The impact of attrition on the representativeness of cohort studies of older people

Abstract

Background: There are well-established risk factors, such as lower education, for attrition of study participants. Consequently, the representativeness of the cohort in a longitudinal study may deteriorate over time. Death is a common form of attrition in cohort studies of older people. The aim of this paper is to examine the effects of death and other forms of attrition on risk factor prevalence in the study cohort and the target population over time.

Methods: Differential associations between a risk factor and death and non-death attrition are considered under various hypothetical conditions. Empirical data from the Australian Longitudinal Study on Women's Health (ALSWH) for participants born in 1921-26 are used to identify associations which occur in practice, and national cross-sectional data from Australian Censuses and National Health Surveys are used to illustrate the evolution of bias over approximately ten years.

Results: The hypothetical situations illustrate how death and other attrition can theoretically affect changes in bias over time. Between 1996 and 2008, 28.4% of ALSWH participants died, 16.5% withdrew and 10.4% were lost to follow up. There were differential associations with various risk factors, for example, non-English speaking country of birth was associated with non-death attrition but not death whereas being underweight (body mass index < 18.5) was associated with death but not other forms of attrition. Compared to national data, underrepresentation of women with non-English speaking country of birth increased from 3.9% to 7.2% and over-representation of current and ex-smoking increased from 2.6% to 5.8%.

Conclusions: Deaths occur in both the target population and study cohort, while other forms of attrition occur only in the study cohort. Therefore non-death attrition may cause greater bias than death in longitudinal studies. However although more than a quarter of the oldest participants in the ALSWH died in the 12 years following recruitment, differences from the national population changed only slightly.

Figure 1

Changes to prevalence of the hypothetical risk factor, assuming no association between the risk factor and the risk of death, in the population or the cohort; no association between the risk factor and non-death attrition in the cohort. The left panel, Figure 1A, assumes no bias and the right panel, Figure 1B, assumes lower prevalence of the risk factor at the beginning of the study.

Figure 2

Changes to prevalence of the hypothetical risk factor, assuming an association between the risk factor and the risk of death, in the population and the cohort; no association between the risk factor and non-death attrition in the cohort. Figure 2A assumes no bias and Figure 2B assumes lower prevalence of the risk factor at the beginning of the study.

Figure 3

Changes to prevalence of the hypothetical risk factor, assuming no association between the risk factor and the risk of death, in the population or the cohort; an association between the risk factor and non-death attrition in the cohort. Figure 3A assumes no bias and Figure 3B assumes lower prevalence of the risk factor at the beginning of the study.

Figure 4

Changes to prevalence of the hypothetical risk factor assuming an association between the risk factor and the risk of death, in the population and the cohort; an association between the risk factor and non-death attrition in the cohort. Figure 4A assumes no bias and Figure 4B assumes lower prevalence of the risk factor at the beginning of the study.

Figure 5

Prevalence of a non-English speaking country of birth in the Australian Census and the ALSWH cohort (Figure 5A), and prevalence of current and ex-smokers in the Australian National Health Survey and the ALSWH cohort (Figure 5B).