# 16  Analysis of Observer Variability and Measurement Agreement

This chapter was written by FE Harrell, 1987

## 16.1 Intra- and Inter-observer Disagreement

Before using a measurement instrument or diagnostic technique routinely, a researcher may wish to quantify the extent to which two determinations of the measurement, made by two different observers or measurement devices, disagree (inter-observer variability). She may also wish to quantify the repeatability of one observer in making the measurement at different times (intra-observer variability). To make these assessments, she has each observer make the measurement for each of a number of experimental units (e.g., subjects).

The measurements being analyzed may be continuous, ordinal, or binary (yes/no). Ordinal measurements must be coded such that distances between values reflects the relative importance of disagreement. For example, if a measurement has the values 1, 2, 3 for poor, fair, good, it is assumed that “good” is as different from “fair” as “fair” is from “poor”. if this is not the case, a different coding should be used, such as coding 0 for “poor” if poor should be twice as far from “fair” as “fair” is from “good”. Measurements that are yes/no or positive/negative should be coded as 1 or 0. The reason for this will be seen below.

There are many statistical methods for quantifying inter- and intra-observer variability. Correlation coefficients are frequently reported, but a perfect correlation can result even when the measurements disagree by a factor of 10. Variance components analysis and intra-class correlation are often used, but these make many assumptions, do not handle missing data very well, and are difficult to interpret. Some analysts, in assessing inter-observer agreement when each observer makes several determinations, compute differences between the average determinations for each observer. This method clearly yields a biased measurement of inter-observer agreement because it cancels the intra-observer variability.

A general and descriptive method for assessing observer variability will now be presented. The methods uses a general type of statistic called the $$U$$ statistic, invented by Hoeffding Hoeffding (1948)1. For definiteness, an analysis for 3 observers and 2 readings per observer will be shown. When designing such a study, the researcher should remember that the number of experximental units is usually the critical factor in determining the precision of estimates. There is not much to gain from having each observer make more than a few readings or from having 30 observers in the study (although if few observers are used, these are assumed to be “typical” observers).

• 1 The Wilcoxon test and the $$c$$-index are other examples of $$U$$ statistics.

• The intra-observer disagreement for a single subject or unit is defined as the average of the intra-observer absolute measurement differences. In other words, intra-observer disagreement is the average absolute difference between any two measurements from the same observer. The inter-observer disagreement for one unit is defined as the average absolute difference between any two readings from different observers. Disagreement measures are computed separately for each unit and combined over units (by taking the mean or median for example) to get an overall summary measure. Units having more readings get more weight. When a reading is missing, that reading does not enter into any calculation and the denominator used in finding the mean disagreement is reduced by one.

Suppose that for one patient, observers A, B, and C make the following determinations on two separate occasions, all on the same patient:

A B C
5,7 8,5 6,7

For that patient, the mean intra-observer difference is $$(|5-7| + |8-5| + |6-7|)/3 = \frac{2+3+1}{3} = 2$$.

The mean inter-observer difference is $$(|5-8| + |5-5| + |5-6|+ |5-7| + |7-8| + |7-5| + |7-6| + |7-7|+$$ $$|8-6| + |8-7| + |5-6| + |5-7|)/12 =$$ $$(3+0+1+2+1+2+1+0+2+1+1+2)/12 =$$ $$\frac{16}{12} = 1.33$$.

If the first reading for observer A were unobtainable, the mean intra-observer difference for that patient would be $$(|8-5| + |6-7|)/2 = \frac{3+1}{2} = 2$$ and the mean inter-observer difference would be $$(|7-8| + |7-5| + |7-6| + |7-7| + |8-6| + |8-7| + |5-6| + |5-7|)/8 =$$ $$(1+2+1+0+2+1+1+2)/8 = \frac{10}{8} = 1.25$$.

The computations are carried out in like manner for each patient and summarized as follows:

Patient Intra-observer Inter-observer
Difference Difference
1 2.00 1.33
2 1.00 3.50
3 1.50 2.66
. . .
. . .
$$n$$ . .
Overall Average (or median) 1.77 2.23
$$Q_{1}$$ 0.30 0.38
$$Q_{3}$$ 2.15 2.84

Here is an example using R to compute mean inter- and intra-observer absolute differences for 4 subjects each assessed twice by each of 3 observers. The first subject consists of data above. The calculations are first done for the first subject alone, to check against computations above.

Code
d <- expand.grid(rep=1:2, observer=c('A','B','C'), subject=1:4)
d\$y <- c(5,7, 8,5, 6,7,
7,6, 8,6, 9,7,
7,5, 4,6, 10,11,
7,6, 5,6, 9,8)
d
   rep observer subject  y
1    1        A       1  5
2    2        A       1  7
3    1        B       1  8
4    2        B       1  5
5    1        C       1  6
6    2        C       1  7
7    1        A       2  7
8    2        A       2  6
9    1        B       2  8
10   2        B       2  6
11   1        C       2  9
12   2        C       2  7
13   1        A       3  7
14   2        A       3  5
15   1        B       3  4
16   2        B       3  6
17   1        C       3 10
18   2        C       3 11
19   1        A       4  7
20   2        A       4  6
21   1        B       4  5
22   2        B       4  6
23   1        C       4  9
24   2        C       4  8
Code
# Function to compute mean absolute discrepancies
mad <- function(y, obs, subj) {
nintra <- ninter <- sumintra <- suminter <- 0
n <- length(y)
for(i in 1 : (n - 1)) {
for(j in (i + 1) : n) {
if(subj[i] == subj[j]) {
dif <- abs(y[i] - y[j])
if(! is.na(dif)) {
if(obs[i] == obs[j]) {
nintra   <- nintra + 1
sumintra <- sumintra + dif
}
else {
ninter   <- ninter + 1
suminter <- suminter + dif
}
}
}
}
}
c(nintra=nintra, intra=sumintra / nintra,
ninter=ninter, inter=suminter / ninter)
}

# Compute statistics for first subject
with(subset(d, subject == 1), mad(y, observer, subject))
   nintra     intra    ninter     inter
3.000000  2.000000 12.000000  1.333333 
Code
# Compute for all subjects
with(d, mad(y, observer, subject))
   nintra     intra    ninter     inter
12.000000  1.583333 48.000000  2.125000 

Zhouwen Liu in the Vanderbilt Department of Biostatistics has developed much more general purpose software for this in R. Its web pages are biostat.app.vumc.org/AnalysisOfObserverVariability and github.com/harrelfe/rscripts. The following example loads the source code and runs the above example. The R functions implement bootstrap nonparametric percentile confidence limits for mean absolute discrepency measures.

Code
require(Hmisc)
getRs('observerVariability.r')
YOU ARE RUNNING A DEMO VERSION 3_2 
Code
with(d, {
intra <- intraVar(subject, observer, y)
print(intra)
summary(intra)
set.seed(2)
b=bootStrap(intra, by = 'subject', times=1000)
# Get 0.95 CL for mean absolute intra-observer difference
print(quantile(b, c(0.025, 0.975)))
inter <- interVar(subject, observer, y)
print(inter)
summary(inter)
b <- bootStrap(inter, by = 'subject', times=1000)
# Get 0.95 CL for mean absolute inter-observer difference
print(quantile(b, c(0.025, 0.975)))
})
Intra-Variability

Measures by Subjects and Raters
subject rater variability N
1        1     A           2 1
2        1     B           3 1
3        1     C           1 1
4        2     A           1 1
5        2     B           2 1
6        2     C           2 1
7        3     A           2 1
8        3     B           2 1
9        3     C           1 1
10       4     A           1 1
11       4     B           1 1
12       4     C           1 1

Measures by Subjects
subject variability N
1       1    2.000000 3
2       2    1.666667 3
3       3    1.666667 3
4       4    1.000000 3

Measures by Raters
subject variability N
1       A        1.50 4
2       B        2.00 4
3       C        1.25 4
Intra-variability summary:

Measures by Subjects and Raters
Variability mean:  1.583333
Variability median:  1.5
Variability range:  1 3
Variability quantile:
0%:  1   25%:  1   50%:  1.5   75%:  2   100%:  3

Measures by Subjects
Variability mean:  1.583333
Variability median:  1.666667
Variability range:  1 2
Variability quantile:
0%:  1   25%:  1.5   50%:  1.666667   75%:  1.75   100%:  2

Measures by Raters
Variability mean:  1.583333
Variability median:  1.5
Variability range:  1.25 2
Variability quantile:
0%:  1.25   25%:  1.375   50%:  1.5   75%:  1.75   100%:  2
2.5%    97.5%
1.166667 1.916667
Input object size:   3192 bytes;     9 variables     12 observations
Renamed variable     rater  to rater1
Renamed variable     disagreement   to variability
Dropped variables   diff,std,auxA1,auxA2
New object size:    1592 bytes; 5 variables 12 observations
Inter-Variability

Measures for All Pairs of Raters
subject rater1 rater2 variability N
1        1      1      2         1.5 4
5        2      1      2         1.0 4
9        3      1      2         1.5 4
13       4      1      2         1.0 4
17       1      1      3         1.0 4
21       2      1      3         1.5 4
25       3      1      3         4.5 4
29       4      1      3         2.0 4
33       1      2      3         1.5 4
37       2      2      3         1.5 4
41       3      2      3         5.5 4
45       4      2      3         3.0 4

Measures by Rater Pairs
rater1 rater2 variability  N
1      1      2       1.250 16
2      1      3       2.250 16
3      2      3       2.875 16

Measures by Subjects
subject variability  N
1       1    1.333333 12
2       2    1.333333 12
3       3    3.833333 12
4       4    2.000000 12
Inter-variability summary:
Measures for All Pairs of Raters
Variability mean:  2.125
Variability median:  1.5
Variability range:  1 5.5
Variability quantile:
0%:  1   25%:  1.375   50%:  1.5   75%:  2.25   100%:  5.5

Measures by Rater Pairs only
Variability mean:  2.125
Variability median:  2.25
Variability range:  1.25 2.875
Variability quantile:
0%:  1.25   25%:  1.75   50%:  2.25   75%:  2.5625   100%:  2.875

Measures by Subjects
Variability mean:  2.125
Variability median:  1.666667
Variability range:  1.333333 3.833333
Variability quantile:
0%:  1.333333   25%:  1.333333   50%:  1.666667   75%:  2.458333   100%:  3.833333
2.5%    97.5%
1.333333 3.208333 
Code
# To load a demo file into an RStudio script editor window, type
# getRs('observerVariability_example.r', put='rstudio')

From the above output, the 0.95 CL for the mean absolute intra-observer difference is $$[1.17, 1.92]$$ and is $$[1.33, 3.21]$$ for the inter-observer difference. The bootstrap confidence intervals use the cluster bootstrap to account for correlations of multiple readings from the same subject.

When the measurement of interest is a yes/no determination such as presence or absence of a disease these difference statistics are generalizations of the fraction of units in which there is exact agreement in the yes/no determination, when the absolute differences are summarized by averaging. To see this, consider the following data with only one observer:

Patient Determinations $$D_{1}, D_{2}$$ Agreement? $$|D_{1} -D_{2}|$$
1 Y Y 1 1 Y 0
2 Y N 1 0 N 1
3 N Y 0 1 N 1
4 N N 0 0 Y 0
5 N N 0 0 Y 0
6 Y N 1 0 N 1

The average $$|D_{1} - D_{2}|$$ is $$\frac{3}{6} = 0.5$$ which is equal to the proportion of cases in which the two readings disagree.

An advantage of this method of summarizing observer differences is that the investigator can judge what is an acceptable difference and he can relate this directly to the summary disagreement statistic.

## 16.2 Comparison of Measurements with a Standard

When the true measurement is known for each unit (or the true diagnosis is known for each patient), similar calculations can he used to quantify the extent of errors in the measurements. For each unit, the average (over observers) difference from the true value is computed and these differences are summarized over the units. For example, if for unit #1 observer A measures 5 and 7, observer 8 measured 8 and 5, and the true value is 6, the average absolute error is $$(|5-6|+|7-6|+ |8-6|+|5-6|)/4 = \frac{1+1+2+1}{4} = \frac{5}{4} = 1.25$$

## 16.3 Special Case: Assessing Agreement In Two Binary Variables

### 16.3.1 Measuring Agreement Between Two Observers

Suppose that each of $$n$$ patients undergoes two diagnostic tests that can yield only the values positive and negative. The data can be summarized in the following frequency table.

Test 2
+ -
Test 1 + a b g
- c d h
e f n

An estimate of the probability that the two tests agree is $$p_{A}=\frac{a+d}{n}$$. An approximate 0.95 confidence interval for the true probability is derived from $$p_{A} \pm 1.96 \sqrt{p_{A} (1 - p_{A})/n}$$~2 If the disease being tested is very rare or very common, the two tests will agree with high probability by chance alone. The $$\kappa$$ statistic is one way to measure agreement that is corrected for chance agreement. $\kappa = \frac{p_{A} - p_{C}}{1 - p_{C}}$

• 2 A more accurate confidence interval can be obtained using Wilson’s method as provided by the R Hmisc package binconf function.

• where $$p_{C}$$ is the expected agreement proportion if the two observers are completely independent. The statistic can be simplified to $\kappa = \frac{2 (ad - bc)}{gf + eh}.$

It the two tests are in perfect agreement, $$\kappa=1$$. If the two agree at the level expected by chance, $$\kappa=0$$. If the level of agreement is less than one would obtain by chance alone, $$\kappa < 0$$.

A formal test of significance of the difference in the probabilities of for the two tests is obtained using McNemar’s test. The null hypothesis is that the probability of + for test 1 is equal to the probability of + for test 2, or equivalently that the probability of observing a $$+-$$ is the same as that of observing $$-+$$. The normal deviate test statistic is given by $z = \frac{b - c}{\sqrt{b + c}}.$

### 16.3.2 Measuring Agreement Between One Observer and a Standard

Suppose that each of n patients is studied with a diagnostic test and that the true diagnosis is determined, resulting in the following frequency table:

Diagnosis
+ -
Test + a b g
- c d h
e f n

The following measures are frequently used to describe the agreement between the test and the true diagnosis. Here $$T^{+}$$ denotes a positive test, $$D^{-}$$ denotes no disease, etc.

Quantity Probability Being Estimated Formula
Correct diagnosis probability Prob$$(T = D)$$ $$\frac{a+d}{n}$$
Sensitivity Prob$$(T^{+} | D^{+})$$ $$\frac{a}{e}$$
Specificity Prob$$(T^{-} | D^{-})$$ $$\frac{d}{f}$$
Accuracy of a positive test Prob$$(D^{+} | T_{+})$$ $$\frac{a}{g}$$
Accuracy of a negative test Prob$$(D^{-} | T_{-})$$ $$\frac{d}{h}$$

The first and last two measures are usually preferred. Note that when the disease is very rare or very common, the correct diagnosis probability will be high by chance alone. Since the sensitivity and specificity are calculated conditional on the diagnosis, the prevalence of disease does not directly affect these measures. But sensitivity and specificity will vary with every patient characteristic related to the actual ignored severity of disease.

When estimating any of these quantities, Wilson confidence intervals are useful adjunct statistics. A less accurate 0.95 confidence interval is obtained from $$p \pm 1.96\sqrt{\frac{p(1-p)}{n}}$$ where $$p$$ is the proportion and $$m$$ is its denominator.

## 16.4 Problems

1. Three technicians, using different machines, make 3 readings each. For the data that follow, calculate estimates of inter- and intra-technician discrepancy.
Technician
1 2 3
1. Forty-one patients each receive two tests yielding the frequency table shown below. Calculate a measure of agreement (or disagreement) along with an associated 0.95 confidence interval. Also calculate a chance-corrected measure of agreement. Test the null hypothesis that the the tests have the same probability of being positive and the same probability of being negative. In other words, test the hypothesis that the chance of observing $$+-$$ is the same as observing $$-+$$.