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the study of the amount and distribution of disease within a population |
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the study of the determinants of disease or reasons for relatively high or low frequency in specific groups |
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primary goal of analytic epidemiology |
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to quantify causal relationships between an exposure and a health or disease outcome.
determine the relationship between the exposure and the health outcome |
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Fundamental Questions about exposures and health outcomes |
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Is there a causal relationship between this health outcome and this exposure?
if so then how strong is this relationship?
how much of this health outcome can be attributed to this exposure? |
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how can we establish causality? |
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experimental study or observational study |
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experimental study as used to establish causality |
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assign treatments or exposures randomly to participants any observed difference in outcomes can be attributed to the treatment
remember: an experiment might not be feasible |
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observational study as used to establish causality |
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includes a case control, cohort, cross-sectional study, etc.
establishing causality from observational data is the central challenge of analytic epidemiology |
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causation: what is a cause? |
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a factor that produces an effect or makes a difference |
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more often than not we are dependent upon our observation and enumeration of defined events for which we then seek antecedents. in other words we see that the event b is associated with the environmental feature a. in what circumstances can we pass from this observed association to a verdict of causation? |
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bradford hill's criteria for assessing causation |
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Definition
strength of association
consistency
specificity
temporality
biological gradient
plausibility
coherence
experiment
analogy |
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large associations are more likely to be causal than small ones
more difficult to think of alternative explanations for large associations - ie more difficult to explain them away by systematic or random error
examples: percival pott's conclusions about chimney sweeps and scrotal cancer
smoking and lung cancer
john snow:relative death rates of cholera in houses supplied by different water companies. |
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evidence for causality is stronger if the association is replicated in different populations, by different researchers at different times using different study designs.
single studies are rarely definitive. |
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is there a one-to-one relationship between exposures and disease outcomes?
note, however, that some causes lead to many diseases like contaminated milk and some diseases have many causes, ie scrotal cancer |
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exposure must precede disease |
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strength of association increases as exposure level increases. example: death rate from cancer increases linearly with number of cigarettes smoked daily.
dose-response. |
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is there an existing biological or social model to explain the association? |
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association consistent with generally known facts of the natural history and biology of disease
similar to plausibility |
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experiment that modifies exposure through prevention, treatment or removal should result in less disease.
may be infeasible or unethical. |
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association between exposure and disease has characteristics or features that are similar to other associations generally regarded as causal
examples: thalidomide and rubella in pregnancy. |
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Internal validity of a study |
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can the study measure what it sets out to measure? is it free from systematic error (bias)? |
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can results be extrapolated to other populations, settings, etc? |
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random error
systematic error (bias) |
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measurement results that differ from the true value due to chance |
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any systematic error in the design, conduct, or analysis of a a study that results in a mistaken estimate of an exposure's effect on the risk of disease. |
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selection bias: absence of comparability between groups being studied. the causal relation between exposure and disease is distorted due to (a) procedures used to select or exclude subjects, (b) differences between participants and nonparticipants, and (c) differences in follow-up or drop-out rates that differ according to a causal exposure. information bias: has the information been gathered in the same way? incorrect determination of exposure and/or outcome; if bias is differential by group this may increase or decrease the relative risk/odds ratio; if non-differential "noise in the system" the odds ratio may be shifted towards 1 (no association). some types of information bias: diagnostic suspsicion bias, surveillance bias, recall bias, reporting or wish bias, bias in abstracting records, bias in interviewing. confounding (bias) is an extraneous factor blurring the effect? the causal relation between exposure and disease is distorted due to association of the exposure with other factors that influence the outcome. the effect of the exposure is mixed together with the effect of another exposure, leading to bias. what is a confounder? if we want to know whether factor A is a cause of disease B, then a third factor X is a confounder if Factor X is a known risk factor of disease B and Factor X is associated with Factor A, but is not a result of factor A. Some approaches to addressing confounding: during study design, restrict study to those without confounder or match on confounder; during data analysis, stratify by confounder or adjust for confounder in multivariate models.
something "different" distorts the planned comparison. |
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