Sensitivity and robustness of comorbidity network analysis

Background: Comorbidity network analysis (CNA) is an increasingly popular approach in systems medicine, in which mathematical graphs encode epidemiological correlations (links) between diseases (nodes) inferred from their occurrence in an underlying patient population. A variety of methods have been used to infer properties of the constituent diseases or underlying populations from the network structure, but few have been validated or reproduced. Objectives: To test the robustness and sensitivity of several common CNA techniques to the source of population health data and the method of link determination. Methods: We obtained six sources of aggregated disease co-occurrence data, coded using varied ontologies, most of which were provided by the authors of CNAs. We constructed families of comorbidity networks from these data sets, in which links were determined using a range of statistical thresholds and measures of association. We calculated degree distributions, single-value statistics, and centrality rankings for these networks and evaluated their sensitivity to the source of data and link determination parameters. From two open-access sources of patient-level data, we constructed comorbidity networks using several multivariate models in addition to comparable pairwise models and evaluated differences between correlation estimates and network structure. Results: Global network statistics vary widely depending on the underlying population. Much of this variation is due to network density, which for our six data sets ranged over three orders of magnitude. The statistical threshold for link determination also had strong effects on global statistics, though at any fixed threshold the same patterns distinguished our six populations. The association measure used to quantify comorbid relations had smaller but discernible effects on global structure. Co-occurrence rates estimated using multivariate models were increasingly negative-shifted as models accounted for more effects. However, only associations between the most prevalent disorders were consistent from model to model. Centrality rankings were likewise similar when based on the same dataset using different constructions; but they were difficult to compare, and very different when comparable, between data sets, especially those using different ontologies. The most central disease codes were particular to the underlying populations and were often broad categories, injuries, or non-specific symptoms. Conclusions: CNAs can improve robustness and comparability by accounting for known limitations. In particular, we urge comorbidity network analysts (a) to include, where permissible, disaggregated disease occurrence data to allow more targeted reproduction and comparison of results; (b) to report differences in results obtained using different association measures, including both one of relative risk and one of correlation; (c) when identifying centrally located disorders, to carefully decide the most suitable ontology for this purpose; and, (d) when relevant to the interpretation of results, to compare them to those obtained using a multivariate model.