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Confounding Azizi
Confounding Azizi
Confounding Azizi
Exposure Disease
Confounder
Confounding - 2
• Key term in epidemiology
• Most important explanation for associations
• Always look for confounding factors
Smoking
Downs’ syndrome by birth order
Birth order
Find confounders
“ third , fourth and fifth child are more often
affected by Downs’ syndrome.”
Maternal age
Downs’ syndrome by maternal age
1000
Cases per
900
100000 live 800
births 700
600
500
400
300
200
100
0
< 20 20-24 25-29 30-34 35-39 40+
Age groups
Find confounders
Alcohol
Find confounders
“A study has found that small hospitals have lower
rates of nosocomial infections than the large
university hospitals. The local politicians use this as
an argument for the higher quality of local
hospitals.”
Well patients
A variable can be a confounder if all the following
conditions are met:
If association is present,
If association is absent no confounding
confounding is possible
Ways to assess if confounding is present:
Yes
No
Further study is needed
Confounder for a male gender-Malaria association?
Male
gender
?
?
Malaria
Confounder for a male gender-malaria association?
Male
gender
Outdoor ?
occupation
Malaria
First criterion:
Is the putative confounder associated with exposure?
Male
gender
?
Outdoor ?
occupation
Malaria
First criterion:
Is the putative confounder associated with exposure?
Males Females
N (%) N (%)
OR=7.8
Outdoor 68 (43.5) 13 (9.0)
Indoor 88 131
156 (100) 144 (100)
Question:
Is outdoor occupation associated with male gender?
Yes
No
Second criterion:
Is the putative confounder associated with the outcome
(case-control status)?
Male
gender
Outdoor ?
occupation
?
Malaria
Second criterion:
Is the putative confounder associated with case-
control status?
. Malaria
Cases Controls
N (%) N (%)
Outdoor 63 (42.0) 18 (12.0) OR=5.3
Indoor 87 132
150 (100) 150 (100)
Question:
Is outdoor occupation (or something for which this
variable is a marker of --e.g., exposure to mosquitoes)
causally related to malaria?
Yes
No
Third criterion:
Is the putative confounder in the causal pathway
exposure outcome?
. Male
gender
?
Malaria
Outdoor Indoor
occupation occupation
Ca
se
sCo
nt
rol
s Ca
se
sCo
nt
rol
s
Ma
les 5
3 15 Ma
les 3
5 53
F
em
ales 1
0 3 F
em
ales 5
2 79
6
3 18 8
7 1
32
OR=1.06 OR=1.00
Ways to control for confounding
Advantages Drawback
35 year old
mothers
Matching
“The process of making a study group and a
comparison group comparable with respect to
extraneous factors.”
Age
Example
Age-stratified DATA form a Hypothetical Case-Control Study of DDE Exposure
and Breast Cancer
Age less than 50 years Age 50 years and older
DDE Level Cases Control DDE Level Cases Contro
l
High 50 300 High 450 300
Low 450 2700 Low 1050 700
Total 500 3000 Total 1500 1000
Stratum-specific Odds ratio =1.0 Stratum-specific Odds ration +
1.0
Each stratum specific odds ratio is 1.0. Thus, the magnitude of the odds ratio(1.0) are
different form the crude odds ratio( 1.9)
The difference between the crude and stratum-specific odds ratio indicates that
confounding by age is present..
Multivariable regression
• Analyse the data in a statistical model that includes both
the presumed cause and possible confounders
• Measure the odds ratio OR for each of the exposures,
independent from the others
• Logistic regression is the most common model in
epidemiology
• But explore the data first with stratification!
Summary
Questions ?