Bland Altman Analysis

The Bland-Altman
analysis is not a statistical test measured with a p-value. Instead, it is a

process used to assess agreement between two methods of measurement. (Bland and Altman
1986, 2003) An important requirement of the Bland-Altman method for measuring agreement is
that the two methods for measuring the same characteristic use the same scale of measurement.
This implies that when plotted, the points should line up along the line y = x (line of identity).
It is possible for two measures to have strong linear agreement using a Pearson’s
correlation (r) when they are not measuring the same quantity because a correlation analysis does
not require that the two measurements be on the same scale or to even be measurements of the
same characteristic.

The analysis is based on examination of two plots:
 Plot of identity: A scatterplot of the two measurements along with the line y =
x. If the measurements are in basic agreement then the points in the scatterplot
will line up closely to the line y = x.
 Bland-Altman plot: A scatterplot of variable means plotted on the horizontal axis
and the differences plotted on the vertical axis which shows the amount of
disagreement between the two measures (via the differences) and lets you see
how this disagreement relates to the magnitude of the measurements. This plot
includes approximate 95% limits (based on an assumption of normal
differences). If differences observed in this plot are not deemed scientifically (or
clinical) important (according to the researcher’s own expertise), this is a
confirmation of agreement. (The decision as to what constitutes a clinically
important difference should be made in advance of the analysis.)

Example
This example uses data from Bland and Altman (1986): two measurements of peak
expiratory flow rate (PEFR) are compared. One of these measurements uses a “Large” meter
and the other a “Mini” meter. The research question of interest is whether these two techniques
are measuring the same phenomenon. The first way to examine the two measure is with A plot
of identity.

To get the file used in the analysis

http://www.stattutorials.com/SASDATA/Bland_Altman.sas

and SAVE the file to the C:\SASDATA directory

For this data, the plot is shown here:

Note that the line drawn here is the line y = x, not the regression line. If the scatter of
points in this plot lies near the line, it indicates that the two ways of measuring PEFR are
similar. From this plot you can see that the scatterplot falls close to the line which suggests that
the two machines are measuring the same characteristic. The SAS code to produce this graph
follows.

Step 1: Calculate the differences and averages. (Actually the differences are used in the plot of
identity above) using this code:

DATA BA;
input large mini;
diff=large-mini;
avg=(large+mini)/2;
datalines;
… data follow…

Step 2: Specify values for the x and y axes for the plot, and this is done with macro variables in
the following code:

%let miny=-100;%let maxy=100;%let ticky=20;
%let minx=100;%let maxx=700;%let tickx=50;

The “tick” variable specifies how often ticks will appear on the axis. For the X axis the
minimum and maximum should reflect values that fully encompass the values of the original
data (mini and large in this case.)

Step 3: Create necessary information to produce the mean line at 0 using the information in the
“anno” data set shown below:

data anno;
function='move'; xsys='1'; ysys='1'; x=0; y=0; output;
function='draw'; xsys='1'; ysys='1'; color='red'; x=100; y=100; size=2;
output;
run;

Step 4: The plot of identity is produced using this code (using the mean line information from
the anno dataset.)

symbol1 i=none v=dot c=black height=1;
* X AXIS - HORIZONTAL;
axis1 length=6.5 in width=1
value=(font="Arial" h=1) order=&minx to &maxx by &tickx;
* YAXIS - VERTICAL;
axis2 length=4.5 in width=1
value=(font="Arial" h=1) order=&minx to &maxx by &tickx;
footnote ;
proc gplot data=PERF;
plot large*mini / anno=anno haxis=axis1 vaxis=axis2;
run;

The second plot is a little more difficult to come up with. It is a scatterplot of the average
of the two measurements against the difference (large minus mini) between measurements for
each subject. This plot is a visual check that the magnitudes of the differences are essentially
constant throughout the range of measurement. If the differences are approximately normally
distributed, then you would expect about 5% of the points to lie outside the limit lines. This plot
is displayed here:
Notice that the 95% limit lines are at about plus or minus 75 for the differences between
readings, and the graph shows a few differences outside or close to the limit lines, i.e. differences
in the neighborhood of 75 (the actual limits are -75.4 and 79.6). Bland and Altman (1986)
argue that such large differences are clinically important (a decision not based on any p-value)
and therefore conclude that the two devices do not show sufficient agreement to be used
interchangeably. It is important to note that this lack of agreement is not apparent in the plot of
identity. The following steps are used to calculate the values needed for this plot.

Step 1: Using the BA data set created above, calculate the mean and standard deviation of the
“diff” value and output that information to a file (named diff in this case.) Merge the mean and
std into the original data set (name the combined data set PERF) and use that information to
calculate the upper 95% bound (ubound) and lower bound (lbound) using the following SAS
code:

data prelim;set ba;
proc means noprint data=prelim;var diff;
output out=diff mean=meandiff std=stddiff;
run;
data PERF;set prelim;
if _N_=1 then set diff;
ubound=meandiff+stddiff*2;
lbound=meandiff-stddiff*2;
run;

The PERF data set contains the following information shown in the PERF data set below.
Notice the meandiff and std columns were from the PROC MEANS and
the ubound and lbound were calculated using the code above.

Step 2: Specify the limits for the axes using macro variables:

* AXIS LIMITS FOR GRAPHS;
%let miny=-100;%let maxy=100;%let ticky=20;

This information is something you must observe from the data – note that the minimum
and maximum for the Y axis should be the same magnitude (but one negative) to create a
balanced plot.

Step 3: The next set of code creates a data set named “b” that contains values that are used to
draw the mean line and the two limits (ubound and lbound) on the plot.

data b;set diff;
Maxaxis=&maxy;
meanline=50+(meandiff/(maxaxis*2))*100;
upper = 50+((meandiff+2*stddiff)/(maxaxis*2))*100;
up=(meandiff+2*stddiff);
lower = 50+((meandiff-2*stddiff)/(maxaxis*2))*100;
length color function $8 text $14;
retain xsys '1' ysys '2' when 'a';
/* The lines are positioned using the percentage of the horizontal axis,*/
* --this is the mean value for the y axis;
function='move'; xsys='1'; ysys='1';x=0; y=meanline; output;
function='draw'; xsys='1'; ysys='1';x=100; y=meanline; color='red'; size=2;
output;
* Upper confidence limit ------------- ;
function='move'; xsys='1'; ysys='1'; x=0; y=upper; output;
function='draw'; xsys='1'; ysys='1'; color='green'; x=100; y=upper; size=1;
output;
* Lower confidence limit ------------- ;
*data Lower;
function='move'; xsys='1'; ysys='1'; x=0; y=lower; output;
function='draw'; xsys='1'; ysys='1'; color='green'; x=100; y=lower; size=1;
output;
run;

Step 4: The Bland –Altman graph is created using the following code. The “symbol” statement
specifies the type of dots, color and size of dots. The “axis1” paragraph specifies information
about the X-axis and the “axis2” paragraph specifies information about the Y-axis.In particular,
the numbers used for each are given by the “order” statements. The plot is produced with the
PROC GPLOT statement, which uses the information from the “b” data set to annotate (anno=b)
the plot with the three lines calculated above.

symbol1 i=none v=dot c=black height=1;
* XAXIS - HORIZONTAL - AVERAGE;
axis1 length=6.5 in width=1 OFFSET=(0,0)
label=(f="Arial" h=2 'Average')
value=(font="Arial" h=1)
order=&minx to &maxx by &tickx;
* YAXIS - Vertical - Difference;
axis2 length=4.5 in width=1 OFFSET=(0,0)
label=(f="Arial" h=2 'Difference')
value=(font="Arial" h=1)
order=&miny to &maxy by &ticky;
footnote h=2 f="Arial" 'Bland-Altman Plot';
title h=2 f="Arial" 'Example';
proc gplot data=PERF;
plot diff*avg/ anno=b haxis=axis1 vaxis=axis2;
run;
quit;

Reporting the results of a Bland-Altman analysis
The following example illustrates how you might report the results of a Bland-Altman
analysis in publication format.

Narrative for methods section:
“A Bland-Altman assessment for agreement was used to compare the two peak flow
methods. A range of agreement was defined as mean bias ±2 SD.”
Bland-Altman Analysis
“A Bland-Altman analysis was used to assess the level of agreement between the two
methods to compare the new technique to the established one.”

Narrative for results section:

“The Bland-Altman analysis indicates that the 95% limits of agreement between the two
methods ranged from -75.4 to 79.6. The two methods do not consistently provide similar
measures because there is a level of disagreement that includes clinically important
discrepancies of up to 80 l/min.”

References
 Barnett, V. and Lewis, T. (1994). Outliers in Statistical Data, 3rd edition. New York:
John Wiley and Sons.
 Bland JM and Altman DG. (1986).Statistical methods for assessing agreement between
two methods of clinical measurement, Lancet, February, pp 307-10.
 Bland JM and Altman DG. (2003). Applying the right statistics: analyses of measurement
studies, Untrasound Obstet Gynecol 2003;22: 85-93.
 Elliott, AC, Woodward, WA (2007), Statistical Analysis Quick Reference Guidebook,
Sag, pp 107ff.
 Kleinbaum DG, Kupper LL, Muller KE, Nizam A. (1997). Applied Regression Analysis
and Other Multivariate Methods (3rd Edition), North Scituate, MA: Duxbury Press.
 Mantel, N. (1970). Why stepdown procedures in variable selection,”Technometrics 12,
621-625.
 SAS Institute Inc. (2003). SAS/STAT Software: Reference, Version 9.1, Cary, NC: SAS
Institute Inc.

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The Bland-Altman

analysis is not a statistical test measured with a p-value. Instead, it is a

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