Abstract
Effective dissemination of Tuberculosis (TB) clinical evidence to healthcare providers is essential to address this pandemic. To identify, organize, and aggregate online TB information resources, we analyzed the websites of four CDC-funded TB Centers of Excellence (COE), identified the hosted resources, examined the outward linkages, and collected the external resources. We obtained 154 primary resources from TB COEs and 1521 linkages to external resources. We leveraged a network analysis approach to construct resource networks at the individual resource and parent site levels. We computed the degree of connectivity and PageRank for each node in the networks. Based on these analyses, we successfully identified important TB information hosting sites beyond the four TB COEs and individual TB resources widely cited. The initial results indicate that it is promising to use network analysis approaches to identify online clinical information resources. The generalizability of this approach needs to be examined in future research.
1. Introduction
One-fourth of the world’s population is estimated to be infected with Tuberculosis (TB)1. Quick dissemination of TB clinical research is imperative to minimize the impacts of this disease. TB testing and treatment recommendations are often complicated due to the nature of the disease and the dependence on a patient’s pre-existing medical conditions. Clinical guidelines for TB can become very long, complex, and arduous for healthcare providers to understand, to implement, and to adhere to2. To address these challenges, various online resources and tools have been created to facilitate TB clinical education and patient care through clinical decision support.
The Centers for Disease Control and Prevention (CDC) is the prevailing authority in the United States for development and dissemination of clinical evidence for public health. CDC has funded four regional Centers of Excellence (COE) for TB Training, Education, and Medical Consultation: (1) Curry International Tuberculosis Center (CITC); (2) the Global Tuberculosis Institute (GTI); (3) Heartland National Tuberculosis Center (HNTC); and (4) Southeastern National Tuberculosis Center (SNTC)3. The missions of these TB COEs are: “increasing human resource development through education and training activities” and “increasing the capacity for appropriate medical evaluation and management of persons with TB disease and latent TB infection through medical consultation”3. To serve for these missions, the four COEs have accumulated a variety of online TB information resources. Many of these online information resources are inter-connected through hyperlinks (for webpages) or citations (for documents).
Analyzing the linkages among the existing internet-based resources is a hot research topic in computer science. A popular research method is network analysis, which “can help in identifying the underlying network of relationships in a collaboration that people rely on to find information and solve problems”4. Network analysis assists in delineating the underlying structures within organizations or, in the case of online information, identifying effective approaches for resource dissemination5. It can also be utilized as “an invaluable tool for visualizing the structure of a collaboration and in identifying key roles, information flows and collaboration”4. Yet, few studies have leveraged network analysis to determine potential key sites of online information resources for specific clinical domains or diseases6.
The primary aim of this research is to collect, organize and aggregate online TB information resources. The secondary aim of this study is to identify the critical online TB information resources and their hosting websites through network analysis. The overarching goal of our work is to develop effective approaches to disseminate TB clinical evidence.
2. Methods
2.1. Collection of Online TB Resources
To identify the available online TB resources, we reviewed the websites of the four regional TB COEs for publicly available resources. Each TB COE maintains on its website a resource section that contains a list of materials for healthcare providers to utilize in practice.
2.2. Identification of External Resources through Outward Linkages
We reviewed the “outward linkages” from each TB COE’s website to identify the linked resources. For this purpose, a co-author (MA) evaluated each page from the websites of the four TB COEs and assessed all outward hyperlinks from the webpages and references from the documents to identify the external resources.
2.3. Analyses of TB Resources and Linkages
We analyzed the identified TB resources and linkages with respect to the following characteristics:
1) Format of Resource
We analyzed the format of the linked resources and identified the specific types of resources such as webpages, pdf documents, and multimedia objects (for example, videos).
2) Content of Resource
We reviewed and recorded the specific content of each linked resource to identify the detailed information provided.
3) Category/Theme of Resource
We catalogued the linked resources into specific themes. These themes were derived from a detailed review of the content of each target resource. For example, the theme “medication administration” includes all resources that contain information about medication injections or specific antibiotic instructions.
4) Linkage Context
We assessed the context for each outward linkage to determine the contextual clues of a linkage from a hosting webpage to a target resource.
5) Parent Site of Target Resource
For each target resource, we recorded the information of its parent website. This analysis aimed to identify the organizations that sponsor the target resources.
2.4. Construction and Analysis of TB Resource Network
We constructed the TB resource networks on two separate levels:
1) Individual Resource Level
We treated each linked resource as a node. We treated a linkage (hyperlink or citation) from a resource A to another resource B (webpage, document, or multimedia object) as a directed edge from node A to node B. Each referral to a target resource counted as a single instance. If a resource A is linked to the same target resource B multiple times, the total number of the linkages was assigned as the weight of the directed edge from A to B.
2) Parent Site Level
We treated each parent site as a node. We treated a linkage (hyperlink or citation) from any resource on parent site A to any target resource on parent site B as a directed edge from node A to node B. If a parent site A is linked to a parent site B multiple times, the total number of the linkages was assigned as the weight of the directed edge from A to B.
With the TB resource network constructed, we computed the following measures at both the individual resource and parent site levels for network analyses:
1) Degree of Connectivity
At the individual resource level, we calculated the degrees of connectivity to identify the number of inward and outward linkages for each linked resource. The degree of connectivity is defined as the “the number of nodes that a focal node is connected to, and measures the involvement of the node in the network”7. For this study, out-degree was calculated as the number of outward linkages from a specific resource, whereas in-degree was calculated as the number of inward linkages to that resource. The total degree was calculated as the sum of the in- and out-degrees. At the parent site level, we treated each parent site as a node and calculated the in-degree and out-degree based on the linkages between the sites. Since we identified all the resources through the outward linkages from the four TB COEs (see Sections 2.1 and 2.2), only those four TB COE sites have an out-degree. Meanwhile, all the identified resources have an in-degree. We therefore focused on in-degree for the analysis at the parent site level.
2) PageRank
The PageRank measure was originally developed by Google as a means to indicate the “importance” of a single webpage. In network analysis, “PageRank can be thought of as a model of user behavior”8. This model identifies the probability that a random user transitions from one page to another and thus gives a score of “importance” calculated as a probability to each page in the network.
The calculation of PageRank for an example page “A” is based on the following formula:
Here T1 to Tn are all the other webpages with hyperlinks pointing to A, C(Ti) is the count of hyperlinks from webpage Ti to A, where d is defined as a damping factor, set between 0 and 1, to indicate the probability a user continues to browse webpages following a hyperlink. A common default value for d is 0.85, which was used for this study8. We utilized a software package for network analysis, Gephi (version 0.9.2), to calculate the PageRank for each individual resource and parent site.
2.5. Visualization
Visualization is an intuitive approach to allow direct observation of the structure and other characteristics of a network. For this study, we leveraged the Gephi software package for visualizations.
3. Results
3.1. Online Resources Published by the Four TB COEs
Over the period from February 2018 through December 2018, we analyzed a total of 154 online resources published by the four TB COEs. A majority of these resources (133, 86.4%) were downloadable PDF documents or informational webpages. The remaining 21 (13.6%) resources included multimedia files, toolkits, and continuing medical education (CME) courses. With regard to the topics and prevailing themes of the resources, we identified 29 (18.8%) patient education materials, 19 (12.3%) geographic guidance for clinicians, and 13 (8.4%) for cultural competence training. Among the identified resources, 123 (79.9%) included the date for original publication or revision, ranging from 2001 to 2017. In terms of the size of the materials, the PDF documents ranged from 1 to 326 pages (on average 33 pages), and the multimedia files ranged from 31 seconds to 85 minutes (on average 28 minutes and 29 seconds). A summary of the identified TB resources and their catalogue is shown in Table 1.
Table 1.
Catalogue of TB Resources.
| Hosting TB COE | N | (%) |
| CITC | 25 | 16.23 |
| GTI | 34 | 22.07 |
| HNTC | 32 | 20.77 |
| SNTC | 63 | 40.90 |
| Formats | N | (%) |
| Static PDF | 117 | 75.97 |
| Informational Webpage | 16 | 10.38 |
| Video/multimedia presentation | 11 | 7.14 |
| Toolkits | 7 | 4.54 |
| Downloadable Audio File | 2 | 1.29 |
| CEI Credit Course | 1 | 0.65 |
| Size | N | (%) |
| Printable Material: Single page | 14 | 9.09 |
| Printable Material: 2-10 pages | 40 | 25.97 |
| Printable Material: 11-50 pages | 40 | 25.97 |
| Printable Material: 51-100 pages | 9 | 5.84 |
| Printable Material: 101 pages and above | 14 | 9.09 |
| Multimedia File: 0-15 minutes | 4 | 2.59 |
| Multimedia File: 15-60 minutes | 6 | 3.89 |
| Multimedia File: Greater than 60 min | 1 | 0.65 |
| Not Applicable | 26 | 16.88 |
| Prevailing Theme | N | (%) |
| Patient education | 29 | 18.83 |
| Region-Specific Guidance | 19 | 12.34 |
| Cultural Competence | 13 | 8.44 |
| TB Infection Control | 12 | 7.79 |
| Provider Education | 11 | 7.14 |
| TB Treatment | 10 | 6.49 |
| Harm reduction information | 9 | 5.84 |
| Radiographic Information | 9 | 5.84 |
| Case Management | 8 | 5.19 |
| Contact Investigation Skills | 7 | 4.55 |
| Archived Guideline | 6 | 3.89 |
| Medication Administration | 4 | 2.60 |
| Pediatric TB | 3 | 1.95 |
| TB Evaluation | 3 | 1.95 |
| Nutrition Recommendations | 2 | 1.30 |
| Testing resources | 2 | 1.30 |
| Teaching Curricula | 2 | 1.30 |
| Ethics | 2 | 1.3 |
| Miscellaneous | 3 | 1.95 |
3.2. Identification of Outward Linkages
We recorded a total of 1521 outward linkages from the 154 resources identified. The top linkage contexts included 494 citations (32.48%), 359 referrals for detailed information on specific topics (23.60%), 307 links to patient appropriate educational resources (20.18%), 270 general resources such as printable documents or videos (17.75%), and 29 provider education materials (1.91%). The top linkage topics included materials related to improving clinician’s cultural competency (521, 36.28%), general TB information (254, 17.69%), TB/HIV coinfection (112, 7.80%), TB medication (88, 6.13%), and TB directly observed therapy (84, 5.85%). The parent sites with the most linked target resources included CDC (8.42%), CITC (5.98%), World Health Organization (WHO) (5.92%), SNTC (3.88%), GTI (3.74%), EthnoMed9 (2.43%), and the United States Department of Health Services (USDHS) (1.97%). The details of the outward linkage metrics are shown in Table 2.
Table 2.
Outward Linkage Metrics
| Top Linkage Contexts | N | (%) |
| Citations | 494 | 32.48 |
| Referral for Specific Information | 359 | 23.60 |
| Referral Patient Education Resources | 307 | 20.18 |
| Referral for General Resources (printable/video) | 270 | 17.75 |
| Provider Education Materials | 29 | 1.91 |
| Top Linkage Topics | N | (%) |
| Cultural Competency | 521 | 36.28 |
| General TB information | 254 | 17.69 |
| TB/HIV Coinfection | 112 | 7.80 |
| TB Medication | 88 | 6.13 |
| TB Directly Observed Therapy | 84 | 5.85 |
| Top Parent Sites | N | (%) |
| CDC | 128 | 8.42 |
| CITC* | 91 | 5.98 |
| WHO | 90 | 5.92 |
| SNTC* | 59 | 3.88 |
| GTI* | 57 | 3.74 |
| EthnoMed9 | 37 | 2.43 |
| USDHS | 30 | 1.97 |
TB COE
3.3. Network Analysis - Degree of Connectivity
At the parent site level, we recorded an out-degree of 170 for SNTC, 113 for CITC, 38 for GTI, and 30 for HNTC. The in-degree of the four TB COEs is between 3 and 4, and the total degree ranges from 33 to 174. The details of this analysis are shown in Table 3.
Table 3.
Degree of Connectivity for the Four TB COEs
| Parent Site Organization | Out-Degree | In-Degree | Total Degree |
|---|---|---|---|
| SNTC | 170 | 4 | 174 |
| CITC | 113 | 3 | 116 |
| GTI | 38 | 4 | 42 |
| HNTC | 30 | 3 | 33 |
After combined all the resources from the four TB COEs and other organizations, the top parent sites based on the in-degree are: SNTC, GCI, CDC, WHO, Management Sciences for Health, HNTC, CITC, University of California San Francisco, EthnoMed9, Find TB Resources, TB Controllers of America, Diversity Rx10, and Stop TB Partnership11. The remaining parent sites had an in-degree below 3. The detailed result of this analysis is shown in Table 4.
Table 4.
Top Parent Sites Based on the In-Degree
| Parent Site Organization | In-Degree |
|---|---|
| SNTC* | 4 |
| GTI* | 4 |
| CDC | 4 |
| WHO | 4 |
| Management Sciences for Health | 4 |
| HNTC* | 3 |
| CITC* | 3 |
| University of California at San Francisco | 3 |
| EthnoMed9 | 3 |
| Find TB Resources | 3 |
| TB Controllers of America | 3 |
| Diversity Rx10 | 3 |
| Stop TB Organization11 | 3 |
TB COE
At the individual resource level, the resources with the highest in-degree included: SNTC Main Products page (17), TinyURL Webhosting Page for TB Fotonovela (8), HNTC homepage (8), SNTC homepage (8), New Mexico Department of Health Active TB informational page (8), New Mexico Department of Health Sputum Collection Instruction page (8), US Department of Homeland Security 2008 report on Profiles of Naturalized Citizens for the fiscal year of 2006 (8), GTI homepage (7), and US Census Bureau Fact Finder page (7). The detailed result of this analysis is shown in Table 5.
Table 5.
Top Individual Resources Based on the In-Degree
| Individual Resource | Parent Organization | In-Degree |
|---|---|---|
| SNTC Main Products Page12 | SNTC* | 17 |
| TinyURL Webhosting Page for TB Fotonovela13 | TinyURL Webhost | 8 |
| HNTC Homepage | HNTC* | 8 |
| SNTC Homepage | SNTC* | 8 |
| Active TB Informational Page | New Mexico DOH | 8 |
| Sputum Collection Instruction Webpage | New Mexico DOH | 8 |
| Report on Profiles of Naturalized Citizens for the Fiscal Year 2006 | USDHS | 8 |
| GTI Homepage14 | GTI* | 7 |
| US Census Bureau Fact Finder Page | US Census | 7 |
TB COE
3.4. Network Analysis – PageRank
At the parent site level, the organizations with the top PageRanks were: CDC (0.003654), WHO (0.003654), Management Science for Health (0.003654), SNTC (0.003636), TB Controllers of America (0.003636), Diversity Rx10 (0.003636), University of California at San Francisco (0.003627), CITC (0.003609), GTI (0.003574), and Stop TB Partnership11 (0.003574), as shown in Table 6.
Table 6.
Top 10 Parent Sites by PageRank
| Parent Site Organization | PageRank |
|---|---|
| CDC | 0.003654 |
| WHO | 0.003654 |
| Management Sciences for Health | 0.003654 |
| SNTC* | 0.003636 |
| TB Controllers of America | 0.003636 |
| Diversity Rx10 | 0.003636 |
| University of California at San Francisco | 0.003627 |
| CITC* | 0.003609 |
| GTI* | 0.003574 |
| Stop TB Partnership11 | 0.003574 |
TB COE
At the individual resource level, the webpages with the top PageRanks were: SNTC Main Products page (0.008372), TinyURL Webhosting Page for TB Fotonovela (0.003547), GTI homepage (0.003262), GTI Resources page (0.002305), HNTC Medical Consultation page (0.002251), Drugs.com Amikacin Administration information page (0.002134), Nursing Center Take 5 Z-Track Injection informational page (0.002134), CITC Medication Fact Sheet page (0.001494), GTI TB Interviewing for Contact Investigation: A Practical Resource for the Healthcare Worker page (0.001488), and WHO Regional Office for Europe homepage (0.001488). It is important to note that 6 out of the top 10 resources were hosted by the four TB COEs. The details of the results can be found in Table 7.
Table 7.
Top Individual Resources by PageRank
| Webpage | Parent Organization | PageRank |
|---|---|---|
| SNTC Main Products Page12 | SNTC* | 0.008372 |
| Tiny URL Host for TB Fotonovela13 | TinyURL Webhost | 0.003547 |
| GTI Homepage14 | GTI* | 0.003262 |
| GTI Resources Page15 | GTI* | 0.002305 |
| HNTC Medical Consultation Page16 | HNTC* | 0.002251 |
| Amikacin Administration Information Page17 | Drugs.com | 0.002134 |
| Take 5 Z-Track Injections Information Page18 | Nursing Center | 0.002134 |
| Medication Fact Sheet Page19 | CITC* | 0.001494 |
| TB Interviewing for Contact Investigation: A Practical Resource for the Healthcare Worker20 | GTI* | 0.001488 |
| WHO Regional Office for Europe Homepage21 | WHO | 0.001488 |
TB COE
3.5. Visualizations
Visualization of the TB resource network based on the PageRank of parent site is shown in Figure 1. A parent site with a higher PageRank is presented as a node with a larger size. The thickness of an edge indicates the weight of that edge. The top 10 parent sites and all four TB COEs are pinpointed in Figure 1.
Figure 1.
Visualization of the TB Resource Network Based on the PageRank of Parent Websites
Visualization of the TB resource network based on the PageRank of individual resource is shown in Figure 2. Resources hosted under a top-ranked parent site are presented as nodes in the same color. A resource with a higher PageRank is presented as a node with a larger size. The thickness of an edge indicates the weight of that edge. The details of a specific top-ranked individual resource is zoomed at the lower-right corner of Figure 2.
Figure 2.
Visualization of the TB Resource Network Based on the PageRank of Individual Resources
Discussion
In this study, we assessed the existing web-based TB resources and their linkages. For this purpose, we started from the websites of the four national TB COEs and identified additional resources through hyperlinks and citations. We examined each resource to record its format, content, and theme. This analysis provided important information to understand the structure of online resources, the characteristics of these resources, and the potential strategies for their dissemination, which are essential for biomedical informatics research.
By leveraging network analysis approaches and the associated software tools, we constructed TB online resource networks at both the individual resource and the parent site levels. In particular, we identified major TB resource hosting sites beyond the four TB COEs, such as CDC, WHO, Management Science for Health, University of California at San Francisco, TB Controllers of America, Diversity Rx10, and Stop TB Partnership11. While sites like CDC and WHO are well known for their informational resources, this analysis identified less-known websites, such as EthnoMed8 and Diversity Rx10, which hosted highly useful information for TB healthcare providers.
We utilized two network measures to identify the top sites, i.e., degree of connectivity and PageRank. Each measure has its own advantages and limitations. The degree of connectivity only focuses on the local structure, which makes it very easy to compute. However, simply linked to other nodes may not necessarily mean that such linkages are important. PageRank provides a quantitative measure on value of different linkages by considering the global importance of the linked nodes, and therefore can provide a more accurate evaluation of resources. On the other hand, calculation of PageRank becomes more complex due to this global consideration. It is interesting to note that a significant portion of the identified top sites based on degree of connectivity are overlapped with those based on PageRank. A potential explanation is that we only had two levels of resource linkages when developing the network (the four TB COEs and their linked resources) and therefore the difference between the local and global structures is insignificant. Our future work will explore multiple levels of resource linkages and re-examine the use of specific network measures to identify important hosting sites for TB resources.
Through analysis at the individual resource level, we identified several useful TB resources, such as those about sputum collection and active TB hosted at New Mexico Department of Health. These two resources had a high level of connectivity, with linkages from all four TB COEs. We also found external resources with a high PageRank, such as the Amikacin Administration page hosted at Drugs.com. By identifying resources with high PageRank, we can further examine the specific information that is perceived as important by the TB COEs and their targeting clinicians.
Visualization of the TB resource networks allowed us to directly examine the important parent sites or individual resources identified from the analysis. For example, visualization of the parent site network placed CDC and WHO at the central location, with a node size (indicating PageRank) even larger than the four TB COEs. Visualization of the individual TB resources, on the other hand, requires more efforts to examine due to the large number of nodes in the network. Nevertheless, it still allowed us to identify certain important resources, such as the GTI homepage. Meanwhile, the color coding of resources made it intuitive to observe those hosted at the same parent site as well as the linkages within and beyond the hosting site.
There are a few limitations in this research. First, the collection of online TB information resources was constrained to only the four TB COEs and their direct linkages. Although these four TB COEs represent the major national resources for TB, the completeness of the collected TB resources needs to be further verified. Second, all the online resources were manually reviewed by a single person, which may introduce potential selection bias and reduce the reliability of data collection. Although this reviewer has extensive experience working with TB, ideally we should have multiple independent reviewers to ensure a high quality and fair process of the analyses. Third, the network analysis was limited to two levels of resource linkages. To further examine the use of specific network measures to identify the important resources and the hosting sites, we will need to perform network analysis with multiple levels of resources linkages. Last, this study focused specifically on TB information resources and their linkages. The generalizability of the findings from this study to other diseases and clinical problems needs to be verified in future studies.
Our work in the next steps includes: (1) expanding the review of TB resources to the sites beyond the four COEs; (2) leveraging web crawling technologies to automatically identify linked resources and to facilitate the construction of resource networks; (3) integrating semantic analysis techniques to provide another perspective on content of the resources identified; (4) performing larger scale network analyses with multi-level resource linkages and additional measurement on network properties to identify a complete set of TB information resources; and (5) generalizing the study approaches for applications to other diseases, clinical problems, and public health challenges.
Conclusion
We have analyzed online TB information resources through manual reviewing the websites of the four national TB COEs and their linkages. Based on this analysis, we have successfully constructed TB resource networks at both the parent site and the individual resource levels. Leveraging network analysis methods and the associated tools, we have identified important TB resources and hosting sites. The initial results from this study indicates that it is promising to use network analysis approaches for identification and dissemination of online clinical information resources. Our future work will expand the scope of resource review, develop automated processes to identify resources and linkages, perform larger scale network analysis, and examine the generalizability of the study approaches, with an ultimate goal for more effective dissemination of clinical evidence and better care of patients with TB and other diseases.
Figures & Table
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