EVIDENCE-BASED DERMATOLOGY: REVIEW

OddsRatiosandRelativeRisks O
DDS monly studies. case-control relative RATIOS used The risks and to results studies and express relative odds of
are cohort results best ratios, risks expressed studies in are respec- clinical com-
and as
confidence interval does not include 1, then the result implies a positive association between exposure and out-
come at the 5% significance level (ie, the outcome is more likely in the exposed cohort) (Table, study 3). If the rela-
tive risk is less than 1, and its 95% confidence interval tively. The use and interpretation of these ratios are the
does not include 1, then the result implies a negative
as- subject of this brief review.
sociation between exposure and outcome at the 5% sig- In
a cohort study, a group of individuals exposed
nificance level (ie, the outcome is less likely in the
ex- to an agent are compared with an appropriately selected
posed cohort).1,2 If the 95% confidence interval
includes control group of individuals who are not exposed. Both
the relative risk of 1, then an association of exposure
and groups are observed until an event of interest occurs or
outcome is not proved by the study at the 5% signifi-
for a prespecified time period. The association of expo-
cance level (Table, studies 1 and 2). sure and
outcome is expressed as the relative risk (Table).
Case-control studies are used when an outcome
is Assuming that a study is unbiased, the relative risk is in-
recognized and the exploration of a suspected
causative terpreted as follows: A relative risk of 1 implies no asso-
agent is at an early stage, because case-control studies
are ciation. If the relative risk is greater than 1, and its 95%
cheaper and easier to conduct than cohort studies. They are also useful if there is a very long time lag between
exposure and outcome or if the outcome of interest is Formula and 3 Samples of Relative Risk and Odds Ratio
Calculation
very rare. In a case-control study, patients with an out- come of interest are compared with appropriately se-
Outcome
lected controls without the outcome. The odds of expo- sure to suspected etiologic agents are ascertained in cases
Characteristics
Present (Case) Absent (Control)
and controls (Table).
Formula Exposed to the factor
Yes (cohort) a b No (cohort) c d In a cohort study: relative risk = [a/(a + b)]/[c(c + d)] In a case-control study: odds
ratio = (a/c)/(b/d) = ad/bc
The odds of an event are the ratio of the number of events to the number of nonevents. The odds are equal to
the probability divided by 1 minus the probability Study 1: Outcome Rate, 0.004 in Exposed Subjects Exposed to
the factor
Yes (cohort) 4 996 No (cohort) 1 999 Relative risk = [4/(4 + 996)]/[1/(1 + 999)] = 4 [95% confidence
interval (CI), 0.5-35.7]
(odds=probability/[1−probability]). The formula probability = odds/(odds + 1) is used to convert odds back to
probability. An event is defined by the presence of an exposure to a suspected causal agent or risk factor in a
case-control study. For example, the odds that the cases Odds ratio = ad/bc = 4.01 [CI, 0.5-36]
in study 1 (Table) were exposed to the factor is 4 (4/1).
Error in estimating the relative risk using the odds
ratio = 0.01/4 = 0.25%
The probability that the cases in study 1 (Table) were ex- posed to the factor is 0.8 (4/[4+1] or 4/5). Study 2:
Outcome Rate, 0.04 in Exposed Subjects Exposed to the factor
Yes (cohort) 4 96 No (cohort) 1 99 Relative risk = [4/(4 + 96)]/[1/(1 + 99)] = 4 [CI, 0.5-35.2] Odds ratio (or relative
odds) = ad/bc = 4.13 [CI, 0.5-37.6]
The odds of exposure of cases are divided by the odds of exposure among controls to derive the odds ratio. The
association between exposure and outcome is ex- pressed as the odds ratio in case-control studies. Assum- ing that a
study is conducted in an unbiased manner, the Error in estimating the relative risk using the odds
odds ratio is interpreted as follows: An odds ratio of 1
ratio = 0.13/4 = 3.25%
implies no association. If the odds ratio is greater than Study 3:
Outcome Rate, 0.4 in Exposed Subjects
1, and its 95% confidence interval does not include 1,
Exposed to the factor
then the result implies a positive association between ex-
Yes (cohort) 40 60 No (cohort) 10 90 Relative risk = [40/(40 + 60)]/[10/(10 + 90)] = 4 [CI, 2.1-7.6] Odds ratio (or
relative odds) = ad/bc = 6 [CI, 2.8-12.9] Error in estimating the relative risk using the odds ratio = 2/4 = 50%
posure and outcome at the 5% significance level (ie, the odds of exposure is greater in cases than in controls) (Table,
study 3). If the odds ratio is less than 1, and its 95% confidence interval does not include 1, then the re- sult implies
a negative association between exposure and
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See also page 775

outcome at the 5% significance level (ie, the odds of ex- posure is smaller in cases than in controls).1,2 If the 95%
confidence includes the odds ratio of 1, then an associa- tion of exposure and outcome is not proved by the study at
the 5% significance level (Table, studies 1 and 2).
For example, suppose a case-control study was per- formed to study the relationship between limb defor- mity
and exposure to thalidomide. The results of the study indicated that patients with limb deformities were more likely
than controls to have been exposed to thalido- mide in utero. The odds ratio for thalidomide exposure was 3.5, and
the confidence interval was 1.8 to 6.6. Thus the odds that patients with limb deformities were ex- posed to
thalidomide in utero were 3.5 times the odds of thalidomide exposure in controls. Since the odds ra- tio is greater
than 1, and its 95% confidence interval does not include 1, the result implies a positive association be- tween
thalidomide use and limb deformities. These re- sults (an odds ratio of 3.5 and confidence interval of 1.8 to 6.6)
were actually the results of a study by Wolf et al,3 who studied the relationship between sunscreen use and
melanoma in a case-control study in Austria. Their re- sults indicated that patients with melanoma were more likely
than controls to have used sunscreen often.
Researchers often use the results of a case-control study to infer a causal relationship between the expo- sure
and the outcome. For example, the results of the sun- screen melanoma study mentioned above, if deemed to be
unbiased, can be interpreted to imply that the odds of developing melanoma is 3.5 times higher in people who use
sunscreen often compared with those who do not use sunscreen. The practice of using a case-control study to infer
the odds ratio of outcomes in exposed and unex- posed cohorts is valid because the odds ratio obtained
retrospectively in a case-control study is mathemati- cally equivalent to the odds ratio that would have been obtained
in a prospective (cohort) study (Table, sample [ad/bc]). It is important to remember that the ratio of the odds of
exposure to a suspected etiologic agent in cases and controls is actually determined in case-control stud- ies.
Ascribing a causal relationship between exposure and outcome is an interpretation of the collected data. This
practice is valid only if the study is free of biases. Other
features of case-control studies that strengthen the va- lidity of this interpretation include a strong association (ie, a
high odds ratio), a dose-response gradient, consis- tency among studies, and biological plausibility.
Technically, relative risk should not be used to ex- press results in case-control studies because the disease
prevalence is not known and the apparent relative risk is dependent on the number of controls chosen.4 How- ever,
the odds ratio is a reasonable approximation of the relative risk when the outcome is relatively rare (eg, when less
than 1% of people exposed to an agent develop dis- ease) (Table).4 Using the odds ratio as an approxima- tion of the
relative risk produces progressively larger er- rors as the outcome rate rises above 1% (Table).
To add confusion to an already difficult area, clini- cal researchers will often report results of meta-analyses,
cohort studies, and randomized controlled trials using odds ratios. Odds ratios are used because they have more de-
sirable statistical properties than other measures.4For ex- ample, odds ratios can take any value between 0 and in-
finity, are symmetric, and can be used to make adjustments for confounding factors using multiple regression.4 Un-
fortunately, they are the measure least intuitively under- stood. If a meta-analysis, controlled trial, or cohort study is
reported using odds ratios, it is often possible to calcu- late the relative risk, difference in response rates, or num- ber
needed to treat if the primary data are provided. Al- ternatively, these more readily understood measures can be
derived if the number of subjects in each group, odds ratio, and overall outcome rate are provided.
Michael Bigby, MD Beth Israel Deaconess
Medical Center Harvard Medical School Boston, Mass
1. Sackett D, Richardson W, Rosenberg W, Haynes R. Evidence-Based Medicine: How to Practice and Teach EBM. Edinburgh,
Scotland: Churchill Livingstone; 1996:250. 2. Greenhalgh T. How to Read a Paper: The Basics of Evidence Based Medicine.
London, England: BMJ Publishing Group; 1997:196. 3. Wolf P, Quehenberger F, Mullegger R, Stranz B, Kerl H. Phenotypic
markers, sunlight-related factors and sunscreen use in patients with cutaneous mela- noma: an Austrian case-control study.
Melanoma Res. 1998;8:370-378. 4. Deeks J. Swots corner: what is an odds ratio? Bandolier. 1996;25:6-9.
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remakenestsinthesamelocation.Treatmentofanaffected gerbil is difficult, partly because of the emerging resistance of
avian mites to many of the insecticides currently avail- able.22However,thepetownershouldbeencouragedtocon- tact
a veterinarian familiar with exotic pets and discuss the diagnostic and therapeutic options currently available. In
addition, house cleaning, fumigation, and removal of old cages and bedding material should be helpful.
In summary, we believe that these are the first reports of clinical dermatitis from avian mites acquired from pet
gerbils. We postulate that the gerbils involved with patient 1mighthaveacquiredOsylviarumwithintheenvironment of
the pet store in which they were kept. This suspicion is fortifiedbytheobservationsofoneofus(J.D.A.)whoknows of
several other subsequently affected gerbils in the same neighborhoodinCincinnati.Infact,2otherdermatologists
intheCincinnatiareadiscoveredandtreated4familieswith similar“bites”frominfestedgerbils(DebraAnderson,MD,
andPaulLucky,MD,oralcommunication,1999-2000).In the case of our patient 2, it is proposed that the classroom
chickens shared their avian mites with the classroom ger- bils.Weproposethatbecausetheassociationofavianmites and
gerbils has never been reported, such cases have gone unrecognized or misdiagnosed as bites from other arthro- pods
such as fleas or scabies mites.
Accepted for publication October 3, 2000.
We acknowledge Elizabeth Jones, LVT, and Dana Cooker, LVT, for their role in identifying the mite in case 1
and Tammi Shiveley for manuscript preparation.
Corresponding author and reprints: Anne W. Lucky, MD, Dermatology Associates of Cincinnati, 7691 Five
Mile Rd, Cincinnati, OH 45230.
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Correction
A typographical error appeared in the Table of “Odds Ratios and Relative Risks” by Michael Bigby, MD, in the June 2000 issue
of the ARCHIVES (136:770). The correct formula to calculate relative risk is [a/(a+b)] / [c/(c+d)].
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