Rearranging Stata s output for the analysis of epidemiological tables

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Rearranging Stata s output for the analysis of epidemiological tables 5ª Reunión de Usuarios Españoles de Stata Barcelona, 12/09/2012 Aurelio Tobías IDAEA-CSIC, Barcelona aurelio.tobias@gmail.com http://aureliotobias.weebly.com/

Background In epidemiological research we usually investigate the relationship between a binary response (C/nC) and a binary exposure (E/nE) Risk Exposure Outcome

Background A major capability in Stata is the analysis of epidemiological tables by using any of the epitab commands These report measures of frequency (proportion or odds), association (risk difference, relative risk, or odds ratio) and impact on public health (attributable risks)

. use example 1, clear Contains data from example1.dta obs: 8 vars: 4 ------------------------------------------------------------------------------- storage display value variable name type format label variable label ------------------------------------------------------------------------------- y byte %8.0g cc Response x byte %8.0g yn Exposure z byte %8.0g yn Other N int %8.0g Sample size -------------------------------------------------------------------------------. list, noobs +---------------------------+ y x z N --------------------------- control no no 131 control no yes 234 control yes no 650 control yes yes 295 case no no 122 case no yes 78 case yes no 660 case yes yes 450 +---------------------------+. expand N (2612 observations created)

. cs y x Exposure Exposed Unexposed Total -----------------+------------------------+------------ Cases 1110 200 1310 Noncases 945 365 1310 -----------------+------------------------+------------ Total 2055 565 2620 Risk.540146.3539823.5 Point estimate [95% Conf. Interval] ------------------------+------------------------ Risk difference.1861637.1412291.2310982 Risk ratio 1.525912 1.355638 1.717574 Attr. frac. ex..3446544.2623399.4177835 Attr. frac. pop.2920354 +------------------------------------------------- chi2(1) = 61.43 Pr>chi2 = 0.0000

. cc y x Proportion Exposed Unexposed Total Exposed -----------------+------------------------+------------------------ Cases 1110 200 1310 0.8473 Controls 945 365 1310 0.7214 -----------------+------------------------+------------------------ Total 2055 565 2620 0.7844 Point estimate [95% Conf. Interval] ------------------------+------------------------ Odds ratio 2.143651 1.759248 2.612501 Attr. frac. ex..5335061.4315754.617225 Attr. frac. pop.4520548 +------------------------------------------------- chi2(1) = 61.43 Pr>chi2 = 0.0000

. cc y x Exposed Unexposed Total -----------------+------------------------+------------ Cases 1110 200 1310 Controls 945 365 1310 -----------------+------------------------+------------ Total 2055 565 2620 Odds.54795 1.17460 Point estimate [95% Conf. Interval] ------------------------+------------------------ Odds ratio 2.143651 1.759248 2.612501 Attr. frac. ex..5335061.4315754.617225 Attr. frac. pop.4520548 +------------------------------------------------- chi2(1) = 61.43 Pr>chi2 = 0.0000

. tabodds y x -------------------------------------------------------------------------- x cases controls odds [95% Conf. Interval] ------------+------------------------------------------------------------- no 200 365 0.54795 0.46116 0.65106 yes 1110 945 1.17460 1.07700 1.28105 --------------------------------------------------------------------------. tabodds y x, or --------------------------------------------------------------------------- x Odds Ratio chi2 P>chi2 [95% Conf. Interval] -------------+------------------------------------------------------------- no 1.000000.... yes 2.143651 61.41 0.0000 1.763229 2.606149 ---------------------------------------------------------------------------. mhodds y x Maximum likelihood estimate of the odds ratio Comparing x==1 vs. x==0 ---------------------------------------------------------------- Odds Ratio chi2(1) P>chi2 [95% Conf. Interval] ---------------------------------------------------------------- 2.143651 61.41 0.0000 1.763229 2.606149 ----------------------------------------------------------------

Stratified analysis But... there could be more variables involved in this relationship Risk? Exposure Outcome Third variable

Stratified analysis Analyse the relationship between the binary response (C/nC) and the binary exposure (E/nE) for each stratum taken by a third variable (M/F) Third variable Exposure M Exposure F Risk M Risk F Outcome M Outcome F

Stratified analysis Analyse the relationship between the binary response (C/nC) and the binary exposure (E/nE) for each stratum taken by a third variable (M/F) Third variable Exposure M Exposure F Risk M Risk F Outcome M Outcome F Do specific-stratum estimates look similar?

Effect modification Variation in the magnitude of measure of effect across stratums of a third variable (subgroups of population) Can be tested for by using an statistical test for homogeneity

How to conduct an stratified analysis? Crude analysis Stratified analysis Do stratum-specific estimates look similar? YES NO EFFECT MODIFICATION (Report estimates by stratum)

How to conduct an stratified analysis? Crude analysis Stratified analysis Do stratum-specific estimates look similar? YES NO EFFECT MODIFICATION (Report estimates by stratum)

Confounding Distortion in the of measure of effect because of a third variable Exposure Outcome Third variable Be associated with outcome, independently of exposure Be associated with exposure, without being the consequence of exposure

Confounding A confounder influences (bias) the effect of a exposure in the same way for everyone Needs to be adjusted for There is not statistical test to check for confounding, it is usually assessed by comparing crude and adjusted estimates

How to conduct an stratified analysis? Crude analysis Stratified analysis Do stratum-specific estimates look similar? YES Adjusted analysis Do adjusted estimates look similar to crude estimates? NO EFFECT MODIFICATION (Report estimates by stratum)

How to conduct an stratified analysis? Crude analysis Stratified analysis Do stratum-specific estimates look similar? YES Adjusted analysis Do adjusted estimates look similar to crude estimates? NO EFFECT MODIFICATION (Report estimates by stratum) YES NO CONFOUNDING (Report adjusted estimates)

Stratified analysis Any of the epitab commands jointly with the by() option allow to run stratified analyses reporting; specific stratum measures of association, a test of homogeneity, as well as the crude and adjusted estimates These allow to epidemiologists to check for effect modification or to assess for confounding However users are still being confused about how Stata reports stratified analyses

. cc y x, by(z) Other OR [95% Conf. Interval] M-H Weight -----------------+------------------------------------------------- no 1.09029.8252907 1.440924 50.73576 yes 4.576271 3.375437 6.229908 21.76916 -----------------+------------------------------------------------- Crude 2.143651 1.759248 2.612501 M-H combined 2.136934 1.76373 2.589109 ------------------------------------------------------------------- Test of homogeneity (M-H) chi2(1) = 49.52 Pr>chi2 = 0.0000 Test that combined OR = 1: Mantel-Haenszel chi2(1) = 62.88 Pr>chi2 = 0.0000

. cc y x, by(z) Other OR [95% Conf. Interval] M-H Weight -----------------+------------------------------------------------- no 1.09029.8252907 1.440924 50.73576 yes 4.576271 3.375437 6.229908 21.76916 -----------------+------------------------------------------------- Crude 2.143651 1.759248 2.612501 M-H combined 2.136934 1.76373 2.589109 ------------------------------------------------------------------- Test of homogeneity (M-H) chi2(1) = 49.52 Pr>chi2 = 0.0000 Test that combined OR = 1: Mantel-Haenszel chi2(1) = 62.88 Pr>chi2 = 0.0000 Do stratum-specific estimates look similar? Misleading p-value

. cc y x, by(z) Other OR [95% Conf. Interval] M-H Weight -----------------+------------------------------------------------- no 1.09029.8252907 1.440924 50.73576 yes 4.576271 3.375437 6.229908 21.76916 -----------------+------------------------------------------------- Crude 2.143651 1.759248 2.612501 M-H combined 2.136934 1.76373 2.589109 ------------------------------------------------------------------- Test of homogeneity (M-H) chi2(1) = 49.52 Pr>chi2 = 0.0000 Test that combined OR = 1: H 0 : OR=1 Mantel-Haenszel chi2(1) = 62.88 Pr>chi2 = 0.0000 Misleading p-value

. cc y x, by(z) Other OR [95% Conf. Interval] M-H Weight -----------------+------------------------------------------------- no 1.09029.8252907 1.440924 50.73576 yes 4.576271 3.375437 6.229908 21.76916 -----------------+------------------------------------------------- Crude 2.143651 1.759248 2.612501 M-H combined 2.136934 1.76373 2.589109 ------------------------------------------------------------------- Test of homogeneity (M-H) chi2(1) = 49.52 Pr>chi2 = 0.0000 Test that combined OR = 1: Mantel-Haenszel chi2(1) = 62.88 Pr>chi2 = 0.0000 Misleading p-values No p-values for specific-stratum and crude estimates Missing the relative change between the crude and adjusted estimates

. mhodds y x, by(z) Maximum likelihood estimate of the odds ratio Comparing x==1 vs. x==0 by z ------------------------------------------------------------------------------- z Odds Ratio chi2(1) P>chi2 [95% Conf. Interval] ----------+-------------------------------------------------------------------- no 1.090290 0.40 0.5294 0.83276 1.42746 yes 4.576271 110.14 0.0000 3.34905 6.25319 ------------------------------------------------------------------------------- Mantel-Haenszel estimate controlling for z ---------------------------------------------------------------- Odds Ratio chi2(1) P>chi2 [95% Conf. Interval] ---------------------------------------------------------------- 2.136934 62.88 0.0000 1.763202 2.589884 ---------------------------------------------------------------- Test of homogeneity of ORs (approx): chi2(1) = 48.86 Pr>chi2 = 0.0000

. mhodds y x, by(z) Maximum likelihood estimate of the odds ratio Comparing x==1 vs. x==0 by z ------------------------------------------------------------------------------- z Odds Ratio chi2(1) P>chi2 [95% Conf. Interval] ----------+-------------------------------------------------------------------- no 1.090290 0.40 0.5294 0.83276 1.42746 yes 4.576271 110.14 0.0000 3.34905 6.25319 ------------------------------------------------------------------------------- Mantel-Haenszel estimate controlling for z ---------------------------------------------------------------- Odds Ratio chi2(1) P>chi2 [95% Conf. Interval] ---------------------------------------------------------------- 2.136934 62.88 0.0000 1.763202 2.589884 ---------------------------------------------------------------- Test of homogeneity of ORs (approx): chi2(1) = 48.86 Pr>chi2 = 0.0000 Do stratum-specific estimates look similar? Another misleading p-value

. mhodds y x, by(z) Maximum likelihood estimate of the odds ratio Comparing x==1 vs. x==0 by z ------------------------------------------------------------------------------- z Odds Ratio chi2(1) P>chi2 [95% Conf. Interval] ----------+-------------------------------------------------------------------- no 1.090290 0.40 0.5294 0.83276 1.42746 yes 4.576271 110.14 0.0000 3.34905 6.25319 ------------------------------------------------------------------------------- Mantel-Haenszel estimate controlling for z ---------------------------------------------------------------- Odds Ratio chi2(1) P>chi2 [95% Conf. Interval] ---------------------------------------------------------------- 2.136934 62.88 0.0000 1.763202 2.589884 ---------------------------------------------------------------- Test of homogeneity of ORs (approx): chi2(1) = 48.86 Pr>chi2 = 0.0000 Another misleading p-value Missing the crude estimate, and the relative change between the crude and adjusted estimates

Rearranging the output Rearrange the output of the epitab commands from the scheme of a classic epidemiological analysis Specific stratum estimates, with 95%CI and p-values Test of homogeneity (to check for effect modification) Crude and adjusted estimates, with 95%CI and p-values Relative change between them (to assess for confounding)

. mymhodds y x, by(z) Stratified analysis with test for effect modification ----------------------------------------------------------------------------- z Odds Ratio [95% Conf. Interval] chi2(1) P>chi2 -----------+----------------------------------------------------------------- no 1.09029.832758 1.42746 0.40 0.5294 yes 4.57627 3.34905 6.25319 110.14 0.0000 ----------------------------------------------------------------------------- Test of homogeneity of ORs (approx): chi2(1) = 48.86, P>chi2 = 0.0000 Adjusted analysis with assessment for confounding ----------------------------------------------------------------------------- Odds Ratio [95% Conf. Interval] chi2(1) P>chi2 -----------+----------------------------------------------------------------- Crude 2.14365 1.76323 2.60615 61.41 0.0000 Adjusted 2.13693 1.7632 2.58988 62.88 0.0000 ----------------------------------------------------------------------------- Adjusted/crude relative change = -0.31%

. use example2, clear. expand N (2612 observations created). mymhodds y x, by(z) Stratified analysis with test for effect modification ----------------------------------------------------------------------------- z Odds Ratio [95% Conf. Interval] chi2(1) P>chi2 -----------+----------------------------------------------------------------- no 5.57126 3.45525 8.98315 63.13 0.0000 yes 5.61665 3.42494 9.21089 59.58 0.0000 ----------------------------------------------------------------------------- Test of homogeneity of ORs (approx): chi2(1) = 0.00, P>chi2 = 0.9815 Adjusted analysis with assessment for confounding ----------------------------------------------------------------------------- Odds Ratio [95% Conf. Interval] chi2(1) P>chi2 -----------+----------------------------------------------------------------- Crude 2.14365 1.76323 2.60615 61.41 0.0000 Adjusted 5.59398 3.96622 7.88980 122.56 0.0000 ----------------------------------------------------------------------------- Adjusted/crude relative change = 160.96%

Rearranging the output Rearrange the output of the epitab commands from the scheme of a classic epidemiological analysis Specific stratum estimates, with 95%CI and p-values Test of homogeneity (to check for effect modification) Crude and adjusted estimates, with 95%CI and p-values Relative change between them (to assess for confounding) Furthermore, graphs are always helpful and nice!

. use example1, clear. expand N. mymhodds y x, by(z) graphs

. use example1, clear. expand N. mymhodds y x, by(z) graphs. use example2, clear. expand N. mymhodds y x, by(z) graphs

Conclusions Stata is mainly used in epidemiological research thanks to the epitab commands The cc command must also display the odds epitab commands with capabilities to run stratified analysis with the by() option (cs, cc, ir, and mhodds) must rearrange their output to address effect modification and confounding in a easiest way diagt (SJ4-4) command should also be included in epitab to cover all types of study designs in epidemiological research

Rearranging Stata s output for the analysis of epidemiological tables 5ª Reunión de Usuarios Españoles de Stata Barcelona, 12/09/2012 Aurelio Tobías IDAEA-CSIC, Barcelona aurelio.tobias@gmail.com http://aureliotobias.weebly.com/

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