Cohort Studies

Stephen McCurdy, M.D., M.P.H.

Department of Public Health Sciences
U.C. Davis School of Medicine
 COHORT STUDIES

Objectives:
1. Review Basic Design of Cohort Study
- Prospective
- Retrospective
- Nested Case-Control
2. Review Measure of Effect (Relative
Risk)
 COHORT STUDIES

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 STUDIES

Cohort Study

Key Point:
Presence or absence of risk
factor is determined before
outcome occurs.
 COHORT STUDIES

Disease Basic Idea:

(+) (-) See if those
with the risk
(+) 50% 50% factor develop
R.F. more disease
10% 90% than those
(-) without the risk
factor
 COHORT STUDIES

Basic Approach: Cohort Study

Identify Cohort (s)
Measure exposure and outcome variables
Follow for development of outcomes
 COHORT STUDIES

Fixed Cohort
X = outcome
x
(+) Relative
x
risk
Exposure
= (2/3)/(1/3)
(-) x
= 2.0
 COHORT STUDIES
Fixed cohort
Disease = Hepatitis A Risk = a/(a+b)
(+) (-) =0.3
S a+b
30 a 70 Risk = c/(c+d)
a (+) b 100
= 0.05
l
a (-) 3 c 57 d c+d
60
d Rel. risk=
a
a+b
c
= 0.3/0.05 =6
c+d
 COHORT STUDIES
Rel. risk=
a
a+b
Disease = Hep A c
= 0.3/0.05 =6
c+d

(+) (-)
S
Odds Ratio:
a (+) 30 70 b a+b (a/c)/(b/d)=(a/b)/(c/d)
a
l = 100
a 3 57 d c+d (30/3)/(70/57)= 8.14
(-) c
d = 60
 COHORT STUDIES
Dynamic Cohort
Rel. Risk
X
X = 2/3/2/3 =1
(+)
or
Exposure X
X 2/5py/2/10py
(-)

Years
= 2.0
 COHORT STUDIES

Cohort : 16, 936 Harvard grads

Measure: Question re: activity level
Follow: “Sedentary”: 24 CHD deaths
per 10,000 person-years
vs. “Active”: 16 CHD deaths per
10,000 person-years
Relative risk = 24/16 = 1.5
 COHORT STUDIES

Questions:
Findings due to confounding?
Could subclinical disease have
affected the risk factor (activity)?
 COHORT STUDIES
Take-Home Message:
The best measure of effect is the “relative
risk.” For a fixed cohort, this will be the
ratio of the cumulative incidences. For a
dynamic cohort, this will be the ratio of the
incidence rates.
The odds ratio can be used for fixed cohorts
comparing cumulative incidences. It will
be close to the relative risk for rare
diseases.
 COHORT STUDIES

Variations on a theme:

Retrospective (Historical) Cohort

Nested Case-Control
 COHORT STUDIES

Prospective: Outcomes have not yet

occurred as study begins. Example:
Women’s Health Study.
Retrospective: Outcomes have already
occurred as the study begins.
Example: finding a trove of medical
records allowing you to follow a
cohort born in 1880 to death.
 COHORT STUDIES
Nested case-control
All 97 with new
1000 women in breast cancer
osteoporosis 3.2
study years
vs.
(banked blood)
Random
sample of 244
Cauley et al., 1999 women
without br-ca
 COHORT STUDIES
Nested case-control study:
If you hypothesized that pesticides
caused breast cancer, you could
measure the pesticide levels in all 97
breast cancer patients and compare
with the sample of 244 healthy
control patients. (This saves
money!) The case-control study is
“nested” within the cohort.
 COHORT STUDIES
Utility and Strengths
Incidence and natural history
Temporal sequence
Avoid survivor bias
Avoid reporting bias
Look at multiple outcomes
 COHORT STUDIES
Limitations:

Inefficient for rare diseases

Confounding may occur
Sub-clinical disease may affect risk
factor levels
Loss to follow-up