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(Circulation. 2008;118:2588-2593.)
© 2008 American Heart Association, Inc.

Key Issues in Outcomes Research

Ecological Studies and Cardiovascular Outcomes Research

Jack V. Tu, MD, PhD; Dennis T. Ko, MD, MSc

From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, and Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Canada.

Correspondence to Jack V. Tu, MD, PhD, Institute for Clinical Evaluative Sciences, G-106, 2075 Bayview Ave, Toronto, Ontario, Canada M4N 3M5. E-mail tu@ices.on.ca

Key Words: outcomes research • ecological fallacy • ecological studies • myocardial infarction

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 
Is it better to have a heart attack in the United States or Canada?

Ecological studies are epidemiological evaluations in which the unit of analysis is populations, or groups of people, rather than individuals.¹ They can answer important questions such as the question posed above that cannot easily be answered using any other form of study design. Ecological studies are conducted by researchers in a variety of disciplines, including outcomes researchers, to study potential causal associations between 1 or more exposure and outcome variables. They are frequently used where alternative study designs are not possible (eg, randomized control trials), such as when investigating the effect of geographical and temporal factors on disease incidence or the effect of a government policy change on health outcomes. In this overview, we provide an introduction to the use of ecological studies in cardiovascular outcomes research, drawing on published examples from our group and others. It is important for clinicians to be aware of both the potential strengths and weaknesses of this type of study design. Because ecological studies are ubiquitous in the medical literature, it is not possible to review all published cardiovascular ecological studies in a systematic manner.

Individual-level variables are properties of each person whereas ecological variables are properties of groups, organizations, or places.^1,2 All ecological studies are potentially prone to the so-called "ecological fallacy," which is a term for the biases that may occur when the association that exists between variables at an aggregate level may not represent the true association . . . [Full Text of this Article]