EPID 741: Homework 7

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EPID 741
Homework 7: Bias
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Total points possible: 40 points

1. Please give an example of selection bias and draw the structure of selection bias using a DAG. (5
points)

Example: A study investigates the link between cell phone use and brain tumors. Researchers recruit
participants from a memory clinic, where people with memory problems are more likely to be included.

DAG:

Phone Use

(biased
arrow)

Memory
Problems
(in study)

Brain
Tumor

In this scenario, the memory problems act as a confounder. People with heavy phone use might be
more likely to have memory problems, leading them to visit the clinic. This creates a biased
association between phone use and brain tumors in the study population (people at the clinic), even
though it might not exist in the general population.

2. Please give an example of differential misclassification of the exposure and draw the structure of
this using DAGs. (5 points)
Example: A study examines the association between smoking and lung cancer. However, some non-
smokers might be misclassified as smokers if they were exposed to secondhand smoke.
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DAG:

Smoking
(true)

misclassifica
tion)

Self-reported Smoking
(in study)

Lung Cancer

In this case, non-smokers who are misclassified as smokers due to secondhand smoke exposure
would be more likely to develop lung cancer. This would lead to an overestimation of the true
association between smoking and lung cancer.

3. Fill in the blanks in the following statements. (3 points)

a. Misclassification in epidemiologic studies results from either imperfect definitions of study
variables or flawed data collection procedures. These errors may result in misclassification
of exposure and/or outcome status for a significant proportion of study participants.

b. Information bias, including recall and interviewer bias, is likely to be a larger concern in
case-control studies than in cohort studies, whereas selection bias, including observer and
respondent bias, may occur in both case-control and cohort studies.

c. Non-differential misclassification occurs when the degree of misclassification of exposure is

independent of case-control status (or vice versa). However, differential misclassification
may occur when the sensitivity and/or the specificity of the classification of exposure status
vary between cases and controls.
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4. Explain how differential losses to follow-up may or may not result in bias. (3 points)

Bias:

Overestimation of effect: If participants with a positive outcome (e.g., improvement in a treatment

group) are more likely to be lost to follow-up, the observed effect of the exposure (treatment) will
be weaker than the true effect. This is because we're missing data from the group that would
strengthen the positive association. Conversely, if participants with a negative outcome (e.g.,
worsening in a control group) are more likely to be lost, the observed effect will be overestimated.
No Bias:

Random loss: If participants are lost to follow-up for reasons unrelated to the exposure or outcome
being studied, the missing data wouldn't systematically bias the results. This is because the missing
data would likely be a random sample of the original population.

5. True or false? Methods used to prevent recall bias include verification of responses from study
subjects, use of diseased controls in case-control studies, use of objective markers of exposure, and
the conduct of case-control studies within the cohort. (1 point)
False

6. True or false? Survival bias occurs when screening identifies patients whose early subclinical disease
does not evolve to more advanced stages. (1 point)
True

7. Characterize the type of bias listed below as selection or information bias (1 point) and describe one
way you can set up or run a study in order to minimize the bias (1 point) – (8 points total)

a. Nonresponse bias: Selection bias

Minimization:
Increase response rates: Offer incentives, multiple contact attempts, convenient
participation options.
Weighting: Adjust for non-response by weighting data based on known characteristics of the
population.
b. Recall bias: Information bias

Minimization:
Standardized questionnaires: Use clear, unbiased questions and consistent wording across
participants.
Blind interviewers: Interviewers unaware of participants' case/control status can reduce
influence on responses.
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Timeline prompts: Encourage participants to use specific timelines or external aids when
recalling past events.
c. Interviewer bias: Information bias
Minimization:
Standardized training: Train interviewers on objective questioning techniques and avoiding
leading questions.
Blinding: If possible, blind interviewers to participant status (case/control) to minimize
subconscious influence.
Monitoring and feedback: Monitor interviews and provide feedback to interviewers to
ensure consistent application of protocols.
d. Berkson's bias: Selection bias
Minimization:
Stratified sampling: Divide the population into subgroups based on relevant characteristics and
sample proportionally.
Restriction: Limit the study population to a specific subgroup where Berkson's bias is less likely (e.g.,
focusing on a specific age range).
Statistical adjustment techniques: Use methods like regression modeling to account for the selection
process.

8. Scenario 1: An investigator would like to assess the association of melanoma (skin cancer) and
exposure to infrared skin tanning services by using a hospital-based case–control study. Hospitalized
individuals with melanoma will be compared with hospitalized patients without melanoma
(controls). This hospital, located in a low-income area of the city, is famous nationwide for its
expertise in melanoma. Individuals with melanoma (cases) from all over the country go to that
hospital to get the highest quality care that can be provided. However, this hospital is not as well
known for any other medical conditions as it is for melanoma. Therefore, controls will be mostly
local low-income individuals, among whom infrared tanning services are less common. The
investigator predicts that an overestimation of the association between melanoma and skin tan
services may occur. (10 points)

a. Do you agree or disagree with the investigator? Explain your answer in a few sentences.
I agree with the investigator. This scenario is likely to introduce selection bias.

Cases (melanoma patients) are not representative of the general population: People with
melanoma travel to this specialized hospital, leading to a biased sample that doesn't reflect
the exposure (tanning services) prevalence throughout the country.
Controls (local low-income patients) are not comparable to cases: Focusing on local low-
income individuals might underestimate exposure to tanning services compared to the
national average, inflating the apparent association between tanning and melanoma.
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b. Please explain in a few words what type of bias may be present?

The scenario describes selection bias because the study groups (cases and controls) are not
chosen from the same population and are likely to differ in their exposure to tanning services
(the factor being studied).

Cases (melanoma patients): Represent a national population seeking specialized care, likely
with higher use of tanning services compared to the average person.
Controls (local low-income patients): Represent a local low-income population, potentially
with lower use of tanning services compared to the national average.
This mismatch in how the groups are chosen creates a situation where the observed
association between tanning and melanoma might be stronger than the true association in the
general population.

Scenario 2:
A study to assess the association of diabetes and smoking compared a group of hospitalized
individuals with diabetes (cases) with a group of volunteer individuals without diabetes (controls)
who were full-time employees of the same hospital where the cases were identified. The results
from this study reported, for the first time in the literature, a strong association between diabetes
and smoking.

c. What type of bias may be present? Why do you suspect the presence of the bias you have
identified?
Type of bias: Selection bias is likely present.

Reasoning:

Hospitalized cases: People with diabetes severe enough to require hospitalization might be
more likely to have additional health complications (like smoking) compared to people with
diabetes managed through outpatient care.
Volunteer controls: Hospital employees may be more health-conscious than the general
population, potentially leading to lower smoking rates compared to the national average.

d. The magnitude of this association is likely to be either over- or underestimated. Which do

you think is the case, and what makes you think so?

Magnitude of association: This scenario likely overestimates the association between

diabetes and smoking.

Selecting smokers with more severe diabetic complications (hospitalized cases) inflates the
risk of smoking within the diabetes group.
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Selecting healthier controls (hospital employees) underestimates the smoking prevalence in

the general population.
This combined effect exaggerates the observed association between diabetes and smoking.

Scenario 3:
A case–control study was conducted to assess the association of passive smoking and asthma.
Newly diagnosed asthmatic individuals (cases) were compared with a random sample of individuals
without asthma (controls) in regard to self-reported exposure to cigarette smoking from smokers at
home or in the workplace for the previous 10 years.

e. Which type of bias could be introduced into this study?

Scenario 3 describes a potential case of recall bias, a type of information bias.

Self-reported exposure: Both cases (asthmatics) and controls rely on their memory to report past
exposure to secondhand smoke over 10 years.

Differential recall: Individuals with asthma might be more likely to recall past exposure to
secondhand smoke, especially if they believe it might have contributed to their condition. This is
compared to controls who might not have a reason to focus on past smoke exposure.
This difference in how accurately past exposure is reported between cases and controls can skew
the results.