Intended for healthcare professionals

Endgames Statistical Question

Nested case-control studies: advantages and disadvantages

BMJ 2014; 348 doi: (Published 14 February 2014) Cite this as: BMJ 2014;348:g1532
  1. Philip Sedgwick, reader in medical statistics and medical education1
  1. 1Centre for Medical and Healthcare Education, St George’s, University of London, London, UK
  1. p.sedgwick{at}

Researchers investigated whether antipsychotic drugs were associated with venous thromboembolism. A population based nested case-control study design was used. Data were taken from the UK QResearch primary care database consisting of 7 267 673 patients. Cases were adult patients with a first ever record of venous thromboembolism between 1 January 1996 and 1 July 2007. For each case, up to four controls were identified, matched by age, calendar time, sex, and practice. Exposure to antipsychotic drugs was assessed on the basis of prescriptions on, or during the 24 months before, the index date.1

There were 25 532 eligible cases (15 975 with deep vein thrombosis and 9557 with pulmonary embolism) and 89 491 matched controls. The primary outcome was the odds ratios for venous thromboembolism associated with antipsychotic drugs adjusted for comorbidity and concomitant drug exposure. When adjusted using logistic regression to control for potential confounding, prescription of antipsychotic drugs in the previous 24 months was significantly associated with an increased occurrence of venous thromboembolism compared with non-use (odds ratio 1.32, 95% confidence interval 1.23 to 1.42). The researchers concluded that prescription of antipsychotic drugs was associated with venous thromboembolism in a large primary care population.

Which of the following statements, if any, are true?

  • a) The nested case-control study is a retrospective design

  • b) The study design minimised selection bias compared with a case-control study

  • c) Recall bias was minimised compared with a case-control study

  • d) Causality could be inferred from the association between prescription of antipsychotic drugs and venous thromboembolism


Statements a, b, and c are true, …

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