Practical Biostatistics: A Friendly Step-by-Step Approach for Evidence-based Medicine

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First edition 2012

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Foreword

Our increasing awareness of biological mechanisms that underlie disease has vastly increased the possibility of performing clinical trials, epidemiological studies, and tests of new approaches to diagnosis and treatment. This, in turn, raises a major need for the investigator to understand the statistical principles that underlie the design, execution, and data analysis related to clinical research studies. Dr. Suchmacher and Dr. Geller have provided a practical and highly approachable guide to biostatistics in their book Practical Biostatistics. The first section will guide the reader through the steps involved in clinical trial design, including design principles, sample size calculation, choosing the most appropriate test, and hypothesis testing. The presentation is both concise and highly pragmatic, and includes self-evaluation questions with annotated answers. The other sections cover a variety of biostatistical issues, such as association studies, benefit-risk analysis, evaluation of diagnostic tests, approaches to meta-analysis, and correlation and regression analysis.

Although this book will not substitute for the need to collaborate with colleagues who have formal training in biostatistics, it will go a long way towards preparing the clinical investigator to design and carry out better studies. It will also prepare the investigator to work more productively with biostatistical experts. This book answers a real need in clinical research, and will be a welcome addition to the training armamentarium for clinical investigators.

Bruce Korf

Wayne H. and Sara Crews Finley

Professor of Medical Genetics

Chair, Department of Genetics

University of Alabama at Birmingham

USA

Preface

Clinical research has been evolving worldwide at an accelerated pace, over the last 30 years. The growing number of published papers, motivated by postgraduate programs or sponsored by official research incentive programs or pharmaceutical companies, is paralleled by regulatory demands based on sound scientific quality standards, considered undetachable from their ethical nature.

Even though engaged healthcare professionals and students, as well as professional clinical researchers, strive to accomplish the high technical skills demanded, some of them face difficulties in mastering biostatistics tools. These tools are necessary to critically interpret and assess papers already published, as well as to correctly develop and publish their own.

Driven by our own professional demands, we have been facing the challenge of assimilating mathematical concepts through Biostatistics-specialized literature, personal guidance, and clinical trials reading. Over the years, we continually documented the lessons learned until we reached the point where we noticed we had accumulated a significant body of knowledge, shareable with our colleagues. We then decided to organize, review (with the aid of a biostatistician) and publish it. By providing the project with Microsoft Office's Excel 2010 resources, we were able to propose a bridge between Biostatistics and the common technology user.

Obviously, we do not mean to exhaust the subject through this publication, but simply to make a didactic reference available to all professionals committed to the development of healthcare sciences who need to assimilate Biostatistical knowledge. Let them know this source was written by healthcare professionals just like them, who face the same difficulties as theirs. As a consequence, they are able to better interpret the literature necessary to compose their own studies, improve communication with the supporting biostatistician, and present their research as proficiently as possible.

We hope we achieved our goal, and that this modest contribution might be helpful to our readers.

Mendel Suchmacher

Mauro Geller

Acknowledgments

My mother, for taking me by the hand up to the point I could go on with my own feet.

My wife Ester and my son Renan, who accepted sacrificing our shared time so that this project could become a reality.

Luiz Claudio S. Brillanti and Renan Suchmacher, for their contribution to cover art and illustrations.

Joshua Dahlben (NYU) for language review of the manuscript.

Our patients, the very reason this book came into existence.

Table of Contents

Cover Image

Title

Copyright

Foreword

Preface

Acknowledgments

Part I Introduction

Chapter 1. Study Type Determination

1.1 Epidemiological Studies

1.2 Analytical Studies

1.3 Summary of Study Types

Suggested Reading

Part II. Observational Studies

Chapter 2. Determination of Association Strength between an Exposure Factor and an Event in Observational Studies

2.1 Case–Control Studies

2.2 Cohort Studies

Chapter 3. Increasing Accuracy in Observational Studies

3.1 Stratified Analysis

3.2 Multivariable Analysis

Suggested Reading

Part III. Step-by-Step Biostatistics of a Clinical Trial

Chapter 4. Step 1: Investigator’s Hypothesis and Expression of its Corresponding Outcome

Chapter 5. Step 2: Estimation and Assessment of a Published Trial

5.1 Factors Influencing n Determination

5.2 n Calculation

5.3 Assessing n of a Published Trial

Chapter 6. Step 3: Organization of Variables and Endpoints

6.1 Qualitative Variables

6.2 Quantitative Variables

Chapter 7. Step 4: Measures for Results Expression of a Clinical Trial

7.1 Central Tendency Measures

7.2 Dispersal Measures

7.3 Position Measures: Quantiles

Appendix 7.1 How to Calculate Mean Using Microsoft Excel (Section 7.1.1)

Appendix 7.2 How to Trim The Mean of Outliers (Section 7.1.1)

Appendix 7.3 How to Determine Median Using Microsoft Excel (Section 7.1.2)

Appendix 7.4 How to Determine Mode Using Microsoft Excel (Section 7.1.3)

Appendix 7.5 How to Calculate Standard Deviation Using Microsoft Excel (Section 7.2.2)

Appendix 7.6 How to Find the Exact BMI that Corresponds to the 90th Percentile using Microsoft Excel (Section 7.3)

Appendix 7.7 How to Put all BMIs in a Rank and Percentile Perspective using Microsoft Excel (Section 7.3)

Chapter 8. Step 5: Determination of Normality or Non-Normality of Data Distribution

Appendix 8.1 How to Verify Normality of a Graph Curve Using Microsoft Excel

Chapter 9. Step 6: Hypothesis Testing

9.1 Parametric Tests for Independent and Dependent Samples

9.2 Nonparametric Tests

Chapter 10. Step 7: Correlating Sample Data with the General Population – 95% Confidence Interval

10.1 Point Estimation

10.2 Interval Estimation (95% Confidence Interval)

Appendix 10.1 How to Determine Confidence Intervals Using Microsoft Excel (Sample A)

Suggested Reading

Part IV. Additional Concepts in Biostatistics

Chapter 11. Individual and Collective Benefit and Risk Indexes Inferable from Intervention Studies

11.1 Treatment Effect Indexes

11.2 Clinical Decision Analysis Indexes

Chapter 12. Statistical Assessment of Diagnostic Tests for the Clinic

12.1 Detection Capacity Indexes

12.2 Diagnostic Significance Indexes

Chapter 13. Systematic Reviews and Meta-Analyses

13.1 Definitions

13.2 Systematic Review

13.3 Meta-Analysis

13.4 Options if Meta-Analysis Performance is not Advisable

13.5 Systematic Review/Meta-Analysis Limitations

13.6 Systematic Review/Meta-Analysis Stages Summary

13.7 Suggested Resources and Literary Sources

Chapter 14. Correlation and Regression

14.1 Correlation

14.2 Regression

14.3 Multiple Linear Regression

Appendix 14.1 How to Build a Scatterplot and to Add a Trend Line Using Microsoft Excel

Appendix 14.2 How to Calculate Pearson’s Correlation Coefficient Using Microsoft Excel

Appendix 14.3 How to Predict a Dependent Variable Using Microsoft Excel

Chapter 15. Per Protocol Analysis and Intention to Treat Analysis

Suggested Reading

APPENDIX. Microsoft Excel 2010 Basics

A.1 Structure and Main Features of a Microsoft Excel 2010 Worksheet

A.2 Location of Statistical Resources

A.3 Building a Plain Table

A.4 Building a Basic Chart

A.5 Building a Chart Out of a Table

A.6 Pivot Table

Suggested Reading

Glossary

Index

Part I. Introduction

Chapter 1 Study Type Determination

Part I

Introduction

The objective of Part I is to instruct the reader on how to choose the study type that best fits his or her research goals and material resources as well as how to determine the study type of a given paper.

Chapter 1

Study Type Determination

A crucial stage in research planning is to determine the most suitable study type, according to the investigator’s hypothesis (Chapter 4) and material resources available. A proposed classification of study types for epidemiological and clinical research is detailed in this chapter.

1.1 Epidemiological Studies

Epidemiological studies aim to establish the frequency of a condition in a given population. In this type of study, establishing reliable risk or etiological correlations is not possible because precise consistency between risk factors exposure or nonexposure, as well as between affected or nonaffected groups, cannot be achieved. For this reason, epidemiological studies remain mostly limited to measuring frequencies. Suspected risk correlations should be clarified through analytical studies.

Epidemiological studies can be classified into three types: ecological studies, cross-sectional studies, and longitudinal studies.

1.1.1 Ecological Studies

Ecological studies aim to determine the frequency of a given condition, supposedly associated with some environmental factor, during parallel or subsequent past time spans. For example, during the past 3 years, students from school A, which is located in an underprivileged district, have been presenting a higher frequency of upper respiratory virus infection compared to students from school B, which is located in a middle-class district, whose frequency is considered usual.

1.1.2 Cross-Sectional Studies

In cross-sectional studies, the frequency of a given condition in a naturally evolving population under a suspected exposure factor is analyzed, like a snapshot (Figure 1.1).

Figure 1.1 Schematic representation of cross-sectional study type.

1.1.3 Longitudinal Studies

In longitudinal studies, a cohort is followed for several years, or sometimes decades, in order to establish the frequencies of specific conditions and their correlation with environmental or other biological factors. Comparisons can be performed intrasubject or between different subjects, if possible. A classic example is the Framingham Heart Study, which began in 1948 with 5209 subjects and is currently in its third generation of participants. Knowledge on important environmental factors currently associated with cardiovascular risk, such as lifestyle (smoking, diet, and exercise) and aspirin use, has been derived from this study.

1.2 Analytical Studies

Analytical studies aim to establish correlation strength between a condition and a factor putatively associated with its origin and/or natural history. These types of studies are the main focus of this book and can be classified either as observational or intervention studies.

1.2.1 Observational Studies

In observational studies, the frequency of a condition in a population is studied under so-called natural circumstances. As such, active intervention from the investigator on these circumstances is not applicable. The main objective of observational studies is to establish the degree of hazard for a certain condition in relation to a considered exposure factor. Submitting the observed population to real world situations is its advantage. Its limitation is that it yields less accurate conclusions because uncontrolled variables and potential confounders may generate bias. Observational studies can be classified as case–control or cohort studies.

Case–Control Studies

In case–control studies, two groups are retrospectively compared, according to the following model: (1) One group with the condition (case) is subdivided into two subgroups – one exposed and the other nonexposed to a studied exposure factor; and (2) another group without the condition (control) is subdivided into two subgroups – one exposed and the other nonexposed to the same factor (Figure 1.2).

Figure 1.2 Schematic representation of a case–control study type.

Case–control studies aim to determine the odds of acquiring a condition under exposure to a considered factor. For example, the odds of miners presenting asbestos-associated lung fibrosis relative to the general population are 1.5:1. The advantages of case–control studies are that they are less expensive to perform compared to cohort studies and they can be performed immediately because they are generally retrospective. Also due to this latter aspect, their limitations are: poor control over the exposure factor, uncontrolled variables, and potential confounders. Given the fact they focus on the outcome and move back toward the exposure factor, they are generally retrospective. Their inferred association