Starting Risk

RIZWANUL KARIM
Risk
Risk generally refers to the probability of some
untoward event.
Risk is the probability that people who are
exposed to certain risk factors will
subsequently develop a particular disease
more often than similar people who are not
exposed
Important Jargon
Exposure (E) an explanatory factor; any potential
health determinant; the independent variable
Disease (D) the response; any health-related
outcome; the dependent variable
Measure of association (syn. measure of effect) a
statistic that quantifies the relationship between an
exposure and a disease
Measure of potential impact a statistic that
quantifies the potential impact of removing a
hazardous exposure
"For the things of
this world cannot be
made known
without a knowledge
of mathematics."-
Roger Bacon
Measures of association are mathematical
comparisons
Mathematic comparisons can be done in
absolute terms or relative terms
Let us start with this ridiculously simple example:
I have $2
You have $1
Absolute Comparison
In absolute terms, I have
$2 $1
= $1 more than you
Note: the absolute
comparison was made
with subtraction
It is as simple as that
Relative Comparison
Recall that I have $2 and you
have $1.
In relative terms,
I have $2 $1 = 2, or
twice as much as you
Note: relative comparison
was made by division
Applied to Risks
Suppose, I am exposed to a risk
factor and have a 2% risk of
disease.
You are not exposed and you
have a 1% risk of the disease.
Of course we are assuming we are
the same in every way except for
this risk factor.
In absolute terms, I have 2% 1%
= 1% greater risk of the disease
This is the risk difference
Applied to Risks
In relative terms I have
2% 1% = 2,
or twice the risk
This is the relative risk
associated with the exposure
9
Terminology
10
For simplicity sake, the terms risk
and rate will be applied to all
incidence and prevalence measures.
Difference Measures
Comparing disease occurrence among the
exposed with the disease occurrence
among the unexposed comparison group
by subtracting one from the other.
Risk Difference
Risk Difference (RD) absolute effect
associated with exposure
0 1
R R RD =
where
R
1
risk in the exposed group
R
0
risk in the non-exposed group
Interpretation: Excess risk in absolute terms
Risk/Rate Difference
(also called Attributable Risk/Rate)
RD/AR = Rate or risk in exposed (R
exp
)
Rate or risk in unexposed (R
unexp
)

For CI: CI
exp
- CI
unexp

= a / (a+b) - c / (c+d)

For IR: IR
exp

- IR
unexp
= a / PT
exp
- c / PT
unexp


RD/AR = 0 when there is no association
Yes No Total
Yes 117 13,305 13,422
No 125 106,416 106,541
Total 242 119,721 119,963
Hypertension

Non Fatal Heart Attack
Example
RD = CI
exp
- CI
unexp
= 117 / 13,422 - 125 / 106,541
= .00872 - .00117 = .00755 or 755 / 100,000
Interpretation: The excess occurrence of non-fatal
heart attack among these hypertensive women was
755 per 100,000. Or, if hypertension causes non-fatal
heart attacks then 755 cases of non-fatal heart attack
per 100,000 women could be eliminated if the
hypertension were treated.
Solution
Risk/Rate Difference (continued)/
Attributable risk
Purpose: Gives information on
the absolute effect of exposure on disease
occurrence.
the excess disease risk in the exposed group
compared to the unexposed group.
the public health impact of an exposure, that is,
how much disease would be prevented if the
exposure were removed. This assumes that the
exposure causes the disease.
Rate/Risk Ratio
(also called Relative Risk)

Comparing
Disease occurrence among exposed
with
Disease occurrence among comparison group
(usually unexposed)


Defined Population
NOT EXPOSED EXPOSED
NO
DISEASE
DISEASE
NO
DISEASE
DISEASE
Not Randomly Assigned
Rate/Risk Ratio (also called Relative Risk)
RR= Rate or risk in exposed group (R
exp
) /
Rate or risk in unexposed group (R
unexp
)
For CI: CI
exp

/ CI
unexp

= a / (a+b) / c / (c+d)
For IR: IR
exp

/ IR
unexp
= a / PT
exp
/ c / PT
unexp


Rate/Risk Ratio (also called Relative Risk)
Purpose: Gives information on the relative
effect of the exposure on the disease.
Tells you how many times higher or lower
the disease risk is among the exposed as
compared to the unexposed. Is commonly
used in etiologic research
Example: Cohort study of hypertension and
cardiovascular morbidity and mortality
(Nurses Health Study)
Yes No Total
Yes 117 13,305 13,422
No 125 106,416 106,541
Total 242 119,721 119,963
Hyper-
tension
Non Fatal Heart Attack
Example: Cohort study of hypertension and
cardiovascular morbidity and mortality
(Nurses Health Study)
RR = CI
exp
/ CI
unexp
= 117/13,422 = .00872 = 7.5
125/106,541 .00117
Interpretation: Women with hypertension
have 7.5 times the risk of having a non-fatal
heart attack compared to women without
hypertension.
Comparison of RR and RD/AR
Lung Cancer Coronary Heart
Disease
Cigarette Smoker 140 669
Non Smoker 10 413
RR 14.0 1.6
RD 130/100,000/YR 256/100,000/YR
Annual Mortality Rate Per 100,000
Conclusion: Cigarette smoking is a much stronger risk factor
for lung cancer but (assuming smoking is causally related to
both diseases) the elimination of cigarettes would prevent far
more deaths from coronary heart disease.
Odds
Odds, is the ratio of two probabilities, p the
probability of an event) to that of (1-p) 1- the
probability of the event.
Odds and probability contain the same information,
but they express it differently:
Odds = probability of an event /(1- the probability
of the event)
Probability = Odds / (1+ Odds)
Odds ratio in a case control study
Calculation of Proportions Exposed in a Case-Control study
First select
Cases ( with disease) Controls(without
disease)
Then Measure
The Exposure
Were exposed
a b
Were not exposed
c d
totals a + c b + d
Proportion exposed

c a
a
+ d b
b
+
Odds ratio in a Case-control study
Cases
(with
disease)
Control
(without
disease)
History of
Exposure
a b
No history
Of Exposure
c d
bc
ad
d
b
c
a
= =
exposed was control a that odds
exposed was case a that Odds
People with
the disease
People without
the disease
Cases Controls
Start
With :
and
Then determine
Exposure History:
and
People without
the disease

Were
exposed
Were not
exposed

People with
the disease
Were
exposed
Were not
exposed

Cases Controls
The Odds Ratio (Relative Odds)
In a case-control study, however, we do not know
the incidence in the exposed population or the
incidence in the non-exposed population because
we start with diseased people (cases) and non-
diseased people (controls).

Hence, in a case-control study we cannot calculate
the relative risk directly.

The odds of an event can be defined as the
ratio of the number of ways the event
can occur to the number of ways the
event cannot occur.
Odds ratio in a Case-control study
Cases
(with
disease)
Control
(without
disease)
History of
Exposure
a b
No history
Of Exposure
c d
bc
ad
d
b
c
a
= =
exposed was control a that odds
exposed was case a that Odds


The odds of a case having been exposed are a:c or


The odds of a control having been exposed are b:d or

in a case-control study, is defined as the ratio of the
odds that the cases were exposed to the odds that
the controls were exposed. This is calculated as
follows:
bc
ad
d
b
c
a
=
|
.
|

\
|
|
.
|

\
|
c
a
d
b
Calculating Odds ratio
Example of calculating an Odds Ratio from a case control Study
First select
CHD Cases Controls
Then Measure
Past Exposure
Smokers
Non-Smokers
Totals 200 (a + c) 400 (b + d)
Proportions of Smoking
Cigarette
56%
44%

Odds ratio

112 (a) 176 (b)
88 (c) 224 (d)
62 . 1
88 176
224 112
= =
X
X
bc
ad
Population Risk/Rate Difference (PRD)
/population attributable risk
Purpose: Measures excess disease
occurrence among the total population that
is associated with the exposure. Helps to
evaluate which exposures are most relevant
to the health of a target population.
Population Risk/Rate Difference (PRD)
/Population attributable risk
Two formulas for PRD:
PRD/PAR = (RD/AR) (P
exp
) where
P
exp
= proportion of population that is exposed,
and RD/AR is the risk or rate difference
PRD/PAR = R
total
- R
unexp
where
R
total
= risk/rate in total population and
R
unexp
= risk/rate among unexposed
Population Risk/Rate Difference
example
Yes No Total
Yes 117 13,305 13,422
No 125 106,416 106,541
Total 242 119,721 119,963
Hypertension
Non-fatal Heart Attack
PRD/PAR = [(117/13,422) - (125/106,541)] x (13,422/119,693)
= (.00755) x (.112) = .00085
or PRD/PAR = 242/119,963 - 125/106,541 = .00202 - .00117
= .00085 or 85/100,000
Interpretation: Hypertension results in an excess incidence of
8.5/10,000 non-fatal heart attacks in the total study population.
Or, if hypertension were eliminated, 8.5/10,000 cases of non-fatal
heart attacks could be eliminated among the total study
population. (Assumes that hypertension causes heart attacks.)
Solution
Population Risk/Rate Difference
A relatively weak risk factor (in terms of
relative risk) that is quite prevalent could
account for more of disease incidence in a
population than a stronger risk factor that is
rarely present.
Thank you