Do case‐only designs yield consistent results across design and different databases? A case study of hip fractures and benzodiazepines

BACKGROUND: The case‐crossover (CXO) and self‐controlled case series (SCCS) designs are increasingly used in pharmacoepidemiology. In both, relative risk estimates are obtained within persons, implicitly controlling for time‐fixed confounding variables. OBJECTIVES: To examine the consistency of relative risk estimates of hip/femur fractures (HFF) associated with the use of benzodiazepines (BZD) across case‐only designs in two databases (DBs), when a common protocol was applied. METHODS: CXO and SCCS studies were conducted in BIFAP (Spain) and CPRD (UK). Exposure to BZD was divided into non‐use, current, recent and past use. For CXO, odds ratios (OR; 95%CI) of current use versus non‐use/past were estimated using conditional logistic regression adjusted for co‐medications (AOR). For the SCCS, conditional Poisson regression was used to estimate incidence rate ratios (IRR; 95%CI) of current use versus non/past‐use, adjusted for age. To investigate possible event‐exposure dependence the relative risk in the 30 days prior to first BZD exposure was also evaluated. RESULTS: In the CXO current use of BZD was associated with an increased risk of HFF in both DBs, AOR(BIFAP) = 1.47 (1.29–1.67) and AOR(CPRD) = 1.55 (1.41–1.70). In the SCCS, IRRs for current exposure was 0.79 (0.72–0.86) in BIFAP and 1.21 (1.13–1.30) in CPRD. However, when we considered separately the 30‐day pre‐exposure period, the IRR for current period was 1.43 (1.31–1.57) in BIFAP and 1.37 (1.27–1.47) in CPRD. CONCLUSIONS: CXO designs yielded consistent results across DBs, while initial SCCS analyses did not. Accounting for event‐exposure dependence, estimates derived from SCCS were more consistent across DBs and designs. © 2015 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons Ltd.