Measures of Impact

Lyle Petersen 1999, Thomas Grein 2000-2003

You are in charge of health prevention

Want to reduce automobile-related deaths
Have a limited budget but want to have the greatest impact
on reducing deaths

Conduct a cohort study to examine causes for

automobile-related deaths

RR = 5.0
0.00000050
0.00000010
0.50
0.10

% exposed
to risk
factor?

Measures of Impact
Measures of association providing information
about absolute effects of exposure
Two concepts
- Attributable risk among exposed
- Population attributable risk

Attributable Risk (AR)

Quantifies disease burden in exposed group
attributable to exposure
Provides answers to
- What is the risk which can be attributed to the
exposure?
- What is the excess risk due to the exposure?

Calculated as risk difference (RD)

Attributable Risk
Incidence

Iexposed Iunexposed

Exposed

Unexposed

I = Incidence

AR: Fast driving

Dead
Fast

100

Not dead
1900

Risk
2000

RD

0.05
0.04

Slow

80

7920

8000

180

9820

10000

0.01

AR: Fast driving

Dead
Fast

100

Not dead
1900

Risk
2000

RD

0.05
0.04

Slow

80

7920

8000

180

9820

10000

0.01

AR: Drunk driving

Dead
Drunk

45

Not dead
255

Risk
300

RD

0.150
0.136

Not d.

135

9565

9700

180

9820

10000

0.014

AR: Drunk driving

Dead
Drunk

45

Not dead
255

Risk
300

RD

0.150
0.136

Not d.

135

9565

9700

180

9820

10000

0.014

Attributable Risk Percent (AR%)

AR expressed as a percentage of risk in exposed
Provides answers to
- What is the proportion of disease among the exposed
which
can be attributed to the exposure?
could be avoided by eliminating the exposure?

Synonyms
- Attributable proportion
- Etiologic fraction (EF)

Attributable Risk Percent

Incidence

%
Exposed

Iexposed - Iunexposed RR - 1

x 100
RR
Iexposed
Unexposed

AR%: Fast driving

Dead

Not dead

Risk

Fast

100

1900

2000

0.050

Slow

80

7920

8000

0.010

AR%
0.050- 0.010
0.050
= 80%

180

9820

10000

AR%: Drunk driving

Dead

Not dead

Risk

Drunk

45

255

300

0.150

Not d.

135

9565

9700

0.014

AR%
0.150- 0.014
0.150
= 91%

180

9820

10000

AR & AR% in Case-Control

Studies
No direct risk estimates in case-control study
- No calculation of AR (risk difference) and AR% possible

If odds ratio approximates relative risk, then

OR - 1
AR%
x 100
OR

Prevented Fraction (PF)

If relative risk <1
- Proportion of potential new cases which would have
occurred if the exposure had been absent
- Proportion of potential cases prevented by the exposure

Iunexposed - Iexposed
PF
Iunexposed
1 - RR

PF: Vaccine efficacy

Pop.

Cases

Cases/1000

RR

Vaccinated

301,545

150

0.49

0.28

Unvaccinated

298,655

515

1.72

Ref.

Total

600,200

665

1.11

PF

1.72 - 0.49
0.72
1.72

1 - 0.28

0.72

Expected number of cases among

vaccinated if unvaccinated

301,545
x 1.72
1,000

519

Observed number of cases

150

Estimated number of cases prevented

369 (72%)

Population Attributable Risk (PAR)

Excess risk of disease in total population
attributable to exposure
Reduction in risk which would be achieved if
population entirely unexposed
Helps determining which exposures relevant to
public health in community

PAR Ipopulation - Iunexposed

( AR) (Pexposed)
P = proportion

Population Attributable Risk

Risk

Ipopulation - Iunexposed

Population

Unexposed

Risk

x% exposed
(100-x) %
unexposed

Risk
Exposed

Population

Unexposed

Unexposed

Population Attributable Risk

Percent (PAR%)
PAR expressed as a precentage of total risk in
population

Ipopulation - Iunexposed
PAR%
x 100
Ipopulation

PAR: Fast driving

Dead

Not dead

Risk

Fast

100

1900

2000

0.050

Slow

80

7920

8000

0.010

180

9820

10000

0.018

PAR 0.018 - 0.010 0.008

PAR%

0.018 - 0.010
x 100 44%
0.018

PAR: Drunk driving

Dead

Not dead

Risk

Drunk

45

255

300

0.150

Not d.

135

9565

9700

0.014

180

9820

10000

0.018

PAR 0.018 - 0.014 0.004

PAR%

0.018 - 0.014
x 100 22%
0.018

Conclude
44% of driving-related deaths in population were
presumably due to fast driving
22% of driving-related deaths in population were
presumably due to drunk driving

PAR% in Case-Control Studies

Cohort study

P (RR - 1)
PAR%
x 100
P (RR - 1) 1
where P = % population exposed

Case-control study
If % controls exposed % population exposed:

Pcon (OR - 1)
PAR%
x 100
Pcon (OR - 1) 1
where Pcon = % controls exposed

Summary

Where will you put your money to have the greatest

impact on reducing automobile-related deaths?

Association between smoking

and lung cancer (case study)

Association between smoking

and cardiovascular disease

Smoking and mortality due to

CV disease and lung cancer

based on 102,600 PY, there were 133 deaths due to lung cancer
and 976 deaths due to cardiovascular disease

What is the Appropriate

Measure?
"Control of prostitution will prevent most
heterosexual HIV transmission!
"He got lung cancer. But he probably would have
gotten lung cancer anyway even if he didn't
smoke.
"Should I fly Angolan Airlines or Quantas?"