Biases and errors in

Epidemiology
By
Dr Utpal Sharma
PG Student
Department of Community Medicine ,GMCH

ERROR: Definitions

A false or mistaken result obtained in a study or

experiment

. Random error is the portion of variation in

measurement that has no apparent connection to any
other measurement or variable, generally regarded as
due to chance
. Systematic error which often has a recognizable
source, e.g., a faulty measuring instrument, or pattern,
e.g., it is consistently wrong in a particular direction
(Last)

These errors are generally produced by

one or more of the following:
RANDOM ERROR
RANDOM MISCLASSIFICATION
BIAS
CONFOUNDING

Cont.

Random error
Deviation of results and inferences from the truth,
occurring only as a result of the operation of chance.
Can produce type 1 or type 2 errors.

Random (Non Differential Classification )

Misclassification
Random error applied to the measurement of an
exposure or outcome. Errors in classification can
only produce type 2 errors, except if applied to a
confounder or to an exposure gradient.

Bias
Error in design or execution of a study, which produces results that
are consistently distorted in one direction because of nonrandom
factors.
Bias can produce either a type 1 or a type 2 error, but we usually
focus on type 1 errors due to bias.
Bias can occur in RCTs but tends to be a much greater problem in
observational studies.

Confounding
It is defined as one which is associated with both the
exposure and the diseases, and is unequally distributed in
the study and the control groups

Bias and Confounding

Bias creates an association that is not true, but
confounding describes an association that is
true, but potentially misleading.

Relationship b/w Bias and Chance

No. of observations

BP measurement
(sphygmomanometer)

True BP
(intra-arterial cannula)

Chance
Bias

80

90

Diastolic Blood Pressure (mm Hg)

Properties of
measurement

Validity
The degree to which a measurement measures
what it purports to measure
(Last)

Degree to which the data measure what they

were intended to measure that is, the results
of a measurement correspond to the true state
of the phenomenon being measured
(Fletcher)

Also known as Accuracy

Reliability
The degree of stability expected when a measurement is
repeated under identical conditions; degree to which the
results obtained from a measurement procedure can be
replicated
(Last)

Extent to which repeated measurements of a stable

phenomenon by different people and instruments, at
different times and places get similar results
(Fletcher)

Also known as Reproduciblity and Precision

Validity and Reliability

VALIDITY
High

High
RELIABILITY

Low

Low

Types of bias
Selection bias is a distortion in the estimate of association
between risk factor and disease that results from how the
subjects are selected for the study.
Information bias is due to systematic measurement error or
misclassification of subjects on one or more variables, either
risk factor or disease status.
Confounding -results when the risk factor being studied is so
mixed up with other possible risk factors that its single effect is
very difficult to distinguish.

Selection bias
Non-response bias occurs because individuals who
do not respond to a call to participate in research
studies are generally different from those who do
respond.
Hospital admission rate bias- a selection bias
that rears its head when hospital-based studies,
especially casecontrol studies, are undertaken.

Berksonian bias - the problem is that

hospitalized individuals are more likely to suffer
from many illnesses, as well as more severe
illnesses, and engage in less than healthy
behaviors.

Cont

Exclusion bias occurs when in certain

circumstances epidemiologic studies
exclude participants to prevent
confounding.
If the
exclusion criteria are different for cases and
controls or different for the exposed and nonexposed, an exclusion bias may be introduced.

Publicity bias (awareness bias) occurs

when media attention is drawn to a
particular illness.
Publicity bias can occur from snippets of celebrities
or news reports not related to individuals.

Information Bias
Interviewer Bias an interviewers knowledge may
influence the structure of questions and the manner of
presentation, which may influence responses

Recall Bias those with a particular outcome or

exposure may remember events more clearly or amplify
their recollections

Cont

Observer Bias observers may have preconceived

expectations of what they should find in an examination

Loss to follow-up those that are lost to follow-up

or who withdraw from the study may be different from
those who are followed for the entire study

Reporting bias- occurs when a case emphasizes the

importance of exposures that he or she believes to be
important.

Cont

Hawthorne effect an effect first documented at a

Hawthorne manufacturing plant; people act differently if
they know they are being watched

Surveillance bias the group with the known

exposure or outcome may be followed more closely or
longer than the comparison group

Lead time bias

Lead time is the period of time b/w the detection of a
medical condition by screening and when it ordinarily
would be diagnosed because a pt. experiences
symptoms and seeks medical care
As a result of screening, on an average, pt will survive
longer from the time of diagnosis than who are
diagnosed otherwise, even if T/t is not effective.
Not more survival time, but more disease time

How lead time affects survival time

Unscreened

Diag

Screened
Early T/t not effective

Diag

Screened
Early T/t is effective

Diag

Onset of Ds

Death

Survival after
diagnosis

Confounding
When another exposure exists in the study population
(besides the one being studied) and is associated both with
disease and the exposure being studied. If this extraneous
factor itself a determinant of or risk factor for health outcome
is unequally distributed b/w the exposure subgroups, it can
lead to confounding
(Beaglehole)
Confounder must be..
1. Risk factor among the unexposed (itself a determinant of
disease)
2. Associated with the exposure under study
3. Unequally distributed among the exposed and the
unexposed groups

Examples confounding

COFFEE DRINKING

HEART DISEASE

(Smoking increases
the risk of heart ds)

(Coffee drinkers are

more likely to smoke)

SMOKING

Methods for controlling Selection Bias

During Study Design
1. Randomization
2. Restriction
3. Matching
During analysis
4. Stratification
5. Standardization

Restriction
Subjects chosen for study are restricted to only those
possessing a narrow range of characteristics, to
equalize important extraneous factors
Limitation: generalisability is compromised; by
excluding potential subjects, cohorts / groups
selected may be unusual and not representative of
most patients or people with condition
Example :OCP example - restrict study to women
having at least one child

Matching
The process of making a study group and a comparison
group comparable with respect to extraneous factors
(Last)
For each patient in one group there are one or more
patients in the comparison group with same
characteristics, except for the factor of interest
(Fletcher)

Cont

Matching is often done for age, sex, race, place of

residence, severity of disease, rate of progression
of disease, previous treatment received etc.
Limitations:
- Controls for bias for only those factors involved in
the match
- Usually not possible to match for more than a few
factors because of the practical difficulties of
finding patients that meet all matching criteria

Stratification
The process of or the result of separating a sample
into several sub-samples according to specified
criteria such as age groups, socio-economic status
etc.
(Last)
The effect of confounding variables may be
controlled by stratifying the analysis of results
After data are collected, they can be analyzed and
results presented according to subgroups of
patients, or strata, of similar characteristics
(Fletcher)

Standardization
A set of techniques used to remove as far as possible
the effects of differences in age or other confounding
variables when comparing two or more populations
The method uses weighted averages of rates specific
for age, sex, or some other potentially confounding
variable(s), according to some specified distribution
of these variables
(Last)

Dealing with measurement bias

1.
-.
-.
-.

Blinding
Subject
Observer / interviewer
Analyser

2. Strict definition / standard definition for

exposure / disease / outcome
3. Equal efforts to discover events equally in all
the groups

Controlling confounding
Similar to controlling for selection bias
Use randomization, restriction, matching,
stratification, standardization etc.