Cohort Studies

Prof JH Kim
School of Public Health and Primar Care
The Chinese Uni ersit of Hong Kong
Fall Semester
1

Re ie :
Major T pes of Epidemiological Stud Designs

De c i i e die (f h he i ge e a i g & i ga
di ea e di ib i )
Ca e e /ca e e ie
C e a i a (ec gica ) die
C - ec i a die

A a ica die (f a di ea e de e i a
ei g )
Cohort studies
Ca e-c die
Ra d i ed c ed ia /C i T ia
2

1
 Lecture Learning Objecti es
U de a d ba ic c ce i he de ig fc h die

De c ibe e gi ica a ec fc d ci gc h die

Be ab e de c ibe he 2 e fC h S die

U de a d he i i a i a d e gh fc h d de ig

Ca c a e a d i e e he Mea e fA cia i i c h die

K he i a C h S die i P b ic Hea h.

1st some Definitions:

C h : a de ig a ed g f i di id a h aef ed
aced e a e i d f i e

C h S d (a a: F - S d , L gi di a S d ) :
A gi di a d ea e he i cide ce f di ea e i a
ai , ei a , e he ca a /e i gica
e a i hi be ee e e a d c e ( he a e
a a e ia c - ec i a d ).

Ei g : The ca e igi f a c di i a de e i ed b
edica diag i .

2
 Main Purpose of Cohort Studies

1 P e a di ea e i cide ce ( e ca e f di ea e
a i i gi aa- i ai fi e e )

2 dP ei e a a e he ca a e a i hi be ee
E e / i fac /ca e And
O c e /di ea e /effec

E e ha a e be ie ed be ha f a d i c ea e he
i f di ea e= Ri Fac

vetve
-

E e ha a e be ie ed be be eficia a d dec ea e
he i f di ea e = P ec i e Fac

Re ie : Cross-sectional Studies
Target Population

Stud Sample

E p +/Dis + E p+/Dis - E p -/Dis + E p-/ Dis -

Pre alence Disease Compared

Pre alence Disease
ith
In E posed In Non-E posed

Simultaneousl measure each indi idual s disease status and

e posure status
Compare the pre alence of Disease in E posed & Non-e posed.
☆ No-follo -up in Cross-sectional studies
“Disease” can be an outcome of interest

3
In simple English:
HOW TO CONDUCT A COHORT STUDY
Se ec d b ec h d ha e he di ea e

Di ide he

F
⼀
he f 三
b ec ba ed

a ce ai i e
he e e e e

Mea e he i i each g h de e he
c e( ) f i e e (i.e. i cide ce f di ea e)

Da a A a i = E a i e Mea e f A cia i
(Re a i e Ri f I cide ce, chec - a e , Ri
Diffe e ce)

I e e e
7
(The a e c i ica , ic , e ice ec e da i )

P I: D C S

Pa I: De ig f C h
S die

4
 Design of a COHORT Stud
1. Baseline sur e - get 2. Follo -up the cohort and measure 3. Estimate the
samples preferabl ith ne cases of disease in each group association b/t
probabilistic sampling & e posure and disease
measure e posures
E posed Incidence of disease
Establish
the cohort Relati e Risk
and (RR)= Ie/I0
measure
risk
factors Non- Incidence of disease
E posed

Check all subjects regularl , identif the e ents

Procedure is er similar to Randomi ed Control Trials

9

SELECT STUDY SUBJECTS

ASSEMBLY OF COHORT
S b ec be i i ia f ee f he di ea e f i e e

S d b ec h d be a i f de e i g he
di ea e - population at risk:
- 要 有 机 会 確診
If he d c e i i fec i di ea e, e c de h e
acci a ed
If he d c ei a ia ca ce , e c de h e
e ed b h a ie , (a d e e e )!
If he d c e i fi e i de f e, e c de
h e h e i had e
10

5
Eysmesedws
HOW DO WE DETERMINE EXPOSURE
STATUS IN COHORT STUDIES?
時長
Ca a ag i de f e e (d g d e, a f
ic i e c ed each da , i a ad, e e
e i e a a ,a fh he c e each
da )
㵟
F e e c fe e (# i e eg a , f e e c e ed
hea h e age , f e e c f ec ed e , be i e
iha i , ic i f c i e e c)

E e a ea ed i g he a e f da a
c ec i e h d i e ide i g (Q e i ai e , Ph ica
e a i a i , ab e , e c )

11

SOMETIME WE USE SPECIAL E posed/Non-E posed

GROUPS

Ch e beca e f e e a ,
e ecia he e ei a ei
ge e a nnrnnnnrg
ai
E a e
U a e e: a ic b b
i
G i h ecia die a / ife e
a e : 7 h-da Ad e i ( ege a ia ),
M ( caffei e), ( e )
Occ a i a c h e ed a
ace i ha i c i
ge e a ai : a i i e ,
hi a d e (a be )
Hea h beha i : i ec i d g e ,
12
e c.

6
 C h S d E eA e e

13

HOW DO MEASURE OUTCOMES?

Sa e a a ih e ide i gica die :

Dea h ce ifica e

A ec d

H i a /c i ic ec d

Medica e a i a i

Q e i ai e f ha d- be e c e (e.g. i c ea ed e f c d ,
i ed a i de a d acci e , e f- e cei ed ee i e e e ).

14

7
 1st t pe of Cohort Stud :
Prospecti e Cohort Stud
S a he c h f ba e i e a d f - he c h f a g ei d f i e
a ce ai c ee e
F - e i d cc ch gica af e he a f
he S d Pe i d
E a e:
Sa i g da , e e a d - e
The f f he e 20 ea
Rec d i cide ce f c a hea di ea e d i g f -
ei d f he e 20 ea .

15

1st t pe of Cohort Stud :

Prospecti e Cohort Stud

Recruit stud sample and Continuousl monitor the cohort &

determine e posure status record the occurrence of e ents

% de eloping the Disease

E posed (Incidence Rate in E posed)

。
(100 people) (40 people/100)
Establish Compare
the cohort Incidence
Non-e posed % de eloping the Disease RR=4.0
(200 people) (Incidence Rate in Une posed)
20/200
F - Pe i d
Present F e
S d Sa (S a fS d e i d)
16

8
 TIMING OF COHORT STUDY
Ti e Pe i d
Follo -up Period: Ti e e i d i hich b ec a e
f ed a ce ai c e fi ee
E a e: S e i f ed f 20 ea f 1/1/60
12/31/79 f he de e e fc a hea di ea e
F - ei d a a ge a he e f a fe da TO
DECADES! he e die a a ea g i e c e e.
Stud Period: Ti e e i d i hich a i e iga ef
a d
E a e: I e iga i i ia e a d 9/26/06 a d c ee
i 12/31/07

17

2nd t pe of Cohort stud :

Retrospecti e Cohort Stud

Look for a suitable historical Look through records to see if outcomes

cohort and determine the occurred
e posure status

E posed % de eloping the Disease

(Incidence Rate in E posed)
Look for a Compare
cohort in Incidence
past Non-e posed % de eloping the Disease
(Incidence Rate in Une posed)
F - Pe i d

Past Pee
N e: F - e i d cc ed (S a fS d e i d
ch gica bef e he a f he Which e d he i e iga
S d Pe i d
e i d )

9
 (a a H ca C S d )

Prnie.
ospectierketve
wspectivetve
比較
PROSPECTIVE VS. RETROSPECTIVE STUDIES
Prospecti e Cohort Stud Retrospecti e Cohort Stud

Be e c f he a i P e da a
a d a i f he da a ai / a i

tve.ve
Ve i ec i g Q ic d

E e e e e i e Re a i e chea
tve

I b h die , e ei f ai ea ed bef e he c ee e
cc .

Di ea e i ca c a ed f b h die b c a i g I cide ce i e ed
20
a d -e ed g

10
Combined
Retrospecti e/Prospecti e Cohort Stud

Ha b h e ec i e a d ec i e ha e
F - Pe i d bega ch gica bef e he
a f he S d Pe i d b c i e i he
f e
E a e:
S a i g da
Ide if e a d - e a f 1/1/86
h gh hi ica ec d
F i 12/31/15 h gh hi ica ec d AND
c i f -
Rec d i cide ce f c a hea di ea e d i g
f - ei d
21

Combined Retrospecti e/Prospecti e Cohort

Stud

Get info on e posure and outcomes on a historical cohort Then continue follo -up

F - Pe i d

E posed (Incidence Rate (Ie) Additional Incidence

Identif the
a ailable
cohort ith Calculate
e posure RR
information
Non-
e posed (Incidence Rate (I0) Additional Incidence

Past Pee F e
22 S d Sa he e

11
 Pa II: Da a A al i fC h S die

R R
A R

23

Ho do e Anal e the Results of Cohort Studies

so that e can make recommendations for polic
and practice?

1 Ca c a e he I cide ce f he c e fi e e
(c a i e i cide ce f c ed c h die )
(i cide ce a e f e c h die ) f di ea e i
he e ed a d -e ed g

2
4

12
 Closed Cohort (can use Cumulati e Incidence):

C a i g i a d e ia fi ed e i d f f -

D
D
D
D

A ed e f -
2
5

Cohort Stud ith Cumulati e

Incidence Data
I di id a ha e he a e a da e a d e d da e f
he a e i e i e a
Sa f a i di id a a e d f i e
i e a
N f -
Need ecif i e i e a
I ea ife, f he i e e diffic

2
6

13
 Open Cohort
A ed a ic
Ne b ec added a i g ba i d i gf -
ei d
Li e i e, b ec ca be a a i ef -
e i dd e ff i e i ig a i , ef a
a ici a e, i i g ac f he e e (e.g.
h e e i di id a )
The f - e i d f each e a be
diffe e

2
7

Open Cohort (need to use Incidence Rate)

----D
-----------------
-----------------------------------D
-------
----------------------------D
-------------------D

----------- --------D
--------------------------------------------- D
_________________________________________________
Begi E d
2
8

14
 Mea e fA cia i
Af e e ca c a e ei he C a i e I cide ce I cide ce Ra e f
each e e ca eg .

We ca THEN a MEASURES f ASSOCIATION be ee he

e ea d c e (i.e. Re a i e Ri Ri Diffe e ce ea e ).

Mea e f A cia i i h gh fa h ch he e ea d
di ea e a e e a ed e a he

29

1st General T pes of Measures of Association:

Ratio Measures or Relati e Risk
①
RR
1) Re a i e i : a ge e ic e efe i g a ai ea e

2) RR = I cide ce f di ea e i he e ed/I cide ce f di ea e i he -

e ed

3) Ratio measures (relati e risk comparison) RR = Re /R -e = Ie/I0

I dica e he i e ih d f de e i g he di ea e i he e ed g
RELATIVE he -e ed

U ed a e ide ce f ETIOLOGY!
3
0

15
 Strength of Association and Causal
Relationship
RR=1 ea he i cide ce i he e ed a d
-e ed g a e he a e - he e i NO
a cia i be ee e e a d he di ea e.
The f he he RR i a a f 1 (<1 >1),
he ge he a cia i .
The ge he a cia i , he e i e
he e i a ca a e a i hi be ee he i
fac a d he di ea e.

3
1

Strength of Association

Relati e Risk (RR) Strength of association

0.9-1.0 1.0-1.2 N e/Ma gi a

0.7-0.8 1.2-1.5 Wea
0.4-0.6 1.5-3.0 M de a e
0.1-0.3 3.0-10.0 S g

<0.1 >10.0 Ve S g
<1 1 >1
Protecti e factors No association Harmful factors

32

16
2nd general t pe of measure of association:
Difference Measures Risk Dikneee
②
Ri Diffe e ce = I cide ce f di ea e i he e ed - i cide ce f
di ea e i he -e ed

H ch f he di ea e i he ai i ca ed b he e e.

P ide i f a i ab he ab e effec f he e e
de e i e he e ce a f di ea e a ib ab e he e e

Diffe e ce ea e ae ed if he e i g e ide ce f
ca a i !!!

U ed f ic e c -effec i e e die . Ve ef f
P b ic Hea h e !!!
3
3

Risk Difference (a a Attributable Risk )

= I c de cee I c de ce e ed

R D ffe e ce= e e ce be f ca e e d a e
( e e ea a )d e e d ed e e

E. . E ce c de ce f ca ce a e ac
34 d d e e - e

17
AHnbuteR.is K % 器
:
_

Attributable Risk %= (R D ffe e ce/ Ie )* 100

P f e I c de ce ee ed e d a
a b ab e ee e

35

EXAMPLE OF RELATIVE RISK & ABSOLUTE RISK USING

CUMULATIVE INCIDENCE (CI) DATA

2X2 TABLE
DISEASE NO DIS RISK OF DISEASE
EXPOSED A B CIE= A/A+B
NON-EXP C D CI0 =C/C+D

RELATIVE RISK FOR DISEASE= CIE /CI0

RISK DIFFERENCE FOR DISEASE= CIE- - CI0

3
6

18
EXAMPLE:
CLOSED COHORT STUDY WITH CUMULATIVE INCIDENCE DATA
5-YEAR RISK OF DEATH AND SMOKING (MACMAHON & TRICHOPOULOS)

DEATH
YES NO TOTAL C a i e I cide ce
SMOKERS 23 42 65 23/65 =0.354
NON-SMOKERS 7 20 27 7/27 =0.259

RR = CI e /CI - e = [0.354] / [0.259] = 1.37

I e eai f e a i e i : THE RISK OF DEATH AMONG SMOKERS IS 1.37 TIMES

THE RISK OF DEATH AMONG NON-SMOKERS.

RD = Ci e - CI - e = [0.354] - [0.259] = 0.095

I e eai f Ri Diffe e ce: SMOKERS HAD 35.4/100 RISK f Dea h a d hi

i a d hi i a 9.5/100 HIGHER (EXCESS RISK)THAN NON-SMOKERS.
37

Cohort Stud ith Incidence Rate Data

Di ea e+ Pe Ti e I cide ce Ra e
E ed a N1 IRE= a/N1
N -E c N0 IR0 = c/N0

Mea e fA cia i

Rate Ratio (RR) = IRE/IR0

Rate Difference (RD) = IRE IR0

3
8

19
EXAMPLE:
O e C h S d i g INCIDENCE RATE da a
BREAST CANCER RATES & THERAPEUTIC RADIATION
EXPOSURE
CASES Pe -Yea I cide ce Ra e
Radia i e e 41 28010 14.6/10000PY
N e e 15 19017 7.9/10000PY

RATE RATIO = [14.6/10,000]/[7.9/10,000] = 1.8

W e h had ecei ed adia i ea e had 1.8 he i e ih d f de e i g

b ea ca ce ha e h ee e ed

3
9

EXAMPLE:
O e C h S d i g INCIDENCE RATE da a
BREAST CANCER RATES & THERAPEUTIC RADIATION
EXPOSURE
CASES Pe -Yea I cide ce Ra e
Radia i e e 41 28010 14.6/10000PY
N e e 15 19017 7.9/10000PY

RATE DIFFERENCE = 14.6/10,000 - 7.9/10,000

= 6.7/10,000 ca ce ca e /Pe -Y

I hi d , he e i a e ce f 6.7 BREAST CANCER CASES/10,000 P*Y

a g e ecei i g adia i he a .
4
0

20
 Other Risk Difference Measures (understand the
concepts onl , calculations ill not be tested)
① P ai A ib ab e Ri :
P i f he i cide ce f di ea e a ib ab e a
e e i he e i e ai ( he d a e)
Ca hi fi a a i cide ce i he a i - i cide ce
f e ee ed i he ai

② P a i A ib ab e Ri %:
population ( )
(. .

4
1

好處

Main Ad antages of cohort stud

Ca di ec ea e f i cide ce ( ib e i h
de c i i e, c - ec i a ca e-c die )

Ab e d i e c e (effec f ce ai
che ica ai ca ce ).

U i eC - ec i a die , he e i a c ea
i dica i f i e e e ce

Le bia ed i f ai ha he e f
die
4
2

21
 壞處

Disad antages of Cohort Studies

La ge a e i e
If d ch ic di ea e
L gf - i e ae c e

E e i e $$$

L f - ca be a h ge b e , e ecia
f g die .

Ve i efficie f RARE OUTCOMES!!!!

4
3

wgufnnzs
H d e b ai high F ll - ?
($$, ,
① ,
⼀

).

R
⼀
- (
② , - , )

S (
③
⼀

, ..).

4
4

22
 Summar of Major Steps of
Conducting Cohort Studies
Rec i d b ec h a e f ee f he di ea e
-

Mea e/ ec d he i fac f a b ec
F - he c h e i e ihc i
i i g f hea h c e

CII RRRIRD
C a e he di ea e i cide ce i e ed a d
-e ed g
-

E i a e he a cia i be ee i fac a d
he di ea e
Ma e a ec e da i ba ed RR a d RD
ea e .
4
5

I a C h S die

4 h :// .cha i g.ha a d.ed / h /

6

23
 Nurses Health Studies
E ab i hed i 1976 a Ha a d U i e i
I i ia G a : I e iga e g- e effec f a
c ace i e
Ta ge P a i : Regi e ed e age 30-55
Li e i a ed a ici a e
Li e ab e e d acc a e

h :// .cha i g.ha a d.ed / h /

4
7

Nurses Health Stud

Se ec ed i g b a d e be hi i 11 ae
170,000 e e e f i i a i (g 72% e e a e)
Q e i ai e e e e ea (90% e e ae

F dF e e c Q e i ai e added i 1980 (e e 4 )

Q ai f Life Q e i ai e added i 1992 (e e 4 ea )

68,000 e ai a e c ec ed i 1982-84 ea e die

c e (e.g. i ea ) ea i a e ed b e i ai e

33,000 b d a e c ec ed i 1998-90
18,700 ec d a e c ec ed i 2000-01
4
8

24
 Nurses Health Stud II
E ab i hed i 1989 a Ha a d (Wa e Wi e )
I i ia G a : I e iga e he effec f h e , die , a d
ife e i fac a g ge e f ca ce ,
ca di a c a di ea e a d he c di i
E ed 116, 686 egi e ed N e age 25-42
Q e i ai e e e e ea (90% e e a e)

F dF e e c Q e i ai e e i 1991 (e e 4 )
Q ai f Life Q e i ai e a ed i 1993 (e e 4 )
30,000 b d a d i e a e c ec ed i a e 1990
4
9
30,000 chee ce a e c ec ed i 10/04- 6/06

5
0

25
 Health Professionals Stud
E ab i hed i 1986 (Wa e Wi e a d Mei S a fe f Ha a d)
I i ia G a : I e iga e he effec f i i a fac ch ic
di ea e a g e
C e e he N e Hea h S die
E ed 51,529 e
29,683 de i
4,185 ha aci
3.745 e i
2,220 e a h h icia
1,600 dia i
10,098 e e i a ia
Q e i ai e e e e ea

5
h :// .h h.ha a d.ed /h f /
1

Important Findings from Nurses Health

& HP Studies
S i g i a i fac f Hea Di ea e, C Ca ce , e e
di ea e ch a ca a ac a d hi f ac e b B ea
Ca ce .

Oa C ace i e i c ea e i f B ea Ca ce b
dec ea e i fC Ca ce

Medi e a ea Die ed ce i f b ea ca ce a d c
ca ce a d Ca di a c a Di ea e

P a e ca ce i a cia ed i h highe ca ci i a e

M de a e a c h i a e ca ed ce i f hea di ea e,
e, c g i i e i ai e b i i c ea e he i f
ca ce
5
2

26
 F a i gha Hea ST d
>5000 F , USA 1948 ( 3
- ). T , ,
.

>1000 .F :

1960-1970 : R , ,
, , .M .

1980-1990 : H HDL

F R S , 10-
(CHD) . A 40 , CHD 50% 33%
.( )
5
3

5
4

27