Measures of

Comparison

Comparison
Purpose
Summarize relationship between exposure and disease by
comparing at least two measures of disease frequency

Overall rate of disease in an exposed group says nothing

about whether exposure is a risk factor for or causes a
disease. This can only be evaluated by comparing
disease occurrence in an exposed group to another group
that is usually not exposed. The latter group is usually
called the comparison or reference group.

Comparison is the essence of epidemiology.

Comparison
 Two Main Options for Comparison

1. Calculate ratio of two measures of disease

frequency ( a measure in exposed group
and a measure in unexposed comparison
group)

2. Calculate difference between two

measures of disease frequency (a measure
in exposed group and a measure in
unexposed comparison group)
Comparison
 Data Set Up: Two by Two Table

For cumulative incidence and prevalence

Disease
Yes No Total

Yes a b a+b

No c d c+d
Exposure
Total a+c b+d a+b+c+d

Comparison
 For Incidence Rates
Disease

Yes No Person-Time

Yes a - PTexp

Exposure
No c - PTunexp

Total a+c - Total PT

Comparison
 Rate/Risk Ratio
(also called Relative Risk)
Comparing disease occurrence among exposed with
disease occurrence among comparison group (usually
unexposed) in a ratio measure.

Comparison
Rate/Risk Ratio (also called Relative Risk)

RR= Rate or risk in exposed group (Rexp) /

Rate or risk in unexposed group (Runexp)

For CI: CIexp / CIunexp = a / (a+b) / c / (c+d)

For IR: IRexp / IRunexp = a / PTexp / c / PTunexp

Comparison
Rate/Risk Ratio (also called Relative Risk)

Purpose: Gives information on the relative

effect of the exposure on the disease. Tells
you how many times higher or lower the
disease risk is among the exposed as
compared to the unexposed. Is commonly
used in etiologic research

Comparison
 Rate/Risk Ratio

RR=1.0 -- no association between exposure

and disease

RR=2.0 -- two times the risk of disease in the

exposed compared to the unexposed

Comparison
 Rate/Risk Ratio (contd)

RR=1.6 -- 1.6 times the risk of disease in the

exposed compared to the unexposed or 60%
increased risk of disease in the exposed

(1.6 - 1.0 = .60 = 60%)

RR = 0.5 -- 0.5 times or the risk of disease in

exposed compared to unexposed.

Comparison
 Example: Cohort study of hypertension and
cardiovascular morbidity and mortality
(Nurses Health Study)

Non Fatal Heart Attack

Yes No Total

Yes 117 13,305 13,422

Hyper- No 125 106,416 106,541

tension
Total 242 119,721 119,963

Comparison
 Example: Cohort study of hypertension and
cardiovascular morbidity and mortality
(Nurses Health Study)

RR = CIexp / CIunexp =

117/13,422 = .00872= 7.5

125/106,541 .00117

Interpretation: Women with hypertension have

7.5 times the risk of having a non-fatal heart
attack compared to women without hypertension.
Comparison
 Example of an R x C Table in a Study of
Magnetic Field Exposure and Leukemia
Leukemia
Yes No Total RR

Low 2,264 65,160 67,424 1.0

Magnetic Field
Exposure Medium 61 1,408 1,469 1.23

High 30 644 674 1.33

Note: Low exposure group is the comparison group for both high and
medium exposures.

Interpretation: Children exposed to medium levels have a

23% increased risk of leukemia, and those exposed to
high levels have a 33% increased risk as compared to
children exposed to low magnetic field levels.
Comparison
Difference Measures

Comparing disease occurrence among the

exposed with the disease occurrence
among the unexposed comparison group
by subtracting one from the other.

Comparison
Risk/Rate Difference (also called Attributable
Risk/Rate)

RD=Rate or risk in exposed (Rexp) Rate

or risk in unexposed (Runexp)

For CI: CIexp - CIunexp = a / (a+b) - c / (c+d)

For IR: IRexp - IRunexp = a / PTexp - c / PTunexp

RD = 0 when there is no association

Comparison
Risk/Rate Difference (continued)
Purpose: Gives information on

the absolute effect of exposure on disease

occurrence.
the excess disease risk in the exposed group
compared to the unexposed group.

the public health impact of an exposure, that

is, how much disease would be prevented if
the exposure were removed. This assumes
that the exposure causes the disease.
Comparison
 Non Fatal Heart Attack

Yes No Total

Yes 117 13,305 13,422

Hypertension No 125 106,416 106,541

Total 242 119,721 119,963

RD = CIexp - CIunexp = 117 / 13,422 - 125 / 106,541 =

.00872 - .00117 = .00755 or 755 / 100,000

Interpretation: The excess occurrence of non-fatal heart

attack among these hypertensive women was 755 per
100,000. Or, if hypertension causes non-fatal heart
attacks then 755 cases of non-fatal heart attack per
100,000 women could be eliminated if the hypertension
Comparison
were treated.
 Comparison of RR and RD
Annual Mortality Rate Per 100,000
Lung Cancer Coronary Heart
Disease
Cigarette Smoker 140 669
Non Smoker 10 413
RR 14.0 1.6
RD 130/100,000/YR 256/100,000/YR
Conclusion: Cigarette smoking is a much stronger risk
factor for lung cancer but (assuming smoking is causally
related to both diseases) the elimination of cigarettes
would prevent far more deaths from coronary heart
disease. Why is this so? Comparison
Population Risk/Rate Difference (PRD)

Purpose: Measures excess disease

occurrence among the total population that
is associated with the exposure. Helps to
evaluate which exposures are most relevant
to the health of a target population.

Comparison
Population Risk/Rate Difference (PRD)
Two formulas for PRD:

PRD = (RD) (Pexp) where Pexp = proportion

of population that is exposed, and RD is the
risk or rate difference

PRD = Rtotal - Runexp where Rtotal = risk/rate in

total population and Runexp = risk/rate among
unexposed
Comparison
 Population Risk/Rate Difference
Non-fatal Heart Attack
Yes No Total
Yes 117 13,305 13,422
Hypertension No 125 106,416 106,541
Total 242 119,721 119,963

PRD = [(117/13,422) - (125/106,541)] x (13,422/119,693) =

(.00755) x (.112) = .00085
or PRD = 242/119,963 - 125/106,541 = .00202 - .00117 = .
00085 or 85/100,000
Interpretation: Hypertension results in an excess incidence of 8.5/10,000
non-fatal heart attacks in the total study population. Or, if hypertension
were eliminated, 8.5/10,000 cases of non-fatal heart attacks could be
eliminated among the total study population. (Assumes that hypertension
causes heart attacks.)
Comparison
Population Risk/Rate Difference
Note the dependence of PRD on prevalence of
exposure. What would the excess of non-fatal heart
attack due to hypertension be if the prevalence of
hypertension were 1% rather than 11.2%?
A relatively weak risk factor (in terms of relative risk)
that is quite prevalent could account for more of
disease incidence in a population than a stronger risk
factor that is rarely present.

Comparison
Calculating Measures of Comparison for
Cigarette Smoking and Lung Cancer*
Simple Rates

Death rate from lung cancer in smokers 0.96 /

1,000 / year
Death rate from lung cancer in non-smokers: 0.07
/ 1,000 / year
Prevalence of smoking in population: 56%

* Estimated data from Doll and Hill. Br J Med 1:1399-1410, 1964.

Comparison
 Calculating Measures of Comparison for
Cigarette Smoking and Lung Cancer*

Compared Rates

Rate Ratio: 0.96 / 1,000 / year / 0.07 / 1,000 /

year = 13.7
Rate Difference: 0.96 / 1,000 / year 0.07 /
1,000 / year = 0.89 / 1,000 / year
Population Rate Difference: 0.89 / 1,000 / year x
0.56 =0.50 / 1,000 / year
* Estimated data from Doll and Hill. Br J Med 1:1399-1410, 1964.

Comparison
 Exercise to Practice Measures of Comparison

The 58th annual convention of the American Legion was held in Philadelphia
from July 21 until July 24, 1976. People at the convention included
American Legion delegates, their families, and other legionnaires who were
not official delegates. Between July 20th and August 30th, some of those
who were or had been present became ill with a type of pneumonia
subsequently named Legionnaire's Disease. No one attending the
convention developed the disease after august 30th. Following are the
numbers of delegates and non-delegates who developed Legionnaire's

Disease during the period July 20 to August 30 (41 day period).

Comparison
 Exercise to Practice Measures of Comparison

Developed Legionnaires Disease

Yes No Total

Delegate 125 1724 1849

a b a+b
Convention
Status Non- 3 759 762
Delegate c d c+d
Comparison
Exercise to Practice Measures of Comparison

1.Compute the "rate" of Legionnaires'

Disease among the delegates and non-
delegates. What type of measure of
disease frequency is this "rate"?

CI Del 125/1849 = .068 in 41 Days

CI No 3/762 = .004 in 41 Days
Comparison
Exercise to Practice Measures of Comparison

2.Calculate the "rate" ratio of Legionnaires'

Disease among delegates compared to
non-delegates. State in words the
meaning of this rate ratio.

RR .068 / .004 = 17

Comparison
Exercise to Practice Measures of Comparison

3.Calculate the "rate" difference of

Legionnaires' Disease for delegates. State
in words the meaning of thisrate difference.

AR = .068 - .004 = .064 or 64/1000

Comparison
 Further Analysis of Convention Delegates

Developed Legionnaires Disease

Yes No Total
Hotel of Hotel A 62 628 690
Residence
Other
63 1,098 1,161
Hotel

Cumulative incidence among Hotel A residents: 62 / 690 = 9.0

/ 100 or 9.0%
Cumulative incidence among other hotel residents: 63 / 1,161
= 5.4 / 100 or 5.4%
RR= 9.0 / 5.4 = 1.7

RD = 9.0 %- 5.4% = 3.4%

Comparison
Epidemiology In the News

Comparison
 Epidemiology In the News
What is the exposure under study?
How is it defined?
What are the diseases under study?
Find the measures of disease frequency.
Find the measures of association.
What did the investigators do to ensure that
the comparisons were fair?
Comparison