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Case Control Survilance
Case Control Survilance
Cliniminds:
by sandeep.k
Representativeness: Ideally, cases are a random sample of all cases of interest in the source population (e.g. from vital data, registry data). More commonly they are a selection of available cases from a medical care facility. (e.g. from hospitals, clinics)
2. Method of Selection
Selection may be from incidence or prevalence case:
Incident cases are those derived from ongoing-ascertainment of cases over time.
Characteristics of Controls
Who is the best control? What universe should controls come from?
cases are a random sample of cases in the population. Then controls should be a random sample of all non-cases in the population sampled at the same time.
If
The control should be at risk of the disease The control should resemble the case in all respects except for the presence of disease (and any as yet undiscovered risk factors for disease)
(study base).
Study Base
Imagining the study base is a useful exercise before deciding on control selection. The study base is composed of a population at risk of exposure over a period of risk of exposure.
Cases emerge within a study base. Controls should emerge from the same study base, except that they are not cases. For example, if cases are selected exclusively from hospitalized patients, controls must also be selected from hospitalized patients.
If cases must have gone through a certain ascertainment process (e.g. screening), controls must have also.
If cases must have reached a certain age before they can become cases, so must controls. If the exposure of interest is cumulative over time, the controls and cases must each have the same opportunity to be exposed to that exposure.
Disadvantages
1. Susceptible to bias if not carefully designed 2. Especially susceptible to exposure misclassification
Examples of Problems
Dolls
1952 study of smoking and lung cancer. The problem was that the control population ( lung disease) was biased in relation to the exposure. McMahons 1981 study of coffee and pancreatic cancer. Problem was that some of the controls may have been biased in relation to the exposure, because diseases related to coffee were excluded from the control series.
1980 s Aspirin and Reyes sydrome Tampon use and toxic shocks syndrome L-tryptopham and eosinophilia-myalgia syndrome AIDS and sexual practices 1990s Vaccine effectiveness Diet and cancer
Basic Analysis
For one control Data is expressed in a four-fold table, and an odds ratio is calculated (relative risks have no meaning herewhy?) Case Controls Exposed Unexposed a c OR= ad/bc b d
Paired Analysis
Exposed
Controls
Unexposed Mixed
Paired Analysis
For one control
Case Exposed Exposed Controls Unexposed Unexposed
r t
s u
McNemar chi2=(t+s)2/(t-s)
The odds ratio is a good estimate of the relative risk when the disease is rare (prevalence <20%) Can be extended to N>1 controls
Statistical testing is by simple chi-square (unmatched analysis) or by McNemars chi square (matched-pairs analysis) Can be extended to multiple strata ( MantelHaenzel chi-square)
Theoretical Foundation
Case-control studies should be viewed as efficient sampling schemes of the disease experience of the underlying open or closed cohorts The exposure odds ratio derived from case-control studies equals the disease odds ratio derived from cohort studies