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Cook's Distance

A regression diagnostic identifying observations with disproportionately large influence on estimated coefficients, based on how much fitted values would change if removed.

Last reviewedDarrin Baines IP Ltd

Concept Architecture

Concept

Theoretically, Cook's Distance is a regression diagnostic measure that quantifies the influence of an individual observation on the estimated regression coefficients. Developed by R. Dennis Cook, it combines information on residual size and leverage to identify observations that disproportionately affect model estimation. In health economics, Cook's Distance is used to assess influential observations in regression models estimating healthcare costs, health utilities, treatment effects and resource utilisation.

Mathematically, Cook's Distance measures the change in the fitted regression model that would occur if a particular observation were omitted from the analysis. The statistic incorporates both the squared residual and the leverage of each observation, providing a single measure of overall influence. Larger values indicate observations that have a greater impact on parameter estimation and model predictions.

In practice, Cook's Distance is calculated after fitting a regression model and is examined alongside leverage, studentised residuals and DFBETAs. Observations with unusually large Cook's Distance values are investigated to determine whether they represent data errors, influential but valid observations or important population subgroups. The statistic supports model diagnostics but does not, by itself, justify removing observations from an analysis.


Purpose

Used to identify influential observations, assess regression model stability, evaluate the effect of individual data points on parameter estimates and support regression diagnostics in health economic analyses.


Mathematical Formulae

Primary Formula

D? = (e?� / (p ? MSE)) ? (h?? / (1 ? h??)�)

where:

e? = residual for observation i

h?? = leverage for observation i

p = number of estimated regression parameters (including the intercept)

MSE = mean squared error

Supporting Formulae

e? = y? ? ??

H = X(X?X)??X?

h?? = diagonal element of H

A common rule of thumb is:

D? > 1

or

D? > 4 / n

may indicate an influential observation requiring further investigation.

Related Mathematical Methods

Linear Regression

Hat Matrix

Leverage

Studentised Residuals

DFBETAs

Regression Diagnostics

Ordinary Least Squares


Example

A health economist fits a multiple regression model to estimate annual healthcare costs using age, disease severity and treatment group.

One patient has a very high annual cost and a Cook's Distance of 1.34, while all remaining observations have values below 0.12. The observation is investigated to determine whether it reflects a data entry error, an unusually complex patient or a clinically meaningful subgroup. After verification, the observation is retained and sensitivity analyses are performed to assess its impact on the model.


Excel Implementation

FunctionExample FormulaHealth Economics Application
LINEST=LINEST(B2:B201,C2:E201,TRUE,TRUE)Estimate regression coefficients
SUMXMY2=SUMXMY2(B2:B201,F2:F201)Calculate residual sum of squares
MMULT=MMULT(A2:C201,D2:F4)Matrix multiplication for leverage calculations
MINVERSE=MINVERSE(A2:C4)Matrix inversion for hat matrix estimation
TRANSPOSE=TRANSPOSE(A2:C201)Matrix transposition in regression diagnostics

VBA (Optional)

Automate calculation of Cook's Distance and related regression diagnostic measures, generating reports that identify influential observations for further review.


Sources

Cook RD. Detection of Influential Observation in Linear Regression. Technometrics. 1977;19(1):15?18.

Cook RD, Weisberg S. Residuals and Influence in Regression.

Kutner MH, Nachtsheim CJ, Neter J, Li W. Applied Linear Statistical Models.

Briggs A, Claxton K, Sculpher M. Decision Modelling for Health Economic Evaluation.

Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the Economic Evaluation of Health Care Programmes.

Library

Publications

1
  • Book

    Statistical Analysis of Cost-Effectiveness Data — Willan & Briggs, 1st Edition ed., 2006 (John Wiley & Sons)

    A synthesis of statistical methods for analysing cost-effectiveness data, including net-benefit regression, confidence intervals for the ICER, cost-effectiveness acceptability curves, and covariate adjustment. Part of the Wiley Statistics in Practice series.

Frequently Asked Questions (6)

  • What is Cook's distance?

    A regression diagnostic identifying observations with disproportionately large influence on estimated coefficients, based on how much fitted values would change if removed.

    Source: Cook 1977

  • What does Cook's distance identify in a regression?

    Cook's distance identifies observations that exert an outsized influence on a regression's estimated coefficients, by measuring how much the fitted model would shift if a given point were removed. A large value marks a case that, on its own, pulls the results noticeably, whether because it is extreme in its predictors, its outcome, or both. Flagging such points prompts a check of whether they are errors, genuine outliers, or unduly shaping the conclusions. Spotting overly influential observations is its purpose. Kirkwood and Sterne (2003) describe this diagnostic.

    Source: Kirkwood & Sterne 2003

  • How is Cook's distance calculated?

    Cook's distance for an observation is calculated from the change in all the fitted values that results from omitting that observation, scaled by the number of parameters and the error variance; equivalently, it combines the observation's residual with how far its predictor values lie from the others, so that a point with both a large residual and unusual predictor values receives a large Cook's distance. So Cook's distance is calculated as a summary of how much the fitted values shift when a case is removed, integrating the size of its residual and how extreme its predictor values are into one measure, which allows the overall influence of each observation on the regression to be quantified and compared.

    Source: Cook 1977

  • How is Cook's distance interpreted?

    Cook's distance is interpreted by its size relative to the other observations and to rough thresholds, with larger values indicating greater influence; observations with notably high Cook's distance are examined as potentially influential. Various rule-of-thumb cut-offs exist, but these are guides rather than strict rules. So Cook's distance is interpreted by flagging observations whose values are large compared with the rest, marking them as influential cases warranting scrutiny, and rather than automatically removing such points, the analyst investigates why they are influential, since a high Cook's distance signals that a single observation is strongly affecting the regression results.

    Source: Cook 1977

  • Why is Cook's distance useful?

    Cook's distance is useful because a single influential observation can distort a regression, pulling the estimated coefficients and fitted values, and identifying such points allows the analyst to check whether the results depend unduly on a few cases. This supports robust and honest modelling. So Cook's distance is useful for detecting observations that exert excessive influence on a regression, prompting investigation of whether they are errors, unusual but valid cases, or points that unduly drive the conclusions, which helps ensure that a fitted model reflects the general pattern in the data rather than being dominated by a small number of influential observations.

    Source: Cook 1977

  • What should be done about influential observations identified by Cook's distance?

    Observations flagged by Cook's distance should be investigated rather than automatically deleted: the analyst checks whether they result from data errors, represent unusual but legitimate cases, or reveal model inadequacy, and considers the sensitivity of conclusions to their inclusion. Removal is justified only for genuine errors or with clear rationale. So influential observations identified by Cook's distance are examined to understand why they are influential and how much they affect the results, with the response depending on the cause, since discarding valid data merely because it is influential can bias the analysis, whereas retaining an erroneous point can distort it.

    Source: Cook & Weisberg 1982

Trust Record

Verified by Dr Darrin Baines

British health economist

Professional identity: darrinbaines.org

Verification date: 12 Dec 2025

Content version: 1.0.0

Canonical Identity

Term code
HE-ES-SA-036

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