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Emergency department injury surveillance and aetiological research: bridging the gap with the two-stage case–control study design
  1. Brent E Hagel
  1. Departments of Paediatrics and Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
  1. Correspondence to Brent Hagel, C4-434, Alberta Children's Hospital, 2888 Shaganappi, Trail NW, Calgary, Alberta T3B 6A8, Canada; brent.hagel{at}


Objective To provide an overview of the two-stage case-control study design and its potential application to ED injury surveillance data and to apply this approach to published ED data on the relation between brain injury and bicycle helmet use.

Methods Relevant background is presented on injury aetiology and case-control methodology with extension to the two-stage case-control design in the context of ED injury surveillance. The design is then applied to data from a published case-control study of the relation between brain injury and bicycle helmet use with motor vehicle involvement considered as a potential confounder. Taking into account the additional sampling at the second stage, the adjusted and corrected odds ratio and 95% confidence interval for the brain injury-helmet use relation is presented and compared with the estimate from the entire original dataset. Contexts where the two-stage case-control study design might be most appropriately applied to ED injury surveillance data are suggested.

Results The adjusted odds ratio for the relation between brain injury and bicycle helmet use based on all data (n=2833) from the original study was 0.34 (95% CI: 0.25-0.46) compared with an estimate from a two-stage case-control design of 0.35 (95% CI: 0.25-0.48) using only a fraction of the original subjects (n=480).

Conclusion Application of the two-stage case-control study design to ED injury surveillance data has the potential to dramatically reduce study time and resource costs with acceptable losses in statistical efficiency.

  • Injury surveillance
  • case–control study
  • two-stage design
  • methods
  • surveillance

Statistics from


  • Funding BEH holds the Alberta Children's Hospital Foundation Professorship in Child Health and Wellness, funded through the support of an anonymous donor and the Canadian National Railway Company, as well as the Alberta Heritage Foundation for Medical Research Population Health Investigator and Canadian Institutes of Health Research New Investigator Awards.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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