Two sample rate comparison
(ratio or average comparison)

What is the type of the study? Independent experiment order as subjects

(independent, cross, repetitive, factorial, etc.) will be assigned randomly to groups
How many groups are there in the study? 2 groups; classical and new treatment
How is the distrubition rate to groups? groups
Distrubition rate is (1:1)
What is the direction of research hypothesis Two-tailed
(H1)?
What is the probability of type 1 error in the Maximum alpha= 0,05 Type-1 error can be
study? made
What is the probability of type 2 error Usually the planned power should be 0.80 or
(power of test) in the study? above
(Beta=0.20)
How much DIFFERENCE between the two While the classical treatment success is 0.60, if
groups should be considered clinically the increase of at least 25% is clinically
significant? important, the success of the new method
(or how many % effect size) should be 75%.
the smallest difference for clinical significance is
=0.15
 POWER ANALYSIS
O There are three types of power analysis: 1) theoretical (priori), 2)
experimental (post hoc) and 3)compromise in scientific research.
O 1. Theoretical (priori) power analysis made at the beginning of the
study to determine the clinical truth with pioneering work or theoretical
assumptions
O 2. Experimental (post hoc) power analysis : At the end of the study, the
power of the study is calculated and evaluates whether the results have
a significant effect
O 3. Compromise power analysis If the number of difficult subjects is
calculated, it is the balance based on q=ß/α. instead of ES (Effect size).
The sample size will be high when the effect size is low, if it is not
possible to examine this number of samples, in this case, with q=ß/α
formula a balance between the a and b is searched for, rather than at least
80% of the power value.
Difference between groups (d) and Effect Size (ES)

O Difference between groups (d): In contrast to clinical

significance, it is the absolute difference between the
comparison groups selected by the researcher and
constituting the basis of the determination.
d= Average of treatment group – Average of control group

O Effect Size: it is the smallest difference level that is

clinically important, which shows how far the predicted
statistics of the study can deviate from the population
parameter, and is the measurement dimension that is taken
as the basis for statistical significance control.
ES= (Average of treatment group – Average of control group)/ Control group Standard Deviation)
 O In cases where the number of opposing groups
is more than two, d and ES are calculated with
the following formulas.
d= Largest group average – Smallest group average
ES= (Largest group average – Smallest group average)/ Error squares avarege

Effect Size Interpretation

İnsignificant effect
Small effect level
Small effect level
Large effect level

*In clinical studies it is recommended that the effect size value

be 0.50 or higher
 RESULT
O In clinical studies, Type-I error level (α), Type-II error level (ß) ,d or effect size,
group disturbition ratio and direction of research hyphothesis are are components
that have affect and must be known in determination of sample size by power
analysis

If multiple variables are evaluated independently, then the difference values and the
effect sizes are calculated for each variable. For these d and ES values, sample
numbers are determined with a specific alpha and power value.

The maximum number of samples determined is the sample number of the study.
• power decreases as α decreases
• power decreases as difference (d) and effect size (ES) decreases.
• power decreases as sample number decreases
• power decreases as standard deviation increases
• power in two-tailed hypotheses is lower than one-tailed hyphothesis