1. Biostat 215 Clarifying the Causal Question Thomas B. Newman, MD, MPH

2. Take-home message n In order to know how to get the answer, you need to be clear on the question n Often this means not only what question is being asked, but why it is important. What decisions might be affected by the results?

3. Examples n Phototherapy for newborns n TPA and death in stroke patients (Kurth) –Different models addressed effect of TPA on different groups of patients n MSM for effect of ASA on CV mortality (Cook) –Total Effect ASA, including benefit from starting after ASA after MI n Hormone Replacement Therapy in nurses to prevent CV mortality (Hernan) –Effect of starting vs being on HRT

4. New Example: Cerebral Palsy n A group of nonprogressive disorders of movement and posture caused by abnormal development of, or damage to, motor control centers of the brain. n Incidence about 2/1000 live births n One (uncommon) cause is kernicterus. n RQ: What are risk factors for cerebral palsy in the Northern CA Kaiser Permanente Medical Care Program? Late Impact of Getting Hyperbilirubinemia or photoTherapy

5. Late Impact of Getting Hyperbilirubinemia or photoTherapy (LIGHT) Study n Design: Historical cohort n Subjects: 573,899 newborns born alive 1995- 2011 n Predictor variables: hospital, prenatal, perinatal variables from electronic record n Outcome: CP, obtained from diagnoses in KP Virtual Data Warehouse (VDW) or California Dept of Developmental Services (DDS), confirmed by chart review by child neurologist

6. ?What variables should I include/control for? n Facility? n Mother’s education? n Gestational age? n Birth weight?

7. I am interested in PREVENTABLE causes of CP n Particular interest in differences by facility, since there may be practice differences leading to differences in CP n Should I control for birth weight? n Should I control for gestational age?

8. Depends on perspective, i.e., what interventions are envisioned n Pediatrics n Obstetrics n Public health n Starting with live births (especially ≥ 35 wks gestation) already reflects a pediatric perspective! n Starting with pregnancies reflects an obstetric prespective

9. Course review