What Does the Odds Ratio Estimate in a Case-Control Study?

The use of the term 'odds ratio' in reporting the findings of case-control studies is technically correct, but is often misleading. The meaning of the odds ratio estimates obtained in a case-control study differs according to whether controls are selected from person-time at risk (the study base), persons at risk (the base-population at risk at the beginning of follow-up), or survivors (the population at risk at the end of follow-up). These three methods of control selection correspond to estimating the rate ratio, risk ratio, or the odds ratio respectively, by means of calculating the odds ratio in the subjects actually studied. None of these estimation procedures depends on any rare disease assumption. Where the rare disease assumption is relevant is whether the effect which is estimated (e.g. the odds ratio) is approximately equal to some other effect measure of interest (e.g. the risk ratio or rate ratio) in the underlying study base. To avoid confusion on this issue, authors should be encouraged to not only specify the manner in which controls have been selected (e.g. by density sampling) but also the corresponding effect measure which is being estimated (e.g. the rate ratio) by the 'odds ratio' which is obtained in a case-control analysis.