The landscape of research in quality in primary care: A bibliometric analysis of articles between 2000 and 2025

ABSTRACT

Background:

Over the last two decades, there has been an increasing focus on quality in primary care. While the field initially centered around defining quality indicators and patient satisfaction, research has shifted to incorporate complex themes like equity, patient-centeredness, and integration of digital health. A comprehensive mapping of this progressing field is necessary to understand trends and guide future research.

Objective:

To systematically assess global scientific literature on quality in primary care from 2000 to 2025 using bibliometric analysis, and identify leading contributors, collaborative networks, and thematic trends.

Materials and Methods:

A structured search strategy was executed in the Scopus database using predefined keywords. Articles published between January 1, 2000, and June 30, 2025, were included. Data were analyzed using Biblioshiny for performance metrics and VOSviewer for network visualization.

Results:

Of the 5679 articles identified, 4683 met the inclusion criteria. There has been a consistent rise in publications, with 365 articles in 2024 alone. The United States is the most productive and cited country, followed by the United Kingdom and Australia. Richard Grol, Lisa Rubenstein, and Stephen Campbell were among the most influential authors. Recent research themes include patient engagement, implementation science, digital health, and equity. India’s contribution remained low at 0.6%.

Conclusion:

The global research landscape on quality in primary care has grown significantly in the last two decades. Trending topics like implementation science, digital health, patient activation, and social determinants of health are important areas for future research. Considering the low output from India, the research scope for the field is enormous in India.

Introduction

The history of quality in healthcare can be traced back to Ignaz Semmelweis, the 19^th-century Hungarian obstetrician who observed that washing hands before surgery reduced maternal mortality. Almost a century later, Florence Nightingale formulated an association between poor living conditions and high mortality among soldiers of the Crimean War through her meticulous mortality statistics.[1] These laid the groundwork for modern quality frameworks, with Avedis Donabedian proposing his structure-process-outcome model, providing a universal lens for evaluating care, and the Institute of Medicine defining the six components of quality: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.[2,3]

The Alma-Ata declaration (1978) brought primary health care into focus and made it the key to unlock health for all by 2000, but quality of care was not emphasized.[4] The Sustainable Development Goals laid down the target of achieving universal health coverage by 2030, which includes quality essential healthcare services, essential medicines, and vaccines, along with financial risk protection.[5] At the Global Conference on Primary Health Care, 2018, Astana, it was reiterated that fragmented, unsafe, and poor-quality care can no longer be tolerated.[6] Quality in health care has gained momentum over the past few decades, with an increasing amount of research and publications in the field. Initial research in the field focused predominantly on defining quality indicators and measuring patient satisfaction and access to care.[2,7] Over time, with advancements in the field, research themes have evolved to encompass more complex domains such as patient-centered approaches, equity, chronic disease management, and integration of digital health tools.[8,9,10] Through this study, we aim to systematically assess the scientific literature from the field of quality in primary care through a bibliometric analysis to identify the leading authors, institutions, and most productive countries, as well as understand collaborations and the research trends in the field. This will help primary care physicians, budding researchers, and institutions identify relevant figures and works from the field, and will also help in mapping the future scope of research.

Bibliometrics is the quantitative study of published literature and its metadata, which includes abstracts, keywords, references, etc., It is primarily used to evaluate research productivity, assess research impact, and understand the structure and dynamics of research systems.[11] It includes performance analysis and science mapping. Performance analysis examines the contribution of research constituents (articles, authors, institutions, and countries) to the particular field of research, whereas science mapping looks at the interaction between the research constituents, which is visualized as network analysis.[12] The advent of software of the likes of CiteSpace, VOSviewer, and the Bibliometrix package for R studio helps process a large volume of metadata and provide visualizations that help understand the interaction between research constituents, trends, and emerging topics from the field.[13,14,15]

Materials and Methods

The Scopus database, maintained by Elsevier, was selected to carry out the literature search. Scopus is one of the most comprehensive databases for scientific literature, with metadata that is detailed and consistent. Hence, it is the preferred database to capture literature for bibliometric analysis.[16,17] A comprehensive search strategy involving the Title and Author keywords was formulated by the two researchers and executed in Scopus on June 30, 2025. The following keywords were run in the search strategy: (“primary care” OR “primary healthcare” OR “primary health care” OR “general practice” OR “family medicine” OR “family practice” OR “community health services” OR “community medicine” OR “community-based care” OR “community level care” OR “essential care”)) AND (“quality of care” OR “healthcare quality” OR “quality assurance” OR “quality improvement” OR “quality assessment” OR “clinical quality” OR “service quality” OR “patient satisfaction” OR “patient-centered care” OR “quality indicators” OR “quality standards” OR “clinical audit” OR “quality audit” OR “care quality”).

The date of inclusion was set from January 1, 2000, to June 30, 2025. Reviews, conference proceedings, letters, editorials, books, book chapters, and non-English articles were excluded.

Analysis

Articles were retrieved in CSV format and exported to Biblioshiny, a web-based application for Bibliometrix for performance analysis.[15] Most productive authors, institutions, countries, and journals were described in terms of the number of articles, citations, and H-index. The trends in the production of documents by institutions, countries, and journals were graphed. Trending topics across the years were identified based on the frequency of author keywords and plotted in a bubble plot. Retrieved articles were then exported to VOSviewer to visualize intellectual collaborations between articles, authors, institutions, and countries through co-authorship and co-citation analysis. Key research areas under the ambit of the broader topic were visualized using co-occurrence analysis of author keywords.[14]

Results

A total of 5679 articles published between January 1, 2000, and June 30, 2025, in the field of quality in primary care were identified through the literature search, out of which 996 articles were excluded based on the exclusion criteria mentioned above. The metadata of 4683 articles included was extracted for analysis. The number of published articles in the field has been increasing from 53 articles in 2000 to 365 articles in 2024, with an average growth rate of 4.92%. Figure 1 depicts the trend in annual publications. Family Practice by Oxford University Press is the most productive journal with 176 published articles, followed by BMC Health Services Research and Journal of American Board of Family Medicine with 156 publications each. The Journal of General Internal Medicine, however, has been the most impactful with 5399 citations and an H-index of 44, followed by Annals of Family Medicine with 8971 citations and an H-index of 43. Table 1 depicts the leading journals in the field with respect to H-index while also showing the number of published articles and citations. Family Practice has consistently ranked at the top of the publications list, but since 2012, there has been a notable increase in publications by BMC Health Services Research and the Journal of the American Board of Family Medicine [Supplementary Figure 1 ^{(102.8KB, tif)} ].

Figure 1.

Trend in annual publications on quality in primary care from 2000 to 2024. Shows a year-wise increase in scientific publications over the 25 years

Table 1.

Top 10 journals publishing in the field of quality in primary care (2000–2025)

Journal	H-index	G-index	Citations	Articles
Journal of General Internal Medicine	44	69	5399	139
Annals of Family Medicine	43	93	8971	139
British Journal of General Practice	34	55	3641	122
Family Practice	34	54	4033	176
Medical Care	30	55	3044	57
BMC Family Practice	28	42	2551	108
BMC Health Services Research	26	42	2523	156
International Journal for Quality in Health Care	25	37	1700	69
Health Services Research	23	41	1733	45
Journal of the American Board of Family Medicine	22	34	2019	156

This table lists journals ranked by productivity (number of articles), alongside bibliometric indicators including H-index, G-index, and citation counts

Leading countries and affiliations

The United States of America has been the most productive with 1470 articles (31.4%) published in the field since 2000, followed by the United Kingdom with 532 articles (11.4%). America has been leading in terms of relevance as well, with 33103 citations (22.5 citations per article), followed by the United Kingdom with 11537 citations (21.7 citations per article). Table 2 shows the top 10 countries in terms of publications, along with their contribution to the field and citation count. India’s contribution to the literature was 0.6%, comprising 30 articles that garnered a cumulative 174 citations. India ranks 20^th when it comes to the number of publications but 32^nd in terms of the number of citations. Figure 2 represents a network analysis of countries represented by nodes and collaboration between countries for publications depicted by links. The United States, the United Kingdom, Australia, Germany, and the Netherlands emerged as dominant contributors with extensive international collaborations.

Table 2.

Top 10 countries publishing in the field of quality in primary care (2000–2025)

Country	Articles	Contribution (%)	Citations	Average citation per article
The United States	1470	31.4	33103	22.5
United Kingdom	532	11.4	11537	21.7
Australia	261	5.6	3497	13.4
Canada	239	5.1	5680	23.8
Netherlands	186	4.0	4453	23.9
Sweden	90	1.9	1569	17.4
Spain	87	1.9	938	10.8
Brazil	81	1.7	671	8.3
Denmark	80	1.7	896	11.2
Germany	76	1.6	987	13.0
India	30	0.6	174	5.8

The table presents the number of publications, share of total publications (%), total citations, and average citations per article for the top contributing countries

Figure 2.

Country collaboration network map. Visualizes international co-authorship networks; nodes represent countries, and links indicate publication collaborations

Table 3 presents the top 10 most productive institutions in the field of quality in primary care since 2000. All of the top three affiliations are from the United States of America. The University of California has been the most productive institution with 269 publications, followed by the University of Washington and Harvard Medical School with 237 and 233 publications each. The University of Manchester was the leading institution in the field from 2002 through 2018. A rise in publications from the University of California and the University of Toronto is observed after 2018 [Supplementary Figure 2 ^{(107.3KB, tif)} ]. The All India Institute of Medical Sciences is the leading institution from India at 156^th position with 25 publications.

Table 3.

Top 10 institutions publishing in the field of quality in primary care (2000–2025)

Institution	Country	Publications
University of California	The United States	269
University of Washington	The United States	237
Harvard Medical School	The United States	233
University of Toronto	Canada	232
University of Manchester	United Kingdom	222
Mayo Clinic	The United States	180
Oregon Health and Science University	The United States	156
University of Southern Denmark	Denmark	123
University of New South Wales	Australia	119
Radboud University Medical Center	Netherlands	117

The table lists the leading institutions, the country they are located in, and the number of publications in the field

Leading authors in the field

Table 4 presents the bibliometric profiles of the top contributing authors in the field. Richard Grol (Netherlands) demonstrated the highest H-index (24) and G-index (40), with a total of 1,684 citations across 43 publications. Lisa V. Rubenstein (The United States) had the highest total citation count (2,313) among the listed authors, with an H-index of 23 and G-index of 34. Stephen Campbell (the United Kingdom) showed an H-index of 22, a G-index of 42, and 2,034 total citations from 42 publications, highlighting his consistent contributions to the field.

Table 4.

Bibliometric profile of the top contributing authors in the field

Author	Country	H-index	G-index	Total citation	No. of publications
Grol Richard	Netherlands	24	40	1684	43
Rubenstein Lisa V.	The United States	23	34	2313	34
Campbell Stephen	The United Kingdom	22	42	2034	42
Crabtree Benjamin F.	The United States	20	33	1626	33
Meredith Lisa S.	The United States	19	20	2044	20
Roland Martin	The United Kingdom	19	22	1254	22
Wensing Michel	Germany	18	30	953	31
Bailie Ross	Australia	17	26	850	44
Solberg Leif I.	The United States	16	29	872	29
Cohen Deborah J.	The United States	14	24	809	24

The table highlights leading authors’ countries, H-index, G-index, total citations, and number of publications between 2000 and 2025

Author and reference co-citation analysis

Figure 3 shows a network visualization of the co-citation analysis of authors. With a threshold set at 50 co-citations, 591 co-cited authors were analyzed. Nodes represent author citations, and links represent the publications with author co-citations. Colors represent clusters of authors cited together, forming distinct areas of research within the broader field. A total of six unique clusters can be visualized. Authors like Starfield B., Grol R., Wagner E. H., and Crabtree B. F. have large nodes, indicating high co-citation frequency and central influence in the network. Crabtree B. F, Strange K. C., and Starfield B. anchor the red cluster (cluster 1) while Grol R. and Campbell S. M. anchor the green cluster (cluster 2), which is a closely related subfield. Grimshaw J. and Hogg W. anchor the blue cluster (cluster 3), which is another major thematic area. Von Korff M. and Shebourne C. are highly cited in the purple cluster (cluster 5), whereas Safran D. G., Cleary P. D., and Stewart M. are referred to the most in the yellow cluster (cluster 4). A co-citation analysis of references is depicted in Figure 4, in which a threshold of 10 co-citations identified 91 references. The network shows the overall intellectual landscape of quality in primary care dominated by certain seminal works like “Crossing the Quality Chasm,” and publications by Starfield, Donabedian, and Bodenheimer, arranged in 11 clusters that are color-coded.

Figure 3.

Author co-citation network. Shows frequently co-cited authors and thematic groupings; node size indicates co-citation frequency

Figure 4.

Reference co-citation network. Clusters of influential references cited together represent the intellectual structure of the field

Keyword co-occurrence and trending keywords

Figure 5 shows an overlay network visualization of author keywords with a minimum of 20 occurrences. One hundred thirty-six keywords were identified and plotted in a network map with nodes representing the keywords and links representing the co-occurrence of keywords within publications. The size of the nodes is proportional to the frequency of the keywords. Older themes are depicted in blue, and newer emerging themes in orange and red. Patient engagement, patient experience, implementation science, and social determinants of health are some of the recent themes identified from the keyword network analysis. Figure 6 is a thematic trend bubble plot, with prominent themes (author keywords) on the Y-axis and the timeframe in years on the X-axis. The size of the bubble is proportional to the frequency of the keywords, and the most prominent themes of each year are depicted from 2004 to 2024. Themes like telemedicine, COVID-19, implementation science, and artificial intelligence have been observed more recently.

Figure 5.

Overlay visualization of author keywords. Shows co-occurrence of keywords and emerging trends; warmer colors (red/orange) represent newer themes of research

Figure 6.

Thematic trend bubble plot of prominent research topics from 2004 to 2024. Bubbles represent keyword frequency over time; larger bubbles indicate greater prominence

Discussion

Summary

The research landscape of quality in primary care has been expanding since 2000, with a consistently increasing number of publications highlighting the attention given to the field. The United States of America is the leading contributor with the maximum publications and citations, followed by the United Kingdom, Australia, Canada, and the Netherlands. In line with the country-level productivity, five out of the top 10 leading authors are also from the United States, although the author with the highest number of publications and highest H-index is from Australia (Bailey Ross) and the Netherlands (Grol Richard), respectively. The leading institutions are also from the United States, with the University of California topping the chart, followed by the University of Washington and Harvard Medical School. India only contributes 0.6% to the literature and is 32^nd in citation rankings, suggesting a huge scope for research in India.

Country network analysis

The network [Figure 2] reveals distinct regional clusters: a dense European cluster in yellow and green (Germany, Netherlands, Belgium, Nordic countries), a strong Anglosphere cluster in red (the United States, the United Kingdom, Australia, New Zealand, South Africa, and India), and emerging Asian (China, Malaysia, Taiwan, and Hong Kong) and Latin American (Brazil, Mexico, Columbia, and Argentina) clusters in cyan and blue respectively. India is visualized as a minor node in the network, which implies a lack of collaboration of Indian researchers, even with their Asian counterparts.

Co-citation analysis (authors)

Co-citation analysis of authors, as visualized in Figure 3, delineates 6 clusters of authors co-cited frequently, which portray active thematic subfields within the broader field of quality in primary care. Cluster 1 (Red) highlights the thematic areas like leadership, workforce, and organizational resilience, and their role in quality primary care. While Wisbey et al.[18] discussed the adaptive nature of leadership that was necessary in the field of primary care during COVID-19, Howard et al.[19] described the role of physicians as inclusive leaders. Sweeney et al.[20] found that having dedicated staff greatly improved practices’ success in implementing change. Hemler et al.[21] demonstrated that disruptions like staff turnover or system changes can hinder participation in research networks, which are often vital for QI. Cluster 2 (Green) focuses on patient-centered care with studies that involve patients for healthcare improvement and pay-for-performance designed by users.[22,23] In line with the theme of patient-centered care, a number of studies assessing patient satisfaction are also present in cluster 2.[24,25] Continuous quality improvement and quality in the management of non-communicable diseases like diabetes and cardiovascular diseases are other thematic areas touched upon in this cluster.[26,27,28,29,30] Cluster 3 (Blue) is the core cluster within the subject, with authors working in the field of quality improvement in primary care and assessing practice and practitioner factors that determine the quality of care in primary healthcare.[31,32,33] Cluster 4 (Yellow) consists of articles focusing on multimorbidity care with studies that test the effectiveness of patient-centered approaches, their cost-effectiveness, and telemedicine in multimorbidity care.[8,10,34] Another important theme addressed by authors in cluster 4 is equity, with studies by Rodriguez et al.[9] and Taira et al.[35] assessing racial and ethnic disparities in primary care. Cluster 5 (Purple) included authors working in the field of quality in mental health and pain management in primary care.[36,37,38,39] Cluster 6 (Cyan) is dominated by authors who work in the field of indigenous primary care among the Aboriginal tribes in Australia.[40,41] Within this theme of indigenous primary care, a lot of focus is on continuous quality improvement and systems-level approaches.[42,43]

Trending topics and research gaps

Recent appearances of terms like “implementation science,” “practice facilitation,” “vulnerable populations,” “Health equity,” “social determinants of health,” “patient engagement,” and “practice-based research” in Figure 5 show a shift in focus toward implementation, equity, and patient participation. This suggests that research in the field of quality in primary care is increasingly moving toward understanding how effective interventions can be integrated into practice, along with the core themes of primary care, like equitable distribution and community participation. The recent emergence of themes like “telehealth,” “telemedicine,” and “artificial intelligence,” in Figure 6 displays the increasing integration of technology in primary care. A gradual transition in focus from quality control and audits (2004–2006) to quality assurance (2009–2012) to patient satisfaction and quality improvement (2017–2022) can also be appreciated.

Based on the overlay network analysis and keyword trends, research gaps within the field of quality in primary care were identified. Themes like implementation science, patient engagement, social determinants of health, and digital health are emerging but remain insufficiently integrated into the broader quality discourse. Furthermore, the limited linkage between mental health themes and primary care quality highlights a lack of research in the subfield. Future studies should address these areas to ensure that innovations are translated into equitable and patient-centered outcomes across primary care environments.

Strengths and limitations

This study presents a robust and comprehensive mapping of global research on quality in primary care, utilizing metadata from 4,683 articles spanning 25 years to identify critical thematic shifts and influential contributors. A major strength is its dual-methodological approach, combining performance analysis to rank productive authors, institutions, and countries with science mapping to visualize intricate collaboration networks and evolving research clusters. For primary care physicians, this analysis serves as an essential professional roadmap highlighting the transition from traditional quality audits to modern, complex domains such as implementation science, patient-centeredness, and digital health. By identifying the most impactful journals and seminal authors, the study provides clinicians with a clear guide to the most authoritative sources for evidence-based practice and quality improvement. However, the analysis was restricted to the Scopus database, and relevant articles that were indexed in other databases like Web of Science, PubMed, or Embase could be missed. English-language articles alone were counted, which may have missed key contributions made in other languages. Finally, although network visualizations are useful in revealing research foci and collaborations, they don’t convey the full contextual richness or quality of the studies.

Conclusion

The analysis indicates that although the international research environment in quality in primary care has grown enormously from 2000 to 2025, that of India is still limited, with a mere 0.6% contribution to publications. This projects a large potential for India to enhance its research base in this important area. Emerging trends like implementation science, digital health, patient activation, and addressing social determinants of health are important areas for future research, especially in the Indian setting, where varying healthcare requirements and inequities exist. Strengthening research capabilities, building both national and international collaborations, and prioritizing locally relevant quality improvement activities will be instrumental in taking India to the forefront of global research on quality in primary care.

Criteria for authorship

All authors have contributed significantly to the conception, design, data analysis, interpretation, and drafting of the manuscript. Each author meets the ICMJE authorship criteria.

Statement of approval and responsibility

The manuscript has been read and approved by all authors. All authors believe that the manuscript represents honest work. Corresponding author is Dr. Pranav Sankar, is responsible for communication with the journal during manuscript submission, peer review, and publication process, and will ensure that all authors approve the final version of the manuscript.

Conflicts of interest

All authors declare that they have no conflicts of interest relevant to this manuscript.

Supplementary Figure 1

Most productive sources publishing articles on quality in primary care between 2000 and 2025

Supplementary Figure 2

Most productive affiliations publishing articles on quality in primary care between 2000 and 2025

Funding Statement

No funding was received for this study; the authors did not receive financial or material support from any organization for the conduct of this research or the preparation of this manuscript.