Cohort Studies
Dr. P.K. Bardhan
Cohort
A well-defined group of people who have
had a common experience or exposure,
who are then followed up for the incidence
of new disease or events.
Design of a Cohort Study
Begin with Defined Population
Then History,
Exam, Tests Exposed Non-Exposed
Regular
Follow-Up
Then, Develop Do Not Develop Do Not
Identify Outcome Develop Outcome Develop
Outcome Outcome
Hypothesis: Malnourished children are at higher risk of Pneumonia
Exposure/ Risk Factor: Malnutrition in Children
Outcome/Disease: Pneumonia
Defined Population
Begin with
Children <5 yrs in Chandina
Then History, Exposed Non-Exposed
Exam, Tests Malnourished Not Malnourished
Regular
Follow-Up
Then, Develop Do Not Develop Do Not
Identify Outcome Outcome Outcome Outcome
Outcome Pneumonia Pneumonia Pneumonia Pneumonia
Observations
1. Definitions of disease outcome should be well
determined prior to the study's inception and should not
be changed during the course of the study
2. Standard criteria should be applied to both exposed
and non-exposed groups, i.e., there should be no bias in
determining outcomes in exposed vs. non-exposed
3. Every effort should be made to minimize the "lost to
follow-up" rate since large non-response rates (> 20%)
raise questions as to the accuracy of incidence rates in
exposed and non-exposed groups
Presentation of findings: The 2 X 2 table
Presence Of Disease
Characteristic Number With Number Without
(Exposure) Disease Disease Total
Malnutrition Pneumonia No Pneumonia
Present a 60
b 140
a 200
+b
Absent c 30 d 270 c+d
300
Total a+c 90 b+d 410 N
500
Analysis of Data
1. Cumulative Incidence and/or
Incidence rates for the study period
(e.g., 3 years) in the exposed (a/(a+b))
and in non-exposed (c/(c+d)) are
compared by Chi square or Fisher's
exact tests
2. Measure of association: What is the relative risk of exposed
developing the disease compared to the non-exposed?
Incidence in exposed a/(a+b)
Relative Risk = =
Incidence in non-exposed c/(c+d)
Analysis of Data (cont.)
3. May wish to calculate confidence limits
(e.g., 95%) around relative risk estimate
4. If variable lengths of follow-up are present,
may wish to use use person-years to
calculate incidence rates (# cases per 100
person-years of follow- up)
A Hypothetical example of Prospective Study
First: Develop Do Not Total Incidence
Select CHD Develop CHD /1,000/yr
__________________________________________________________________
Healthy Smokers 174 4,826 5,000 34.8
Healthy Non-Smokers 86 5,914 6,000 14.3
174
Incidence in exposed = ---------- X 1,000 = 34.8
5,000
86
in non-exposed = ---------- X 1,000 = 14.3
6,000
Risk of Heart Disease in Smokers and Smokers
Incidence of Heart Disease
Incidence due
to Smoking
Incidence Not Background
due to Smoking Risk
In Smokers In Non-Smokers
Attributable Risk
Amount or proportion of the disease incidence (or disease risk) that can
be attributed to a specific exposure.
Attributable Risk in the Exposed group
Incidence in the exposed group which is attributable to the exposure =
Incidence in exposed group – Incidence in non-exposed group
Proportion of total incidence in the exposed group which is attributable
to the exposure
Incidence in exposed group – Incidence in non-exposed group
= ---------------------------------------------------------------------------------------------
Incidence in exposed group
Attributable risk calculation for the exposed group
Develop Do not Total
CHD Develop CHD
Smokers 174 4,826 5,000
Non-smokers 86 5,914 6,000
_________________________________________________________
Total 260 10,742 11,000
Incidence in smokers = 174/5000 = 34.8/1000
Incidence in non-smokers = 86/6000 = 14.3/1000
Incidence in the exposed group which is attributable to the exposure
= Incidence among smokers – Incidence among non-smokers
= 34.8 – 14.3 = 20.5/1000/year
Proportion of total incidence in the exposed group which
is attributable to the exposure
Incidence in exposed group – Incidence in non-exposed group
= -------------------------------------------------------------------------------------
Incidence in exposed group
34.8 – 14.3
= ----------------- = 0.589 = 58.9%
34.8
It means that 58.9% of the morbidity from CHD among smokers may
be attributable to smoking and presumably could be prevented if
smoking were eliminated.
