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    SV elterly Biostatistics & Epidemiology Diane Essex-Sorlie SUMMARIZING DATA: INDICES TO DESCRIBE HEALTH STATUS / 43 Potter SM, et al: Depression of plasina cholesterol in mildly hypeicholesterolemic men by ‘consumption of baked products containing soy protein. Am J Clin Nutrition 1993; S01. Shattuck A, White E, Kristal A: How women’s adopted low-fat dicts affect their husbands. Am J Public Health 1992;82:1244. Sokal R, Rohlf F: Biometry, 2nd ed. W. H. Freeman, 1981 Self-study Questions 1. Define the mode, median, and mean. Deseribe the properties of each. 2. Define the range, variance, and standard deviation. Describe the properties of each. 3. Define the coefficient of variation. Describe when itis useful 4. Differentiate between statistics and parameters. 5. Identify which measures of central tendency and dispersion, if any, are appropriate for use with nominal, ordinal, interval, and ratio variables. 4. Deseribe how the choice of the most appropriate measure of central tendency and dispersion is affected by the symmetry, or lack of it, of a distribution of observations ‘measured on an interval or ratio scale. . With ordinal data, the mean and standard deviation usually are not used: Jf these ‘measures appear in @ report with ordinal data, what can we assume abont the ordinal scale of measurement? 6. Describe the relationship between the numerical magnitude of measures of central ten- dency for observations that are distributed symmetrically, skewed negatively, and skewed positively, : 7. If-you would like to practice calculating a mean and standard deviation, turn back to the Summarizing Data: Indices to Describe : 4 Health Status Clinical Example 1: Meningococcal Meningitis At the health center of a large universit 21-year-old female student presents ‘ith cough, headache, vomiting, sore throat, fever, chills, and muscle pais. Se dso has a petechia rash on her alla, flanks, wrists, and ankles. A humbar puncture reveals a porulent cerebrospinal fui, with elevated pressure, increased protein, and decreased glucose content. Other laboratory finding®' ificlude’ pro- longed prothrombin time, partial thromboplastin time, and a depressed platelet count In this hypothetical example based on actual clinical experiences, sevetal questions must be addressed before an appropriate treatment plan can be developed. Based on the available information, how likely isit that the patient has meningococcal meningitis? Is further testing reguized to confirm a diognosis? If the patient has meningococcal meningitis, how ely is it 44. / CHAPTER 4 that she will develop shock, myocarditis, cranial nerve damage, nephritis, or other problems? Hi the patient is treated with aqueous penicillin G, how likely is it that she will have an allergic reaction that requires the use of a different drug? How likely is it that individuals who have recent contact with her will develop meningococcal meningitis? Should these individuals be traced and treated with rifampin? Clinical Example 2: Exposure to Environmental Tobacco Smoke Exposure to environmental tobacco smoke is studied to determine if this exposure increased the risk of death from heart disease. The investigator finds that male never-smokers living with a current or former smoker have an approximately 9.6% chance of dying of ischemic heart disease by age 74, compared with a7.4% chance for male never-smokers living with a nonsmoker. ‘The corresponding life- time risks for women are 6.1% and 4.9%” (Steenland, 1992, p 94). Jn this second example, what is meant by the statement that “exposure to environmental tobacco smoke is studied to determine if this exposure increases the risk of death from heart disease?” What does it mean to say that “male never-smokers living with a current or former smoker have an approximately 9.6% chance of dying of ischemic heart disease by age 747” Clinical Example 1 focuses primarily on an individual patient. Clinjcal Example 2 general- izes to male and female never-smokers. Although different, the scénarios share a common ‘element: the frequency of health outcomes, estimated by their likeliness or chance of occur- rence under particular circumstances. Many outcomes (eg, platelet count) are quantitative. Other outcomes, however, are qualitative. In this chapter, we present indices used to describe the frequency of qualitaive outcomes; these indices are employed to characterize the health status of populations and subgroups of individuals. For example, we can describe disease Status (discased/not diseased), survival (sarvived/did not survive), remission (in remission/ ‘disease active), recurrence (disease recurred/disease not detectable), prognosis (poor/g00d), and other similar outcomes. Measures that describe health status, such as births and deaths, are called vital statistics (Dawson-Saunders & Trapp, 1994, p 42). ‘COMMON MEASURES OF HEALTH STATUS. Count A count is the number of events or individuals that satisfy specified criteria. This definition of ‘count is synonymous with our definition of frequency. For example, Roscoe and associates indicate that “Colorectal cancer was the second leading cause of cancer deaths in the United States in 1989, accounting for an estimated 30,000 deaths or 11% of all cancer deaths” (1992, 759). In this example, 30,000 is the count of the number of persons who died from colorectal cancer in the United States in 1989. ‘A ratio contains a pumerator (A) that represents the count of the number of events that meet 8 specified criterion and a denominator (B) thot represents the count of the number of events that satisly a different criterion’ Ratio an ‘SUMMARIZING DATA: INDICES TO DESCRIBE HEALTH STATUS / 45 Common examples of a ratio are: ‘Sex Ratio = -Nomber of Liveborn Maes Number of Liveborn Females Note that we include a multiplier (1000) inthe fetal morality ratio. The mullplier is = base used fo produce a number that quantifies fetal mortality per 1000 live birds in a specified year. In biostatistics, the following bases are often used with ratios and other measures: 1000, 10,000, and 100,000. Proportion Like a ratio, a proportion contains a numerator and denominator. The denominator of a proportion is defined differently, however. In a proportion, the numerator isthe count of the ‘umber of pessons or events that satisfy specified criteria; the denominator is the maximum viduals or events that could satisfy the numerator criteria. Thus, a proportion is number of 2 part divided by a whole. Observe that the numerator in a proportion is subsumed by the ‘denominator: Proportion = In their study of the ink between the dietary habits of husbands and wives, Shattuck and associates (1992, p 1246) classified participants into four age categories: 30 to 49, 50 to 59, 60 10 69, and 70 years and above. In the reference (no dietary intervention) group, 73 of 148 ‘women are between the ages of 50 and 59 years. Therefore, the proportion of woinen in this age group is 73/148 = 0.4932. If we write the denominator in a slightly different way to ‘ indicate the number of women in each of these four age groups, we can see more clearly that the numerator is part of the denominator: TRA + 73 + 59 + 12) = 0.4932. | f / | | | “ | | | { 1991, p24). Of these fatalities, 760,353 are aitributed to diseases of the heart. The of deaths aitributed to heart disease in 1987 i (760,353), 123,323) = 0.3581. Thus, in 1987, { approximately one third of all deaths in the United States are attnibutable to diseases of the ; beart In 1987, 2,123,323 deaths from all causes were recorded in the United States (Boring ct al, ‘ proportion } ! Percentage A percentage is a proportion multiplied by 100%: A alt . 43 Percentage = <5 (100%). The percentage of all deaths attributed to discases of the heart in 1987 is 35.81%. In the study on dietary habits, 49.32% of women in the reference group are between the ages of 50 and 58 years i i 46 / CHAPTERS Rate According to Mausner and Kramer (1985, p 43), “The rate is the basic measure of disease ‘occurrence because it is the measure that most clearly expresses probability or risk of disease in a defined population over a specified period of time.” In general terms, risk isthe chance of ‘occurrence of some untoward cvent (Fletcher et al, 1988, p91). Many epidemiologists define ate as a measure that expresses rapidity, intensity, velocity, or force of some event; an example would be the occurrence of new cases of disease in a specified time period. The numerator of a rate is the number of events or individuals satisfying specified criteria. The denominator is the number of units of exposure examined in eovating the numerator (Green- berg, 1993, p 133). ‘A’unit of exposure is defined ordinarily as the passage of an individual through a certain experience or situation. A common unit of exposure isa person-year, which is a year lived by ‘one person. Another common unit of exposure is pack-years of smoking. In a pack-year, one individual smokes a pack of cigarettes every day for one year. Midyear population sometimes ‘appears in the denominator as an estimate of person-years lived by members of a population during a certain year. We use midyear population when available, because it is more stable than population éstimates taken at the beginning and end of a year. A rate is: a Number of Events Satisfying Specified Criteria iat = Namber of Units of Exposure Examined in Counting Numerator ©" Distinctions are made between crude and specific rates. A crude rate is 2 summary statistic that ignores the heterogeneity of the population under investigation, An example of a crude rate is birth rate—also referred to asthe crude birth rate because it relates to the population in ‘general, without specific reference to homogeneous groupings. ths: Year ‘Midyear Population in Specified Year [Note that the crude birth rate i reportéd per 1000 population. Midyear population appears in the denominator as an estimate of the person-years lived by the population's members during the year. To contrast, specific rates break down the population into homogeneous groups or strata, ‘depending upon one or more demographic or other factors thought to be related to the ‘outcome of interest. Reposted for each homogeneous grouping, specific rates allow us to understand the influence of individual factors: for example, between 1984 and 1988, the age~ race specific, cumulative incidence (number of new cases) for prostrate cancer in Caucasian men, ages 85 years or older, was approximately 1100 per 100,000 (MMWR, June 12, 1992, ‘p-403). During this period, the age-race specific, cumulative incidence “rate” was approxi. mately 350 per 100,000 Caucasian men, ages 65 to 69 years (MMWR, June 12, 1992, p 403). Here is another example of an age-specific birth rate: ths to Women of a Given Age in a Specific Year ‘Ase-specific Birth Rate = "~ \eayear Population of Women of That Age 1000). (Crude Birth Rat Adjusting Rates Suppose we wish to compare the crude rates for death due to heart disease in 1940 and 1990. ‘We can compare two or more rates only if the populations from which they are developed are similar inall characteristics that affect the rate, Thus, the rates due to heart disease deaths will bbe confounded by age, because the distribution of individuals according to age has changed from 1940 to 1990: a greater relative number of individuals lived to older age in the 1990 population than in the 1940 population. This difference in age structure allows for the possibil- "tenance on rt a fn i SE [SUMMARIZING DATA. INDICES TO DESCRIBE HEALTH STATUS / 47 ity that a greater number of persons developed and died ef heart disease in the 1990 popula tion, Consequently, in order to make valid comparisons, the crude rates must be adjusted 10 ‘account for age differences in the two populations (Greenberg, 1993, p 37). The process of i adjustment, referred to by some epidemiologists as standardization, produces a single sum- rary rate that takes into account differences between the populations of interest (in the exainple just given, differences in the relative frequency of individuals of different ages) ‘Thus, when comparing rates adjusted for a specific factor, remaining differences between the populations cannét be attributed to confounding by that factor (Hennekens & Buring, 1987, P 70). Procedures for adjusting rates arc beyond the scope of this chaptes. Intcrested individu. i als may wish to consult Hennekens and Buring (1987) or Dawson-Saunders & Trapp (1994). i A Comment About Rates ‘The term “rate” is often used to characterize demographic and epidemiologic measures that are either true rates, proportions, o ratios (Heanekens & Buring 1987, p 56). Consequently, individuals who read the literature must pay special attention to how a rate is defined. In Particular, we must have a clear definition of the denominator to interpret the rate correctly. For example, if the denominator contains units of exposure, such as person-years exposed to i asbestos, then the “rate” isa true rate. Fora true rate, we discuss the number of new cases of disease per person-time of observation (eg, 3.5 cases per person-year). In contrast, if the | denominator contains a count of the number of individuals exposed to asbestos during 2 specified time period, then the “rate” is actually a proportion. In this case, we focus on the proportion of the at-risk population that developed disease during the time frame of interest (ee, 5 cases per 100 individuals). MEASURES OF PREVALENCE AND INCIDENCE ‘Measures of prevalence and incidence occur frequently in the medical and epidemiological literature to describe the commonness of health outcomes, such as the prevalence of existing ‘cases of disease at a specific point in time. Prevalence Prevalence is the proportion of individuals in a population who have a specified clinical : such as a disease, at a specific point in time. Prevalence is often called a rate, ! characteris ven though iti a proportion (Hennekens & Buring, 1987, p 57). Prevalence is defined as Cases ofa Specifi Disease at Time : Prevalence corer ee ase). 45 i [Note the inclusion of the base in Formula 4.5. Prevalence i often reported per 1000 or 100,000 | persons, although some researchers omit the base in their calculation (Greenberg, 1993, p 15). i For example, investigators conducted a population-based, HIV (human immunodeficiency i ins) serosurvey among women delivering infants in Georgia during 1991; the researchers : found that the prevalencee of HIV infection was 1.6 per 1000 women in Atlanta, 1.8m health

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