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Case study and Odds ratio (OR)
Research methodology
405-Shweta Bhoyar
422-Shweta Nagare
427-Harshada Swami
Definition
• Case-control studies are observational studies, where two groups determine the level of exposure to a risk or a disease, by
identifying a group of individuals with disease and for purpose of comparison, a group of people without the disease.
• The investigator collects retrospective information about exposure to the risk factor from both groups.
• Case-control studies identify subjects by outcome.
• Subjects with disease (or outcome) are called cases and subjects without disease (or outcome) are called controls.
• In case-control studies, the investigator should clearly define the eligibility criteria for both cases and controls (inclusion
and exclusion criteria).
• It is important to select both cases and controls from the same source of the population. This help to maximize the chance of
detecting important association.
Sources of Cases
• Patient attending health facilities
• Medical records
• Death certificates
• Disease registries (e.g., cancer or birth defect registries)
• Cross-sectional surveys
Selection of controls
• Controls must fulfil the same eligibility criteria defined for the cases, with the exception of the disease (outcome). For
example, if the cases are women with cervical cancer, over 50 years-old and more, the controls must be selected from
women in the same age group without the disease.
Sources of controls
• Controls should be selected from the population from which the cases are selected. This helps to provide an estimate of the
exposure prevalence in the population from which the cases arise.
Matching and Data collection
Matching
• It is a method to ensure the comparability between cases and controls.
• Each case is paired individually with a control according to background variables.
• Age, sex, race, sociocultural factors are often used to match cases and controls.
• Appropriate matching helps to reduce the confounders.
Data collection
• Data must be collected in the same way from both groups: cases and controls.
• Investigators must be objective in the search for exposure, especially since the outcome is already known.
• Sometimes it is necessary to interview patients about potential factors, such as smoking history, use of medicine. It may be
difficult for some people to recall these details accurately.
• Study participants with the disease (cases) remember details of exposure in the past better than participants without
(controls).
Case control study design
Measure of association in case-control studies
ODDS:
Chance of event occurring divided by chance of event not occurring.
For example, in 100 births, the probability of a delivery being a boy is 51% and being a girl is 49%
The odds of a delivery being a boy is 51/49 = 1.04
• In simpler term, an odds of an event can be calculated as : Number of events divided by number of non-event
ODDS RATIO
An odds ratio is the odds of the event in one group, for example, those exposed to a drug, divided by the odds of the event in another
group not exposed
Odd ratio in epidemiology: In case control study since the incidence is not available so relative risk can not be
calculated directly. Therefore Odd ratio is obtained which is a measure of strength of association between exposure and outcome.
Case Control
Exposed A B
Odd of exposure among the cases: a/c
Odd of exposure among the control: b/d Unexposed C D
Therefore Exposure odd ratio is:( a/c ) divided by (b/d)
Odd ratio of x indicated the cases are x times more likely to exposed to the risk factor than the control
• Odds ratio can be calculated in a cohort study and in a case-control study.
• The exposure odds ratio is equal to the disease odds ratio.
• Relative risk can only be calculated in a cohort study.
Therefore,Odds ratio can be a measure of relative risk in case control study
Relationship between OR and RR Case Control

Outcome YES Outcome NO
Incidence of outcome among the exposed= a/ a+b Exposed A B

Incidence of outcome among the unexposed= c/c+d
Relative risk = a/ a+b. Unexposed C D
c/c+d
=a/b
c/d
=ad/bc
a<<<b a+b=b
c<<<d; c+d=d
Therefore, Relative risk= Odds ratio

Odds ratio is a measure of true relative risk
when:
• The outcome is relatively rare. ( prevalence is 10% or less in general population)
• The cases must be representative of the cases in the population.
• The controls must be representative of the controls in the population
Interpretation of odds ration

An odds ratio of :
•1.0 (or close to 1.0): There is no association between exposure and the disease.
•Greater than 1.0: The exposure might be a risk factor for the disease.
•Less than 1.0: The exposure might have a protective effect on the disease.
Biases in case control studies
Selection bias
Selection bias occurs when the subjects in one group are different, or the cases and controls are not comparable (other than disease).
In order to prevent this bias, precise selection criteria should be defined for both cases and controls.
Ascertainment bias
It may happen because:
•Cases may recall exposure better than the controls
•Investigators may search for exposure better in cases than in control.
Limitations for recalling past events

In case-control studies much data is collected from interviews. Human beings differ in their capacity to recall information. As
mentioned above, cases may have better recall than controls. It is also possible that the person may not have the information
requested.
Confounding
It occurs when the observed result between exposure and disease is distorted because of the influence of the third variable.
Advantages and disadvantages, Uses of case control
studies
Advantages
• Case-control studies cost less than other studies, e.g. cohort studies.
• Case-control studies are mostly retrospective; cases are identified at the beginning. There is no need to follow cases over a period of time,
unlike cohort studies.
• Case-control studies are more appropriate for rare diseases.
• The association between diseases and multiple exposures can be studied at the same time.
Disadvantages
• Case-controls are subject to multiple biases (especially selection and recall biases).
• Case-control studies cannot estimate the incidence rate unless the rates are population based.
• Case-control studies are difficult for determining the time period between the exposure and disease.
Uses of ODDS Ratio (OR)

• OR are appropriate measure of RR in case control studies.
• OR are commonly used in meta analysis.
• OR are the output of logistic regression analysis
The link below provides access to an example of a case-control study
Article
Heit JA, Silverstein MD, Mohr DN, Petterson TM, O’Fallon WM, Melton LJ. Risk Factors for Deep Vein Thrombosis and Pulmonary
Embolism: A Population-Based Case-Control Study. Arch Intern Med. 2000 Mar 27;160(6):809-15.
http://dx.doi.org/10.1001/archinte.160.6.809
References
• Evidence Based Medicine Toolkit: Clinical Epidemiology Glossary [Internet]. Buckingham Jeanette, Fisher Bruce, Saunders Duncan. c2008- [cited 2017 May ]. Available from: http://www.ebm.med.ualberta.ca/Glossary.html
• https://www.youtube.com/watch?v=BQI2NjzPU68

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Case study and Odds ratio (OR)

• Case-control studies identify subjects by outcome.

The odds of a delivery being a boy is 51/49 = 1.04

Relationship between OR and RR Case Control

Incidence of outcome among the exposed= a/ a+b Exposed A B

Therefore, Relative risk= Odds ratio

Interpretation of odds ration

Limitations for recalling past events

Uses of ODDS Ratio (OR)

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