Study types

Cohort and case-control studies

Charlotte Glümer
Bendix Carstensen

STAR-course

Epidemiology and Biostatistics

Aurangabad 2005
 Aim of epidemiological studies
• To determine distribution of disease

• To examine determinants of a disease

• To judge whether a given exposure causes

or prevents disease
Epidemiologic Design Strategies

• Descriptive studies
– Populations
• Correlated studies
– Individuals
• E.g. case-series, case reports, cross-sectional surveys
• Analytical studies
– Observational studies
• Case-control studies
• Cohort studies
– Intervention studies
• Clinical trials
 Case-control study
Exposed
Cases

Non-exposed
Study Population
Exposed
Controls
Non-exposed
 Cohort study / Follow-up study
Disease +
Exposed
Disease -
Study population
Disease +
Non-exposed
Disease -
 Selection of cases
• Establish a strict diagnostic criteria for the
disease:
Examples:
– Type 1 diabetes in children: severe
symptoms, very high BG, marked glycosuria,
and ketonuria.
– Type 2 diabetes: few if any symptoms, Slightly
elevated BG, diagnosis “complicated”.
 Selection of cases
• Population-based cases: include all subjects or
a random sample of all subjects with the disease
at a single point or during a given period of time
in the defined population:
– Danish childhood diabetes register

• Hospital-based cases:
All patients in a hospital department at a given
time
 Selection of Controls
Principles of Control Selection:
• Study base:
– Controls can be used to characterise the distribution of
exposure
• Comparable-accuracy
– Equal reliability in the information obtained from cases
and controls  no systematic misclassification
• Overcome confounding
– Elimination of confounding through control selection
matching or stratified sampling
 Selection of Controls

• General population controls:

– registries, households, telephone sampling
– costly and time consuming
– recall bias
– eventually high non-response rate
• Hospitalised controls:
– Patients at the same hospital as the cases
– Easy to identify
– Less recall bias
– Higher response rate
 Ascertainment of Disease and
exposure status
• External sources:
– Death certificates, disease registries, Hospital
and physicians records etc.

• Internal sources:
– Questionnaires and interviews, information
from a surrogate (spouses or mother of
children), biological sampling( e.g. antibody)
 Bias in Case-Control studies

• Selection bias
– Non-response
– Detection bias
• cases and controls are identified not independently of
the exposure
• Observation bias
– Recall Bias: Cases are more likely to remember
exposure than controls
2 minutes
 Cohort studies
• Retrospective
– Exposure Disease
• Yes ?
• No ?
• Prospective
– Exposure Disease
• Yes ?
• No ?
• Ambidirectional
 Prospective vs. retrospective
Cohort Studies
• Prospective Cohort Studies
– Time consuming, expensive
– More valid information on exposure
– Measurements on potential confounders
• Retrospective Cohort Studies
– Quick, cheap
– Appropriate to examine outcome with long latency
periods
– Admission to exposure data
– Difficult to obtain information of exposure
– Risk of confounding
 Selection of the Exposed
Population
• Sample of the general population:
– Geographically area, special age groups, birth cohorts
(Framingham Study)

• A group that is easy to identify:

– Nurses health study

• Special population (often occupational

epidemiology):
– Rare and special exposure
– Permits the evaluation of rare outcomes
 Selection of the Comparison
Population
• Internal Control Group
– Exposed and non-exposed in the same Study
population (Framingham study, Nurses health
study)
• Minimise the differences between exposed and non-
exposed
• External Control Group
– Chosen in another group, another cohort
(Occupational epidemiology: Asbestosis vs.
cotton workers)
• The General Population
 Data Collection
External Data Sources Internal Data Sources

Exposure Hospital records, Questionnaires,

employers physical examinations,
and/or blood tests, other
diagnostic tests

Event Disease registries, Questionnaires,

death certificates, physical examinations,
physician and hospital and/or blood tests, other
records diagnostic tests

Confounder Hospital records Questionnaires,

registries physical examinations
 Bias
• Selection bias:
– Non-response during data collection
– Losses to follow up
– Healthy worker effect
• Misclassification on exposure or event
– Random
– Systematic
• Confounder
– Difference in other risk factors between
exposed and non-exposed
 Strengths in Cohort vs. Case-
control?
Cohort study Case-control study
• Rare exposure • Quick, inexpensive
• Examine multiple effects • Well-suited to the
of a single exposure evaluation of diseases
• Minimizes bias in the in with long latency period
exposure determination • Rare diseases
• Direct measurements of • Examine multiple
incidence of the disease etiologic factors for a
single disease
 Limitations in Cohort vs. Case-
control?
Cohort study Case-control study
• Not rare diseases • Not rare exposure
• Prospective: Expensive • Incidence rates cannot be
and time consuming estimated unless the
study is population based
• Retrospective: in • Selection Bias and recall
adequate records bias
• Validity can be affected
by losses to follow-up