CASE CONTROL

STUDY DESIGN

Ni Luh Putu Ariastuti,MD., MPH

Learning Outcomes

1. To describe the figure and procedures

of case control studies
2. To explain advantages and
disadvantages of case control studies
3. To explain risk(s) interpretation in
case control studies
Reference(s):
Chapter 9. Case Control (Greenberg
et al., 2001; pp. 127 – 137)

Optional:
1. Bonita et al., 2006. Basic
Epidemiology (WHO)
2. Webb and Bain, 2011. Essential
Epidemiology
 ILLUSTRATION:
Parikesit, a cardiologist, delivered a community
health education related to coronary heart disease
(CHD).
He explained that from 100 patients with CHD, 80
of them were having high blood pressure. He then
concluded that hypertension is the major risk
factor for CHD.

Please explain your comment about his

conclusion!
 Onset of
2012 study (2013)

Secondary Disease (+)

Data
Exposed
Disease (-)

Eligible “CAUSE TO EFFECT”

Subjects

Disease (+)
Unexpose
d
Disease (-)
Retrospective

Direction of Inquiry
 Time

Risk Factor
(+) Onset of
Risk Factor (- Cases study
) Study
Population

“EFFECT TO CAUSE” (Case +)

Case (-)
Risk Factor
(+)
Control
Risk Factor (-
)

Direction of Inquiry
 CASE CONTROL STUDIES:
To study the risk of ‘cause and effect’ or to
estimate the relative risk

Observational analytical study

Retrospective study

The strength of causal relationship is superior

than cross-sectional analytic but inferior than
Cohort or Clinical Trials
INDICATION (s) of Case Control
Studies

To explore the relationship between risk

factors and disease

The incidence of disease under

investigation is rare (WHEN??)
 STUDY PROCEDURES
1.Case definition  people who had a
disease ‘X’
2.Control definition  people who are
free of disease ‘X’
3.Define your study population (including
how many is your sample size)
4.Measuring the effect and risk factors 
to study the ‘probability’ of causal effect
5.Data analysis
CASES
A. Criteria for Case
Definition
People with a disease of interest (could be new
or old cases)  define using standard
criteria(s)
Examples:
1. Tuberculosis  Criteria???
2. Cervical cancer  Criteria???
3. Fever  Criteria???
CASES
B. Sources of Cases
1. Healthcare Facilities (such as from
hospitals, Puskesmas, clinics, private
practices, etc between specific period (e.g.
new-born babies with low birth weight from
2010-2011)
2. Direct community survey (one point survey)
 for example anaemia during pregnancy
by measuring Hb level of all pregnant
women in Denpasar year 2013.
CASES
C. Number of Cases (Sample
Size)
1. How many do we need?
2. How long does it take to get them?
3. Statistical requirements?

D. Condition
Cases selected should be representative
toward the population where they taken
from
CONTROL

People without the disease of interest

Examples:
1. Normal weight babies
2. People without CHD
 Control
Selection

CONDITION :
1. Representative to population
2. Comparable to cases group (except
for disease of interest and risk factors)

SOURCE OF CONTROL : Healthcare

facilities, general community, cases
family members, friends of cases

METHODS :
1. Matching or no matching
2. Sampling random or non random
Exploring Risk Factors/Exposure
Data
Condition:
Methods used for cases group MUST
exactly the same to control groups
(comparable between cases and
control)

Method(s):
Medical Record
Interview  CAUTION of Recall Bias!!
DATA ANALYSIS
THE ESTIMATION OF RELATIVE RISK (RR)
 ODD RATIO (OR)

The OR will be close to RR when the

selected cases and control are representative
toward population where they were taken
from

When the incidence of a disease is rare

(lower than 20% among exposed population)
 Cases Control Total
Exposed A B A+B
Non Exposed C D C+D

Total A+C B+D n

Odd Cases = [A/(A+C)]/[C/(A+C)] = A/C

Odd Control = [B/(B+D)]/[D/(B+D)] = B/D

OR = (Odd Case)/(Odd Control) = A/C:B/D = AD/BC

Data Analysis: Calculating CI

(Greenberg et al., 2001, p. 206)

 Pernah Tdk pernah Total
abortus abortus

Plasenta previa 12 56 68

Tdk plasenta 9 59 68
previa

Total 21 115 126

Coba hitunglah OR dari tabel diatas!

 Matched Case-Control
 to match upon a potential confounding variable  to
remove the confounding effect

 Controls are selected based on some characteristic of

case

 Analysis: only discordant pairs are used

 Types:
 one-to-n matching
 frequency-matching
 Calculation OR for Matched-
Controlpaired
Control Total
Exposed Unexposed

Case Exposed A B A+B

Case C D C+D
Unexposed
Total A+C B+D n

OR = B/C
95%CI = (OR) exp[+1.96 1/B+1/C]
 OR Interpretation
A study wanting to explore the relationship
between smoking and lung cancer. From a
case control study were found OR was 2,5.

The probability of cases (people with lung cancer) to

smoke is 2,5 time higher than the control group; it
can be concluded that smoking increased the
likelihood of developing lung cancer 2.5 time greater
then non smoking
 CI Interpretation
A study wanting to explore the relationship
between smoking and lung cancer. From a
case control study were found OR was 2,5
(95% CI = 2,2 – 14)

If we repeat the same study over 100 time, 95% of

the studies will have OR between 2.2 to 14,0; it can
be concluded that smoking increase the risk of
developing lung cancer
 Bias in Case Control
Studies
Confounding
Bias
Selection Bias

Information Bias

Measurement error
 CASE CONTROL STUDIES:

Advantages Limitations
Efficient for the study of rare diseases Risk of disease can not be estimated
directly

Efficient for the study of chronic diseases Not efficient for the study of rare
exposure

Tend to require smaller sample size More susceptible to selection bias

compare to other study designs than alternative designs

Less expensive than alternative study Information on exposure maybe less

designs accurate than that available in
alternative designs
Maybe completed more rapidly than
alternative designs
Question (s) ???