Readers guide to critical appraisal of cohort studies: 3. Analytical strategies to reduce confounding

Analytical strategies can help deal with potential confounding but readers need to know which strategy is appropriate The previous articles in this series1 2 argued that cohort studies are exposed to selection bias and confounding, and that critical appraisal requires a careful assessment of the study design and the identification of potential confounders. This article describes two analytical strategies—regression and stratification—that can be used to assess and reduce confounding. Some cohort studies match individual participants in the intervention and comparison groups on the basis of confounders, but because matching may be viewed as a special case of stratification we have not discussed it specifically and details are available elsewhere.3 4 Neither of these techniques can eliminate bias related to unmeasured or unknown confounders. Furthermore, both have their own assumptions, advantages, and limitations. Regression uses the data to estimate how confounders are related to the outcome and produces an adjusted estimate of the intervention effect. It is the most commonly used method for reducing confounding in cohort studies. The outcome of interest is the dependent variable, and the measures of baseline characteristics (such as age and sex) and the intervention are independent variables. The choice of method of regression analysis (linear, logistic, proportional hazards, etc) is dictated by the type of dependent variable. For example, if the outcome is binary (such as occurrence of hip fracture), a logistic regression model would be appropriate; in contrast, if the outcome is time to an event (such as time to hip fracture) a proportional hazards model is appropriate. ![][1] Stratification of the cohort helps minimise bias Credit: SAMBA PHOTO/PHOTONICA Regression analyses estimate the association of each independent variable with the dependent variable after adjusting for the effects of all the other variables. Because the estimated association between the intervention and outcome variables adjusts … [1]: /embed/graphic-1.gif