Definition of “cohort”

cohort

• Latin: cohors
– Company of soldiers
– All the same type of soldier (e.g. calvary)
– Roman armies: band of 300-600 soldiers
• Concept:
– Group of individuals, all similar in some
trait, and move forward together as a unit
 Types of cohort
• Birth cohort : all born in the same
period (usually a year) in a defined area
• Inception cohort: Assembled at a
given point based on some factor, e.g.
where they live or work
• Exposure cohort: Assembled as a
group based on a common exposure
– e.g. radiation exposure during desert testing
g asbestos exposure
– e.g. p in the shipyards
py
 Types of cohort
• Fixed Cohort : all born in the
same pperiod (usually
( y a year)
y ) in a
defined area
• Dynamic or open cohort:
Assembled at a given point
based on some factor, e.g.
where they live or work
 Cohort Studies
AKA: Longitudinal,
g , follow-upp studies
• Observe a cohort (or cohorts), over time, to
measure outcome(s)

2 primary purposes:
• Descriptive (measures of frequency): Describe
incidence of an outcome over time, or simply
describe the natural history of disease

• Analytic (measures of association): Assess

associations between outcomes rates and risk
factors or predictive factors
T
Types off C
Cohort
h Studies
S di
• Prospective
• Retrospective
R t ti
• Ambi
Ambi-spective
spective or ambi-
ambi
directional
 Cohort Studies: Examples
The Framingham study
• Began in 1948: n=5,209 (5,123 spouses
and children added in 1971)
• Selected not based on exposures, but
on stable pop., wide spectrum of
occupations,
ti single
i l hospital,
h it l annuall
updated population lists
• Outcomes:
O t Incidence
I id rates
t and d other
th
descriptive measures
 Cohort Studies: Examples
The nurses’ health study.
• 12,000 nurses
– Surveyed at baseline and periodically
• Data on many factors and outcomes
collected over many years
• Split by exposures e.g. OCP use vs. not
• Outcomes compared e e.g.
g CA
CA, AMI
AMI, etc
– Addressed questions not formulated
at study initiation
 Outcome measures
• Descriptive
–Incidence
I id or risk
i k (fixed
(fi d cohort)
h t)
–Incidence rate ((dynamic
y cohort))
• Cummulative incidence or risk from
Kaplan meier analysis
 Outcome measures
Analytic approach
• Risk ratio or relative risk (fixed
cohorts)
–Logistic
Logistic regression (?Odds ratio)
• Rate ratio (Dynamic cohort)
–Proportional hazards (Cox)
regression
 Odds ratio or Relative Risk?
Does it matter?
• Odds ratio Exposed Unexposed
– Odds in favor of
Disease A B
exposure among
cases to odds in No disease C D
favor of exposure
among non-cases
• Relative risk OR= A/B ÷ C/D = AD/BC
– Ratio of risk of
disease among RR= A/A+C ÷ B/B+D
exposed to risk of
disease among
unexposed
It probably only matters
for smaller studies.
 Cohort study: Advantages
• Best to study disease incidence
• Ideal for rare exposures
• Unlike case
case-control
control studies:
– Clear temporal sequence
– Multiple effects from a single exposure
• Prospective ↓bias
b in exposure
measurement
• Much less expensive than RCTs
• Often best/only ethical way to do study
Cohort study: Disadvantages
• Highly sensitive to losses to F/U
• Inefficient for rare outcomes
• Prospective, can be as
expensive as RCT
• Retrospective,
Retrospective dependent upon
the adequacy of records
Cohort study: Minimizing Bias
• Exclude those likely to become “lost”
lost
– Planning to move, Unwilling to return
• Obtain complete tracking info
– Address, phone #, SSN
– Same for friend/close relative, Primary MD
• Maintain periodic contact
– Reminders, updates
• Use 2o data
d sources for
f criticall info
f
– Death registries, Medicare records,
voter/driver registration
Cohort study: Minimizing Bias

• Appropriate duration of F/U for

outcome
• Valid and reliable measure of
outcomes
• High F/U rate (>85%)
( 85%) achieved
• Compare characteristics of
unavailable
l bl group to available
l bl