ࡱ>  1|bjbjss ~/W^^D5555$Y5Y3=SSSSnnn2222222$Q462EnL"nnn2SS3nX8SS2n26/D2Spht502)30Y30778D27D2Pnnnnnnn22"nnnY3nnnn7nnnnnnnnn^ g: Unit 8 Practice Questions and Answers Epidemiology 6000 Question 1 In a study of endometrial cancer and use of exogenous estrogen, we observe an odds ratio of 2.5. However, we suspect that menopausal status may confound this association. For menopausal status to be a confounder, which of the following are required? a. Menopausal status must be associated with both endometrial cancer and exogenous estrogen use (and menopausal status can not be a result of exogenous estrogen use). b. Menopausal status must be evenly distributed between the exposed and the nonexposed. c. Menopausal status must be evenly distributed between the cases and the controls (and menopausal status can not be a result of exogenous estrogen use). d. Menopausal status must be a stronger risk factor for endometrial cancer compared to exogenous estrogen use. Question 2 An investigator decides that socioeconomic status is indeed a confounder of the association between hormone use and the occurrence of cancer in a case-control study. The investigator looks at the following list of options to control for confounding. Which of the following options can she use? Choose ALL that apply. Stratify the sample into two groups: low socioeconomic status and high socioeconomic status. Then calculate an odds ratio for each stratum, and compare the crude to the stratified odds ratios. Use multiple logistic regression modeling, incorporating as independent variables estrogen use and socioeconomic status, and breast cancer as the dependent variable. c. Include in the sample only women who have a yearly income of $40,000 or more. d. Match the cases of breast cancer to controls without breast cancer by socioeconomic status. e. Use the appropriate hypothesis test to calculate the p-value for the association between socioeconomic status and estrogen use. Use frequency matching to ensure that the proportion of women of high and low socioeconomic status is similar in the case group and the control group. Question 3 Effect-modification refers to the: Design in which persons are randomly allocated to receive a therapy and a placebo. Situation when interviewers gather information differently from cases and controls. Situation when the magnitude of the association between the exposure and the disease varies by a third factor. Situation when the association between the exposure and the disease is spuriously elevated or reduced by a third factor. Selection of study groups that arise from different populations. Question 4 Write True or False next to each statement: a. True Standardization is used to compare the occurrence of disease or death in populations with differing underlying demographic structures. b. False Randomization can be used to control for confounding in analytic observational studies.  c. FalseWhen we use 1:1 matching to reduce confounding, the OR is computed based on concordant pairs. d. TrueIn direct adjustment, we use the internal rates found in our study and derive the adjustment using a standard population. e. FalseEffect-modification should be controlled for in statistical analyses. f. FalseIn all study designs, it is preferable to indirectly adjust rather than directly adjust rates.  Question 5a-c In a study assessing the effect of foot pain on disability in older women, the investigators considered falling as a potentially confounding factor (PCF). They postulated that the causal pathway was as follows: Answer True (A) or False (B):  SHAPE \* MERGEFORMAT  Question 5a - In this causal model (DAG), falling should be adjusted for as a confounder. A. True B. False Rationale: falling is a consequence of exposure, intermediate in the causal pathway. The investigators then considered a second causal model (DAG):  Question 5b - In this causal model, falling should be adjusted for as a confounder. A. True Rationale: Falling is independently associated with foot pain and with B. False disability. Because these investigators were very thorough, they considered a third possible causal pathway (DAG):  Question 5c - In this causal model, falling should be adjusted for as a confounder. A. True B. False Rationale: Falling is a consequence of both exposure and disease and can not confound the E-D association. Question 6 a - h Read the following abstract and answer the related questions. Dr. Smith has conducted a case-control study to explore the relationship between gender and the development of malaria. The crude OR for this association is 2.2. She suspects that occupation might be a potential confounding factor for the relation between gender and development of malaria, so she decides to stratify the results of her study by occupation (works outside vs. works inside) and then calculates stratified measures of the association between gender and the development of malaria. The stratified measure for individuals working outside was 1.22 and the measure for those who work inside was. 1.18. Dr. Smith also calculated an adjusted value for this association controlling for the influence of occupation and obtains a Mantel-Haenszel OR of 1.19. Question 6a Which of the measures calculated in the above abstract is closest to the True value for the association between gender and the development of malaria? The crude OR b. The stratified OR for those who work outside c. The stratified OR for those who work inside The Mantel-Haenszel adjusted OR Question 6b When Dr. Smith compared the crude OR with the stratified ORs, she: Found that occupation was no longer a concern for her as a potential confounding factor. Suspected that occupation might still be a potential confounding factor. Suspected that the crude OR was close enough to the True value of the association between gender and malaria. Remembered that the stratified ORs do no assist the researcher in understanding the role of a confounding factor. Question 6c When Dr. Smith compared the crude OR with the adjusted OR, she: a. Concluded that the measure of association was distorted in some way by the variable occupation. b. Concluded that the variable occupation had no influence on the results of her study. c. Began to think that chance had more of an effect on her results than confounding variables. d. Thought that the influence of the confounding variable was too small to be concerned about it. Question 6d Assuming that confounding was present in this research, not controlling for the variable occupation most likely would have a. Caused the study results to underestimate the true association (biased toward the null). b. Caused the study results to overestimate the true association (biased away from the null). c. Caused the study results to alter the true association, but it is not possible to tell in which direction it would go from the information provided. d. Caused the study results to alter the true association, but it is just as likely to have overestimated the true association as to underestimate the true association. Question 6e Dr. Smith decides to publish her results in a paper. Which odds ratio(s) represent(s) the best answer(s) to her research question? 2.2 1.18 and 1.22 1.18 or 1.22 1.19 Question 6f Assume that sex=1 (male) is the exposure and sex=0 (female) is the reference group. The Mantel-Haenszel OR of 1.19 can be interpreted as: a. The risk of developing malaria is 1.19 times more likely among males than females when one does not control for the variable occupation. b. The risk of developing malaria is 1.19 times more likely among females than males when one does not control for the variable occupation. c. The risk of developing malaria is 1.19 times more likely among males than females after controlling for the influence of occupation on the association. d. The risk of developing malaria is 1.19 times more likely among females than males after controlling for the influence of occupation on the association. Question 6g If Dr. Smith had decided to control for potential confounding variables in the design phase of her study, which of the following methods might she employ? a. Matching b. Randomization c. Stratification d. Multivariate Analysis Question 6h If Dr. Smith had detected effect-modification by occupation in this study, and felt that it was important to inform the research community about the role it plays in this research question, she would most likely: a. Report the crude odds ratio and inform the public that it is biased because of an effect modifier. b. Report the stratified odds ratios to show how the association changes with different levels of the effect modifier. c. Report the adjusted odds ratio since it removes the influence of effect modification. d. None of the above because effect modification cannot be controlled for. Question 7 a - d The following tables show data from a case-control study of the crude and stratified association between anxiety disorder and parental abuse use by parity (parity is defined as the total number of live births per participant). Parity d" 2 Parity > 2 CaseControlAnxiety9010No Anxiety3020CaseControlAnxiety1020No Anxiety1090 All Parity CaseControlAnxiety10030No Anxiety40110 Question 7a Fill in the numbers in the crude table. Question 7b Calculate the odds ratios for each table. Parity d" 2: OR = 6.00 Parity > 2: OR = 4.50 All Parity: OR = 9.17 Question 7c Calculate the Mantel-Haenszel odds ratio, adjusting for parity. M-H OR = 5.35 Question 7d What is your conclusion? a. The M-H OR shows that effect-modification still exists. b. The adjusted M-H OR now lies outside the interval of the stratified odds ratios. c. We cannot compute the adjusted M-H OR with the information given. d. The adjusted M-H OR now lies within the interval of the stratified odds ratios. Question 8 When a factor is considered an effect-modifier, what is meant/what can be said about this factor? The factor influences the magnitude (or strength) of the association between the study exposure and study outcome. That is, the association of interest changes by each level/stratum of the effect-modifying (E-M) factor. If, for each level of the E-M factor you have a two-by-two table, then the point estimate (OR/RR) will be different for each of those tables. Or, individuals exposed and who also have the E-M factor will have a higher (or lower) risk for the outcome compared to individuals who just have the exposure but do not have the E-M factor. Question 9 a- b Dr. Lauer would like to compare death rates in a sample of 800 individuals who are classified as obese (Body Mass Index > 30) who she has been following to what she might expect if people were dying at the same rate as the general population. She illustrates her data in the following table: Age (years) Study group # observed deaths Death rate (gen pop) per 100,000 Expected deaths <20 97 1 300 0.291 20-39 145 3 1,000 1.45 40-59 359 12 2,000 7.18 60+ 199 20 5,000 9.95 Total 800 36 18.87  Question 9a Calculate the expected deaths (last column) and express the SMR for Dr. Lauers data. O = 36 E = 18.87 O/E = 1.907 or 190.7% Question 9b What is your interpretation of the indirect standardization that you conducted? If Dr. Lauers study group (obese individuals) had the same death rates as that expected based on national death statistics from the general population, she would expect to see 18.87 deaths. She observed 36. Therefore, in her sample of obese patients, the SMR was 1.91 times (or 91%) higher over the follow-up period than people in the general population. One might conclude that obese individuals have a higher expected death rate than individuals in the general population. Note: This might be under-estimated in the current study, since 1/3 of all people in the general population are obese. Therefore, the true SMR is likely even higher than what Dr. Lauer observed. 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