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Case control studies

Dr/ Mirella Youssef

Case control study= retrospective
study=case referent study
• Purpose:
1- study the association between
disease and one or more exposure
factors
2- confirmation of new hypothesis

defined according to the presence of the disease 2.the group of cases.the group of controls defined according to the absence of the disease . :Design • Two groups are compared 1.

:Cases • Defined as having the disease( the working definition of the disease should be set) • Selected to represent all the population of cases in the community (inclusion of mild cases or severe cases only is not representative of the whole spectrum of the disease .

Ex: In studying the association between oral contraceptive (OC) and deep venous thrombosis (DVT). :Cases • Should have some reasonable probability of having had their diseases induced by the exposure under study. cases with post-operative DVT should not be included .

:Cases • Should have been at potential risk of exposure to the factor under study: ex.: unmarried . or women with contraindications for OC are not eligible for the above study . hyterectomized.

Ambiguity of temporal relationship .To avoid recall bias . :Cases • Should better be newly diagnosed (incident cases): -To avoid to be missed in the selection as in short course diseases and diseases with high fatality .

:Cases • Should have a reasonable probability of homogeneity of etiology: Ex. squamous cell type (RR=30- 40) is not homogenous with adenocarcinoma (RR=3-4) .: in studying lung cancer and smoking.

:Cases • Source may be -the hospital -Disease registries -Records -Community survey .

friends of cases . neighbors. :Controls • Similar to cases in everything except the disease under the study • Must have a similar chance of exposure compared to cases • Source may be :general population.

>1/1 when the number of cases is limited up to 4/1 • Number of control groups .1/1 when cases are easy to find at no extra cost . :Controls • Number of control per case .If the control group is suspected to have a specific bias a second group might be used to increase validity .Usually one group .

:Controls • Matching may be used to ensure equal distribution in the two groups of factors that might affect the studied relationship • Assessment of exposure is done in both groups (case and control) using the same maneuver .

+ E + . Cases (D) E retrospective assessment of exposure + E - (Controls (D - E .

:Analysis of case control studies exposed Non. total exposed Cases A B A+B (D +) 80 20 100 Control C D C+D (D -) 30 70 100 total A+C B+D A+C+ B+D 110 90 200 .

The probability that a case was exposed previously is estimated by The case exposure probability= exposed cases all cases = A/A+B = 80/100 2-The probability that a case was not exposed previously is estimated by cases not exposed all cases =B/A+B= 20/100 . (Odds ratio (OR 1.

(Odds ratio (OR • The odds of exposure of cases = exposed cases cases not exposed all cases all cases = A/A+B =A/B= 80/20=4 B/A+B • The odds of exposure of controls =C/D= 30/70=0.4 .

3 C/D This represents the degree of association between the disease and exposure under investigation . (Odds ratio (OR • The odds ratio is the odds of exposure for cases divided by the odds of exposure for controls= A/B = AD/BC= 70x80/20x30=56/6=9.

Advantages of case.control studies • Feasibility: short time and costs • Confirms a new hypothesis • Most suitable for the studying of rare diseases • High statistical efficiency due to equal groups .

Classify case as disease or the reverse will lead to underestimate the OR • Classification of exposure . :Problems • Misclassification: this is the placement of a study subject in an improper cell in the 2x2 table • .misclassification of disease ex.

missing all cases that are not able to reach the hospital( died – lack of money…) 3. :Problems • Selection bias: this may be encountered in either cases or controls: .lack of representation of cases referred from wide areas to a specialized center .Selection of cases from the hospital may lead to: 1.Selection of controls from the hospital lead to lack of representation because the hospital population is different from the general population (higher exposure to many risk factors) .missing all cases that didn’t need hospital care (mild cases) 2.

:Problems • Difficult in selection of proper control group • Recall bias • Uncertainty of temporal relationship between exposure and outcome specially in chronic diseases of insiduous onset .