Case control studies and Cohort

study
• Dr. Pawale S.D.
Associate Professor
M.D.,PhD (Scholar)
Dept. of RSBK,
PMT’s Ayurved College Shevgaon

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 Observational study

• The investigator does not intervene anywhere during the

study.
• In observational studies we record information about the
features and natural history of disease or a condition in
population or effect of a treatment that is prescribed
routinely.

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 Analytical study

• It is a type of observational studies, where you observe as

well as test the hypothesis.
• Here you can compare and study, association of various
factors and disease.

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 Types of analytical study

Case
control
Analytical study
Cohort

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Cohort

Case control

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Exposure and Disease measures

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 Case control study

Case Control (2,3 or 4)

Diseased Study Disease free

Diagnostic & eligibility criteria Diagnostic & eligibility criteria

Hospitals / Relatives/
Hospitals / General Population Neighbourhood/
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 CASE CONTROL

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 Study design
Also called “Retrospective study/ Backward looking study/ Effect to
Cause study/ Outcome to Exposure study/ TROHOC study

Exposure and outcome have occurred before start of study

Proceeds backwards from effect to cause

selection of cases and controls,

measurement of exposure and analysis and interpretation

Odds ratio obtained Dr. S.D.Pawale

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 Basic steps

Selection of cases and controls

(1)SELECTION OF CASES :
Vital to define a case- Diagnostic Criteria
- Eligibility criteria

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 Cont….

• Diagnostic criteria :
Define case as per text books or some standard
guidelines or may be operational definition developed by
researcher.
• Eligibility criteria :
only new cases (incident cases) within a specified
period of time are eligible.

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 Sources of cases

• The cases may be drawn from -

1) Hospitals
2) Work place
3) General population

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 SELECTION OF CONTROLS

• The controls must be free from the disease under study.

• They must be as similar to the cases as possible, except for
the absence of the disease under study.

• Small groups-1:4
• Large groups- 1:1
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 Sources of controls

1) Hospital
2) Relatives(Siblings)
3) Neighbors
4) Occupational associates
5) General
Controls should emerge from the same study base, expect that they
are not cases.
Sibling controls are unsuitable in genetic studies.
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 Matching

• We must ensure comparability between cases and controls.

• Group matching.(Age,Occupation,Social class)
• A "confounding factor" is defined as one which is
associated both with exposure and disease, and is
distributed unequally in case and control groups.

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 Precautions while matching:-

• If matching factor is associated with disease but not

exposure = analysis will be statistically less efficient.
• If matching factor is associated with exposure but not
disease = odds ratio will be biased.
• Do not match unless matching variables is known to be
associated both with disease & exposure.

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 Data of exposure

This may be obtained by -

• Interviews,
• Questionnaires
• Physical examination
• Laboratory investigations
• Studying past records of cases (hospital records,
employment records)etc.
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 Analysis

a) Exposure rates among cases and controls to suspected

factor
b) Estimation of disease risk associated with exposure (Odds
ratio).
Can not provide with incidences, so relative risk cannot be
calculated, estimate of relative risk i.e. Odds ratio.
• Odds Ratio = ad/bc
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Odds ratio or Cross product ratio
Disease
Case control 
Yes No
Exposed a B
Not exposed c D
  a+c b+d

Odds of exposure given disease aXd

cXb
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• 1. OR > 1 : Positive association

• 2. OR = 1 : No association

• 3. OR < 1 : Negative association

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 ADVANTAGES

• Relatively easy to conduct.

• Rapid and inexpensive (compared with cohort studies)
• Require comparatively few subjects
• Particularly suitable to investigate rare diseases or
diseases about which little is known.

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 Cont…

• No risk to subjects
• Possible to study of several different causative factors
(e.g., smoking, physical activity and personality
characteristics in myocardial infarction)
• Risk factors can be identified. Rational prevention and
control programs can be established
• No attrition problems, because case control studies do
not require follow-up of individuals into the future
• Ethical problems minimal
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 DISADVANTAGES

• Problems of bias
(confounding,recall,selection,berkesonian,interviewer)
• relies on memory or past records, the accuracy of
which may be uncertain; validation of information
obtained is difficult or sometimes impossible
• difficult to get appropriate control group.
• We cannot measure incidence, and can only estimate
the relative risk

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 Cont….

• Do not distinguish between causes and associated factors.

• Not suited to the evaluation of therapy or prophylaxis of
disease

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 Cohort study
• Cohort is a group of people with common characteristics (e.g.,
age, occupation, exposure to a drug or vaccine, pregnancy
etc).
• Also called as prospective study/ longitudinal study/Incidence
study/Forward looking study/Cause to effect study/
• Exposure to outcome study/ follow up study
• Cohort is identified before the appearance of disease. Then,
you observe these individuals for a certain length of time and
test your hypothesis by comparing those who get the disease
and those who do not.
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Types of cohort studies

Types of cohort study Prospective

Ambispective

Retrospective
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 Study
starts Exposure Disease
2021 2025 2030 Prospective

Time
Study
Exposure Disease
starts
2016 2026 Ambispective
2021

Time

Exposure Study
Disease
2015 starts
2020 Retrospective
2021

Time

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 STEPS OF A COHORT STUDY

a)Selection of study subjects:

• Study cohort:(people are exposed to suspected factors)
• Control cohort:(People are unexposed to suspected factors)

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b)Obtaining data on exposure:

• Obtained by-
• interviews,
• review of records,
• personal examination,
• some investigations,
• environmental surveys.

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c)Follow-up :

• periodic medical examination of each member of the

cohort
• reviewing records from physician and hospital
• by surveillance of death records
• mailed questionnaires, telephone calls, periodic home
visits - preferably all three ,on an annual basis

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d)Analysis

• The data are analyzed in terms of :

(a) Incidence rates of outcome among exposed and non­
exposed
(b) Estimation of relative risk :

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 Analysis
Disease
Cohort Yes No Total

Exposed a b a+b

Not exposed c d c+d

Incidence of Exposed = a/(a+b)

Incidence of not exposed = c/(c+d)
Relative risk = a/(a+b)
c/(c+d)
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 Calculation of different risks-

1.Relative risk- ratio

:-health education of people
2.Attributable risk- difference
:-clinician to guide his patient
3.Population attributable risk- minus
:-public health expert

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 Advantages
• (a)Incidence can be calculated
• (b)an opportunity to study many outcomes related to the
exposure.
• (c)Done for Rare Cause.
• (d) cohort studies provide a direct estimate of relative risk.
• (e) certain types of bias can be minimized.

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 Disadvantages:

• Unsuitable for investigating rare diseases.

• Expensive
• Ethical problems.
• It takes a long time to complete
• Lose a substantial proportion of the original cohort - they may migrate,
lose interest in the study or simply refuse to provide any required
information
• Administrative problems ie large number of people
• Over a period diagnostic criteria of a disease may change.
• Dilute the strength of association.

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Case control study Cohort study

Proceeds from “effect to cause”. Proceeds from “cause to effect”.

Main differences between case control and cohort studies
Starts with people exposed to risk
Starts with the disease
factor.

Tests whether the suspected cause
occurs more frequently in those with the
disease than among those without the
disease.
Tests whether disease occurs more
frequently' in those exposed, than in
those not similarly exposed.

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Case control Cohort study

Involves fewer number of subjects Involves larger number of subjects

Yields relatively quick results Long follow-up period

Suitable for the study of rare

Suitable for Rare cause
diseases

Generally yields only estimate of RR Yields incidence rates, RR as well as AR.

(odds ratio)

Cannot yield information about

Can yield information about more than one
diseases other than that selected
disease
for study
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 Conclusion
With the help of analytical studies one can comment -

 on the existence of association between cause and

effect.

 Whether the association is statistically significant.

 Qualitatively superior than descriptive studies.

 But the ultimate proof of causation is still missing.

For that we have to conduct experimental studies.
Thank you….

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