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Nciph ERIC14
Nciph ERIC14
Second Edition
equally misclassified among cases and controls. Non- Combined errors in both sensitivity and specificity further
differential misclassification in a cohort study occurs when increase the bias towards the null, but specificity errors
exposure status is equally misclassified among persons produce larger biases overall.
who develop and persons who do not develop the health
Differential misclassification
outcome.
Differential misclassification occurs when
Non-differential misclassification of health outcome status
misclassification of exposure is not equal between
occurs in a case-control study when the health outcome
subjects that have or do not have the health outcome, or
status is equally misclassified among exposed and
when misclassification of the health outcome is not equal
unexposed subjects. Non-differential misclassification of
between exposed and unexposed subjects.
the health outcome status occurs in a cohort study when a
study subject who develops the health outcome is equally Differential misclassification causes a bias in the risk
misclassified among exposed and unexposed cohorts. ratio, rate ratio, or odds ratio either towards or away from
the null, depending on the proportions of subjects
Effect of non-differential misclassification of exposure
misclassified.
Non-differential misclassification biases the risk ratio, rate
Effect of differential misclassification of exposure or
ratio, or odds ratio towards the null if the exposure
health outcome
classification is dichotomous, i.e., either exposed or
unexposed. If exposure is classified into 3 or more Differential misclassification of the exposure or health
categories, intermediate exposure groups may be biased outcome can bias the risk ratio, rate ratio, or odds ratio
away from the null, but the overall exposure-response trend either towards or away from the null. The direction of bias
will usually be biased towards the null. is towards the null if fewer cases are considered to be
exposed or if fewer exposed are considered to have the
Effect of non-differential misclassification of the health
health outcome. The direction of bias is away from the
outcome
null if more cases are considered to be exposed or if more
In most cases, non-differential misclassification of the exposed are considered to have the health outcome.
health outcome will produce bias toward the null, i.e. the
The effect of differential misclassification of the exposure
risk ratio, rate ratio or odds ratio will be biased towards
or health outcome can bias the risk ratio, rate ratio, or
1.0. If errors in detecting the presence of the health
odds ratio in either direction. The direction of bias is
outcome are equal between exposed and unexposed
towards null if fewer cases are considered to be exposed
subjects (i.e. sensitivity is less than 100%) but no errors
or if fewer exposed subjects are considered to have the
are made in the classification of health outcome status (i.e.
health outcome. The direction of bias is away from the
specificity is 100%), the risk ratio or rate ratio in a cohort
null if more cases are considered to be exposed or if more
study will not be biased, but the risk difference will be
exposed subjects are considered to have the health
biased towards the null.
outcome.
Effect of non-differential misclassification of health
Interviewer bias
outcome status
Interviewer bias is a form of information bias due to:
If no errors are made in detecting the presence of the
health outcome (i.e. 100% sensitivity), but equal errors are 1. lack of equal probing for exposure history
made among exposed and unexposed in the classification between cases and controls (exposure
of health outcome status (i.e. specificity less than 100%), suspicion bias); or
the risk ratio, rate ratio, and risk difference (as applicable)
will be biased towards the null.
2. lack of equal measurement of health may result in bias away from null, though this is less likely
outcome status between exposed and than bias towards the null.
unexposed (diagnostic suspicion bias)
Non-differential misclassification of a health outcome
Solutions: limited to a loss of sensitivity of detecting the health
outcome without any loss in specificity does not bias
1. blind data collectors regarding exposure or
toward null, whereas a loss of specificity always biases
health outcome status
toward the null.
2. develop well standardized data collection
Conclusions
protocols
Some inaccuracies of measurement of exposure and
3. train interviewers to obtain data in a
health outcome occur in all studies.
standardized manner
If a positive exposure-health outcome association is found
4. seek same information about exposure from
and non-differential measurement errors are more likely
two different sources, e.g. index subject and
than differential ones, measurement error itself cannot
spouse in case-control study
account for the positive finding since non-differential error
nearly always biases towards the null.
Recall or reporting bias
Strive to reduce errors in measurement:
Recall or reporting bias is another form of information bias
1. develop well standardized protocols
due to differences in accuracy of recall between cases and
non-cases or of differential reporting of a health outcome 2. train interviewers and technicians well
between exposed and unexposed.
3. perform pilot studies to identify problems
Cases may have greater incentive, due to their health with questionnaires and measuring
concerns, to recall past exposures. Exposed persons in a instruments
cohort study may be concerned about their exposure and
4. attempt to assess the direction of bias by
may over-report or more accurately report the occurrence
considering likelihood of non-differential or
of symptoms or the health outcome.
differential misclassification
Solutions:
Answers are at the end of this notebook Rothman KJ, Greenland S. Modern Epidemiology. Second
Edition. Philadelphia: Lippincott Williams and Wilkins,
1) Researchers conduct a case-control study. The
following table shows the true classification of exposure 1998.
and the health outcome (Note: these data are hypothetical
Dr. Steve Marshall and Dr. Jim Thomas Epidemiology
and typically researchers would not know the true
unbiased distribution of exposure and outcome). 710, Fundamentals of Epidemiology course lectures,
2009-2013, The University of North Carolina at Chapel
Have health out- Do not have health out- Hill, Department of Epidemiology
come come
Exposed 200 210 Dr. David Richardson Epidemiology 718, Epidemiologic
Unex- 340 500 Analysis of Binary Data course lectures, 2009-2013, The
posed
Acknowledgement
a) Calculate the odds ratio The authors of the Second Edition of the ERIC Notebook
w ou l d lik e to ackn ow le dge the auth ors o f th e E RI C
Now imagine that 50 people with the health outcome were N o te b ook, F irs t E dit ion : Mi ch el I brah im , MD, PhD,
misclassified as being unexposed and 20 people with the L orra in e Al exa nder, DrP H, Car l Sh y, MD , Dr PH ,
health outcome were misclassified as being exposed. Ga y le Shi moku ra, MSP H an d Sherr y Far r, G RA,
D epa rt men t o f E p i de mi o log y a t the Uni ver si t y o f
N or th Ca ro l ina a t Cha pe l H i l l. Th e Fi rs t E di ti on o f
b) Create the corrected 2x2 table
t he ER I C No te bo ok was pro du ce d b y the E du cat i onal
A rm o f th e E p i de mi o log i c R es ear ch an d In for ma ti on
Have health out- Do not have health Ce nt er a t Du rham , N C. The fun ding for the E RI C
come outcome N o te b ook F irs t E di t ion was pr ov i de d b y the
Exposed D epa rt men t o f Ve ter ans Affa irs (D V A), V et era ns
H ea l th A dm in is tra ti on (V HA ), Co op era ti ve Stu die s
Unex- P rog ram ( CS P) t o p ro mo te the st rat eg ic gr ow th o f
posed
The bias was away from the null (the null value is
1.0).