Systematic error (Bias)

Types of Bias
Non- response
bias
Healthy worker
effect
Berkson bias

Prevalence
(Neyman) bias
Ascertainment
(sampling) bias

High unresponse rate to surveys/ questionnaires

can cause errors if unresponders differ in some way
from responders. Better people selected.
Study populations are healthier than general
populations. Better people selected.
Disease studied using only hospital based patients
may lead to results not applicable to target
population.
(the researcher parked in the hospital and never
came out). Worse people selected.
Exposures that happen long before disease
assessment can cause study to miss diseased
patients that die early or recover.
Study population differs from target population
duo to nonrandom selection methods. Ex. Severely
ill patients are the most likely to enroll on cancer
trials leading to results that are not applicable to
patients with less advanced cancer. Worse people

delected.

Selective survival occurs in case-control studies when cases are

selected from the entire disease population instead
bias

Late look bias

of just those who are newly diagnosed. Ex. Study

on cancer survival that is not limited to newly
diagnosed patients will contain a higher proportion
of relatively benign malignancies as these patients
generally live longer. Better people selected.
People with severe disease are less likely to be
enrolled as they are harder to access and many of
them died.
Comment: I think it is the same as selective survival bias

Better people selected.

By:Khaled Elfert

Referral
(admission rate
bias)

Attrition bias
(loss of followup)

Allocation bias

Susceptibility
bias

Recall bias

By:Khaled Elfert

When the case and control populations differ duo

to admission or referral practices. Ex. Study
involving cancer risk factors performed at a
hospital specializing in cancer research may enroll
cases referred from all over the nation. However,
hospitalized control subjects without cancer may
come from only local area.
Significant loss of study participants may cause
bias if those lost to follow-up differ significantly
from remaining subjects.
A problem for prospective studies. If subjects drop
out of the study for a reason somehow related to
outcome, the lost subjects will differ in their risk
of developing the outcome compared to the
remaining subjects. To reduce it, investigators try
to achieve high rates of follow-up. Better people
stay as worse people dropped. Attrition = ,
Can result from the way that treatment and control
groups are assembled. It may occur if subjects are
assigned to the study groups in a nonrandom
fashion. Ex. In a study comparing oral NSAIDs and
intra-articular corticosteroids for OA ttt, obese
patients may be preferentially assigned to the
corticosteroid group.
Occurs when treatment regimen selected for a
patient depends on severity of the patient
condition. I guess it is more or less like Allocation
bias. Your heart is susceptible to patient condition
:P .
Also, Intention to treat analysis makes us avoid
this bias. QID: 7691 UW-2
Results from inaccurate recall of past exposure by
people in the study and applies mostly to
retrospective studies such as case control studies.
People who have suffered and adverse event (such
as having child with congenital abnormalities) are
more likely to recall previous risk factors than
people who have not experienced a poor outcome.

The risk is known at the time of enrollment in

prospective studies, so recall bias is eliminated.
FA: reduce bias by decreasing time from exposure
to follow-up
Becker: Also if people dont remember clearly what
happened, so they make things up or distorts the
past based on perspective of the present.
Subjects in different groups are not treated the
Procedure bias
same.
Reduce by blinding and use of placebo.
U proceeed wiz the diseeeeased
The risk factor itself may lead to extensive
Detection
diagnostic investigation and increase the
(Surveillance)
probability that a disease is identified. Ex. Patients
bias
who smoke may undergo increased imaging
surveillance duo to their smoking status, which
would detect more cases of cancer in general.
When a screening test diagnoses a disease earlier
Lead time bias
than it would have appeared by natural history so
that the time from diagnosis until death is
prolonged. Affected studies may not accurately
reflect an improvement in survival or alteration of
the natural history.
To reduce this bias, Measure back-end survival
(adjust survival according to
the severity of disease at the time of diagnosis)
Information is gathered in a way that distorts it.
Measurement
Poor data collection with inaccurate results. Ex.
bias
Miscalibrated scale consistently overstates weights
of subjects. Reduce by using standardized methods
of data collection.
Hawthorne effect Tendency of a study population to affect outcome
duo to knowledge of being studied. It occurs
commonly in studies concerning behavioral
outcomes or outcomes that can be influenced by
behavioral changes. To minimize, studied subjects
can be kept unaware that they are being studied
but pose ethical problems.
By:Khaled Elfert

Observer bias

When observer misclassifies data secondary to

individual differences in interpretation or
preconceived expectations regarding the study
(Pygmalion effect, Belief in efficacy of a ttt
changes the outcome). It can be reduced by
performing a double blind study and by having
multiple observers encode and verify the recorded
data. Also, it can be reduced by measuring
objective outcomes (e.g. mortality).
Becker: Researchers see things based on prior
knowledge.

Confounding
bias

When a factor is related to both the exposure and

outcome, but not on the causal pathway factor
distorts or confuses effect of exposure on outcome.
To reduce, do multiple/ repeated studies, crossover studies and matching
Results when an external variable positively or
negatively impacts the observed effect of a risk
factor on a disease status. When this occurs,
stratified analysis will reveal a significant
difference between the stratified groups.
Ex. New surgical technique is done by most expert
surgeons so there is inflated estimate of benefits of
the technique.

Effect
modification
(NOT a bias)
Proficiency bias

Reporting bias

Subjects over or under-report exposure history duo

to perceived social stigmatization (e.g. sexual
behavior, Drug use)
Respondent bias: When outcome is obtained by the patient's
response, and not by objective diagnostic method
(e.g. Migraine headache)

By:Khaled Elfert

UW Classification for Biases:

1- Selection Biases: Inappropriate selection or poor retention
of study subjects.
Include: Ascertainment (sampling), Nonresponse, Berkson,
Prevalence, Attrition biases.
Add also, Susceptibility bias.
2- Observational Biases: Inaccurate measurement or
classification of disease, exposure, or other variable.
Include: Recall, Observer, Reporting, Surveillance (detection)
Biases.

FA Classification for biases:

Bias in recruiting participants selection bias
Bias in performing study: Recall, measurement, procedure,
observer-expectancy bias.
Bias in Interpreting results: Confounding, lead time.
-----------------------------------------------------------------References: UW for step 1, UW for step 2 CK, FA for step1, Becker step 1.

By:Khaled Elfert