Research ArticleResearch

Assessing the impact of Canadian primary care research and researchers

Citation analysis

Monica Aggarwal, Brian Hutchison, Alan Katz, Sabrina T. Wong, Emily Gard Marshall and Steve Slade
Canadian Family Physician May 2024; 70 (5) 329-341; DOI: https://doi.org/10.46747/cfp.7005329

Abstract

Objective To describe the citation impact and characteristics of Canadian primary care researchers and research publications.

Design Citation analysis.

Setting Canada.

Participants A total of 266 established Canadian primary care researchers.

Main outcome measures The 50 most cited primary care researchers in Canada were identified by analyzing data from the Scopus database. Various parameters, including the number of publications and citations, research themes, Scopus h index, content analysis, journal impact factors, and field-weighted citation impact for their publications, were assessed. Information about the characteristics of these researchers was collected using the Google search engine.

Results On average, the 50 most cited primary care researchers produced 51.1 first-author publications (range 13 to 249) and were cited 1864.32 times (range 796 to 9081) over 29 years. Twenty-seven publications were cited more than 500 times. More than half of the researchers were men (60%). Most were clinician scientists (86%) with a primary academic appointment in family medicine (86%) and were affiliated with 5 universities (74%). Career duration was moderately associated with the number of first-author publications (0.35; P=.013). Most research focused on family practice, while some addressed health and health care issues (eg, continuing professional education, pharmaceutical policy).

Conclusion Canada is home to a cadre of primary care researchers who are highly cited in the medical literature, suggesting that their work is of high quality and relevance. Building on this foundation, further investments in primary care research could accelerate needed improvements in Canadian primary care policy and practice.

High-performing primary care (PC) is widely acknowledged as the cornerstone of effective and efficient health care systems.1,2 Herein, primary care is defined as an

[i]nclusive term to cover the spectrum of first-contact healthcare models from those whose focus is comprehensive, person-centered care, sustained over time, to those that also incorporate health promotion, community development and intersectoral action to address the social determinants of health.1,3

In 2008, the World Health Organization highlighted the importance of producing knowledge and research to accelerate primary care reform.4 Despite this recognition, investment in PC research and the number of publications are low in Canada and abroad.5 The National Academies Committee on Implementing High-Quality Primary Care concluded there is a paucity of published literature on primary care reform and a substantial need for PC-oriented research identifying the practices and approaches to improve the delivery of high-quality PC.6

In Canada, investment in PC research has been made through several initiatives: In 2000, the Government of Canada established the $800-million Primary Health Care Transition Fund to support pilot and demonstration projects and research.7 In 2003, the Canadian Institutes of Health Research (CIHR) launched the Transdisciplinary Understanding and Training on Research–Primary Health Care program; funding ended in 2013.8,9 In 2012, the CIHR Institute of Health Services and Policy Research and Institute of Population and Public Health launched the Community-Based Primary Health Care Signature Initiative,10 which provided funding to 12 interdisciplinary, cross-jurisdictional innovation teams to conduct research and provide research training and mentorship.9 In 2014, the CIHR implemented the Community-Based Primary Health Care pan-Canadian Strategy for Patient-Oriented Research Network in Primary and Integrated Health Care Innovations.9,11 These initiatives showcase the country’s commitment to fostering research excellence in PC. However, total investment in PC research represented only 3% of total CIHR research funding from 2016 to 2017 and from 2017 to 2018.3

Canada’s underinvestment in PC research now coincides with the current PC crisis. Approximately 14% of Canadians do not have a regular care provider.12 Among seniors aged 65 or older in 11 Commonwealth countries, Canada has the lowest rate of those who can see a doctor or nurse on the same or the next day and the second highest rate of seniors going to the emergency department for health problems that could have been handled by a PC provider.13 This underinvestment in PC research, evidence, and knowledge exacerbates our ability to adequately navigate the current crisis.

Despite the low investment in PC research, Canada is home to PC researchers who have received international recognition and have made important contributions to the field.14-23 However, there is limited awareness of their scholarly productivity and the impact of their research. This study analyzes and describes the research publication impact of PC research and researchers. Specifically, it identifies the 50 most cited Canadian PC researchers and their individual and aggregate citation impact; characteristics of the most cited Canadian PC researchers; and the most cited peer-reviewed publications by Canadian PC researchers. By undertaking this study, we aim to celebrate the achievements of Canadian PC researchers and highlight the knowledge they bring to the field.

METHODS

Design

We conducted a citation analysis24 using quantitative bibliometrics,25,26 which is exempt from ethics review board approval. One measure of the impact (ie, the scientific contribution of a published work) of research studies is the frequency of manuscript citations by other scholars.27 Citation analysis has been used to describe and analyze trends in scientific articles, authorship, journals, and different research fields.28-37

Sample

To identify Canadian PC researchers, we used a sequential nomination process. The sampling frame included those who were 1 or both of the following: a researcher whose research is focused on PC or a PC clinician who does research. The initial list was created in March 2020 and consisted of recipients of research honours from the College of Family Physicians of Canada.38-41 Additional researchers were added to the list based on input from senior researchers and leaders. The list was sent to the research directors of the 17 family medicine departments across Canada who provided names of researchers whose first-author peer-reviewed papers are highly cited (ie, researchers who publish multiple papers per year, many as the first author, often in high-impact journals). Finally, 6 additional researchers were added from the Stanford University researcher list of Canadian researchers. We eliminated 26 researchers due to no first-author publications, no research in PC, or limited time spent in Canada. The final list comprised 266 established PC researchers.

Data sources

The Scopus database was used to obtain bibliometric data since it includes a comprehensive overview of science, technology, medicine, social science, and arts and humanities research. For the 266 PC researchers, we produced a list of their respective publications and the number of citations (excluding self-citations) in December 2022.

Data collection and analysis

We identified the 50 most cited researchers (top 20%) based on the number of citations of their first-author publications. To ensure this metric was valid, we confirmed a high correlation between first-author citations and rank as well as first- and last-author citations (ρ=0.803) and rank (ρ=0.814), as well as between first-author citations and rank and first-, second-, and last-author citations (ρ=0.750) and rank (ρ=0.765).

Using a Microsoft Excel spreadsheet, we collected data on the number of first-author publications, number of co-author publications, number of first-author publication citations, number of co-author publication citations, date of initial first-author peer-reviewed publication and date of most recent peer-reviewed publication (either as first author or co-author), research themes, and h index.42 The time between a researcher’s first peer-reviewed first-author publication and their most recent peer-reviewed publication was used as a proxy for the duration of their research career to date.

To collect data on the characteristics of these PC researchers, targeted Internet searches were conducted in Google to find the following information: sex, province of residence, university and department affiliation, academic rank, faculty research intensity of current university,43 graduate degrees, university or institution, discipline or program, researcher type (eg, clinician-researcher [and clinical discipline], health scientist [nonclinician]), and health profession. In our analysis, we have primarily considered researchers’ current affiliations; however, it is important to acknowledge that researchers may have multiple affiliations or collaborations throughout their careers, which could influence their research productivity in various contexts.

Using Scopus, we identified peer-reviewed publications with more than 500 citations and recorded contextual information on each article, including title, authors, journal, the number of citations, journal impact factor, field-weighted citation impact,44 full citation, and abstract. The research team reviewed data extraction. We used point-serial correlation and Pearson correlation tests to examine associations between different variables in Table 1.

View this table:
Table 1.

Tests of relationships within the most cited researcher cohort

RESULTS

Table 2 lists the 50 Canadian PC researchers with the highest number of citations of first-author peer-reviewed publications in descending order of the number of first-author citations. Researcher profiles are available in the supplementary material in CFPlus.* Collectively, the 50 most cited PC researchers have published 2555 papers as first authors and have been cited 93,216 times. The researcher with the highest number of career citations is Dr Dave Davis from the University of Toronto in Ontario (9081 career citations) followed by Dr Moira Stewart from Western University in London, Ont (6686 career citations).

View this table:
Table 2.

Fifty most cited Canadian primary care researchers

The characteristics of the most cited PC researchers are provided in Table 3. Thirty researchers are male and 20 are female. Most (54%) reside in Ontario, followed by Quebec (22%), British Columbia (12%), and Alberta (8%). One-third are affiliated with the University of Toronto. Family medicine is the primary departmental affiliation (86%). Sixty-four percent are certified family physicians. The number of first-author publications per researcher varies from 13 to 249, with a median of 49 and a mean of 51. The number of first-author citations varies (from 796 to 9081), with a median of 1191 and a mean of 1864. The researchers’ h index scores range from 15 to 87, with a median value of 37. Statistical analysis found that career duration is moderately associated with the number of first-author publications (Figure 1). All other correlations tested were weak and not statistically significant.

View this table:
Table 3.

Characteristics of the 50 most cited Canadian primary care researchers

Figure 1.
Figure 1.

Relationship between number of first-author publications and duration of research career

The 27 peer-reviewed publications by Canadian PC researchers cited more than 500 times are listed in Table 4.22,45-70 All first authors were among the most cited PC researchers. The year of publication ranged from 1992 to 2018. All but 7 were published in journals with an impact factor greater than 5. The majority of publications were in international journals (Figure 2, available from CFPlus*). One was in the New England Journal of Medicine, 4 were in JAMA, and 3 publications were in the Canadian Medical Association Journal. The New England Journal of Medicine stands out due to its exceptionally high impact factor of 158.5, making it one of the most influential medical journals globally. Its widespread citation in scientific literature distinguishes it as a noteworthy platform for disseminating PC research findings.71 All but 4 publications for which information was available scored greater than 10 for the field-weighted citation impact score, indicating they were cited substantially more often than similar articles. Four had a field-weighted citation impact greater than 50.

View this table:
Table 4.

Most cited peer-reviewed publications by Canadian primary care researchers

The research topics covered are diverse, many focusing on professional education, clinician behaviour change, and patient relationships (see Figure 3, available from CFPlus,* for a word cloud of key topics). Sixteen publications reported the results of systematic reviews or reviews. Drs Dave Davis, Moira Stewart, Merrick Zwarenstein, Martin Fortin, and Pierre Pluye authored multiple papers that were most cited.

Most researchers were clinician scientists (86%) with their primary academic appointment in family medicine. Forty-two researchers (84%) were found to have graduate degrees (see Figure 4, available from CFPlus,* for a word cloud of degrees). Most were affiliated with 5 universities (University of Toronto; McGill University in Montréal, Que; Western University; University of British Columbia in Vancouver; and McMaster University in Hamilton, Ont).

DISCUSSION

This study suggests that Canada has much to celebrate, showcasing the notable research productivity and impact of Canada’s 50 most cited PC researchers despite limited research investments in the field. This research has the potential to influence clinical practice, health care policy, and patient-oriented outcomes. A comparative perspective of citation rate in different disciplines suggests that researchers in physical activity and aging receive fewer citations on highly cited papers compared with citation rates observed among PC researchers in this study, suggesting a notable impact within the field.72 Future research should focus on examining PC researchers’ first-author citation impact across countries and disciplines and the participation of researchers in international collaboration, which can further enrich our understanding of researchers’ contributions on a global scale.

While we have highlighted papers with more than 500 citations as a metric of high-impact publications, it is important to note that these citations encompass a spectrum of medical disciplines and health care topics, and not all of them are exclusive to PC research. Future research endeavours may explore research topics in greater depth to provide a more comprehensive understanding of PC research in Canada. Furthermore, most of the highest cited publications were not in PC-specific journals (Figure 2) but published in general medical journals. While PC-specific journals are pivotal for discussions within the PC community, the inclusion of PC research in broader medical journals extends its reach and impact by enabling PC researchers to engage with a wider readership, including specialists and policy-makers, who may not regularly peruse PC-specific journals.

The citation impact of PC researchers, despite low levels of research investment in the field, might be explained by an individual’s psychological and cognitive characteristics. Psychological and cognitive traits and time spent on research for family medicine faculty are the most predictive of research productivity.73 These factors included enhancing research skills, establishing a definable research agenda, fostering research networks, having multiple research projects, maintaining in-depth knowledge of a research area, and clearly understanding research expectations for promotion and tenure.73

There was substantial heterogeneity in the characteristics of the top 50 PC researchers. This group included more male researchers (60%) than female researchers. Several studies suggest women publish less than men.74-77 A US study found that female faculty members were underrepresented as first authors in prominent family medicine journals.78 Female faculty with dependent children are less productive than all males as well as females without children, especially those who are early-career researchers with young children.79,80 We acknowledge the intersection of sex and career duration, recognizing that there are fewer female researchers and practitioners among those with longer career durations.81 This intersection may contribute to the observed gender disparity among top researchers. In line with the evolving landscape of academic research, we acknowledge that contemporary academic collaborations increasingly involve interdisciplinary teams, international cooperation, and larger authorship groups. This could influence the traditional importance attributed to the first author’s position. However, studies demonstrate female faculty potentially have fewer and smaller collaborations throughout their professional journeys compared with their male counterparts.82

Longer career duration was positively associated with the number of first-author citations, underscoring the enduring impact and productivity of these PC researchers. This aligns with the literature, suggesting that research experience since completing a PhD83 and tenure-track PC roles increases academic productivity.84 We also found that most researchers were clinician scientists (86%) with primary academic appointments in family medicine. Forty-two researchers (84%) had graduate degrees (Figure 4). Most were affiliated with 1 of 5 universities. Research impact is facilitated by institutional factors such as resources, incentives, and effective leadership.85-89 A US study revealed that high-capacity family medicine departments are characterized by more research-trained faculty, substantial internal funding investments, and securing substantial external funding.90 These factors could have shaped research productivity in the most productive institutions. This study also found that all of the 50 most cited researchers were located in the 4 largest provinces (Ontario, Quebec, British Columbia, and Alberta) that offer additional grant funding opportunities.91-94 This may influence the number of grants awarded to researchers and institutions, leading to greater productivity of researchers.95 High-quality researchers may be attracted to larger academic centres, a factor that may contribute to research productivity.

Limitations

Despite our best efforts, some researchers meeting the inclusion criteria may have been unintentionally omitted, particularly those not affiliated with a family medicine department, including those affiliated with nursing, public health, epidemiology, and health services. The study focuses on first-author publications. We acknowledge that highly productive research scientists may also be the second or last authors on publications and contribute to research impact by supporting teams and students. Furthermore, Scopus does not have universal coverage of all journals and may have errors or omissions. In addition, the h index is captured for the period between 2007 and 2022. The researcher profiles are based on publicly available data and did not permit examination of the role of ethnicity or racialization on research productivity, which requires further investigation. Future studies could consider incorporating additional bibliometric measures, such as the h index or d index, for a more comprehensive assessment. This study did not include a detailed analysis of research topics and their frequencies. Future research endeavours may explore research topics in greater depth to provide a more comprehensive understanding of PC research in Canada. Finally, it is important to note that bibliometrics alone cannot capture the entirety of a researcher’s contributions, clinical impact, patient outcomes, and societal relevance.

Conclusion

While our study celebrates the remarkable contributions of highly productive and cited PC researchers in Canada, we acknowledge the need for further investigation into the broader landscape of PC research. Our analysis has laid a foundation by highlighting the concentration of PC research papers and citations among a select group of researchers, along with their affiliations and their commendable citation rates. However, we recognize the importance of addressing unanswered questions, such as comparisons with PC researchers in other countries and across disciplines; the prevalence of research topics among Canadian PC researchers and international collaborations; evaluating how interdisciplinary teams impact first-author positions; the perspectives of researchers regarding their identification with PC research; and investigation of metrics related to research impact on clinical practice, health care policy, and patient-oriented outcomes, which are vital to advancing PC research in Canada. Further investments in PC research and researchers hold the potential to accelerate the generation of knowledge that supports the Quintuple Aim,96 enhances health equity, and aligns with patient-oriented outcomes.

Acknowledgment

We thank Selin Bilgic for assistance with data collection and Dragan Klujic for assistance with statistical analysis.

Footnotes

  • ↵* Supplementary material and Figures 2-4 are available from https://www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.

  • Contributors

    All authors contributed to designing the study. Dr Monica Aggarwal collected all the data. Drs Monica Aggarwal and Brian Hutchison analyzed all the data. All authors contributed to interpreting the data. Dr Monica Aggarwal developed the manuscript. All authors contributed to the manuscript.

  • Competing interests

    None declared

  • This article has been peer reviewed.

  • Cet article a fait l’objet d’une révision par des pairs.

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Assessing the impact of Canadian primary care research and researchers
Monica Aggarwal, Brian Hutchison, Alan Katz, Sabrina T. Wong, Emily Gard Marshall, Steve Slade
Canadian Family Physician May 2024, 70 (5) 329-341; DOI: 10.46747/cfp.7005329
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