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COHORT STUDY

DR. Mirella Youssef


Lecturer of Public Health
Community Medicine
Department
Cohort studies
longitudinal
Prospective studies
Forward looking study I
Incidence study
Follow up study

 startswith people free of disease


 assesses exposure at “baseline”
 assesses disease status at “follow-
up”
Cohort studies
 Purpose:
- Study of the association between an
exposure factor and one or more
diseases outcomes
- Confirmation of hypothesis (a step
further towards causation)
•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.
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 sample funds are available
Design:
 Two groups are studied:
- Study group (cohort
- Control group

Defined according to the presence or


the absence of the exposure under
investigation
Study group (cohort)
 Defined as those who:
- Have the exposure factor under the
study (working definition of the
exposure should be set)
- Are free from the disease or outcome
under study and,
- Are at risk of developing this disease
or outcome
Study group (cohort)
 Selected to represent all the
population of exposed individuals
 Source of selection may be;

-workplace
-Registries
- Hospital records
- community
WHAT IS COHORT
 Ancient Roman
military unit, A
band of warriors.
 Persons banded
together.
 Group of persons
with a common
statistical
characteristic.
[Latin]
Control group
 Similar to the study group in
everything except the exposure
under the study
 Must have a similar chance of the
occurrence of the outcome,
compared to the study group
 Source: general pop., neighbors,
friends of cases, hospital…
 Matching of factors that might affect
the studied relationship (confounding
factors)
After selection of the two
groups
 Baseline information should be obtained
from members of the two groups. This
information includes:
- Exposure factor: to ensure its presence in
the study group and its absence in the
control group
- Outcome: to ensure its absence in both
groups
- Confounding factors: to assess their
presence and level
Follow up
A rigorous system of follow up should be
planned and implemented to avoid losses
 The same follow-up maneuver should be
done in both groups
 In each follow-up, subjects are assessed
for the occurrence of the outcome under
study (endpoint) which must be:
- objectively measurable (hard point)
- specific
-valid
Ascertainment of exposure status in each
follow-up visit
Follow up

 Theperiod of follow-up is determined


by the nature of the expected
outcome and its latency from the
exposure, it should be:
- not too short: no enough time
for the outcome to occur
- not too long: probability of the
occurrence in the control group
approaches that in the study group
Follow up
(historical( Today 2007

Past (1945) disease

Start historical follow-up Time


Of
Control group The
FU study
no disease
Follow up
(concurrent) Futur
e

Time
Of 2010
disease
The
stud
y Start
Concurrent FU

FU No
disease
In either study
 Identification and classification of
cohort is based on exposure status
 Disease is not present at the start of
FU
 Follow-up is in the direction of the
natural history of the disease
ANALYSIS

 Calculation
of incidence rates among
exposed and non exposed groups

 Estimation of risk
Incidence rates of outcome

Diseased Not
diseased Total

Study
cohort Yes a b a+b
(exposed)

No c d
Control (not c+d
exposed)

a+b+
a+c b+d
c+d
Incidence rates
 Incidence rate among exposed=
Ie = a/a+b
 Incidence among unexposed=
Iu = c/c+d

 Total incidence= a+c/a+b+c+d


Estimation of risk= measures the
strength of association between exposure and
outcome

 RelativeRisk
incidence of disease among
exposed
RR = ______________________________
Incidence of disease among non-
exposed
a/a+b
= _________
c/c+d
Attributable Risk
( measures the absolute increase in the risk of
disease due to exposure)
 Attributable Risk

Incidence of disease among exposed – incidence of disease


among non exposed
AR = _______________________________
Incidence of disease among exposed

a/a+b – c/c+d
AR = _______________
a/a+b
Smoking Lung cancer Total

YES NO

YES 70 6930 7000

NO 3 2997 3000

73 9927 10000

Find out RR and AR for above data


 Incidence of lung cancer among smokers
70/7000 = 10 per 1000
 Incidence of lung cancer among non-
smokers
3/3000 = 1 per thousand
RR = 10 / 1 = 10
(lung cancer is 10 times more common
among smokers than non smokers)
AR = 10 – 1 / 10 X 100
= 90 %
(90% of the cases of lung cancer among
smokers are attributed to their habit of
smoking)
Cohort studies
Strengths
Weaknesses
 We can find out  losses to follow-up
incidence rate and risk
 often requires large
 More than one disease
sample
related to single
exposure  ineffective for rare
diseases
 can establish cause -
effect  long time to complete
 good when exposure is  expensive
rare  Ethical issues
 minimizes selection  Status change with
and information bias long follow up
 Change in diagnosis
along FU