Chapter 6 EVALUATION OF EVIDENCE
Chapter 6 EVALUATION OF EVIDENCE
Ephrem M (MPHE)
Validity of epidemiological studies
It is undesirable
• Unrepresentative sampling
Source population
?? ??
Cases Controls
Criteria for selection of cases and controls should be
similar except for the outcome variable?
Exposure Outcome
Confounder
The role of confounding cont…
???
(the confounder) is strongly and independently associated
both with the outcome (dying) and with the exposure (grey
hair)
A B
Coffee drinking Myocardial infarction
Steps
Step I. Is there an association?
Heavy coffee drinking is significantly associated with
higher rates of MI.
A B
Obesity MI
Steps
Step I. Is there an association?
Obesity is statistically significantly associated with
higher rates of MI. Is obesity then a cause of MI?
Obesity Cholesterol MI
• Example
– Smoking and asbestos dust Vs Lung cancer.
Interaction
• Factor A having RR= 2.0 to develop disease D
Restriction
Stratification
Multivariable Adjustment
In the Study Design:
2. Restriction
For example, if sex and race are potential confounding factors, the
A+ A-
B D B D
confounding
stratification
• Stratification: Involves the evaluation of the association within homogenous
• Step 2: Do analysis after stratifying (in the presence and absence of the potential
confounder)
• Step 3: Compare the results for difference between stratified and combined
• Interpretation of result:
– if no (much) difference between stratified and combined then the potential
confounder is not a real confounder.
– If the combined effect is higher than their additive effect then there is an
interaction
Example
• Association thought: Alcohol Vs MI
• Possible confounder: cigarette smocking
Combined Outcome
Exposed
+ -
+ 100 50
700 1000
OR= 2.9
Example
• Step 2: Do analysis after stratifying (in the presence and
absence of the potential confounder)
Stratified
Smokers Non-smokers
Outcome Outcome
+ - + -
+
Expos
70 20
+
Expos
30 30
– Interpretation of result:
• if no (much) difference between stratified and combined
then the potential confounder is not a real confounder.
• The most common way that many factors are controlled for
simultaneously is through the use of a multiple regression model.
• The wider the CI, the greater was the variability in the
estimate of the effect and the smaller the sample size.
• Analogy
– Induced smoking in animal experiments showed increased
lung cancer
Consistency
• Repeated observation of an association in studies conducted on
different populations under different circumstances
• If studies conducted by….
– different researchers
– at different times
– in different settings
– on different populations
– using different study designs
……all produce consistent results, this strengthens the argument for
causation