流行病學(xué)隊(duì)列研究

隊(duì)列研究CohortStudy

隊(duì)列研究

Cohortstudy

Incidencestudies

Longitudinalstudies

Follow-upstudies

Prospectivestudies發(fā)病率研究縱向研究隨訪研究前瞻性研究OutlineExampleDesignandimplementMeasuresofRiskDatasortandanalysisBiasandControlAdvantage，disadvantage概述實(shí)例研究設(shè)計(jì)與實(shí)施資料的整理與分析偏倚及控制優(yōu)缺點(diǎn)隊(duì)列研究

Cohortstudy隊(duì)列研究簡(jiǎn)史定義與目的原理與類型HistoryofcohortstudyDefinitionandPurposePrincipleandTypes歷史History起源

OriginsGraunt(17thcentury)usedcross-sectionalmortalitydatatoreconstructlifehistoryusinglife-tablemethodsGraunt(17世紀(jì))用橫斷面死亡資料，用壽命表方法構(gòu)建生命史Farr(19thcentury)advancedtheuseoflife-tablemethodsaanindicatorofpopulationhealthFarr（19世紀(jì)）將壽命表方法發(fā)展為人群健康的指標(biāo)Insuranceindustrystudy1870–1899

保險(xiǎn)業(yè)研究1870–1899Tuberculosis(20thcentury)

結(jié)核（20世紀(jì)）WHFrostperformedthefirstretrospectivecohortstudyinacohortof132homeswithtuberculosisWHFrost在有結(jié)核的132個(gè)家庭的隊(duì)列開展第一個(gè)回顧性隊(duì)列研究Usedperson-yearstoestimateattackrates用人年來估計(jì)罹患率歷史HistoryWHFrostinitiatedprospectivecohortstudyoftuberculosisinWilliamsoncounty,TennesseeWHFrost在德州啟動(dòng)有關(guān)結(jié)核的前瞻性隊(duì)列研究歷史HistoryFraminghamstudyofcardiovasculardisease,1948Japaneseatomicbombsurvivors,1946Britishphysicianstudy,1950sColoradoPlateauuraniumminers,1950sAniline-dyeoccupationalcohort,1954Asbestosexposureandlungcancermortality1965RetrospectivecohortstudiesProspectivecohortstudiesNursesHealthstudy,1976topresentBritishphysicianstudyMulti-centerAIDSCohortStudyMACS,1984–1999

CurrentStudies

Anepidemiologicdesigninwhichtheincidenceofadisease(orcondition)iscomparedamongexposedandunexposedindividuals

是比較暴露與非暴力人群發(fā)病率的一種流行病學(xué)設(shè)計(jì)

定義What’thecohortstudyCohortStudyBeginwithdisease-freepatientsClassifypatientsasexposed/unexposedRecordoutcomesinbothgroupsCompareoutcomesusingrelativerisk從沒有疾病人群開始

將研究對(duì)象分為暴露與非暴露組記錄兩組結(jié)局用相對(duì)危險(xiǎn)度比較結(jié)果CohortStudy

KeyPoint:Presenceorabsenceofriskfactorisdeterminedbeforeoutcomeoccurs.Whatisacohort?

隊(duì)列Cohort

-Latinwordforoneofthe10divisionsofaRomanlegionAgroupofindividuals

sharingsameexperiencefollowedupforaspecifiedperiodoftimeExamplesbirthcohortoccupationalcohortchemicalplantworkers隊(duì)列拉丁語原意是指古羅馬軍團(tuán)中的一個(gè)分隊(duì)一組人群有共同經(jīng)歷隨訪一特定時(shí)間例如出生隊(duì)列職業(yè)隊(duì)列暴露指接觸過某種物質(zhì)、具備某種特征或處于某種狀態(tài)。危險(xiǎn)因素泛指能引起某特定不良結(jié)局,或使其發(fā)生的概率增加的因子，包括個(gè)人行為、生活方式、環(huán)境和遺傳等多方面的因素。ExposurecontactsomematerialofbeinginsomestatusRiskfactorisavariableassociatedwithanincreasedriskofdiseaseorinfection.Includingbehavior,lifestyle,environmentalandgeneticfactorandsoon.

目的

Purpose

Describeincidenceofoutcomesovertime,naturalhistoryofdiseaseDeterminecausalrelationshipsbetweenthoseoutcomesandexposures(riskorprognostic)factors.

描述隨著時(shí)間變化結(jié)果的發(fā)生率，疾病自然史確定結(jié)果與暴露（危險(xiǎn)或預(yù)后）因素間的因果關(guān)系目的PurposeDetermineaprognosisEvaluatenewtherapiesanddiagnosticsEvaluatescreeningprocedures確定預(yù)后評(píng)價(jià)新的治療與診斷方法評(píng)價(jià)篩檢過程FraminghamstudyofcardiovasculardiseaseIndividuals30–62yearsoldincommunityatriskfordiseaseFramingham,MA,1948topresentExamplesofcohortstudyGoaltoelucidatethenaturalhistoryofHIV/AIDS5000gaymen,volunteers5citiesinUS1984–Extensiveevaluations

QuestionnairePhysicalexaminationLaboratorytestingMulti-CenteredAIDSCohortStudySource:partiallyadaptedfromWHO,1993R1R0A1A0IncidencerateamongexposedIR1=A1(no.exposedcases)

/R1(totalperson-timeexposed)IncidencerateamongunexposedIR0=A0(no.unexposedcases)/R0(totalperson-timeunexposed)Incidencerateratio(exposedvs.unexposed)=IR1/IR0=(A1/A0)/(R1/R0)PrincipleofaCohortStudyCharacteristics

特點(diǎn)ObservationalCategorybyexposureNeedcontrolProspective觀察性研究根據(jù)暴露分組需要對(duì)照前瞻性類型TypesBasedonrecruittimeofstudysubjectProspectivestudyv.s.RetrospectiveStudyBasedonthetypeofcohortFixedcohortv.s.Dynamiccohort

依據(jù)研究對(duì)象召集的時(shí)間前瞻性研究VS回顧性依據(jù)隊(duì)列的類型固定隊(duì)列VS動(dòng)態(tài)隊(duì)列

類型TypesCombinedwith

case-controlstudy

Nestedcase-controlstudycase-cohortstudy與病例對(duì)照研究結(jié)合

巢式病例對(duì)照研究病例隊(duì)列研究

ProspectivecohortstudytimeExposureStudystartsDiseaseoccurrence依據(jù)研究對(duì)象召集的時(shí)間分類ProspectivecohortstudyIdentifycohortinthepresentDetermineexposurestatusorpossibleexplanatory/prognosticfactorsInthepresentorinthefuture現(xiàn)在確定隊(duì)列確定暴露狀態(tài)或可能暴露/預(yù)后因素在現(xiàn)在或?qū)?/p>

依據(jù)研究對(duì)象召集的時(shí)間分類Follow-uptoidentifyoutcomeQuestioncanbeincidenceorriskofoutcomeQuestioncanbewhatfactorsassociatedwithoutcomeAscertainmentofoutcomedoneinfuture隨訪確定結(jié)局可以是發(fā)病率或結(jié)局的風(fēng)險(xiǎn)可以是什么因素與結(jié)局有關(guān)確認(rèn)將來發(fā)生的結(jié)局

依據(jù)研究對(duì)象召集的時(shí)間分類ProspectivecohortstudyProspectiveCohortExampleQuestion:Arenon-steroidalanti-inflammatorydrugsariskfactorforGIbleeds?問題:非甾體固醇抗炎藥是否為胃腸道出血的危險(xiǎn)因素?ExampleIdentifycohort:newdiagnosesofrheumatoidarthritisfromOctober17,2002toOctober17,2003Determineexposurestatus:identifypatientsprescribedNSAID’sandthosewhoarenot確定隊(duì)列:2002.10-2003.10診斷的類風(fēng)濕關(guān)節(jié)炎患者確定暴露狀態(tài):確定開與未開NSAID’s藥物處方的病人Determineoutcomes:follow-upallpatientsfor1year–identifyhowmanyGIbleedsthereareineachsub-cohortorexposuregroup確定結(jié)局:

隨訪所有的病人1年—確定在暴露及非暴露組出現(xiàn)多少胃腸道出血的病人ExampleProspectiveCohortStudiesAdvantagetimesequencestrengthens

inferenceaboutcausemoreaccurate

measurementofrisk

factors(donotneedto

reconstructpastexposures)morecomplete

measurementofconfounding優(yōu)點(diǎn)因果推斷的時(shí)間順序強(qiáng)危險(xiǎn)因素測(cè)量跟準(zhǔn)確(不需要夠姜過去的暴露)更準(zhǔn)確的測(cè)量混雜因素Disadvantage:expensiveandtimeconsuming(inceptionandfollow-up)largenumbersrequiredtostudyrareoutcomesdifficulttostudychronicdiseaseswithlonglatency缺點(diǎn):昂貴,費(fèi)時(shí)間(啟動(dòng)及隨訪)研究罕見結(jié)局是需大樣本難與研究慢性潛伏期長(zhǎng)的疾病ProspectiveCohortStudies前瞻性隊(duì)列研究應(yīng)用條件明確地檢驗(yàn)假設(shè)所研究疾病的發(fā)生率較高,一般不低于5‰明確規(guī)定暴露因素和結(jié)局變量可靠的測(cè)量手段足夠的觀察人群和暴露情況能完成隨訪的人群足夠的人、財(cái)、物力RetrospectivecohortstudytimeExposureStudystartsDiseaseoccurrenceHistorical(Retrospective)CohortStudyIdentifycohortinthepastE.g.,throughrecordsoradministrativedatabasesDetermineexposureorprognosticfactorsinthepastAgain,recordsordatabasesIdentifyoutcomeOutcomecanbeidentifiedinpastorpresentOutcomemustbeafterprevioustwostepsHistoricalCohortExampleQuestion:Arenon-steroidalanti-inflammatorydrugsariskfactorforGIbleeds?問題:非甾體固醇抗炎藥是否為胃腸道出血的危險(xiǎn)因素?HistoricalCohortExampleIdentifycohort–e.g.,peoplediagnosedwithrheumatoidarthritisbetweenJanuaryandDecember1992Determineexposurestatus.WhichofthesepatientswereprescribedNSAID’s?Determineoutcome.Didpatientdevelopkidneydiseaseduringthefiveyearsafterinceptionintocohort?(follow-uplasteduntilDecember1997)Historical(Retrospective)CohortStudies

Advantage:cohorteasiertoassemble(inceptionperiodinpast)baselinemeasurementsalreadyavailablefollow-upperiodalreadytakenplacelesscostlyandtime-consuming優(yōu)點(diǎn):隊(duì)列易召集(在過去起始)基線測(cè)量已經(jīng)可以利用已經(jīng)隨訪耗費(fèi)少,省時(shí)間Disadvantage:nocontroloverthequalityofpastmeasurementsincompletedatasetscontrolforconfoundingmaybeincomplete缺點(diǎn)無法控制過去暴露的質(zhì)量資料不全混雜因素控制不全Historical(Retrospective)CohortStudiesMixedCohortExampleQuestion:Arenon-steroidalanti-inflammatorydrugsariskfactorforGIbleeds?Identifycohort(patientswhowerediagnosedwithrheumatoidarthritisbetweenOctober2000andSeptember2001)WhichofthesepatientsareprescribedNSAID’s?HowmanyofthesepatientswillexperienceGIbleedsduringnextfiveyears?FixedCohortStartEndCohortStudyDesignTypesFixedCohort

AgroupofindividualsrecruitedandenrolledatauniformpointinthenaturalhistoryofadiseaseorbysomedefiningeventCohortdoesnottakeonnewmembersafteritisassembledExamplesPatientsadmittedtotheERwithacuteMISurvivorsofHiroshimabombingsChildrenborntoHIV-infectedmothersTypesDynamiccohortAgroupofindividualsrecruitedandenrolledthroughamechanismthatallowsforinandoutmigrationofpeopleDefinedbycharacteristicotherthandisease,e.g.,geographiclocation,administrativeunitDynamicpopulationExamplesFraminghamStudyKaiserPermanenteDynamicCohortStartEnd二硫化碳長(zhǎng)期低劑量的暴露與冠心病的關(guān)系

第二節(jié)實(shí)例研究二硫化碳（CS2）神經(jīng)系統(tǒng)毒物，抑制酶的活性，影響脂蛋白代謝，造成心血管疾病長(zhǎng)期接觸低濃度CS2可引起慢性中毒和動(dòng)脈粥樣硬化短時(shí)間接觸高濃度的CS2蒸氣可急性中毒研究因素長(zhǎng)期低劑量的CS2暴露定義在有CS2暴露但不至引起急性中毒的車間工作>5年20世紀(jì)60年代芬蘭職業(yè)衛(wèi)生研究所Hernberg和Tolonen教授做的前瞻性隊(duì)列研究二、確定研究結(jié)局

心肌梗死血壓變化心電圖的改變心絞痛發(fā)作三、確定研究現(xiàn)場(chǎng)和人群

暴露組

1942—1967年某粘纖廠25至64歲，343名男性工人有5年以上CS2暴露史對(duì)照組

年齡±3歲出生地區(qū)相同工種的體力消耗相當(dāng)在同一城市的造紙廠隨機(jī)選擇的343名男性工人

四、資料收集

查閱檔案記錄用藥情況、既往車間CS2的濃度等詢問

姓名、性別、年齡、工種及工作年限、吸煙、業(yè)余時(shí)間的體力活動(dòng)情況實(shí)驗(yàn)室檢查

血糖、血脂、血清膽固醇水平、血壓、心電圖、心臟大小、體重及車間CS2濃度的動(dòng)態(tài)變化

五、資料分析表4-1暴露組和對(duì)照組的心肌梗死發(fā)生率及RRCS2暴露組發(fā)生心肌梗死的RR為3.57，兩組致死性心肌梗死發(fā)生率和總的心肌梗死發(fā)生率差異有顯著性

CS2在不同臨床類型冠心病的發(fā)生中作用程度不同臨床類型RRAR心肌梗塞3.575.25致死性心肌梗塞4.693.21非致死性心肌梗塞2.742.04心絞痛1.8911.6心電圖冠心樣改變1.46.1表4-2CS2與不同臨床類型冠心病的RR和AR比較六、結(jié)論

長(zhǎng)期低劑量與冠心病發(fā)病和死亡存在因果關(guān)系CS2所致的冠心病，以致死性心肌梗死為主措施芬蘭當(dāng)局已于1972年把CS2的車間最高容許濃度從20ppm降至10ppmIdentifyexposuresIdefineoutcomesIdentifystudyfieldandpopulationSamplesizeDatacollectioanandFollow-upbothgroupsQualitycontrol確定研究因素確定研究結(jié)局確定研究現(xiàn)場(chǎng)與研究人群確定樣本量資料的收集與隨訪質(zhì)量控制第三節(jié)設(shè)計(jì)和實(shí)施DesignandimplementIdentifyExposure

確定研究因素MainexposureBasedondescriptivestudyandcase-controlstudyFactormayeffectoutcomeconfounder,demographycharacteristic

主要暴露因素在描述性研究和病例對(duì)照研究的基礎(chǔ)上確定可能影響結(jié)局的因素混雜因素人口學(xué)特征等MeasuringExposureContent-Natureoftheexposure;biologicmechanismsQualityContinuous-e.g.,serumcholesterolPeriodic-e.g.,cigarettes,sexualcontactsSingular-e.g.,nuclearexposureQuantityContinuousandperiodicexposuresmustbequantifiedDose-responserelationshipMeasuringExposureMeasurementsInterviewMedicalexamBloodtestsorotherspecimens,Biomarkers,OtherlaboratorytestsRecords,medicalrecordsSamplestorageEnvironmentsurveillancedataMeasuringExposureMeasuringexposureisoneofthefundamentalactivitiesofacohortstudyExposuremeasurementmustbecomparableforallmembersofthecohortCarefullydefinedinadvanceofstudySpecificattentionshouldbegiventotheaccuracyandprecisionofproposedmeasurementsPilotstudiesoftenneededOutcomeDefinitionExpectedresultsoffollow-upPrimaryoutcome-themaineventthatwillberelatedtotheexposureFailure-timeoutcomesDeathDiseaseoccurrenceRepeatedmeasures

OutcomeDefinitionSecondaryoutcomes-othereventsthatareofinterestandmaycorroboratethefindingsofthemainoutcomeUsingexistedinternationalstandardExamplesofOutcomesorDiseasesLungCancerHeartDiseaseMotorvehicleinjuryHIVinfectionDiabetesDiphtheriaDefineConfoundingDefineconfoundinginthestudyControlconfoundingindesigndatacollectiondataanalysis

StudyPopulationDefinePopulationatRiskusinginclusioncriteriaIndividualswithoutcomeofinterestattimeofscreeningandenrollmentarenoteligibleforstudySelectionofexposedpopulationThegeneralpopulation(i.e.,theoutcomeofinteresthasahighincidencerate)Specialexposuregroups(e.g.,smokers,X-rayworkersSpecialoccupationalexposuregroup(uraniumminersorasbestosworkers.Cooperation,goodrecord,regu.Exam,easyfollow-up)SelectionofexposedpopulationSpecialresourcegroups(e.g.,alumni,physicians,nurses,insured)Geographicallyorfacility-definedgroups(e.g.,ThreeMileIsland,hospitalswithspecializedmaternitycare)SelectionofNonexposedgroup

GeneralpopulationAccordingtotheexposurestatusgroupcanbedividedintosubgroups(exposure+andexposure-)Specificcomparisongroup Example:foreffectofradiationifradiologistscohortgroupcomparisongroupmaybeinternalizes. Textileworkersforasbestosworkers,

SelectionofNonexposedgroup

StudyPopulationsExamplesFraminghamstudyofcardiovasculardiseaseIndividuals30–62yearsoldincommunityatriskfordiseaseFramingham,MA,1948topresentFraminghamStudyCohortAssemblyNo.MenNo.WomenTotalRandomSample3,0743,4336,507Respondents2,0242,4454,469Volunteers312428740RespondentsfreeofCHD19752,4184,393VolunteersfreeofCHD307427734TotalfreeofCHD2,2822,8455,127StudyPopulationsMACSMulti-CenteredAIDSCohortStudyGoaltoelucidatethenaturalhistoryofHIV/AIDS5000gaymen,volunteers5citiesinUS1984–1999ExtensiveevaluationsQuestionnairePhysicalexaminationLaboratorytestingRepository

SampleSizeIncidenceingeneralpopulationIncidenceinexposedpopulationSignificantlevelPower(1-)EstimatedofRRFollow-upPurposeoffollowingupTracksubjectsinbothexposedandnon-exposedgroupDefineoutcomeeventsFurthercollectdatainexposuresandconfounding

Follow-upCompletenessandnon-participation90%ruleofthumbAllsubjectsmusthaveanequallikelihoodfordetectingtheoutcomeDiseaseascertainmentmustbecomparablebetweentheexposedandunexposedsubjectsNumberofvisitsReasonsforadditionalevaluationsFollow-upmechanismsActivePassiveFollow-upFollow-upPassiveSurveillanceHospitalsDiseaseRegistriesClinicsorphysicianofficesSurveillancesystems,e.g.,NationalDeathIndex,CDCreportableconditionsActivesurveillanceSystematicevaluationsforoutcomeofinterestRegulartimeintervalsInallstudysubjects Regardlessofactiveorpassivesurveillance,thepersonsevaluatingsubjectsmustbeblindedtoexposurestatusFollow-upFollowup

WhentostartfollowNeedtohavetimeaftertheexposureforthediseasetodevelop.Theinductionperiod+incubationFollowupperiodHowlongtofollowupIndividualsfollowuptooutcome(disease,death,syndrome)CohortsfollowupexpectedresultsFollowupintervaldependontheincidence,latency.THEISSUEOFFOLLOW-UPSomecohort(retrospectiveorprospective)studiesextendoverlongperiodsoftime.Difficulttotrackindividualsandevents.Ifalargeproportionofparticipantsarelosttofollow-upthevalidityofthestudymaybequestion—follow-upbiasIflosstofollow-upisdifferentialbetweencohortgroups,and/orforreasonsrelatedtoboththeexposureandoutcome,thevalidityofthestudymaybeinquestion.THEISSUEOFFOLLOW-UP調(diào)查員選擇調(diào)查員培訓(xùn)制定調(diào)查員手冊(cè)監(jiān)督ChoseofinvestigatorTrainingofinvestigatorFormulationbrochureforinvestigatorMonitor質(zhì)量控制QualityInsurance

第三節(jié)設(shè)計(jì)與實(shí)施BasicmodelfordatasortingPersontimecalculateRatecalculateEffectestimation

第四節(jié)資料的整理和分析Datasortingandanalysis資料的基本整理模式人時(shí)的計(jì)算率的計(jì)算效應(yīng)估計(jì)一、資料的基本整理模式

Basicmodelofdatasorting病例case非病例noncase合計(jì)total暴露組exposureaba+b=n1非暴露組Nonexposurecdc+d=n0合計(jì)a+c=m1b+d=m0a+b+c+d=t暴露組發(fā)病率=a/n1Incidenceofexposedgroup非暴露組發(fā)病率=c/n0Incidenceofnon-exposed

表4-3隊(duì)列研究資料歸納整理表Datasorttableforcohortstudy二、人時(shí)的計(jì)算

Calculateforperson-time

精確法近似法壽命表法ExactmethodApproximationmethodLifeexpectancymethod三、率的計(jì)算

calculateofrate累積發(fā)病率發(fā)病密度標(biāo)化死亡比標(biāo)化比例死亡比CumulativeincidenceIncidencedensityStandardizedmortalityratio,SMRStandardizedproportionalmortalityratio,SPMR

變化范圍0-1

range:0-1

適用條件樣本大

suitablefor:largesample

人口穩(wěn)定

stablepopulation

整齊的資料

evendata

報(bào)告時(shí)必須注明時(shí)間長(zhǎng)短N(yùn)otethetimeperiodwhenreport累積發(fā)病率

(cumulativeincidence,CI)CI=觀察期內(nèi)發(fā)病（或死亡）Numberofnewcase(ordeath)

觀察開始時(shí)的人口數(shù)

Numberofpersonsenteringobservation

發(fā)病密度

(incidencedensity)

變化范圍0-∞r(nóng)ange:0-∞

適用條件觀察時(shí)間長(zhǎng)

Suitablefor:longobservation

人口不穩(wěn)定

Unstablepopulation

存在失訪

withlostfollowup

資料不很整齊

datanotevenID=觀察期內(nèi)發(fā)?。ɑ蛩劳觯┤藬?shù)Numberofnew(death)cases觀察人時(shí)Observedpersontime標(biāo)化死亡比

(standardizedmortalityratio,SMR)變化范圍0-∞

range：

0-∞適用條件結(jié)局事件的發(fā)生率低

suitablefor：lowincidenceofoutcome

不宜直接計(jì)算率時(shí)

notsuitablecalculateratedirectly

SMR=研究人群觀察期內(nèi)發(fā)?。ɑ蛩劳觯┤藬?shù)Numberofnew(death)casesinstudiedpopulation標(biāo)準(zhǔn)人口預(yù)期發(fā)?。ɑ蛩劳觯┤藬?shù)Numberofexpected(death)casesinstandardpopulation

全人口某病的發(fā)病（死亡）率×觀察人口數(shù)Newcases(death)ofadiseaseintotalpopulationXNumberofobservedpersons預(yù)期發(fā)?。ㄋ劳觯?shù)的計(jì)算：Expectedcases(death):SMR的意義

被研究人群發(fā)生（死于）某病的危險(xiǎn)性是標(biāo)準(zhǔn)人群的多少倍

Thetimesofriskofadisease(ordeath)instudypopulationoverstandardpopulationSMR=1研究人群某病發(fā)病（死亡）危險(xiǎn)=標(biāo)準(zhǔn)人群

IftheSMRisquotedasaratioandisequalto1.0,thenthismeansthenumberofobserveddeathsequalsthatofexpectedcases.

SMR>1研究人群某病發(fā)?。ㄋ劳觯┪ｋU(xiǎn)>標(biāo)準(zhǔn)人群，是標(biāo)準(zhǔn)人群的SMR倍

Ifhigherthan1.0,thenthereisahighernumberofdeathsthanisexpected,istheSMRtimesofstandardpopulation

SMR<1

研究人群某病發(fā)?。ㄋ劳觯┪ｋU(xiǎn)<標(biāo)準(zhǔn)人群標(biāo)化比例死亡比

（standardizedproportionalmortalityratio,SPMR）

變化范圍0~∞

適用條件不能得到歷年人口資料僅有死亡人數(shù)、原因、日期和年齡

SPMR=ActuallydeathNo.ExpecteddeathNo.Range0~∞Suitablefor:noyearlypopulationdata,onlythereisdeathNo.,cause,dateandageofdeath

預(yù)期死亡數(shù)計(jì)算（ExpecteddeathNo）：全人口中某病因死亡數(shù)全部死亡數(shù)×某單位實(shí)際全部死亡數(shù)Deathduetoadisease

TotalNo.ofDeath×ActuallydeathNo.insomedepartment率的顯著性檢驗(yàn)

significancetestofrateU檢驗(yàn)

Utest

直接概率法

Probablenumbermethod

二項(xiàng)分布檢驗(yàn)

Binomialdistribution

泊松分布檢驗(yàn)

Poissondistribution

2檢驗(yàn)

2test

計(jì)分檢驗(yàn)scoretest

四、效應(yīng)的估計(jì)

TheEstimationofEffectRelativeRisk(RR)AttributableRisk(AR)ARPercent(AR%)PopulationAR(PAR)PARPercent(PAR%)Doseresponserelationship

相對(duì)危險(xiǎn)度歸因危險(xiǎn)度歸因危險(xiǎn)度百分比人群歸因危險(xiǎn)度人群歸因危險(xiǎn)度百分比劑量反應(yīng)關(guān)系相對(duì)危險(xiǎn)度（RelativeRiskRR）

意義

implicationE發(fā)病或死亡的危險(xiǎn)是ē的多少倍

thetimesoftheprobabilityofthediseaseordeathoccurringintheexposedgroupversusanon-exposedgroup.RR值暴露的效應(yīng)暴露與結(jié)局關(guān)聯(lián)強(qiáng)度

RReffectofexposedtheassociationbetweenexposureandoutcome暴露組率Rateinexposed非暴露組率Rateinnonexposed意義

implication

吸煙者因肺癌死亡的危險(xiǎn)是非吸煙者的10.7倍

Smokerswouldbe10.7timesaslikelyasnon-smokerstodieoflungcancer

吸煙者因心血管疾病死亡的危險(xiǎn)是非吸煙者的1.7Smokerswouldbe1.7timesaslikelyasnon-smokerstodevelopcardiovasculardiseaseCardiovasculardisease170.321.7表4-4吸煙者與非吸煙者死于不同疾病的RRRRofdeathfromdifferentdiseasesinsmokerandnonsmoker

LungcancerDisease296.7550.12Smoker4.69Non-smoker10.7RR（1/10萬人年）

表4-5RR與關(guān)聯(lián)強(qiáng)度

RRandstrengthenofassociation

很強(qiáng)verystrengthen10~＜0.1

強(qiáng)Strengthen3.0~9.90.1~0.3

中Middle

1.5~2.90.4~0.6弱Weak

1.2~1.40.7~0.8

無Noassociation1.0~1.10.9~1.0關(guān)聯(lián)強(qiáng)度RRstrengthenofassociationRR的95%CI

RR95%CI

反自然對(duì)數(shù)即為RR95%CI

Theanti-logarithmoflnisRR95%CI

Woolf法()dcbaRRVar1111+++=ln()RRVarRRln96.1±lnln歸因危險(xiǎn)度(AttributableRisk,AR)

意義implicationE與ē人群比較，所增加的疾病發(fā)生數(shù)量

TheincreasedNo.ofdiseasescomparinganexposedpopulationandanunexposedpopulation

AR值暴露因素消除后所減少的疾病數(shù)量

Eliminatingtheexposure,thereducedNo.ofdiseasesca或()1000-=-×=RRIIIRRAR010nnIIARe-=-=

意義RR吸煙對(duì)肺癌的病因?qū)W意義較大AR戒煙對(duì)心血管疾病的預(yù)防作用較大即公共衛(wèi)生意義較大

表4-6RR與AR的區(qū)別ThedifferencebetweenRRandARCardiovasculardiseaseLungcancerDisease1.710.7RR126.43170.32296.7545.434.6950.12ARNon-smoker

Smoker（1/10萬人年）ImplicationRRsmokinghaslargeretiologysignificanceofonlungcancerARstopsmokinghashigherpreventablesignificanceoncardiovasculardiseases,i.e.thepublichealthsignificance歸因危險(xiǎn)度百分比AR%

（病因分值

EtiologicfractionEF）意義implication:

暴露人群中的發(fā)病或死亡歸因于暴露的部分占全部發(fā)病或死亡的百分比

Theproportionofthecasesthattheexposurehadplayedacausalroleinitsdevelopment.

RR

或-%100%0×=eIIIeAR%1001%×-=RRAR人群歸因危險(xiǎn)度

(populationattributablerisk,PAR)

意義暴露人群與一般人群比較，所增加的疾病發(fā)生率的大小

TheincreaseddiseaseintheexposedcomparingwithgeneralpopulationPAR值暴露因素消除后所減少的疾病數(shù)量

PARthereductioninincidenceaftereliminatetheexposure

PAR=It－I0

It：總?cè)巳郝?/p>

rateintotalpopulationIo：非暴露組率

rateinNon-exposedpopulation

人群歸因危險(xiǎn)度百分比PAR%

意義implication

PAR占總?cè)巳喝堪l(fā)病（或死亡）的百分比

TheproportionofPARincasesor(death)intotalpopulation

或

Pe：總?cè)巳旱谋┞侗壤?/p>

proportionofexposedintotalpopulation劑量反應(yīng)關(guān)系Doseresponserelationship分析方法列出不同暴露水平下的發(fā)病率以最低暴露水平組為對(duì)照，計(jì)算各暴露水平的RR和危險(xiǎn)度差(RD)必要時(shí)，應(yīng)對(duì)率的變化作率的趨勢(shì)性檢驗(yàn)

AnalysismethodListtheincidenceofdifferentexposedlevelsCalculatetheRRandARofdifferentexposedlevelsusingthelowestasreferenceCarriedouttendencytestifnecessary

結(jié)果血清膽固醇水平患冠心病的RR說明存在劑量效應(yīng)關(guān)系表4-740-59歲男子按初始血清膽固醇分組冠心病6年發(fā)生情況

血清膽固醇(mmol/L)

人數(shù)

病例數(shù)

危險(xiǎn)度

平均年發(fā)病率

RR

AR

<210

454

16

0.0352

0.0059

1.00

0.0000

210-

455

29

0.0637

0.0106

1.81

0.0285

>245

424

51

0.1203

0.0200

3.39

0.0851

合計(jì)

1333

96

0.0720

0.0120

選擇偏倚失訪偏倚信息偏倚混雜偏倚第五節(jié)偏倚及其控制Biasandcontrol

Selectionbiasfollowupbiasinformationbiasconfoundingbias一、選擇偏倚selectionbias

Subjectsaredifferentwithgeneralpopulationortargetedtotalpopulationinsomeimportantaspect,whichresultintheoutcomeofresearchbias.

研究人群在一些重要因素方面與一般人群或待研究的總體人群存在差異，而導(dǎo)致研究結(jié)果的偏倚。

產(chǎn)生原因

Causes

選擇對(duì)象的方法不當(dāng)最初選定參加研究的對(duì)象中有人拒絕參加歷史性隊(duì)列研究中部分檔案丟失或記錄不全志愿者隊(duì)列研究開始時(shí)未能發(fā)現(xiàn)早期病人等UnsuitableSelectionmethodforsubjectTheselectedsubjectedrefusetoparticipateFilelostoruncompletedrecordinhistoricalcohortstudyVolunteercohortUnidentifiedearlypatientincohort控制

Contr