Page 1

RESEARCH ARTICLE Open Access

A simple method for estimating relative risk

using logistic regression

Fredi A Diaz-Quijano

Abstract

Background: Odds ratios (OR) significantly overestimate associations between risk factors and common outcomes.

The estimation of relative risks (RR) or prevalence ratios (PR) has represented a statistical challenge in multivariate

analysis and, furthermore, some researchers do not have access to the available methods. Objective: To propose

and evaluate a new method for estimating RR and PR by logistic regression.

Methods: A provisional database was designed in which events were duplicated but identified as non-events.

After, a logistic regression was performed and effect measures were calculated, which were considered RR

estimations. This method was compared with binomial regression, Cox regression with robust variance and

ordinary logistic regression in analyses with three outcomes of different frequencies.

Results: ORs estimated by ordinary logistic regression progressively overestimated RRs as the outcome frequency

increased. RRs estimated by Cox regression and the method proposed in this article were similar to those

estimated by binomial regression for every outcome. However, confidence intervals were wider with the proposed

method.

Conclusion: This simple tool could be useful for calculating the effect of risk factors and the impact of health

interventions in developing countries when other statistical strategies are not available.

Keywords: Logistic regression, Odds ratio, Prevalence ratio, Relative risk.

Background

The odds ratio (OR) is commonly used to assess asso-

ciations between exposure and outcome and can be esti-

mated by logistic regression, which is widely available in

statistics software. OR has been considered an approxi-

mation to the prevalence ratio (PR) in cross-sectional

studies or the risk ratio (RR, which is mathematically

equivalent to PR) in cohort studies or clinical trials.

This is acceptable when the outcome is relatively rare (<

10%). However, since many health outcomes are com-

mon, the interpretation of OR as RR is questionable

because OR overstates RR, sometimes dramatically [1-3].

Moreover, the OR has been considered an “unintelligi-

ble” effect measure in some contexts [3].

Binomial regression has been recommended for the

estimation of RRs (and PRs) in multivariate analysis [4].

However, sometimes this statistical method cannot esti-

mate RR because convergence problems are frequent.

Therefore, the Cox regression with robust variance has

been recommended as a suitable method for estimating

RRs [5,6].

However, these statistical methods (binomial and Cox

regression) are not widely available in freeware (such as

Epidat or Epi-Info). Therefore, the ability to estimate

PRs and RRs in multivariate models could be limited in

research groups with scant resources. In this article, a

strategy for estimating RRs with ordinary logistic regres-

sion is proposed. This new method could be useful for

identifying risk factors and estimating the impact of

health interventions in developing countries.

Methods

Database

A database of 1000 observations with dichotomous vari-

ables was created to simulate a cohort study in which a

common event (incidence of 50%) would be strongly

Correspondence: frediazq@msn.com

Grupo Latinoamericano de Investigaciones Epidemiológicas, Organización

Latinoamericana para el Fomento de la Investigación en Salud (OLFIS),

Bucaramanga, Colombia

Diaz-Quijano BMC Medical Research Methodology 2012, 12:14

http://www.biomedcentral.com/1471-2288/12/14

© 2012 Diaz-Quijano; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons

Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in

any medium, provided the original work is properly cited.

Page 2

related to two independent predictors (A and B). These

predictors would also be statistically associated with one

another, resulting in a moderate confounding effect.

Then, a third independent variable with a prevalence of

40% was included (predictor C). This variable was ran-

domly distributed, but more often in positive than nega-

tive predictor A group. Thus, this variable was

statistically associated with the outcome in a univariate

analysis but the association would be explained by the

presence of predictor A in a multivariate model. Finally,

additional dependent variables were generated by ran-

domly selecting a proportion of cases. Thus, outcome

variables with frequencies of 20% and 5% were obtained.

The first table shows the hypothetical distribution of

subjects according to the predictors and outcomes

(Table 1).

Statistical analysis

Statistical analysis was performed using STATA soft-

ware (STATA®/IC 11.0). RRs and 95% confidence inter-

vals (CI) were estimated by applying log-binomial

regression and Cox regression with a constant in the

time variable [6]. In order to obtain corrected CIs by

Cox regression, the robust variance option was applied

[7]. ORs and their correspondent CIs were also esti-

mated using an ordinary logistic regression. After uni-

variate estimations were calculated, ORs and RRs were

obtained in multivariate models including all indepen-

dent variables (predictors A, B and C).

Proposed modification to logistic regression analysis

The log-binomial model is similar to logistic regression

in assuming a binomial distribution of the outcome.

However, in a logistic regression the link function is the

logarithm of the odds, which is the ratio between cases

and non-cases, while in binomial regression the link

function is the logarithm of the proportion, i.e., the ratio

between cases and cases plus non-cases [4].

In a binomial regression model with k covariates, the

function is written as:

?a/(a + b)?

where a is the number of cases and b is the number

of non-cases, and Xithe covariates. Thus, a/(a + b) is

the probability of success (e. g., the proportion of sick

persons in a group), and the RR (or PR) estimated of a

given covariate Xiis ebi.

On the other hand, in a logistic regression model, the

function is written as:

?a/b?

where a/b is the odds of success and the OR estimated

of a given covariate Xiis ebi.

In order for the case information to be included in the

denominator of the estimates in a logistic regression, all

observed cases were duplicated in a provisional database

and identified as non-cases. Thus, a number of observa-

tions was included equaling that of the cases and con-

taining the same information about the covariates. Thus,

this new logistic function could be written as:

?a/(y)?

where y includes non-cases as well as cases, although

all of them are identified as non-cases. Afterwards, a

logistic regression procedure was performed with the

modified dataset. The “ORs” obtained were considered

direct estimations of RRs because bidefined the rela-

tionship between Xiand the Log [a/(y)], which in this

model would be mathematically similar to Log [a/(a +

b)] of the log-binomial model. For each outcome, a pro-

visional database was prepared.

This strategy for logistic regression recognizes an

entire cohort as controls. This trick is innovative but

analogous to the analysis of case-cohort studies. In that

design, cases of a particular outcome are compared with

Log= β0+ β1X1+ ... + βkXk

Log= β0+ β1X1+ ... + βkXk

Log= β0+ β1X1+ ... + βkXk

Table 1 Hypothetical distribution of subjects according to the predictors and outcome incidence

High incidence

(50%)

Intermediate

incidence (20%)

Low incidence

(5%)

Independent

Variable

Cases

(n = 500)

Non-cases

(n = 500)

Cases

(n = 200)

Non-cases

(n = 800)

Cases

(n = 50)

Non-cases

(n = 950)

Total

(n = 1000)

Predictor A

positive

negative

409

91

191

309

161

39

439

361

45

5

555

395

600

400

Predictor B

positive

negative

398

102

102

398

159

41

341

459

36

14

464

486

500

500

Predictor C

positive

negative

227

273

173

327

84

116

316

484

23

27

377

573

400

600

Diaz-Quijano BMC Medical Research Methodology 2012, 12:14

http://www.biomedcentral.com/1471-2288/12/14

Page 2 of 6

Page 3

a sample (sub-cohort) of the entire cohort that gave rise

to all cases [8]. The objective of selecting this sub-

cohort is to estimate the frequency of exposure in the

entire cohort. For this reason, such studies have also

been called case-exposure studies [9].

This sub-cohort may include some cases, which would

consequently be overrepresented in the analysis. Then,

by comparing the frequency of exposure between the

cases and the sub-cohort set, we obtain a direct estimate

of RR (not OR) [9-11]. Similarly, in the method pro-

posed here, the cases would be compared against the

entire cohort and thus all cases would be overrepre-

sented. This affects the variance of the estimates and for

this reason the CIs are wider [11]. Therefore, an infla-

tion factor for the Standard Error (SE) of each predictor

and outcome incidence was calculated as the ratio

between SE obtained with the proposed method and SE

resulting from binomial regression (as reference

method).

Results

For the rarer event (incidence of 5%), RRs estimated by

log-binomial were similar to those calculated both by

the Cox regressions and the proposed method (modified

logistic regression) (Table 2). Few differences were iden-

tified among the CIs of RRs: CIs from the modified

method were wider than those estimated by log-bino-

mial and Cox regression with the robust variance

option. ORs estimated by ordinary logistic regression

were close to RR values. Predictors A and B were statis-

tically associated with the outcome in univariate analysis

but only A was independently associated in the multi-

variate model (Table 2).

For the second and third outcomes, with incidences of

20% and 50% respectively, the differences between RRs

in log-binomial regression and ORs in ordinary logistic

regression were more evident (Tables 3 and 4). This was

especially remarkable for the commonest event, where

the ORs of predictors A and B were at least twice the

corresponding RR values (Table 4).

On the other hand, RRs estimated in Cox regressions

and modified logistic regression were similar or virtually

identical to those estimated by log-binomial regression.

However, the CIs outputted by the proposed method

were wider than those obtained by the other models

(Tables 3 and 4). Consequently, the SE inflation factor

rose for each predictor as the outcome frequency

increased (Figure 1).

Discussion

The use of an adjusted odds ratio to estimate an

adjusted relative risk or prevalence ratio is appropriate

for studies of rare outcome but may be misleading when

the outcome is common. Such overestimation may inap-

propriately affect clinical decision-making or policy

development [3]. For example, overestimation of the

importance of a risk factor may lead to unintentional

errors in the economical analysis of potential interven-

tion programs or treatment, which could be particularly

harmful in developing countries.

The ordinary logistic model estimates OR (not RR)

and was initially adapted for case-control studies since

data from this type of study design can only determine

OR [12]. Moreover, a case-control study is an optimal

choice for analyzing rare-event risk factors, for which

OR is a close approximation of RR. Thus, ordinary logis-

tic regression is eminently useful for case- control stu-

dies mainly because the numeric value of OR mimics

RR [12].

On the other hand, RR and PR can be directly deter-

mined from data based on cohort and cross-sectional

studies, respectively, which are practical only for rela-

tively common outcomes. However, in such circum-

stances OR estimated by ordinary logistic regression will

Table 2 RRs and ORs and corresponding CIs of associations between a rare event (incidence = 5%) and three

independent variables, estimated by Log-binomial regression, ordinary logistic regression, Cox regression with robust

variance and logistic regression with the proposed modification

Independent

variableregression: RR

(CI) (CI)

Log-binomial Logistic

regression: OR

Cox

regression -

robust: RR (CI)

Modified

Logistic

regression: RR (CI)

Predictor A

Unadjusted

Adjusted *

6 (2.4 - 14.98)

4.96 (1.89 - 12.98)

6.41 (2.52 - 16.28)

5.26 (1.97 - 14.06)

6 (2.4 - 14.99)

4.97 (1.91 - 12.92)

6 (2.36 - 15.25)

4.99 (1.86 - 13.34)

Predictor B

Unadjusted

Adjusted *

2.57 (1.4 - 4.71)

1.59 (0.85 - 2.97)

2.69 (1.43 - 5.06)

1.64 (0.85 - 3.18)

2.57 (1.4 - 4.71)

1.59 (0.84 - 3.01)

2.57 (1.37 - 4.83)

1.59 (0.82 - 3.09)

Predictor C

Unadjusted

Adjusted *

1.28 (0.74 - 2.2)

0.98 (0.57 - 1.69)

1.29 (0.73 - 2.29)

0.97 (0.54 - 1.74)

1.28 (0.74 - 2.2)

0.97 (0.57 - 1.65)

1.28 (0.72 - 2.26)

0.96 (0.54 - 1.72)

* Adjusted by the other independent variables.

Diaz-Quijano BMC Medical Research Methodology 2012, 12:14

http://www.biomedcentral.com/1471-2288/12/14

Page 3 of 6

Page 4

be more discrepant than RR (or PR). This was exempli-

fied in the results of this paper in that ORs progressively

overestimated RRs as the outcome frequency increased.

Indeed, OR will always be greater than RR if RR is

greater than 1 (adverse event) and OR will also be less

than RR if RR less than 1 (protective effect). Therefore,

the uncritical application of logistic regression and the

misinterpretation of OR as RR can lead to serious errors

in determination of both the importance of risk factors

and the impact of interventions on clinical practice and

public health [13].

For these reasons, several strategies for estimating RRs

in multivariate analysis have been proposed [7,14-16].

Binomial regression is considered the most adequate

choice. However, binomial models often predict prob-

abilities greater than one and sometimes this regression

cannot find possible values and converge in a model.

Consequently, other alternative methods have been

proposed when binomial regression cannot converge in

a model. Cox regression with robust variance using a

constant in the time variable seems like a good alterna-

tive [7]. However, these options and other statistical

alternatives are only available in sophisticated software

that some research groups cannot afford.

This paper presents a strategy for logistic regression

that recognizes an entire cohort as controls. As the

results show, this method can appropriately estimate

RRs or PRs, even in analyses with common outcomes.

Moreover, the method proposed in this article could be

easily performed using free statistics programs that

include only logistic regression for multivariate analysis

of dichotomous outcomes.

However, the proposed method is associated with SE

inflation, which increases confidence intervals. A simple

and practical correction factor cannot be established for

this problem because, in a multivariate regression, the

Table 3 RRs and ORs and corresponding CIs of associations between an intermediate frequency event (incidence =

20%) and three independent variables, estimated by Log-binomial regression, ordinary logistic regression, Cox

regression with robust variance and logistic regression with the proposed modification

Independent

variable regression: RR

(CI)

Log-binomialLogistic

regression: OR

(CI)

Cox

regression -

robust: RR

(CI)

Modified

Logistic

regression: RR

(CI)

Predictor A

Unadjusted

Adjusted *

2.75 (1.99 - 3.81)

1.79 (1.27 - 2.52)

3.39 (2.33 - 4.95)

2.06 (1.36 - 3.12)

2.75 (1.99 - 3.81)

1.77 (1.26 - 2.48)

2.75 (1.9 - 3.99)

1.75 (1.16 - 2.64)

Predictor B

Unadjusted

Adjusted *

3.88 (2.82 - 5.34)

3.15 (2.24 - 4.43)

5.22 (3.6 - 7.56)

4.07 (2.75 - 6.03)

3.88 (2.82 - 5.34)

3.15 (2.26 - 4.39)

3.88 (2.69 - 5.59)

3.15 (2.13 - 4.65)

Predictor C

Unadjusted

Adjusted *

1.09 (0.85 - 1.4)

0.92 (0.72 - 1.17)

1.11 (0.81 - 1.52)

0.89 (0.63 - 1.25)

1.09 (0.85 - 1.4)

0.92 (0.72 - 1.17)

1.09 (0.8 - 1.48)

0.93 (0.67 - 1.28)

* Adjusted by the other independent variables.

Table 4 RRs and ORs and corresponding CIs of associations between a common event (incidence = 50%) and three

independent variables, estimated by Log-binomial regression, ordinary logistic regression, Cox regression with robust

variance and logistic regression with the proposed modification

Independent

variableregression: RR

(CI)

(CI)

Log-binomialLogistic

regression: OR

Cox

regression -

robust: RR

(CI)

Modified

Logistic

regression: RR

(CI)

Predictor A

Unadjusted

Adjusted *

3 (2.48 - 3.62)

1.9 (1.58 - 2.28)

7.27 (5.44 - 9.72)

4.07 (2.88 - 5.74)

3 (2.48 - 3.62)

1.89 (1.56 - 2.28)

3 (2.31 - 3.89)

1.88 (1.41 - 2.51)

Predictor B

Unadjusted

Adjusted *

3.9 (3.26 - 4.67)

3.08 (2.56 - 3.72)

15.23 (11.19 - 20.71)

10.97 (7.95 - 15.14)

3.9 (3.26 - 4.67)

3.09 (2.56 - 3.72)

3.9 (3.04 - 5.01)

3.09 (2.36 - 4.04)

Predictor C

Unadjusted

Adjusted *

1.25 (1.1 - 1.41)

1.02 (0.95 - 1.1)

1.57 (1.22 - 2.03)

1.12 (0.8 - 1.57)

1.25 (1.1 - 1.41)

1.05 (0.96 - 1.15)

1.25 (1 - 1.55)

1.06 (0.84 - 1.34)

* Adjusted by the other independent variables.

Diaz-Quijano BMC Medical Research Methodology 2012, 12:14

http://www.biomedcentral.com/1471-2288/12/14

Page 4 of 6

Page 5

standard error for each predictor depends on its correla-

tion with all variables included in the model.

Therefore, since the obtained CIs can be wider than

those estimated by other models, investigators must be

aware that the risk of Type II error could be higher. For

this reason, when an association is not statistically sig-

nificant with the proposed method, ordinary logistic

regression could be used for testing the hypothesis that

association measure is different than unity. This is possi-

ble since the null hypothesis is mathematically equiva-

lent for both OR and RR, because when RR is equal to

1, OR is also equal to 1.

Conclusion

The proposed method may be useful for estimating RRs

or PRs appropriately in analysis of common outcomes.

However, because the resultant CIs are wider than those

derived from other methods, this strategy should be

employed when logistic regression is the only method

available. This new method may help research groups

from developing countries where access to sophisticated

programs is limited.

Abbreviations

CI: Confidence interval; OR: Odds ratio; PR: Prevalence ratio; RR: Relative risk;

SE: Standard Error

Authors’ contributions

FAD conceived the study, created the database, designed and executed the

analysis, and wrote the manuscript.

Competing interests

The author declares that they have no competing interests.

Received: 1 August 2011 Accepted: 15 February 2012

Published: 15 February 2012

References

1.McNutt LA, Wu C, Xue X, Hafner JP: Estimating the relative risk in cohort

studies and clinical trials of common outcomes. Am J Epidemiol 2003,

157:940-3.

2.Zhang J, Yu KF: What’s the Relative Risk? A Method of Correcting the

Odds Ratio in Cohort Studies of Common Outcomes. JAMA 1998,

280:1690-1691.

3. Pearce N: Effect measure in prevalence studies. Environ Health Perspect

2004, 112:1047-1050.

4.Wacholder S: Binomial regression in GLIM: estimating risk ratios and risk

differences. Am J Epidemiol 1986, 123:174-184.

5. Nijem K, Kristensen P, Al-Khatib A, Bjertness E: Application of different

statistical methods to estimate risk for self-reported health complaints

among shoe factory workers exposed to organic solvents and plastic

compounds. Norsk Epidemiologi 2005, 15:111-116.

6.Lee J, Chia KS: Estimation of prevalence rate ratios for cross sectional

data: an example in occupational epidemiology. Br J Ind Med 1993,

50:861-862.

7.Barros AJD, Hirakata VN: Alternatives for logistic regression in cross-

sectional studies: an empirical comparison of models that directly

estimate the prevalence ratio. BMC Med Res Methodol 2003, 3:21.

8. Kulathinal S, Karvanen J, Saarela O, Kuulasmaa K: Case-cohort design in

practice - experiences from the MORGAM Project. Epidemiol Perspect

Innov 2007, 4:15.

9.Flanders WD: Limitations of the case-exposure study. Epidemiology 1990,

1:34-38.

10. Sato T: Estimation of a common risk ratio in stratified case-cohort

studies. Stat Med 1992, 11:1599-605.

11. Sato T: Risk ratio estimation in case-cohort studies. Environ Health Perspect

1994, 102(Suppl 8):53-6.

12.Lee J, Tan CS, Chia KS: A practical guide for multivariate analysis of

dichotomous outcomes. Ann Acad Med Singapore 2009, 38:714-719.

Figure 1 Inflation Factor of Standard Error (SE) for each predictor according to incidence of outcome.

Diaz-Quijano BMC Medical Research Methodology 2012, 12:14

http://www.biomedcentral.com/1471-2288/12/14

Page 5 of 6

Page 6

13. Schwartz LM, Woloshin S, Welch HG: Misunderstandings about the effects

of race and sex on physicians’ referrals for cardiac catheterization. N

Engl J Med 1999, 341:279-83.

Localio AR, Margolis DJ, Berlin JA: Relative risks and confidence intervals

were easily computed indirectly from multivariable logistic regression. J

Clin Epidemiol 2007, 60:874-882.

Thompson ML, Myers JE, Kriebel D: Prevalence odds ratio or prevalence

ratio in the analysis of cross sectional data: what is to be done? Occup

Environ Med 1998, 55:272-277.

Coutinho LM, Scazufca M, Menezes PR: Methods for estimating prevalence

ratios in cross-sectional studies. Rev Saude Publica 2008, 42:992-998.

14.

15.

16.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2288/12/14/prepub

doi:10.1186/1471-2288-12-14

Cite this article as: Diaz-Quijano: A simple method for estimating

relative risk using logistic regression. BMC Medical Research Methodology

2012 12:14.

Submit your next manuscript to BioMed Central

and take full advantage of:

• Convenient online submission

• Thorough peer review

• No space constraints or color figure charges

• Immediate publication on acceptance

• Inclusion in PubMed, CAS, Scopus and Google Scholar

• Research which is freely available for redistribution

Submit your manuscript at

www.biomedcentral.com/submit

Diaz-Quijano BMC Medical Research Methodology 2012, 12:14

http://www.biomedcentral.com/1471-2288/12/14

Page 6 of 6