1. COHORT STUDY DR. A.A.TRIVEDI (M.D., D.I.H.) ASSISTANT PROFESSOR email : dr_aatrivedi@yahoo.com dr_aatrivedi@yahoo.com

2. Epidemiology Defined by John M. Last in 1988 “Study of Distribution and Determinants of health related state or event in a specified population and the application of this study to the control of health problem”. “Study of Distribution and Determinants of health related state or event in a specified population and the application of this study to the control of health problem”. We measure – We measure – Disease frequency Disease frequency Diseases distribution Diseases distribution Determinants of disease. Determinants of disease.

3. TYPES OF EPIDEMIOLOGICAL STUDIES 1.OBSERVATIONAL STUDIES A.DESCRIPTIVE STUDY DESCRIBE DIESEASE BY TIME PLACE PERSON B.ANALYTICAL STUDIES ECOLOGICAL STUDY CROSS SECTIONAL STUDY CASE-CONTROL STUDY COHORT STUDY 2.EXPEREMENTAL STUDIES RANDOMIZED CONTROLLED TRIAL (RCT) FIELD TRIAL COMMUNITY TRIAL

4. Descriptive Epidemiology Describe the disease by Describe the disease by Time Time Place Place Person Person

6. Cohort study is undertaken to support the existence of association between suspected cause and diseaseCohort study is undertaken to support the existence of association between suspected cause and disease A major limitation of cross-sectional surveys and case-control studies is difficulty in determining if exposure or risk factor preceded the disease or outcome. A major limitation of cross-sectional surveys and case-control studies is difficulty in determining if exposure or risk factor preceded the disease or outcome. Cohort Study: Cohort Study: Key Point: Presence or absence of risk factor is determined before outcome occurs. Presence or absence of risk factor is determined before outcome occurs.

7. WHAT IS COHORT Ancient Roman military unit, A band of warriors. Ancient Roman military unit, A band of warriors. Persons banded together. Persons banded together. Group of persons with a common statistical characteristic. [Latin] Group of persons with a common statistical characteristic. [Latin] E.g. age, birth date, E.g. age, birth date,

8. Cohort studies longitudinal longitudinal Prospective studies Prospective studies Forward looking study I Forward looking study I Incidence study Incidence study starts with people free of disease starts with people free of disease assesses exposure at “baseline” assesses exposure at “baseline” assesses disease status at “follow-up” assesses disease status at “follow-up”

9. INDICATION OF A COHORT STUDY When there is good evidence of exposure and disease. When there is good evidence of exposure and disease. When exposure is rare but incidence of disease is higher among exposed When exposure is rare but incidence of disease is higher among exposed When follow-up is easy, cohort is stable When follow-up is easy, cohort is stable When ample funds are available When ample funds are available

12. b+d Frame work of Cohort studies cc+d aa+b TotalYes Disease Status Yes No Exposure Status b d a+c N No Study cohort Comparison cohort

13. General consideration while selection of cohorts Both the cohorts are free of the disease. Both the cohorts are free of the disease. Both the groups should equally susceptible to disease Both the groups should equally susceptible to disease Both the groups should be comparable Both the groups should be comparable Diagnostic and eligibility criteria for the disease should be defined well in advance. Diagnostic and eligibility criteria for the disease should be defined well in advance.

14. Elements of cohort study Selection of study subjects Selection of study subjects Obtaining data on exposure Obtaining data on exposure Selection of comparison group Selection of comparison group Follow up Follow up Analysis Analysis

15. Selection of study subjects General population General population Whole population in an area Whole population in an area A representative sample A representative sample Special group of population Special group of population Select group Select group occupation group / professional group (Dolls study ) occupation group / professional group (Dolls study ) Exposure groups Exposure groups Person having exposure to some physical, chemical or biological agent Person having exposure to some physical, chemical or biological agent e.g. X-ray exposure to radiologists e.g. X-ray exposure to radiologists

16. Obtaining data on exposure Personal interviews / mailed questionnaire Personal interviews / mailed questionnaire Reviews of records Reviews of records Dose of drug, radiation, type of surgery etc Dose of drug, radiation, type of surgery etc Medical examination or special test Medical examination or special test Blood pressure, serum cholesterol Blood pressure, serum cholesterol Environmental survey Environmental survey By obtaining the data of exposure we can classify cohorts as By obtaining the data of exposure we can classify cohorts as Exposed and non exposed and Exposed and non exposed and By degree exposure we can sub classify cohorts By degree exposure we can sub classify cohorts

17. Selection of comparison group Internal comparison Internal comparison Only one cohort involved in study Only one cohort involved in study Sub classified and internal comparison done Sub classified and internal comparison done External comparison External comparison More than one cohort in the study for the purpose of comparison More than one cohort in the study for the purpose of comparison e.g. Cohort of radiologist compared with ophthalmologists e.g. Cohort of radiologist compared with ophthalmologists Comparison with general population rates Comparison with general population rates If no comparison group is available we can compare the rates of study cohort with general population. If no comparison group is available we can compare the rates of study cohort with general population. Cancer rate of uranium miners with cancer in general population Cancer rate of uranium miners with cancer in general population

18. Follow-up To obtain data about outcome to be determined (morbidity or death) To obtain data about outcome to be determined (morbidity or death) Mailed questionnaire, telephone calls, personal interviews Mailed questionnaire, telephone calls, personal interviews Periodic medical examination Periodic medical examination Reviewing records Reviewing records Surveillance of death records Surveillance of death records Follow up is the most critical part of the study Follow up is the most critical part of the study Some loss to follow up is inevitable due to death change of address, migration, change of occupation. Some loss to follow up is inevitable due to death change of address, migration, change of occupation. Loss to follow-up is one of the draw-back of the cohort study. Loss to follow-up is one of the draw-back of the cohort study.

19. ANALYSIS Calculation of incidence rates among exposed and non exposed groups Calculation of incidence rates among exposed and non exposed groups Estimation of risk Estimation of risk

20. Incidence rates of outcome N dc ba YesNo Disease Status Yes No Exposure Status a+b c+d b+d a+c Total Study cohort Comparison cohort

21. Incidence rate Incidence among exposed = Incidence among exposed =aa+b Incidence among non-exposed = Incidence among non-exposed =cc+d

22. Estimation of risk Relative Risk Relative Risk incidence of disease among exposed RR = ______________________________ Incidence of disease among non-exposed a/a+b =_________ c/c+d

23. Estimation of Risk Attributable Risk Attributable Risk Incidence of disease among exposed – incidence of disease among non exposed AR = _______________________________ Incidence of disease among exposed a/a+b – c/c+d AR = _______________ a/a+b

24. SmokingLung cancerTotal YESNO YES7069307000 NO329973000 73992710000 Find out RR and AR for above data

25. Incidence of lung cancer among smokers Incidence of lung cancer among smokers 70/7000 = 10 per 1000 Incidence of lung cancer among non-smokers Incidence of lung cancer among non-smokers 3/3000 = 1 per thousand RR = 10 / 1 = 10 (lung cancer is 10 times more common among smokers than non smokers) AR = 10 – 1 / 10 X 100 = 90 % (90% of the cases of lung cancer among smokers are attributed to their habit of smoking)

26. Types of Cohort Study Prospective cohort study Prospective cohort study Retrospective (historical) cohort study Retrospective (historical) cohort study Combination of Retrospective and Prospective cohort study. Combination of Retrospective and Prospective cohort study.

27. Cohort studies Strengths Strengths We can find out incidence rate and risk We can find out incidence rate and risk More than one disease related to single exposure More than one disease related to single exposure can establish cause - effect can establish cause - effect good when exposure is rare good when exposure is rare minimizes selection and information bias minimizes selection and information bias Weaknesses Weaknesses losses to follow-up losses to follow-up often requires large sample often requires large sample ineffective for rare diseases ineffective for rare diseases long time to complete long time to complete expensive expensive Ethical issues Ethical issues

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