CME Topic
Table 1. Calculating a risk ratio and an odds ratio in
a cohort study
Develop Do not develop
outcome outcome
Exposed a b
Not exposed c d
If data in the table are from a cohort study, a risk ratio (RR) can be directly
calculated as follows:
incidence in exposed a/(a ⫹ b)
RR ⫽ ⫽
incidence in unexposed c/(c ⫹ d)
The same data can also be used to calculate an odds ratio (OR):
odds that an exposed person
develops the outcome a / b ad
OR ⫽ ⫽ ⫽
odds that an unexposed c/d bc
person develops the outcome
When the outcome in question is rare, a and c will be small numbers so that
their presence in the denominator of the RR calculation will make a/(a ⫹ b)
a close approximation to a/b. Likewise, c/(c ⫹ d) will be a close approxi-
mation of c/d. Therefore, the OR will approximate the RR.
fraction is called a probability (and is what we mean when we
talk about the “chance” of something). A ratio in which the
denominator does not include that which is mathematically rep-
resented in the numerator is called “odds.” Note in the calcula-
tions accompanying Figure 1 that the odds are greater than the
probability.
Cohort Studies
Let us return to thinking about the cohort study. If investi-
gators simply divide the number of people exposed to the risk
factor who developed the outcome (eg, smokers who developed
lung cancer) by the number of people exposed to the risk factor
who did not develop the outcome (eg, smokers who did not
develop lung cancer), they have determined the odds of devel-
oping the outcome in an exposed person (represented by a/b in
Table 1). Investigators could similarly determine the odds of
developing the outcome in an unexposed person by dividing the
number of people not exposed to the risk factor who developed
the outcome (eg, nonsmokers who developed lung cancer) by
the number of people not exposed to the risk factor who did not
develop the outcome (eg, nonsmokers who did not develop lung
cancer) (represented by c/d in Table 1). The relative odds are
simply the first odds divided by the second: the odds ratio (OR).
This OR tells us whether the odds of developing the outcome are
greater if a person is exposed to a risk factor. If the OR ⫽ 1, then
the odds are the same in the two groups. If the OR is ⬎1, the
odds of the outcome are greater in those with the exposure; and
if the OR ⬍1, the odds of the outcome are lower in those with
the exposure. For example, a cohort study presenting an OR of
15 for the association between cigarette smoking and lung can-
Southern Medical Journal • Volume 101, Number 7, July 2008
Fig. 1 The difference between probability (A) and odds (B). If
the segment out of the “pie” represents a seventh, the fraction
represented in A is 1/7, and the ratio represented in B is 1/6. If
there are 700 people in a group exposed to some risk factor, and
100 develop the outcome, then the incidence, or risk, (a proba-
bility) is 100/700 which equals 0.14. The odds of developing the
outcome is 100/600 (sometimes said as 1:6, or “1 to 6”), which
equals 0.17. Probability (P) and odds (O) can be converted by
the formulae:
O
Pⴝ
Oⴙ1
and
P
Oⴝ
1ⴚP
Note that an odds of 1 is equal to a probability of 0.5. So,
when flipping an unbiased coin, the odds of the coin landing on
heads is 1 (or “1 to 1”) and the probability of heads is 50%.
cer tells us that the odds of developing lung cancer in the smok-
ers was 15 times the odds of developing lung cancer in the
nonsmokers.
Case Control Studies
To appreciate the value of the odds ratio, let us now
consider the design of a case control study. In this type of
study, investigators begin by identifying a group of people
who have the outcome of interest (eg, lung cancer) as well as
a select group of people who do not have the outcome but
who are otherwise, except for the exposure of interest, similar
to the people who do. Investigators then look back in time—
often through chart review or interviews—to assess for the
presence or absence of the potential risk factor/exposure (eg,
cigarette smoking). The investigators cannot calculate inci-
dence (risk) in the two groups because the overall prevalence
of the outcome is not known. The investigators can, however,
calculate the odds that a person with the outcome had the risk
factor (represented by a/c in Table 2) and the odds that a
person without the outcome had the risk factor (represented
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