The value and hazards of standardization in clinical epidemiologic research

The statistical standardization of rates produces a single summary value that converts crude rates of occurrence into "standardized" rates that are adjusted for differences in the composition of compared populations. Although the process is well described in the epidemiologic literature and is regularly applied in comparisons of large populations, many investigators are not familiar with three important hazards that are magnified for the smaller groups studied in clinical epidemiologic research. This report contains a new "symmetrical" outline of the direct and indirect standardization processes, and an illustration of three pragmatic hazards: (1) Because the direct standardizing factor uses the observed stratum-specific rates, and because any stratum-specific rates that depend on small denominators may be misleading or unstable, the indirect method is preferred when the observed strata have small denominators. (2) Both the direct and indirect standardizing methods are highly vulnerable both to the choice of reference population and to the boundaries chosen when strata are demarcated or consolidated. The standardized rates can be altered dramatically according to differences in the stratum proportions of the reference population, or to distinctions produced when standardizing strata are consolidated. (3) If the stratum-specific rates and stratum proportions have different patterns of variation across the strata of the compared groups, the use of a single summary value--no matter what method of standardization is applied--may obscure cogent patterns of variation and significant differences in the stratum-specific rates. These hazards can be overcome if the studied group and the reference population are carefully compared for inconsistent variations in the stratum-specific rates and proportions before any standardizing procedure is applied. In many instances, the best approach may be to compare the unaltered stratum-specific rates, without standardization.