1. Measures of Impact Lazareto, Menorca, Spain Sept 2006 L Petersen 1999, T Grein 2000-2004, M Valenciano 2005-2006

2. You are in charge of health prevention Want to reduce automobile-related deaths Limited budget but want to have the greatest impact on reducing deaths Cohort study to examine causes for automobile-related deaths

3. RR = 5.0 0.00000050 0.00000010 0.50 0.10 % exposed to risk factor?

4. Measures of Impact Measures of association providing information about absolute effects of exposure Reflect apparent contribution of an exposure to the frequency of disease Three concepts -Attributable risk among exposed -Prevented fraction among exposed -Population attributable risk

5. Attributable risk (AR)

6. Attributable Risk (AR) Quantifies disease burden in exposed group attributable to exposure Provides answers to -what is the risk attributed to the exposure? -what is the excess risk due to the exposure? Calculated as risk difference (RD)

7. Attributable Risk I exposed – I unexposed I = Incidence

8. Dead Not dead Risk RD Fast 100 1900 2000 0.05 0.04 Slow 80 7920 8000 0.01 180 9820 10000 AR: Fast driving

9. Dead Not dead Risk RD Fast 100 1900 2000 0.05 0.04 Slow 80 7920 8000 0.01 180 9820 10000 AR: Fast driving

10. Drunk 45 255 300 0.150 0.136 Not d. 135 9565 9700 0.014 180 9820 10000 AR: Drunk driving Dead Not dead Risk RD

11. Drunk 45 255 300 0.150 0.136 Not d. 135 9565 9700 0.014 180 9820 10000 AR: Drunk driving Dead Not dead Risk RD

12. Attributable Risk Percent (AR%) Etiologic fraction Attributable risk expressed as a percentage of risk in exposed What is the proportion of disease among the exposed which … -can be attributed to the exposure? -could be avoided by eliminating the exposure? Synonyms -Attributable proportion -Attributable fraction -Etiologic fraction (EF)

13. Attributable Risk Percent (AR%) %

14. Dead Not dead Risk AR% Fast 100 1900 2000 0.050 0.050- 0.010 0.050 = 80% Slow 80 7920 8000 0.010 180 9820 10000 AR%: Fast driving

15. Dead Not dead Risk AR% Drunk 45 255 300 0.150 Not d. 135 9565 9700 0.014 180 9820 10000 AR%: Drunk driving 0.150- 0.014 0.150 = 91%

16. No direct estimate of risk in case control studies. Cannot compute impact measures hee, hee....

17. AR & AR% in Case-Control Studies No risk estimates in case-control study -Attributable risk (risk difference) -and AR percent calculation not possible

18. AR & AR% in Case-Control Studies No direct risk estimates in case-control study -AR (risk difference) and AR% calculation not possible If odds ratio approximates relative risk, then Yes, if you have a good control group...

19. Prevented fraction

20. Prevented Fraction (PF) For exposures associated with decreased risk If relative risk <1 -exposure is protective Proportion of potential cases -which would have occurred if the exposure had been absent -prevented by the exposure

21. Prevented fraction Unexposed

22. PF: Vaccine efficacy

23. Expected number of cases among vaccinated if unvaccinated Observed number of cases 150 Estimated number of cases prevented 369 (72%)

24. Population attributable risk

25. Excess risk of disease in total population attributable to exposure Reduction in risk achieved if population entirely unexposed Helps determining exposures relevant to public health in community Population Attributable Risk (PAR)

26. Population Attributable Risk

27. Proportion of cases in the population attributable to the exposure PAR expressed as a percentage of total risk in population Population Attributable Risk Percent (PAR%) (Population Attributable Fraction)

28. Population Attributable Risk Percent (PAR%) where P = proportion population exposed

29. Dead Not dead Risk Fast 100 1900 2000 0.050 Slow 80 7920 8000 0.010 180 9820 10000 0.018 PAR%: Fast driving

30. Dead Not dead Risk Drunk 45 255 300 0.150 Not d. 135 9565 9700 0.014 180 9820 10000 0.018 PAR%: Drunk driving

31. Conclude Driving related deaths in population -44% presumably due to fast driving -22% presumably due to drunk driving

32. PAR% in USA and Italy for cervical cancer, various risk factors Source, Parazzini et al. 1990

33. PAR% in case control studies Cohort study Case-control study If % controls exposed % population exposed where P = % population exposed where P con = % controls exposed

34. Summary Among exposed -Attributable risk -Attributable risk percent -Prevented fraction In the population -Population Attributable Risk -Population Attributable Risk percent

35. Summary Where will you put your money to have the greatest impact on reducing automobile-related deaths?

36. What is the Appropriate Measure? "Control of prostitution will prevent most heterosexual HIV transmission! "He got lung cancer… But he probably would have gotten lung cancer anyway even if he didn't smoke. "Should I fly Georgian Airlines or Lufthansa?"

38. I population = Pe(I exposed ) + (1-Pe)I unexposed Divide numerator and denominator by Iunexposed