EPID 600; Class 4

Measures of association

University of Michigan School of Public Health

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 Three key dimensions to epidemiologic
studies
Measures of association
Relative measures (relative risks, rates, and odds)
Absolute measures (risk and rate differences)
Study design
Observational
Cohort
Case-control
Cross-sectional
Experimental
Randomized trial
Field trials
Group randomized trials
Units of analysis
Individual
Group
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 Three key dimensions to epidemiologic
studies
Measures of association
Relative measures (relative risks, rates, and odds)
Absolute measures (risk and rate differences)
Study design
Observational
Cohort
Case-control
Cross-sectional
Experimental
Randomized trial
Field trials
Group randomized trials
Units of analysis
Individual
Group
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 Measurement of association

Epidemiologic studies strive to determine the difference in

measures of disease occurrence between populations
Populations typically considered as “exposed” vs
“unexposed” and measures of association then seek to
define an association between “exposure” and disease
“outcome” of interest
Measures of association reflect statistical relations between
variables, they are not measures of “effect” which are
unobserveable counterfactual contrasts, but they are the
best we can do

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 The world

persons “exposed” persons “unexposed”

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 The epidemiologic study

persons “exposed” persons “unexposed”

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 The epidemiologic study

persons “exposed” with disease persons “unexposed” with disease

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 Reminder...prevalence (proportion)

Number of cases
at a specified
Prevalence =
time
Number of persons in
population

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 Prevalence ratio

prevalenceexp osed
prevalence ratio =
prevalenceun exp osed

Prevalence ratio is uncommonly used in epidemiology due to limitations of

prevalence (including both incidence and duration of disease) discussed in
class 3 9
 Reminder...risk (incidence proportion)

The probability that a person will develop a given disease

Number of new cases of disease over a time

Risk =
Number of persons followed period

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 Relative risk (risk ratio)

The ratio of risks for two populations

Rexp osed
RR =
Run exp osed

Ranges from 0 to +∞ , has no units

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 Risk difference

The additional risk among those exposed when compared

to those unexposed

RD = Rexp osed − Run exp osed

Ranges from -1 to +1, has no units

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 Reminder...incidence rate

Number of new cases

Incidence Rate =
Total time at risk of persons followed

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 Relative rate (incidence rate ratio)

The ratio of rates for two populations

IRexp osed
IRR =
IRun exp osed
Ranges from 0 to +∞ , has no units

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 Rate difference

The additional incidence rate comparing those exposed

vs. those unexposed

IRD = IRexp osed − IRun exp osed

Ranges from -∞ to +∞ , has unit of time-1

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 GI infection: what are the causes?

Bacterial gastrointestinal infections cause considerable

morbidity even in industrialized countries
We’ve figured out that certain microbes produce illness in
certain people – but what beyond that?
Who gets those microbes? What determines who gets
symptomatic GI infection?
We start by looking for associations between the illness and
factors of interest

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Simonsen, Frisch, and Ethelberg. Socioeconomic Risk Factors for Bacterial Grastrointestinal infections. Epidemiology. 2008; 19(2):282-290
 GI infection and SES: an association?

Little is known about socioeconomic factors affecting the

risk of infection in industrialized settings

A group in Denmark got curious…

What did they do?

Link 3 national registries and follow the entire population of

Denmark (5.3 million people) from 1993 to 2004 to track GI
infection
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Simonsen, Frisch, and Ethelberg. Socioeconomic Risk Factors for Bacterial Grastrointestinal infections. Epidemiology. 2008; 19(2):282-290
 GI infection and SES
RESEARCH
PROCESS DATA SOURCE

Identify a cohort Danish Civil

of interest Registration
System
Find Create
information on Integrated
Database for extended
each
individual’s Longitudinal 2x2 tables
SES Labor Market and do an
Research analysis
Obtain
National Registry
information on
of Enteric
their disease
Pathogens
patterns
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Simonsen, Frisch, and Ethelberg. Socioeconomic Risk Factors for Bacterial Grastrointestinal infections. Epidemiology. 2008; 19(2):282-290
 GI infection and SES

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Simonsen, Frisch, and Ethelberg. Socioeconomic Risk Factors for Bacterial Grastrointestinal infections. Epidemiology. 2008; 19(2):282-290
 GI infection and SES

These data provide

evidence that higher
SES is associated with
Campylobacter Cases Person Adjusted
infection years risk ratio
(1000s)
Income
<100,000 6487 13,490 0.93

100,000-199,000 9718 21,604 1.00

We compare
the risk of each
200,000-299,999 5507 11,051 1.10
income bracket
to the median
bracket (the 300,000-399,999 1190 2165 1.28
reference
category) >400,000 639 1068 1.51

Simonsen, Frisch, and Ethelberg. Socioeconomic Risk Factors for Bacterial Grastrointestinal infections. Epidemiology. 2008; 19(2):282-290
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 Reminder...odds

probability, or risk

p
odds =
1− p

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 Relative odds (odds ratio)

pexp osed
oddsexp osed 1 − pexp osed
OR = =
oddsun exp osed pun exp osed
1 − pun exp osed

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 Absolute vs. relative scales

The two types of effect measures we have articulated

here are on an absolute scale (i.e., subtraction) and on
a relative scale (i.e., division)
In epidemiology we may be interested in both
Absolute differences tell us the increase (or decrease)
in effect
Relative differences tell us the relative increase or
decrease in effect comparing one quantity to another

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 Absence of an effect in the absolute scale

If there is no effect on an absolute scale, the Risk

Difference (RD), or the Rate Difference (IRD) are equal to 0
That is, there is no increased risk or increased rate of
disease among exposed compared to unexposed
Therefore, on an absolute scale, the “null” is 0

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 The relative effect on a relative scale

The relative effect is equivalent to the proportion change in

absolute effect among exposed compared to unexposed (e.g., if
original amount is x, and new amount is y, the proportion increase
is y−x
x

Risk difference
Relative effect =
Risk in unexposed

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 Therefore...

Relative Rexp osed − Run exp osed Rexp osed Run xp osed
effect
= = − = RR − 1
Run exp osed Run exp osed Run exp osed

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 Implications

When we talk about greater population risk of a particular

outcome among exposed compared to unexposed, we
should be using RR-1, not RR
Typically, we present RR
So, if RR=3, relative effect=3-1=2
So, if RR=3 we say, there is a 200% increase in risk of
disease among exposed compared to unexposed
So, NO EFFECT is 0, i.e., RR-1=0, i.e., RR=1
RR=1 is then the “null”

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 Key way to see through this

All these formulas are related to one another in relatively

simple ways that rest on understanding (not memorizing)
what they mean and where they come from

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 Reminder...risk and incidence rate

Risk = Incidence rate x time....therefore...

Riskexp osed Incidenceexp osed * time Incidenceexp osed

RR = = = = IRR
Riskun exp osed Incidenceun exp osed * time Incidenceun exp osed

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 Reminder...risk and incidence rate

Risk = Incidence rate x time....therefore...

Riskexp osed Incidenceexp osed * time Incidenceexp osed

RR = = = = IRR
Riskun exp osed Incidenceun exp osed * time Incidenceun exp osed

if....time period is sufficiently comparable among exposed group and

unexposed group; typically this is if the time period is short
remember...we had said that R=IR*t when R is low
therefore...RR is a reasonable approximation for IRR when both risk is low
and when time period of observation is short

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 Epidemiologic confusion

Sometimes epidemiologists use the term “relative risk” to

refer to either risk ratio or to incidence rate ratio assuming
the two are equivalent
This is obviously wrong; please do not do that

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 The world

persons “exposed” persons “unexposed”

32
 The epidemiologic study

persons “exposed” persons “unexposed”

33
 The epidemiologic study

persons “exposed” with disease persons “unexposed” with disease

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 The “2x2” table

Disease No disease Total

Exposed a b a+b

Not exposed c d c+d

Total a+c b+d a+b+c+d

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 Relative risk, i.e., risk ratio

a
Rexp osed =
a+b
c
Run exp osed =
c+d
a
RR = a + b
c
c+d
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 Relative odds, i.e., odds ratio

a a a
Pexp osed a + b a + b a + b a
Oddsexp osed = = = = =
1 − Pexp osed 1 − a a+b−a b b
a+b a+b a+b
c c c
Pune xp osed c + d c + d c + d c
Oddsun xp osed = = = = =
1 − Pun xp osed 1 − c c+d −c d d
c+d c+d c+d
a
Oddsexp osed b a*d
OR = = =
Oddsun exp osed c b * c
d 37
 Example

In a particular study out of 100 exposed persons, 20 develop disease; out of

200 unexposed, 25 develop disease

Disease No disease Total

Exposed a b a+b

Not exposed c d c+d

Total a+c b+d a+b+c+d

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 Example

In a particular study out of 100 exposed persons, 20 develop disease; out of

200 unexposed, 25 develop disease

Disease No disease Total

Exposed a b 100

Not exposed c d 200

Total a+c b+d 300

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 Example

In a particular study out of 100 exposed persons, 20 develop disease; out of

200 unexposed, 25 develop disease

Disease No disease Total

Exposed 20 b 100

Not exposed 25 d 200

Total 45 b+d 300

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 Example

In a particular study out of 100 exposed persons, 20 develop disease; out of

200 unexposed, 25 develop disease

Disease No disease Total

Exposed 20 80 100

Not exposed 25 175 200

Total 45 255 300

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 Example

Disease No disease Total

Exposed 20 80 100
Not exposed 25 175 200
Total 45 255 300

20
20*175
RR = 100 = 1.60 OR = = 1.75
25 25*80
200
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 Going back to an example

T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 T13 T14 T15 T16 T17 T18 T19 T20 TT

P1 14

P2 20

P3 11

P4 11

P5 20

P6 20

P7 10

P8 20

P9 2

P10 9

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 An example

T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 T13 T14 T15 T16 T17 T18 T19 T20 TT

P1 14

P2 20

P3 11

P4 11

P5 20

P6 20

P7 10

P8 20

P9 2

P10 9

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 An example

T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 T13 T14 T15 T16 T17 T18 T19 T20 TT

P1 14

P2 20

P3 11

P4 11

P5 20

P6 20

P7 10

P8 20

P9 2

P10 10

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 Cohort approach

2 2
IRexp osed (14 + 20 + 10 + 2)
IRR = = = 46 = 4.0
IRun exp osed 1 1
(20 + 11 + 11 + 20 + 20 + 10) 92
2
Rexp osed
RR = = 4 = 3.0
Run exp osed 1
6
pexp 0.5
1 − pexp 1 − 0.5 2*5
OR = = = 5.0 also can be calculated as = 5.0
pun exp 0.167 1* 2
1 − pun exp 1 − 0.167
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 Notes

As in this example, OR is greater than RR when OR and

RR are > 1
OR approximates RR when disease is rare (<1%
typically)

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 Why? (first premise)

a
Disease No disease Total

RR = a + b
c Exposed a b a+b

c+d Not exposed c d c+d

a a
is always < Total a+c b+d a+b+c+d

a+b b
c c
is always <
c+d d
a a a
a +b a c b > a +b
and if > 1, then, > , and
c a+b c+d c c
c+d d c+d
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 Why? (second premise)

a Disease No disease Total

RR = a + b Exposed a b a+b

c Not exposed c d c+d

c+d Total a+c b+d a+b+c+d

if disease is rare, then a + b ≅ b and c + d ≅ d

a
b a*d
therefore, RR ≅ ≅ ≅ OR
c b*c
d 49
 Some notes about terminology...

For OR, RR, and IRR, if value is >1 typically we say that
there is a “positive association”, 1 is no association, and < 1
is a “negative association”
Of course, interpretation fully depends on what is “exposed”
and what is “non-exposed”
Remember...the “null” is 1 for relative measures of
association and 0 for absolute measures; hence “away
from” or “towards” the null

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 The “2x2” table involving time

Disease Time

Exposed a T1

Not exposed c To

Total a+c T1+To

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Incidence rate ratio

a
IRexp osed =
T1
c
IRun exp osed =
T0
a
T1
IRR =
c
T0
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 Example

In a particular study 20 smokers out of 10,000 PY of exposure developed

heart disease and 25 nonsmokers out of 20,000 PY of follow-up develop
heart disease

Disease Time

Exposed a T1

Not Exposed c To

Total a+c T1+To

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 Example

In a particular study 20 smokers out of 10,000 PY of exposure developed

heart disease and 25 nonsmokers out of 20,000 PY of follow-up develop
heart disease

Disease Time

Exposed 20 10,000

Not Exposed 25 20,000

Total 45 30,000

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 Example

Disease Time

Exposed 20 10,000

Not Exposed 25 20,000

Total 45 30,000

20
10, 000
IRR = = 1.6
25
20, 000 55
 Attributable fraction among exposed

Proportion of the disease burden among exposed people that is

due to the exposure

R exposed -R unexposed
AFexposed =
R exposed

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 And...

R exposed -R unexposed R exposed R unexposed 1 RR-1

AFexposed = = - =1- =
R exposed R exposed R exposed RR RR

so....if RD is the R among exposed when subtracting R among unexposed,

then dividing RD by R among exposed gives the proportion of effect among
exposed that is due to exposure
this is often interpreted as the proportion of disease cases among exposed
that would be removed if there were no longer any exposure
note, that among exposed, we do NOT remove ALL of effect, even if
exposure is not longer there
WHY?....clearly “exposure” is not the only cause

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 Attributable fraction in population

Proportion of the disease burden among the whole population that

is due to the exposure

R population -R unexposed
AFpopulation =
R population
so....if subtracting the R among unexposed from overall population R gives
us the effect, then dividing this by R among population gives the proportion
of effect among population that is due to exposure
this is often interpreted as the proportion of disease cases in the population
that would be removed if there were no longer any exposure
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 And...

p*(RR-1)
AFpopulation =
p*(RR-1)+1

where p is the prevalence of exposure in the whole population

so...if the population attributable fraction is 20%, then if exposure is
removed, we would expect that disease would be reduced by 20% in the
population

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