Epidemiologi

Klinik
(Clinical
Epidemiology)
Patients are likely to have many
questions :
Am I sick ?

How sure are you ?

If Im sick, What is causing my illness

?
How will it affect me ?

What can be done about it ?

How much will it costs ?

 Clinicians caring for patients, must
respond to those questions to guide
their course of action

Various source of information :

- Their own experience
- Advice of their colleagues
- Medical literatures

Depend on past observations on other
similar patients to predict what will
happen to patient at hand
 The manner the observations are
made and interpreted
determined whether the
conclusions they meet are valid
how helpful the conclusions
will be to patients
Clinical epidemiology
The science of making
predictions about individual
patient by counting clinical
events in similar patients, using
strong scientific method for
studies of groups of patients to
ensure that the predictions are
accurate.
 The purpose of Clinical
Epidemiology:
To develop and apply methods of
clinical observation that may lead to
valid conclusions by avoiding being
misled by systematic error and
chance.

Terminology:
Clinical epidemiology derived from
two parent diciplines: CLINICAL
MEDICINE and EPIDEMIOLOGY
Clinical Medicine
Clinicians are, by and large concerned on
individual patients they largely oriented
towards the mechanism of disease and
foster to belief that to understand medicine
is to understand the detail the process of
disease in individual patients through basic
medical science like anatomy, histology,
physiology, biochemistry etc, how it occurs
at pathognetic and mechanistic level.
EPIDEMIOLOGY
Study of distribution and
determinants of health related
states in a specific population,
and theapplication of the study
to the control of health problems
in that population
 Clinical because it seeks to answer clinical
questions and to guide clinical decision making
with the best available evidence
Epidemiology because many of the methods
used to answer these questions have been
develop by epidemiologist and because the care
of individual patients is seen in the context of the
larger population of which the patient is a
member.
John R. Paul (President of the American
Society of Clinical Investigation, 1968):
Application of principles and methods of
Epidemiology to problems in Clinical
Medicine
Basic Principles
Basic purpose of Clinical
Epidemiology is to Foster
Methods in clinical observation
and interpretation.
1. Clinical Questions
2. Health Outcome
1. Clinical Question : questions
addressed by clinical
epidemiology are the same
questions confronting doctors
and patients:
 Issues Answers
1. Is a person sick or well? What abnormalities are Normality /
associated with having a disease ? Abnormality
2. How accurate are diagnostic tests used to find a Diagnosis
disease ?
3. How often does a disease occur ? Frequency
4. What factors are associated with increase Risk
likelihood of a disease ?
5. What condition results in disease ? Cause
What is the pathognetic mechanism ?
6. What are the consequences of having a disease Prognosis
7. How does treatment change the future course Treatment
of a disease ?
2. Health Outcomes
The clinical events of primary interest in
clinical epidemiology are the health
outcomes of particular concern to
patients
 OUTCOMES OF DISEASE (THE
FIVE Ds)
DEATH A BAD OUTCOME IF UNTIMELY

DISEASE A SET OF SYMPTOMS, PHYSICAL SIGNS, AND

LABORATORY ABNORMALITIES

DISCOMFORT SYMPTOMS SUCH AS PAIN, NAUSEA, ITCHING AND

TINNITIS

DISABILITY IMPAIRED ABILITY TO GO ABOUT USUAL ACTIVITY AT

HOME

DISSATISFACTION EMOTIONAL REACTION TO DISEASE AND ITS CARE SUCH

AS SADNESS AND ANGER
BIAS
Bias is a process at any stage of inference
tending to produce results that depart
systematically from the true value systematic
error).
Exp: treatment A is found to work better than
treatment B, What kinds of biases might have
brought about this observation, if it were not
true?
Perhaps :
1. A is given to healthier patients than B
2. A might taste better than B
3. A might be a new, very popular drug while B an old
one.
 Possibilities of biases, due to:
1. Systematic difference in health between
the groups of patients rather than
difference in the effectiveness of
treatment;
2. Patients take the drug more regularly;

3. Researchers and patients are more

incline to think that the new drug works
better wether or not it really does.
 Bias is a systemtic error in a study that
leads to distortion of the results.
Bias can occur in any research, but is of
particular concern in observational
studies because lack of randomization
increas the chance that study groups will
differ with respect to important
characteristics.
 Although dozen of biases have been defined,
most fall into one of three Broad Categories:
1. Selection bias: occurs when comparisons are
made between groups or patients that differ in
characteristics of outcome other than the one
under study;
2. Information bias: occurs when the methods of
measurement are dissimilar among groups of
patients;
3. Confounding: occurs when two factors are
associated (travel toge- ther ) and the effect of
one is confused with or distorted by the effect of
the other.
 1. SELECTION BIAS
A variety of procedures can be used to select
subjects for study. It is not possible to include all
individuals with a particular disease or exposure
in a study a sample of subjects must be
choosen.
The procedures for the selection of subjects
depend on a number of factors ( design and
setting of study, disease or exposure of interest,
etc)
Often subjects are selected in a manner that is
convenient to the investigators.
Under optimal circumstances the method for
inclusion of subjects leads to a valid comparison
and yealds a correct information regarding the
disease or treatment.
 The selection process itself may
increas or decreas the chance that a
relationship between axposure and
disease of interest will be detected,
creating a selection bias.
Selection bias refers to the
introduction of systematic error into
study results through the manner in
which study subjects were selected.
This kind of bias poses a partticular threat in
case-control studies: exposed persons with
disease were more likely than unexposed
persons with disease to be selected for the
study. In this illustration: an opposite
sampling pattern is displayed for persons
without disease, so exposed persons were
less likely to be selected for the study than
were unexposed persons.

CASECONTROLSTUDY:

RESERPIN BREAS CANCER

CARDIOVASCULAR DISEASE:
(HYPERTENSION RESERPIN)

- NOT EXCLUDED ASSOCIATION (-)

 2. INFORMATION BIAS
Misclassification bias = measurement bias
Systematic error in study findings that originate
in the approach in collecting information.
Two kinds of information bias can exist:

1. Nondifferential misclassification
If the error in classification exposure or disease
status are independent of the level of the other
variable.
Subjects may answer a question about the
exposure with a socially aceptable, even
sometimes inaccurate, response, regardless
wether they have the disease of interest. Exposre
of interest: prior intake of food of high in
saturated fat; respondents may underreported
intake of food of high fat content because they
think low fat diet are more acceptable to
investigator.
2. Differential misclassification
Occurs when the misclassification of one variable
depends on the status of the other: information on
exposure status depends on wether the subject has
the disease. A case of myocardial infarction is more
likely to overestimate the level of dietary fat intake
than a control subject. Bias would lead to an
overestimate of the relationship between dietary fat
intahe and risk of developing myocardial infarction
A. RECALL BIAS:
Result from differential ability of subjects to
remember previous activities and exposures.
Patients who have serious disease may search
their memory for an exposure in an attempt to
explain or to understand why they acquired the
illness. Control subjects who dont have the
disease may be less likely to remeber an
exposure, because less meaning and less
important for them
B. Interviewer bias:
when interviewers are employed to
determine exposure in case-control studies,
results may be influenced by how
interviewers collect information: if they are
aware of research hypothesis, the
interviwers, intentionally or unintentionally,
may inflience the responses of the subjects
 3. CONFOUNDING
Mixing of the effects of an extraneous variable with
yhe effect of exposure of interest ( mixing of the
primary effect of interst with the effect of one or
more extraneous factors. )
Association: high total serum cholesterol
risk of Infarction
myocardial

Result of other studies:

Obesity associated with risk of myocardial infarction.
Total serum cholesterol level also correlate with
obesity
When the association is examined seperately in
obese and non-obese patient: in both group no
association is found. Obese is confounder
 CASE CONTROL STUDY:

ALCOHOLICS ORAL CANCER

CIGARETTES SMOKING
CONFOUNDING