Charles R Drew University

Mervyn M. Dymally (MMD) School of Nursing

NUR 627: Advanced Epidemiology and Biostatistics for Nursing

Assignment 1 FALL 2017

Due OCTOBER 9, 2017

Please save the file with your last name before you attach to Black Board.

The test includes 40 questions for a total of 50 points. (20% of the course grade)

Please answer all the questions and provide rationale for the answer for each question using
your own words and show your calculations to get full credit.

1. Which of the following is a case-control study? [ONE POINT]

a. Study of past mortality or morbidity trends to permit estimates of the occurrence of
disease in the future -cohort study

b. Study of the incidence of cancer in men who have quit smoking-follow up study

c. Analysis of previous research in different places and under different circumstances to

permit the establishment of hypotheses based on cumulative knowledge of all known factors-
cross sectional study

d. Obtaining histories and other information from a group of known cases and from a
comparison group to determine the relative frequency of a characteristic or exposure
under study

e. Both a and c

this is case control study because we are dealing with known cases which makes the study a
case controlled study

2. In a study of a disease in which all cases that developed were ascertained, if the relative
risk for the association between a factor and the disease is equal to 1.0, then: [ONE
POINT]

a. There is no association between the factor and the disease

b. There is either no association or a negative association between the factor
and the disease
c. The factor protects against development of the disease
 d. Either matching or randomization has been unsuccessful
e. The comparison group used was unsuitable, and a valid comparison is not
possible

If the relative risk for association between a factor and the disease is 1, it means the factor is not
a risk for the disease.

3. A random sample of middle age sedentary males was selected from four census tracts, and
each man was examined for coronary artery disease. All those having the disease were
excluded from the study. All others were randomly assigned to either an exercise group,
which followed for a two-year program of systematic exercise, or to a control group, which
had no exercise program. Both groups were observed semiannually for any difference in
incidence of coronary heart disease.

What type of study (study design) you would assign to this information? Why?
[ONE POINT]

The study design suitable for this information is randomized controlled trial because we
can estimate relative risk, incidence and we can also measure any impact- Randomized
Clinical Trial

Questions 4 and 5 refer to the following information:

OUTCOME AFTER 10 YRS

At Beginning of Study CHD Developed CHD Did Not Develop

2,000 Healthy smokers 190 1,810

4,000 Healthy nonsmokers 35 3,965

The results of a 10-year cohort study of smoking and coronary heart disease (CHD) are shown
above:

4. The incidence of CHD in smokers that can be attributed to smoking is: [ONE POINT]

Attributable risk = incidence rate in the exposed incidence rate in the nonexposed
 Incidence rate among smokers =190 cases/2,000 population at risk x1,000= 95 per 1,000
Incidence rate among nonsmokers=35 cases /4,000 population at risk x1,000=8.75 or 9 per
1,000
95-8.75=86.25 or 86 cases of CHD per 1,000 population incidence of CHD in smokers
that can be attributed to smoking.

5. The proportion of the total incidence of CHD in smokers that is attributable to smoking
is: [ONE POINT]

The proportion of the incidence in the total population = (( incidence in exposed group
incidence in nonexposed group)/incidence in exposed group )x 100

Incidence rate among smokers = 190 cases/2,000 population at risk x 1000= 95 per 1,000

Incidence rate among nonsmokers = 35 cases/4,000 population at risk x 1000 = 8.75 or 9 per
1,000

190/2000-35/4000
/190/2000*100= 0.095-0.00875/ 0.095*100= 90.78% the proportion of the total incidence of
CHD in smokers that is attributed to smoking

6. All of the following are important criteria when making causal inferences except: [ONE
POINT]
a. Consistency with existing knowledge
b. Dose-response relationship
c. Predictive value
d. Consistency of association in several studies
e. Strength of association

Predictive value is not important when making casual inferences because in casual
inferences we are concluding about the conditions of occurrence of an effect.

7. All of the following are measures of process of health care in a clinic except: [ONE
POINT]
a. Proportion of patients in whom blood pressure is measured
b. Proportion of patients advised to stop smoking
c. Proportion of patients whose height and weight are measured
d. Proportion of patients who have complications of a disease
e. Proportion of patients whose bill is reduced because of financial need

Proportion is to adjust or regulate (something) so that it has a particular or suitable

relationship to something else

8. Colon cancer is diagnosed in 55 patients per year within a community of 10,000 unaffected
individuals. A screening test is applied to all residents of this community.
 What is the sensitivity (in %) of the screening test, if it detects 48 of the colon cancer
patients. What is the specificity if the test correctly determines that 9,650 of the
unaffected persons who do not have colon cancer? What is the positive predictive value?
What is the negative predictive value
[Interpret the results and show your calculations for full credit].

a. The sensitivity of the test is 48/55 = 0.87 x 100 = 87%, patient who were positive results

have colon cancer

b. The specificity of the test is 9650/9945 = 0.97

97% of people who tested negative didnt have cancer.

PPV = 48/343 = 0.139 Test Positive Test Negative

Actual Positive 48 7 = 55

Actual Negative 295 9650 = 9945

Total 343 9657 = 10,000

NPV = 9650/9657 = 0.999

So, 13.9% of the probability that people who were screened with a positive screen of colon

cancer was diagnosed with colon cancer and 99.9% the probability that people who were

screened with a negative screen of colon cancer and they dont have colon cancer

c. What are your overall comments about the validity of this test? [ONE POINT]

Going by the sensitivity, specificity, positive predictive and negative predictive values, we

see that it has a good validity.

9. Which of the following is not an advantage of a prospective cohort study? [ONE

POINT]

a. Precise measurement of exposure is possible

b. Incidence rates can be calculated
c. It usually costs less than a case-control study
d. Recall bias is minimized compared with a case-control study
e. Many disease outcomes can be studied simultaneously
 this is not the advantage of a prospective cohort study because the prospective cohort
study costs more than a case control study.
10. A major problem resulting from the lack of randomization in a cohort study is: [ONE
POINT]

a. The possibility that a greater proportion of people in the study may have been exposed
b. The possibility that a smaller proportion of people in the study may have been exposed
c. The possibility that a factor that led to the exposure, rather than the exposure
itself, might have caused the disease
d. That, without randomization, the study may take longer to carry out
e. Planned crossover is more likely

If we observe an association of an exposure with a disease, we are left with uncertainty as

to whether the association may be a result of the fact that people were not randomized to
the exposure, or whether it was factors that led people to be exposed, that are associated
with the disease

11. Which of the following is an approach to handling confounding? [ONE POINT]

a. Individual matching
b. Stratification
c. Group matching
d. Adjustment
e. All of the above

We can approach to handling confounding by individual matching, stratification, group matching

and adjustment, so the correct option is all of the above because all the equations are satisfied for
handling confounding

12. It has been suggested that physicians may examine women who use oral contraceptives
more often or more thoroughly than women who do not. If so, and if an association is
observed between phlebitis and oral contraceptive use, the association may be due to:
[ONE POINT]

a. Selection bias
b. Interviewer bias
c. Nonresponse bias
d. Recall bias
e. Surveillance bias

Surveillance bias what some texts call detection bias, occurs when one group is
followed more closely than the other group. This could lead to an outcome being
diagnosed more often in the more closely followed group, but not because it truly
occurred more often in that group
13. Residents of three villages with three different types of water supply were asked to
participate in a survey to identify cholera carriers. Because several cholera deaths had
occurred recently, virtually everyone present at the time underwent examination. The
 proportion of residents in each village who were carriers was computed and compared. What
is the proper classification for this study? [ONE POINT]

a. Case-control study
b. Concurrent cohort study
c. Non-concurrent cohort study
d. Cross-sectional study
e. Experimental study

this is cross sectional study because the sample was collected from three different villages, then
the data is studied to compute and compare the result for three villages

Question 14 is based on the information given below:

In a case-control study of the relationship of radiation exposure and thyroid cancer,
50 cases admitted for thyroid cancer and 100 controls admitted during the same
period for treatment of hernias were studied. Only the cases were interviewed, and
20 of the cases were found to have been exposed to x-ray therapy in the past, based
on the interviews and medical records. The controls were not interviewed, but a
review of their hospital records when they were admitted for hernia surgery
revealed that only 2 controls had been exposed to x-ray therapy in the past.
14. Based on the description given above, what source of bias is least likely to be present in
this study? [ONE POINT]

a. Recall bias
b. Bias due to loss of subjects from the control group over time
c. Bias due to controls being non-representative of the non-diseased population
d. Bias due to use of different methods of ascertainment of exposure in cases and controls
e. Selection bias for exposure to x-ray therapy in the past

Bias can occur when study cohorts have unequal losses to follow-up.
15. Of 2,000 persons who had received radiation treatment in childhood because of an enlarged
thymus, cancer of the thyroid developed in 30 and a benign thyroid tumor developed in 70.
A comparison group consisted of 6,000 children who had received no such treatment
(brothers and sisters of the children who had received radiation treatment). During the
follow-up period, none of the comparison group developed thyroid cancer, but benign thyroid
tumors developed in 15.

Calculate the relative risk for benign thyroid tumors. Using your own words, interpret the
relative risk. [ONE POINT]

Relative Risk = (70/2000) / (15/6000) = 0.035/0.0025 = 14

Persons who had received radiation treatment would be 14 times as likely as those with no
such treatment to develop benign thyroid.
16. The extent to which a specific health care treatment, service, procedure, program, or
other intervention does what it is intended to do when used in a community-dwelling
population is termed its: [ONE POINT]

a. Effectiveness
b. Effect modification
c. Efficiency
d. Efficacy
e. None of the above

Effectiveness is the ability of an intervention to have a meaningful effect on patients

in normal clinical conditions. Clinical trial measuring effectiveness are also called
pragmatic trials or phase III or IV clinical trials. Effectiveness studies (also known as
pragmatic studies) examine interventions under circumstances that more closely
approach real-world practice, with more heterogeneous patient populations, less-
standardized treatment protocols, and delivery in routine clinical settings.

17. The best index (indices) for concluding that an early detection program for breast
cancer truly improves the natural history of disease, 20 years after its initiation, would
be: [ONE POINT]

a. A smaller proportionate mortality for breast cancer 10 years after initiation of the early
detection program compared to the proportionate mortality prior to its initiation
b. A decrease in incidence of breast cancer
c. A decrease in the prevalence of breast cancer
d. Improved long-term survival rates for breast cancer patients (adjusted for lead
time)
e. None of the above

It is the best indices for concluding that an early detection program for breast cancer improves
the natural history of disease 20 years after its initiation.

18. In general, screening should be undertaken for diseases with the following feature(s):
[ONE POINT]

a. Diseases with a low prevalence in identifiable subgroups of the population

b. Diseases with a natural history that can be altered by medical intervention
c. Diseases for which case-fatality rates are low
d. Diseases that are readily diagnosed and for which treatment efficacy has been
shown to be equivocal in evidence from a number of clinical trials
e. None of the above

Epidemiological screening is to determine the risk factors associated with disease and
to find out the factors tat may protect the people from disease. These studies
cannot prove a specific risk factor that actually causes disease. In contrast, the
 epidemiological evidence shows that certain risk factors are associated with a
higher incidence of disease in population.

19. When a new treatment is developed that prevents death but does not produce recovery
from disease, the following will occur: (ONE POINT)

a. Prevalence of the disease will decrease

b. Prevalence of the disease will increase
c. Incidence of the disease will decrease
d. The incidence and the prevalence of the disease will decrease
e. Incidence of the disease will increase

Since the treatment is only preventing the deaths, but it is not good to control the prevalence of
disease or it is not good in recovering from the diseases. This will increase the number of
patients which means that the prevalence of disease will increase
20. The extent to which a specific health care treatment, service, procedure, program, or
other intervention produces a beneficial result under ideal controlled conditions is its:
[ONE POINT]

a. Effectiveness
b. Efficacy
c. Efficiency
d. Effect modification
e. None of the above

Efficacy is the ability to provide a beneficial effect. In healthcare, efficacy of a product to

yield therapeutic benefits is explored.

21. During August 2017, LA county health department received reports of 10 new cases of
hepatitis A. What additional information is needed to determine whether this group of
cases is an outbreak? [ONE POINT]

We need the median and total number of cases to determine whether this group of cases is an
outbreak. Surveillance records are utilized from department of health, hospital records, registries,
mortality statistics, national data, etc. and a survey can be conducted to figure out the
background of the disease in the county.

22. What are the different types of screening programs? Give example of each type. [ONE
POINT]

Unrecognized symptomatic disease screening: what IS making the person sick?

Ex. Iron deficiency
Disease screening: what WILL make the person sick?
Ex. mammogram
Risk factor screening: what MIGHT make the person sick
Ex. Smoking as risk factor for lung cancer
 Mass screening: screen a whole population
Ex. X-rays for TB
Multiple or multiphasic screening: use variety of screening tests on the same occasion
Ex. Annual health check up
Targeted screening: screen groups with specific exposures, used in environmental and
occupational health
Ex. Battery workers
Case finding screening: patients who consult a medical practitioner for another purpose
Ex. Checking of blood pressure of patients coming in for flu shots

23. What are the different types of biases that can occur in a screening program? Explain.
[ONE POINT]

There are two common types of biases

Information bias - data is not accurate, possibly due to faulty instruments, or possibly the data is
wrong.

Selection bias - the study population is not representative of the larger population, possibly
because of a poor sampling process, or because of a lot of individuals are lost to follow-up

Common biases in screening include: .

Lead time (information bias)- the systematic error of apparent increased survival from detecting
disease in an early stage
Length (information bias) - the systematic error from detecting disease with a long latency or
pre-clinical period
Referral/Volunteer bias (selection bias) - the systematic error from detecting disease in persons
who have a propensity to seek health care
Detection (information bias) - the detection of insignificant disease
Over diagnosis Bias: there is a false increase in rates of detection and diagnosis due to the
screening because the individuals conducting the screening have so much enthusiasm for the
program

24. Data on 2000 male respondents to the 2003 Health Information National Trends
Study were collected from October 2002 to April 2003 and analyzed in 2008 to examine the
associations among race/ethnicity, and the perception of the risk of developing prostate cancer
for African-American, Hispanic, and non-Hispanic white men aged 45 years without a history
of prostate cancer.

- What study design is been used for this study? Why? [ONE POINT]
Case control study
This is case control study because we have control the time period and the ethnicity group to
complete the study
Cross sectional study
25. What is justice? [ONE POINT]
A) Freedom to control their own actions
B) Protection from physical and psychological harm and exploitation
C) Participants right to self-determination
D) Right to fair treatment

Justice includes the right to fair treatment and the right to privacy.

26. Which can cause bias in a study? [ONE POINT]

a. Researcher subjectivity
b. Participants' truthful responses
c. Consistent methods of data collection
d. Adequate study design
Experimenter bias is a process where the researcher performing the research can influence the
results in order to portray a certain outcome.

27. What serves as the basis for regulations affecting research by the U.S.
government? [ONE POINT]

a. The Nuremberg Code

b. The Declaration of Helsinki
c. The Code of Ethics of the American Psychological Association
d. The Belmont Report

The Belmont report provides ethical principles and guidelines for protection of human subject of
research. The Nuremberg Code 10 codes for guidelines for experiments. The Declaration of
Helsinki is a set of ethical principle regarding human experimentation developed for medical
community by the World Medical Association. While The Code of Ethics of the American
Psychological Association applies only to psychologists activities that are part of their scientific,
educational or professional role as psychologist.

28. Explain the relationship between sensitivity and false negative results?
Give example (ONE POINT)

Specificity is the ability to correctly identify the risk of developing prostate cancer in a person
whereas false positive is the ability to incorrectly identify the risk of developing prostate cancer
in a person. For example, if we identify a person without risk of prostate cancer as low risk or
negligible risk, then this specificity. If we identify a person with risk of prostate cancer as a risk
free person, then this is false positive
Inversely proportional

29. Under what circumstances would it be desirable to minimize the percentage of

individuals with false negative results on a test? (ONE POINT)

When the disease under test is spreadable and progresses quickly, then it is desirable to minimize
the percentage of individuals with false negative
 30. Which indicator answers the following question from the patients: Given that I have a
positive test, what is my chance that I have the disease? [ONE POINT]

Positive predicative value which states the probability that a person with a positive result
will have or has the disease

31. A colleague informs the epidemiologist of a new screening test for the early detection of
lung cancer. How might the test be assessed before it is used by the general medical
community? [ONE POINT]
It can be assessed using the sensitivity, specificity and predictive values for a pilot sample
and based on the same it can be extended to general medical community.

32. All of the following are potential benefits of a randomized clinical trial, except: [ONE
POINT]

a. The likelihood that the study groups will be comparable is increased

b. Self-selection for a particular treatment is eliminated
c. The external validity of the study is increased
d. Assignment of the next subject cannot be predicted
e. The therapy that a subject receives is not influenced by either conscious or subconscious
bias of the investigator

All of the following are potential benefits of randomized clinical trial except the external validity
of the study is increased

33. The major purpose of random assignment in a clinical trial is to: [ONE POINT]
a. Help ensure that study subjects are representative of the general population
b. Facilitate double blinding (masking)
c. Reduce selection bias in the allocation of treatment
d. Ensure that the study groups have comparable baseline characteristics
e. Facilitate the measurement of outcome variables

The goal of randomization is to eliminate the possibility that the investigator will know what the
assignment of the next patient will be, because such knowledge introduces the possibility of bias
on the part of the investigator regarding the treatment group to which each participant will be
assigned.
34. Investigators conducted a retrospective cohort study to investigate outbreak of Hepatitis A in
San Diego. Use the results of the following table to answer the following questions:

Food Ate Did not eat

 A. Complete the following:

a. Attack rate (AR) for those who ate the specific identified food and those who did
not eat these food [ONE POINT]
See Table

b. The relative risk (RR) for each specific identified food [ONE POINT]
See Table

c. Which food is the most likely cause of the outbreak? Why? [ONE POINT]
Potato Salad is most likely the cause of outbreak because it has the maximum
value of RR as compared to the other foods.
And Chicken

d. What steps you will take after the identification of the source of outbreak? [ONE
POINT]
We should implement control measures and do preventive measures such as
Destroying Contaminated foods and Make sure of clean meal preparation.

35. Researchers select 200 patients with colon cancer and 200 patients without colon cancer. Of
the 200 patients with colon cancer, 45 smoke cigars while 15 of the 200 patients without
colon cancer smoke cigars. -Case Control Study

a. Calculate a measure of association between colon cancer and cigar smoking. Show
your work. [ONE POINT]

Colon Smoker Non-Smoker Total Incidence

Cancer
Yes 45 155 200 (45/200)=0.225
NO 15 185 200 (15/200)=0.075

Odds ratio: 45 x 185/ 15 x 155 = 8325/2325= 3.58

b. Interpret the measure of association you calculated. [ONE POINT]

A risk ratio of more than 1 suggests an increased risk of that outcome in the exposed
group therefore, smokers have an increased risk of incidence of colon cancer compared to
patients who did not smoke.
 Odds ratio is another measure of association that quantifies the relationship between an
exposure with 2 categories and a health outcome. It is sometimes called the cross product
ratio. The odds ratio of 3.58 and RR of 3 reflect a very strong association between patients
who smoke and patient who do not smoke in the occurrence of Colon CA. It shows that
subjects who smoked are 3.58 times the risk of colon cancer compared to subjects who did
not smoke.

36. To study the relationship between oral contraceptive use and ovarian cancer, CDC initiated a
case-control study the Cancer and Steroid Hormone Study. Case-patients were enrolled
through eight regional cancer registries participating in the Surveillance, Epidemiology, and
End Results (SEER) program of the National Cancer Institute.

a. What types of bias are of particular concern in this study? [ONE POINT]

Confounding, Information Bias, Selection Bias- Ascertainment bias of disease status and
Interviewer Bias
Selection and recall bias

b. What steps might you take to minimize these potential biases in this study? [ONE
POINT]

Enrolling all women with cases of newly diagnosed, histological confirmed, primary
ovarian cancer who resided in one of eight geographic areas covered by cancer registries.
Controls are randomly selected using numbers from same geographic areas.
CDC investigators conducted group sessions to train interviewers in the administration of
pretested standard questionnaire. Same interviewers and questionnaires were used for
control and cases. Neither cases nor controls were told of the specific a priori hypotheses
to be tested by the study. Recall bias of oral contraceptive exposure was minimized by
showing participants a book with photographs of all OC preparations ever marketed in
the United States and by using a calendar to relate contraceptive and reproductive
histories to other life events.

c. Under what circumstances would age be a confounder in this study? [ONE POINT]

In many epidemiologic studies, age is a confounding factor. Cofounding is the

misinterpretation of association between disease and its exposure. Age can be a
confounder in this study if the age is associated with the exposure to disease and with the
outcome which is ovarian cancer. Age was related both to OC use and to case-control
status

d. The primary purpose of this study was to measure and test the association between OC
use and ovarian cancer. The distribution of exposure to OCs among cases and controls is
shown in Table 2 below. From these data in table 2, can you calculate the risk of ovarian
cancer among oral contraceptive users? Provide rationale. [ONE POINT]
Table 2. Ever-use of oral contraceptives among ovarian cancer cases and controls,
Cases Controls
Ever 99 959
Never 80 683
Total 179 1642

We can calculate the risk of ovarian cancer among oral contraceptive using odds ratio to
estimate the measure of association in relation to ovarian cancer. Since this is a case
control study, we cannot directly calculate risk ratio, it is because we do not have the data
for the denominator. The data on b and d cells represent the control group. The odds ratio
is not a good approximation of risk ratio when the disease under study is not rare.

OR= ad/bc
OR=99*683/959*80=67,617/76,720=0.88

No, you cannot calculate the risk. This is a case control study. We are measuring
retrospectively the exposure.
37. What is effect modification? How do you look for effect modification in a study? [ONE
POINT]

When the odd ratio is different among different groups, then we say it effect
modification. We can look for the effect modification by checking the variable rate, i.e.
the rate can be positive or negative. The variable rate can affect the observed risk factor
of exposure to a disease.
For example, if the variable rate is positive, it can lead different age groups to have
unequal odds ratio.

38. The figures (1, 2, and 3) below represented the epidemiologic curve for outbreak
investigation. Discuss the type of source of the epidemic for each figure (TWO POINTS).

1. hours
2. days 3. weeks
1) First figure shows common point source because it has gradual downward slope and sharp
upward slopes
2) Second figure shows common persistent source because in this the people are exposed
continuously to common source which is also harmful to them
3) Third figure shows propagated source because it shows that the diseases is spreading from
one person to other persons.

39. Fill in the spaces: [ONE POINT]

The mean (X ) is a measure of Central Tendency of a distribution while the standard deviation
(SD) is a measure of dispersion of its scores. Both X and SD are descriptive statistics

40. The following list represents the number of nursing students enrolled in a particular nursing
program between the years of 2001 and 2007, respectively:
520, 563,610, 520, 573, 639, and 599.

Calculate the mean, median, and mode of the number of the nursing students enrolled in
the above program between 2001 and 2007. Show your calculations. [ONE POINT]

Mean=520+563+610+520+573+639+599/7=574.86 or 575, which is the number of the

sum of all the numbers divided by how many numbers are added.
Median=520, 520, 563, 573, 599, 610, 639=573, when numbers are arranged in order and
the median is the middle number.
Mode= 520, 520, 563, 573, 599, 610, 639= 520, is the most frequent occurring number.