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Design and statistical problems in prevention.

Clinical and epidemiological research in osteoporosis can benefit from using the methods and techniques established in the area of chronic disease epidemiology. However, attention has to be given to the special characteristics such as the multifactorial nature and the fact that the subjects usually are of high ages. In order to evaluate prevention it is of course first necessary to detect and confirm reversible risk factors. The advantage and disadvantage of different design (cross-sectional, cohort and case-control) are well known. The effects of avoidable biases, e.g. selection, observation and confounding have to be balanced against practical conveniences like time, expenses, recruitment etc. The translation of relative risks into population attributable risks (etiologic fractions, prevented fractions) are complex and are usually performed under unrealistic, simplified assumptions. The consequences of interactions (synergy) between risk factors are often neglected. The multifactorial structure requires application of more advanced multi-level statistical techniques. The common strategy in prevention to target a cluster of risk factors in order to avoid the multifactorial nature implies that in the end it is impossible to separate each unique factor. Experimental designs for evaluating prevention like clinical trials and intervention have to take into account the distinction between explanatory and pragmatic studies. An explanatory approach is similar to an idealized laboratory trial while the pragmatic design is more realistic, practical and has a general public health perspective. The statistical techniques to be used in osteoporosis research are implemented in easy available computer-packages like SAS, SPSS, BMDP and GLIM. In addition to the traditional logistic regression methods like Cox analysis and Poisson regression also analysis of repeated measurement and cluster analysis are relevant.