UKURAN ASOSIASI

Tipe ukuran yang digunakan dalam

epidemiologi
Ukuran asosiasi
Merefleksikan kekuatan atau besar asosiasi
antara suatu eksposur/faktor risiko dan
kejadian suatu penyakit

Memasukkan suatu perbandingan frekuensi
penyakit antara dua atau lebih kelompok
dengan berbagai derajat eksposur

Beberapa ukuran assosiasi digunakan untuk
mengestimasi efek
Basic Question in Analytic Epidemiology
Are exposure and disease linked?
Exposure Disease
Ukuran-ukuran asosiasi
Ukuran rasio (perbandingan relatif)
rasio dua frekuensi penyakit
membandingkan kelompok terpajan dengan
kelompok tidak terpajan
Ukuran perbedaan efek (perbandingan
absolut)
perbedaan antara ukuran frekuensi penyakit
suatu kelompok terpajan dan kelompok yang
tidak terpajan

Arithmetic
Suppose you have $2 and I have $1
Absolute comparisons made by subtraction
$2 $1 = $1
I have $1 more than you
Relative comparisons made by division
$2 $1 = 2 [$ units cancel out]
I have twice as much as you
Arithmetic
Suppose that the 5-year rate of a disease
in smokers is 2 per 100
in non-smokers is 1 per 100
Absolute comparison: (2 per 100) (1 per 100)
= 1 per 100
There is one addition case per 100 smokers
Relative comparison: (2 per 100) (1 per 100)
= 2 [no units; per 100 units cancel out]
Smokers are at twice the risk of non-smokers
UKURAN ASOSIASI
Relative :
RR (relative risk)
Risk ratio
Rate ratio
OR
Absolute :
RD (risk difference)

Measures of Association
How much greater the frequency
of disease is in one group compared
with another.

Often presented in the form of a
two-by-two table.

Two-By-Two Table
a b
c d
Disease
Yes No

Yes
Exposure
No
Total a+c b+d
Total

a+b

c+d
a+b+c+d
Hypothetical Two-By-Two
Table
70 300
15 700
Lung cancer
Yes No

Yes
Smoking
No
Total 85 1,000
Total

370

715
1,085
Relative Risk (RR)
Measures how likely the exposed group
will develop a disease compared to the
unexposed group.


RR = incidence in the exposed = a/(a+b)
incidence in the unexposed c/(c+d)

Example: Hypothetical Study
Lung cancer
Yes No Total
Yes 70 300 370
Smoking No 15 700 715
Total 85 1,000 1,085
Relative Risk = 70/(70+300) = 9.0
15/(15+700)

Which means participants who
smoked were 9 times more likely to
develop lung cancer than those who
did not smoke.
I nterpreting Measures
of Association
RR of 1.0 indicates that the occurrence
of disease in the exposed an
unexposed groups are identical:

No association observed between
exposed and unexposed groups.

I nterpreting Measures
of Association (Continued)
RR greater than 1.0 indicates a
positive association, or an increased
risk among the exposed.

RR less than 1.0 means that there is
a decreased risk among the exposed
group.
Ukuran-ukuran asosiasi
Ukuran rasio
Rasio risiko atau risiko relatif (RR)

terpajan tidak kelompok pada Risiko
terpajan kelompok pada Risiko
RR =
Rasio Insidens Kumulatif (RIK)

terpajan tidak kelompok pada kumulatif Insidens
terpajan kelompok pada kumulatif Insidens
RIK =

Perhitungan RR untuk CI

Outcome (+) Outcome (-) Total

E (exposed) a b a + b


NE (unexposed) c d c + d


Total a + c b + d N
(a + b + c + d)



CI pada populasi exposed (E) --- a/(a + b)
RR=
CI pada populasi unexposed (NE) --- c/(c + d)


THEN, FOLLOW TO SEE WHETHER
Totals
Incidence
rates
of
Disease
Disease
Develops

Disease
Does Not
Develop
Exposed a b a + b


Not
Exposed
c d c + d
FIRST,
SELECT
a
a+b
c
c+d
Incidence in
exposed
Incidence in
non-exposed
=
=
a
a+b
c
c+d
Relative Risk ( RR ) = incidence in exposed

incidence in non-exposed

=
A Prospective Study of 3,000 Smokers and 5,000 Non-
smokers to Investigate Smoking and Coronary Heart Disease
(CHD)
Example :
Develop
CHD
Do Not
Develop
CHD
Total
Incidence
per 1,000
per year
Healthy Smokers 84 2,916 3,000 28.0
Healthy Non-Smokers 87 4,913 5,000 17.4
THEN FOLLOW UP TO
SEE HOW MANY
FIRST,
SELECT
Ukuran-ukuran asosiasi
Ukuran rasio
Rasio rate atau rasio densitas insidens (RDI)

terpajan tidak kelompok pada insidens Densitas
terpajan kelompok pada insidens Densitas
RDI =
Rasio Prevalens (RP)

terpajan tidak kelompok pada Prevalens
terpajan kelompok pada Prevalens
RP =

Perhitungan RR untuk IR

Outcome (+) Person-time

E (exposed) a N
1



NE (unexposed) c N
0



Total a + c T




IR pada populasi exposed (E) --- a/N
1

RR=
IR pada populasi unexposed (NE) --- c/N
0


Contoh 5.
Tabel 1. Kaitan antara merokok dan angka insidens stroke dalam
suatu kohort.

Kategori
merokok
Jumlah kasus
stroke
Orang-tahun
observasi
(lebih dari 8
tahun)
Tingkat
insidens stroke
(per 100.000
orang tahun)
Tidak pernah
merokok
70 395.594 17,7
Mantan perokok
65 232.712 27,9
Perokok
139 280.141 49,6
Total
274 908.447 30,2
Sumber: diterjemahkan dari:Beaglehole et al. Basic Epidemiology. WHO. 1993. 18.
Ukuran-ukuran asosiasi
Dari Tabel 1.
Hitunglah:
Rasio rate atau rasio densitas insidens (RDI)

terpajan tidak kelompok pada insidens Densitas
terpajan kelompok pada insidens Densitas
RDI =
8 , 2
17,7
49,6
RDI = =

Postmenopausal Hormone Supplement and CHD

CHD Person-years

Ever use 30 54,308.7
Past use 19 24,386.7
Current 11 29,922.0
Never use 60 51,477.5



RR ever use vs never use = (30/54,308.7) / ( 60/51477.5) = 0.5

RR past use vs never use = (19/24386.7) / (60/51477.5) = 0.7

RR current use vs never use = (11/29922.0) / (60/51477.5) = 0.3

Ukuran-ukuran asosiasi
Ukuran rasio
Rasio odds (Odds ratio = OR)
Nama lain: Odds relative; rasio kros-produk
rasio dua odds yang digunakan dalam studi
kasus-kontrol untuk mengestimasi rasio rate atau
rasio risiko
Ukuran-ukuran asosiasi
Ukuran rasio
Rasio odds (Odds ratio = OR)
odds untuk satu kelompok dibagi dengan odds
untuk kelompok yang lain
Bisa diinterpretasikan sama seperti risiko relatif,
dg syarat tertentu (misal: incidence rendah
rare disease assumption)
Ukuran-ukuran asosiasi
Odds suatu kejadian
rasio probabilitas bahwa kejadian terjadi
terhadap probabilitas kejadian tidak terjadi
P = Probabilitas suatu kejadian terjadi
1 P = Probabilitas suatu kejadian tidak terjadi
P 1
P
peristiwa suatu Odds

=
THEN, FOLLOW TO SEE WHETHER
Totals
Incidence
rates
of
Disease
Disease
Develops

Disease
Does Not
Develop
Exposed a b a + b


Not
Exposed
c d c + d
FIRST,
SELECT
a
a+b
c
c+d
Incidence in
exposed
Incidence in
non-exposed
=
=
PROSPECTIVE STUDY
CASE CONTROL (REPROSPECTIVE STUDY)
CASES
( with
disease)

CONTROLS
( without
disease)
Were
Exposed
a b
Were Not
Exposed
c d
Totals a + c b + d
Proportion
exposed
a
a+c
b
b+d
FIRST,
SELECT
THEN,
MEASURE
PAST
EXPOSURE
=
Figure 11-5 A, Odds ratio (OR) in a cohort study. B, Odds ratio (OR) in a case-control study.
Downloaded from: StudentConsult (on 8 October 2009 11:44 AM)
2005 Elsevier
In case-control studies, the odds ratio is the ratio of the odds of the cases having been exposed
to the odds of the controls having been exposed, i.e:
In prospective studies, the odds ratio is the ratio of the odds of the exposed people developing
the disease to the odds non-exposed people developing the disease, i.e:
a
b
c
d
=
ad
bc
a
b
c
d
=
ad
bc
:
a
c
b
d
=
ad
bc
a
c
=
ad
bc
:
b
d
The odds ratio (Relative Odds)
Tabel 1. Tabulasi silang pemajan dan status sakit,
insidens sakit dan Probabilitas odds sakit
pada studi kohort.
Status sakit
Pemajan Sakit Tidak
sakit
Total Insiden sakit
(Risk)
Probabilitas odds sakit
+ a b a + b a/(a+b)
- c d c + d c/(c+d)
Total a + c b + d
a+b+c+d
b
a
b a
a
b a
a
=
|
.
|

\
|
+

+
1
d
c
d c
c
d c
c
=
|
.
|

\
|
+

+
1
Odds Ratio (OR) = Relative Odds = Cross
Product Ratio pada studi kasus kontrol
Faktor Kasus Kontrol Total
Perokok 650 (a) 950 (b) 1600
Bukan
perokok
50 (c) 350 (d) 400
Total 700 1300 2000
kontrol untuk pemajan Odds
kasus untuk pemajan Odds
Ratio Odds =
Odds Ratio (OR) = Relative
Odds
c x b
d x a
d
b
c
a
Ratio Odds = =
kontrol untuk pemajan Odds
kasus untuk pemajan Odds
Ratio Odds =
8 , 4
50 950
350 650
= = =
x
x
c x b
d x a
Ratio Odds
Perokok mempunyai risiko menjadi kasus 4,8 kali dari yang bukan
perokok.
Interpretasinya: odds perokok menjadi kasus 4,8 kali lebih besar
dari odds bukan perokok
Prevalence Odds Ratio (POR) = Cross Product
Ratio bila data didasarkan pada kasus-kasus
prevalens
Faktor Kasus Kontrol Total
Perokok 650 (a) 950 (b) 1600
Bukan
perokok
50 (c) 350 (d) 400
Total 700 1300 2000
8 , 4
50 950
350 650
Prevalence = =
x
x
Ratio Odds
25 , 3
125 , 0
40625 , 0
400 / 50
1600 / 650
) ( Prevalence = = = Ratio proportion
The odds ratio ( relative odds) is a good
approximation of the relative risk when :
1.The cases are representative of
all cases with regard to exposure;
2.The controls are representative
of all control with regard to
exposure;
3.The disease being studied is rare
=
Odds Ratio & Risk Ratio
The odds ratio will provide a good estimate of the
risk ratio when:

1. The outcome (disease) is rare
D
+
D
-
E
+
a b
E
-
c d
OR = (a / c) / (b / d)

OR = (ad) / (bc)

a / (a +b )
RR = ------------
c / (c +d)

If the disease is rare, then
cells (a) and (c) will be small
a / (a +b ) a / b ad
RR = ------------ = ------ =-- = OR
c / (c +d) c / d bc

Figure 11-6 Example: The odds ratio is a good estimate
of the relative risk when a disease is infrequent.
Downloaded from: StudentConsult (on 8 October 2009 11:44 AM)
2005 Elsevier
Figure 11-7 Example: The odds ratio is not a
good estimate of the relative risk when a
disease is not infrequent.
Downloaded from: StudentConsult (on 8 October 2009 11:44 AM)
2005 Elsevier
In a prospective study/cohort study,
the Relative Risk can be calculated
directly
In a retrospective study /case control
study , the RR cannot be calculated
directly, so that the Relative Odds or
ODDS RATIO ( Cross Products Ratio )
is used as an estimate of the RR, when
the risk of the disease is low
OR & RR
Pada penyakit yang jarang terjadi,nilai
Odds Ratio hampir sama dengan nilai
Relative Risk (Risk Ratio). Nilai
Prevalence Odds Ratio hampir sama
dengan nilai Prevalence Proportion Ratio.

Pada penyakit yang umum terjadi, nilai
Odds Ratio lebih ekstrim dari pada Risk
Ratio.
Incidence Odds Ratio (POR) = Cross Product
Ratio bila data didasarkan pada kasus-kasus
insidens
Faktor Sakit Tidak sakit Total
Perokok 20 (a) 980 (b) 1000
Bukan
perokok
10 (c) 990 (d) 1000
Total 30 1970 2000
02 , 2
980 10
990 20
I = =
x
x
Ratio Odds ncidence
00 , 2
01 , 0
02 , 0
1000 / 10
1000 / 20
) ( Incidence = = = Ratio risk proportion
Gerstman Chapter 8 (partial) 46
Interpretation of Odds Ratio
Relative odds associated with exposure
OR = 1 no association
OR > 1 positive association
OR < 1 negative association
Size of OR indicates strength of
association
OR RR when disease rare (i.e., risk <
5%); when disease not rare, OR still a
valid measure of association
RR < 1 RR = 1 RR > 1
Risk
comparison
between
exposed and
unexposed
Risk for disease
is lower in the
exposed than in
the unexposed
Risk of disease
are equal for
exposed and
unexposed
Risk for disease
is higher in the
exposed than in
the unexposed
Exposure as a
risk factor for
the disease?
Exposure
reduces disease
risk
(Protective
factor)
Particular
exposure is not a
risk factor
Exposure
increases
disease risk
(Risk factor)
Relative risk
RR OR
Attributable risk
AR PAR
Measure of
Association
Gerstman Chapter 8 (partial) 49
Epidemiology Kept Simple
Chapter 8
Measures of Association
If its not clear
Gordis Leon, M.D., M.P.H., Dr.P.H. 2009.
Epidemiolgy. W.B. Saunders Company.
Philadelphia ,Chapter 11

Epidemiology in Medicine. Henneckens CH,
Buring JE. Edited by Mayrent SL, Chapter 4