Académique Documents
Professionnel Documents
Culture Documents
Nancy Nguyen
Epidemiology/population health Study design, types and selection of studies
Incidence vs. prevalence Descriptive studies
Measures of health status Analytical studies: observational vs. interventional
Survival analysis interpretation Systematic reviews and meta-analysis
Composite health status indicators Obtaining and describing samples
Population pyramids and impact of demographic Methods to handle noncompliance
changes Qualitative analysis
Disease surveillance and outbreak investigation
Study interpretation
Communicable disease transmission
Bias, confounding, and threats to validity
Points of intervention
Internal vs. external validity
Statistical vs. clinical significance
www.usmle.org
Rates: crude and adjusted
Crude = overall (e.g. crude mortality rate)
Adjusted = stratified by different categories (e.g. Age-adjusted mortality rates)
Mortality
Standard mortality ratio = (observed # of deaths per yr/expected # deaths per yr) x 100
If the SMR = 100, this indicates that the # observed deaths is equal to # expected
A. A cross-sectional study
B. A case-control study
C. A concurrent cohort study
D. A retrospective cohort study
E. An experimental study
The physical examination records of the entire incoming freshman class of
1935 at the University of Minnesota were examined in 1977 to see if their
recorded height and weight at the time of admission to the university was
related to the development of coronary heart disease by 1986. This is an
example of:
A. A cross-sectional study
B. A case-control study
C. A concurrent cohort study
D. A retrospective cohort study
E. An experimental study
Residents of three villages with three different types of water supply were asked to
participate in a survey to identify cholera carriers. Because several cholera deaths had
occurred recently, virtually everyone present at the time underwent examination. The
proportion of residents in each village who were carriers was computed and compared.
What is the proper classification for this study?
A. Cross-sectional study
B. Case-control study
C. Concurrent cohort study
D. Nonconcurrent cohort study
E. Experimental study
Residents of three villages with three different types of water supply were asked to
participate in a survey to identify cholera carriers. Because several cholera deaths had
occurred recently, virtually everyone present at the time underwent examination. The
proportion of residents in each village who were carriers was computed and compared.
What is the proper classification for this study?
A. Cross-sectional study
B. Case-control study
C. Concurrent cohort study
D. Nonconcurrent cohort study
E. Experimental study
A case control study is characterized by all of the following except:
Double-blind
Placebo-controlled
Community intervention
Systematic Review Meta-analysis
A research study which aims to provide an A statistical technique used to combine the
exhaustive summary of current literature results of all eligible studies in a
relevant to a research question. systematic review into a single quantitative
estimate or summary effect size
Crucial to EBM
Effect sizes measure the strength of the relationship between two variables, thereby providing
information about the magnitude of the intervention effect
Heterogeneity is a value calculated to determine if individual studies are similar enough to compare
(prefer non-significant findings for heterogeneity)
Publication bias is particularly problematic for systematic reviews because not all studies are
published, depending on the significance and direction of effects detected.
Horizontal line =
confidence interval
Information bias
Occurs during data collection and can lead to misclassification
Sampling bias or non-random sampling bias: a selection procedure that yields a non-
representative sample in which a parameter estimate differs from the existing in the target
population
Example is telephone random sampling which would systematically exclude households without
telephones
Ascertainment bias
Healthcare access bias
Survivor treatment selection bias
Recall bias
If the presence of disease influences the perception of its causes or the search for exposure to the
putative cause
Common in case-control studies where participants are aware of their disease status, but can also
occur in cohort studies
Ecologic fallacy
When analyses realized in an ecological group analysis are used to make inferences at the
individual level
Hawthorne effect
When individuals modify they react or behave in response to their awareness of being observed
An extraneous variable that correlates (directly or inversely) with both the dependent
variable and the independent variable
Example: Drinking coffee and pancreatic cancer
Confounding is not an error in the study but can be considered a true phenomenon that is
identified in a study and must be understood
One approach is to stratify…
If you stratify the data by the confounding variable then you will find that the measure of
association will equal 1.0
If you know of a possible confounder during the design phase of your study, you can match
cases to controls based on the confounding variable
Internal validity
The extent to which a study is able to make causal conclusions based the design and ability to
reduce systematic error
Essentially how well you designed your study (confounding = red flag!)
External validity
Whether the findings of a study can be generalized to the rest of the population
Example: hospital cohorts
Alaa Elmaoued
Nancy Nguyen
Sensitivity and Specificity Number Needed to Harm
Positive and Negative Predictive Values t-Test
Incidence and Prevalence ANOVA
Odds Ratio Chi-square
Relative Risk Pearson Correlation Coefficient
Attributable Risk Error types
Relative Risk Reduction
Absolute Risk Reduction
Number Needed to Treat
Incidence RATE = Number of new cases Prevalence = Number of total existing
/ Population at risk cases / Population at risk
Incidence looks at new cases at a time
Prevalence = incidence x duration of
period
disease
Chronic disease with long duration has a
high prevalence
Disease with short duration has low
prevalence and equals the incidence of
disease
Smithville has a stable population of 100,000 and 2000 individuals in this community
have been diagnosed with disease X. Although 300 individuals in Smithville die each
year from all causes, 100 of those die from disease X. There are 50 new cases of the
disease each year.
The annual incidence of this disease is represented by which of the following?
The incidence is represented by the number of new cases of the disease in a given
period divided by the susceptible population. Because the 2000 people with the
disease are no longer susceptible, they must e subtracted from the total population;
thus the incidence is 50/98,000.
A research group is studying sickle cell disease in a geographically isolated community of
6000 people. A genetic analysis is performed on every community member At the beginning
of the year, it is determined that 10% are homozygous for hemoglobin S and therefore have
sickle cell disease, and 30% of the community is heterozygous for the mutant allele. Over the
course of the year, 100 infants are born, six of whom are diagnosed with sickle cell disease. Of
80 people who die during the year, three had sickle cell disease.
Which of the following is the current prevalence of sickle cell disease in this population?
Prevalence is the total number of cases in a population divided by the total population at risk of
the disease. Multiply the initial population (6000) by the initial prevalence (10%), yielding 600
cases. Over the course of the year, there was a net gain of 3 patients with sickle cell disease,
bringing the new total to 603. Likewise, the new population at risk is 6020, a net gain of 20 people.
Therefore, the current prevalence is 603/6020.
Be Sensitive to Positive people
Sensitivity is how good a test will identify those who have the disease
Sensitivity = True Positives/(True Positives + False Negatives) OR = 1 – false-negative rate
SN-N-OUT
A highly sensitive test Rules Out the disease if it is negative
β-Thalassemia major results from a homozygous genotype that leads to complete absence of both the β-globin
chains. A study subjected 100,000 participants to an intrauterine screening test; 87 tested positive for β-
thalassemia major, and the remaining 99,913 tested negative. In 7 of those 87 cases the results were shown to be
false positive. Ultimately, 100 of those originally screened were found to actually have the disease.
Which of the following is the correct sensitivity of the intrauterine screening test?
Proportion of positive test results tat are truly positive
If the test result is positive in this patient, what is the probability that this patient truly has
the disease?
PPV = TP/ TP+FP
PPV is directly related to prevalence
High prevalence means high PPV
Investigators studying cardiovascular disease discover a new serum protein marker that is
correlated with the presence of ruptured atherosclerotic plaques. It is hoped that this serum marker
could be used as a screening test to identify whether a person has had a recent MI. In a phase III
clinical trial of 1400 subjects, the investigators find that of the 500 subjects who had an MI, 400 tested
positive for the serum marker, whereas 850 subjects who did not have an MI tested negative for the
marker.
If this marker were used to screen patients for recent MI, what is the probability that a person will
have had an MI given a positive serum protein analysis?
The question is asking to calculate the positive predictive value of the test, i.e, the
probability that a person with a positive serum marker on the screening test will indeed
have had a recent MI.
Specificity is the proportion of people without the disease wo test negative
SP-P-IN
Highly specific test when positive rules in the disease.
NPV = True Negatives / All people who tested negative (TN + FN)
NPV is inversely correlated with prevalence
High prevalence = Low NPV
How to determine whether a certain disease is associated with a certain exposure
To determine whether an association exists, we can use data from case-control and
cohort studies
Used in Case-control studies
Odds that group with disease (cases) was exposed to a risk factor (a/c) divided by
the odds that group without the disease (controls) was exposed (b/d)
Researchers are investigating the relationship between cell phone use and brain cancer. Of 50
brain cancer patients, 30 admitted to using a cell phone for 10 year or more. Of 400 healthy
participants in the study, 250 were found to have used a cell phone for 10 years or more.
Which of the following is an appropriate conclusion to draw from this study regarding ell phone
use and brain cancer?
The clinical study described is a case-control study. Case-controls look at those with the
disease (the cases) compared to those without the disease (the controls). The odds ratio
is then calculated as OR=(odds in disease group)/ (odds in control group) = [30/(50-
30)] / [250/(400-250)] = 9/10.
Used in cohort studies
Risk of developing disease in the exposed group divided by risk in the unexposed
group.
Defined as the difference in risk between exposed and unexposed groups, or the
proportion of disease occurrences that are attributable to the exposure
Number needed to treat is defined as the number of patients who need to be
treated for 1 patient to benefit
Important: Increasing the sample size is the most practical and important way of increasing the
power of a statistical test, i.e., there is power in numbers.
A medical resident decides to test the hypothesis that people with Alzheimer’s have
elevated serum sodium levels. The Type I error of this study was 0.078. What does
this analysis represent for the study?
A. Determines the power of a study to detect a significant change
B. Probability of Type I error is known as β
C. Represents the probability of incorrectly rejecting the null hypothesis
D. Most studies used a probability of error level of 0.10 to determine the significance
E. It is equal to 1- β
α should be less than 0.05 to be acceptable
USMLE Step 1 Qbook, Fifth edition
USMLERx Qbank 2015
First Aid 2015 edition
USMLE Step I Secrets
…You should probably start running…
In a city with a population of 1 million, 10, 000 individuals have SLE. There are
1,000 new cases of SLE each year and 200 deaths caused by the disease.
There are 2,500 deaths per year from all causes. Assuming no net
emigration or immigration to the city, the incidence of SLE in this city is
given by which of the following expressions?
A. 800/990,000
B. 800/1,000,000
C. 1,000/990,000
D. 1,000/1,000,000
E. 2,500/1,000,000
F. 10,000/1,000,000
In a city with a population of 1 million, 10, 000 individuals have SLE. There are
1,000 new cases of SLE each year and 200 deaths caused by the disease.
There are 2,500 deaths per year from all causes. Assuming no net
emigration or immigration to the city, the incidence of SLE in this city is
given by which of the following expressions?
A. 800/990,000
B. 800/1,000,000 Don’t forget to subtract the
prevalent cases of SLE! They are
C. 1,000/990,000 not part of the population at risk
of becoming new cases
D. 1,000/1,000,000
E. 2,500/1,000,000
F. 10,000/1,000,000
Researchers are developing a screening test for awesomeness which has a
sensitivity of 95% and a specificity of 90%. If the prevalence of awesomeness is
10%, which of the following is the best estimate for the probability that a
person who tests negative for awesomeness is actually not awesome at all?
A. 45%
B. 50%
C. 85%
D. 90%
E. 95%
F. 99%
Researchers are developing a screening test for awesomeness which has a
sensitivity of 95% and a specificity of 90%. If the prevalence of awesomeness is
10%, which of the following is the best estimate for the probability that a
person who tests negative for awesomeness is actually not awesome at all?
Awesome Not Awesome