CASE-CONTROL
STUDYANSHU RANI
MBBS-2020
ROLL NO. 17
UPUMS SAIFAI
LEARNING OBJECTIVES
WHAT CASE-CONTROL STUDIES ARE?
THE VALUES OF SUCH STUDIES
THE BASIC METHODOLOGY
PROS AND CONS OF SUCH STUDIES
TABLE OF CONTENTS
01 02
INTRODUCTION TO DESIGN OF A CASE
CASE CONTROL STUDY CONTROL STUDY
03 04
ELEMENTS OF A CASE
CONTROL STUDY 0 0 MATCHING
05 06
ODDS RATIO 3 4 PROS AND CONS
INTRODUCTION
Case control studies, often called "retrospective studies"
are a common first approach to test causal hypothesis.
The case control method has three distinct features :
both exposure and outcome (disease) have occurred
before the start of the study
the study proceeds backwards from effect to cause; and
it uses a control or comparison group to support or
refute an inference.
Basic steps
There are four basic steps in conducting a case control
study :
1. Selection of cases and controls
2. Matching
3. Measurement of exposure, and
4. Analysis and interpretation.
SELECTION OF CASES
DEFINITIO
N OF SOURCES
CASE OF CASE
DIAGNOSTIC CRITERIA Hospitals
Histologically same
type General
populations
ELIGIBILITY CRITERIA
Incident cases
Prevalent cases
SELECTION OF
Controls must CONTROLS
be as similar to the cases as
possible, except for the absence of the disease
under study.
SOURCES OF CONTROLS
• Hospital controls
• Relatives (spouses and
siblings)
• Neighbourhood controls
• General Populations
MATCHING
Matching is defined as the process by which we
select controls in such a way that they are similar to
cases with regard to certain pertinent selected
variables (e.g., age) which are known to influence the
outcome of disease and which, if not adequately
matched for comparability, could distort or confound
the results.
A "confounding factor" is defined as one which is
associated both with exposure and disease , and is
distributed unequally in study and control groups.
TYPES OF MATCHING
1. GROUP MATCHING : by assigning cases to
sub-categories (strata) based on their
characteristics (e.g., age, occupation, social
class) and then establishing appropriate
controls.
2. PAIR MATCHING : for each case, a control is
chosen which can be matched quite closely.
MEASUREMENT OF EXPOSURE
1. Information about exposure should be
obtained in precisely the same manner both
for cases and controls.
2. This may be obtained by interviews, by
questionnaires or by studying past records of
cases such as hospital records, employment
records, etc.
ANALYSIS
The final step is analysis, to find out
(a)Exposure rates among cases and
controls to suspected factor
(b)Estimation of disease risk associated
with exposure (Odds ratio)
EXPOSURE RATES
1. A case control study provides a direct estimation of the
exposure rates {frequency of exposure) to a suspected
factor in disease and non-disease groups.
Cases Controls Total
(with lung cancer) (without lung cancer)
Smokers 33 (a) 55 (b) 88 (a+b)
(<5 cigarettes/day)
2 (c) 27 (d) 29 (c+d)
Non-smokers
Total 35 (a+c) 82 (b+d) 117
(n=a+b+c+d)
EXPOSURE RATES
a)Cases= a/(a+c) = 33/35 = 94.2%
b)Controls= b/(b+d) = 55/82 = 67.0%
So, the frequency rate of lung cancer was
definitely higher among smokers than among
non-smokers.
ODDS RATIO
Odds Ratio (OR) is a measure of the strength of
the association between risk factor and
outcome.
The derivation of odds ratio is based on three
assumptions :
a) the disease being investigated must be
relatively rare;
b) the cases must be representative of those
with the disease, and
c) the controls must be representative of those
without the disease
CALCULATION OF ODDS RATIO
Disease present Disease absent
Exposed a b
Not Exposed c d
ODDS RATIO
= 8.1
In the above example, smokers of less than 5
cigarettes per day showed a risk of having lung
cancer 8.1 times that of non-smokers.
BIAS IN CASE CONTROL STUDY
1. Bias is any systematic error in the
determination of the association between the
exposure and disease.
2. TYPES
3. Bias due to confounding.
Selection bias : The cases and controls may not be
representative of cases and controls in the general
population.
There may be systematic differences in characteristics
between cases and controls.
The selection bias can be best controlled by its prevention.
Memory or recall bias: When cases and controls are asked
questions about their past history, it may be more likely for
the cases to recall the existence of certain events or factors,
than the controls who are healthy persons.
Berkesonian bias :The bias arises because of the different
rates of admission to hospitals for people with different diseases
(i.e., hospital cases and controls).
Interviewers bias : Bias may also occur when the interviewer
knows the hypothesis and also knows who the cases are. This
prior information may lead him to question the cases more
thoroughly than controls regarding a positive history of the
suspected causal factor.
ADVANTAGES
1. Relatively easy to carry out.
2. Rapid and inexpensive (compared with cohort studies).
3. Require comparatively few subjects.
4. Particularly suitable to investigate rare diseases or diseases about
which little is known. But a disease which is rare in the general
population (e.g., leukaemia in adolescents) may not be rare in special
exposure group (e.g. prenatal X-rays).
5. No risk to subjects.
6. Allows the study of several different etiological factors (e.g., smoking.
physical activity and personality characteristics in myocardial
infarction).
7. Risk factors can be identified. Rational prevention and control
programmes can be established. 8.
8. No attrition problems, because case control studies do not require
follow-up of individuals into the future.
DISADVANTAGES
1. Problems of bias relies on memory or past records. the
accuracy of which may be uncertain: validation of
information obtained is difficult or sometimes
impossible.
2. Selection of an appropriate control group may be
difficult.
3. We cannot measure incidence, and can only estimate
the relative risk.
4. Do not distinguish between causes and associated
factors.
5. Not suited to the evaluation of therapy or prophylaxis
of disease.
6. Another major concern is the representativeness of
BIBLIOGRAPHY
■ PARK’S TEXTBOOK OF PREVENTIVE AND
SOCIAL MEDICINE BY K.PARK- 26TH EDITION.
■ IMAGE COURTESY WEB SOURCES
THANKS
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