Case Control

Epidemiology 201
Case Control
• Analytic
• Observational
• Retrospective
• Longitudinal
• Study Population (Study Base)
• Cases
• Controls
• Objective
• To show that the probability of exposure is greater in those with the disease
than in those without the disease
Case Control: Uses
• Studying diseases with very long latency periods
• Evaluation of rare diseases
• Evaluation of wide range of potential etiologic exposures that might
relate to a specific disease as well as the interrelationships among
these factors
Case Control: Cases
• Establish case definition
• Establish eligibility criteria
• Inclusion criteria
• Exclusion criteria
• Select cases
• Hospitals or medical facilities
• Population
• Advantage: Avoids bias arising from selective factors thatguide affected individuals to a
particular medical care facility or physician
• Disadvantage: Cost and logistical considerations
Case Control: Cases
• Types of Cases
• Prevalent Cases
• Incident Cases
• Uniform diagnosis
• Accurate recall of exposure
• Temporal sequence
• Non-survivors
• Method of Selection
• Total enumeration
• Random Sampling
Case Control: Controls
• Disease of interest is absent
• Comparable to the source population of the cases
• Should the controls have the disease, they would be considered as cases
• Selection of Controls
• Sources:
• Hospitals and other medical facilities
• General population
• Special controls (siblings, friends, neighbors)
• Methods
• Random sampling
• Paired sampling (Matching)
Case Control: Controls
• Multiple control groups
• may be used when in doubt as to the correct or appropriate control
• Potential problem: inconsistent results
• Advantage: if results are consistent, this could indicate causality
• Case to control ratio
• 1:1 - optimal
• 1:4 - can increase power of study
Case Control: Exposure Ascertainment
• Definition of exposure
• Sources: subjects or medical records
• Method of collection: same for both groups
• Defined reference point
Case Control: Data Analysis
• ODDS RATIO
• But first...
• Odds
Probability of Success

p
1 p  Probability of Failure
Case Control: Data Analysis
• ODDS RATIO

With Outcome Without Outcome Total

With Exposure A B A+B
Without Exposure C D C+D
Total A+C B+D N

AD
OR 
BC
Case Control: Data Analysis
• ODDS RATIO

With Outcome Without Outcome Total

With Exposure 60 40 100
Without Exposure 80 320 400
Total 140 360 500
Case Control: Data Analysis
• ODDS RATIO

With Outcome Without Outcome Total

With Exposure 60 40 100
Without Exposure 80 320 400
Total 140 360 500

AD 60320
OR   6
BC 4080
Case Control: Data Analysis
• ODDS RATIO Interpretation
• =1
• No association
• Exposure to factor not associated with disease
• >1
• Association is present, risk factor
• Odds of exposure among cases is OR times more compared to controls
• <1
• Asssociation is present, protective factor
• Odds of exposure among cases is OR times less compared to controls
Case Control: Advantages
• Quick and inexpensive
• Optimal for rare diseases
• Can examine multiple etiologic factors for a single disease
Case Control: Disadvantages
• Inefficient for rare exposures
• Cannot generate incidence of disease unless population-based
• Difficult to establish temporal sequence
• Prone to bias
Case Control: Bias
• Selection Bias
• Source of study participants
• Non-response
• Self selection
• Information Bias
• Misclassification of subjects
• Differential
• Non-differential
• Recall error
• Confounding
Case Control: Exercise
Baltazar, Tiglao, and Tempongko studied the relationship between
personal and domestic hygiene behavior and hospitalized childhood
diarrhea using a case-control study. Indices of hygiene behavior were
defined for overall cleanliness, kitchen hygiene and living conditions.
The following is taken from their paper.
Case Control: Exercise
“A case was a child under 5 years of age who was a resident of
Metropolitan Manila and who had been admitted to the free service of
a government hospital with diarrhea that began <7 days previously. A
control was a child whose age matched that of a case (plus or minus 6
months), who had not had diarrhea within 30 days prior to recruitment
into the study, who had lived in the same neighborhood as the case,
and who used or would have used the free service of a government
hospital for a serious diarrheal episode.
After discharge of a potential case from the hospital, the child
concerned was visited at home. The search for an eligible control
started with the house located immediately to the right of that of the
case and continued to the next house until a suitable individual was
identified.
Case Control: Exercise
A total of 363 potential cases and 363 potential controls were
identified over the period of April-October 1989: of these, 356 patients
and 357 controls participated. All study subjects belonged to low-
income families, as determined by the occupation of the head of the
household.”

Questions:
What is the hypothesis of the study?
What is their definition of a case?
What is their definition of a control?
What did the authors use to make the cases and controls comparable?
Estrogen Use Endometrial Cancer Cases Controls
Frequency Percentage Frequency Percentage
Dose (mg)
None 274 83 390 96
<1 23 7 9 2
1-2 27 8 5 1
>2 6 2 2 1
Total 330 100 406 100
Duration of use (years)
None 274 81 390 95
<1 11 3 7 2
1-5 17 5 8 2
>5 36 11 3 1
Total 338 100 408 100

From the table immediately above, how is endometrial cancer associated with daily estrogen dose?
Estrogen Use Endometrial Cancer Cases Controls
Frequency Percentage Frequency Percentage
Dose (mg)
None 274 83 390 96
<1 23 7 9 2
1-2 27 8 5 1
>2 6 2 2 1
Total 330 100 406 100
Duration of use (years)
None 274 81 390 95
<1 11 3 7 2
1-5 17 5 8 2
>5 36 11 3 1
Total 338 100 408 100

Describe the relationship of duration of estrogen use and endometrial cancer.