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Changes in stroke research productivity: A global perspective

Background: While stroke is the second leading cause of death worldwide, little work has been done to quantify the growth and progress of stroke publications. The purpose of this study is to quantitatively analyze trends in the stroke literature over the past 12 years, specifically examining changes in worldwide productivity and study methodology. Methods: The study was a retrospective bibliometric analysis of all stroke articles published between 1996 and 2008 indexed in MEDLINE. Country of origin, MEDLINE-defined methodology, specialty of the first author, and funding sources (for US articles) were recorded. Growth was analyzed by using linear and nonlinear regression. Results: Total articles numbered 32,309 during the study period, with leading global contributors including the United States with 8795 (27.2%) articles, Japan with 2757 (8.5%) articles, and the United Kingdom with 2629 (8.1%) articles. Growth globally and in the United States followed a linear pattern at 209.9 and 56.2 articles per year, respectively (both P < 0.001). Review articles and clinical trials numbered 5932 (18.4%) and 2934 (9.1%), respectively. Clinical trials followed an exponential growth pattern of 7.7% per year (P < 0.001). Regarding specialty influence, pain management and rehabilitation had the largest proportional growth in clinical trials from 4 to 51 articles. Conclusions: Within the stroke literature, we observed continued growth worldwide, sustained growth in the United States, and a steady increase in the number of clinical trials, especially by pain management and rehabilitation.


INTRODUCTION
Stroke has recently declined from the third to the fourth leading cause of death in the United States. [46] Nonetheless, it remains the second leading cause of death worldwide. Therefore, continued research into the pathophysiology and potential emerging therapeutic interventions for cerebrovascular disease are more important than ever. Additionally, despite the many setbacks in preclinical experimental stroke research (particularly with regards to the development of novel neuroprotective agents), much room exists for improvement in both the quality and quantity of stroke research. [2,14] Furthermore, others have found an inverse relationship between the growth of stroke-related research productivity and stroke mortality. [13] This suggests the possibility that the decline in stroke-related deaths may be related to sustained stroke-related research productivity. As a result, this bibliometric assessment of stroke-related research from around the world was undertaken so as to understand the current trends in stroke publications. The goals of this study were to quantitatively assess stroke research productivity, specifically with regards to growth in publications within the United States and among the global scientific community. In addition to numbers of publications, other variables examined included study methodology and design, geographic trends, and National Institutes of Health (NIH) funding patterns.

MATERIALS AND METHODS
This study was a retrospective bibliometric analysis of a publically available database and was exempt from Institutional Review Board approval. The National Library of Medicine's MEDLINE database was the primary source of data for this study. This methodology was described in part previously. [18,12,22] More than 17.4 million articles from 5200 journals in 37 languages are indexed. [25,26] As of August 19, 2009, MEDLINE was queried for all articles published between 1996 and 2008 that had stroke as a major topic of the paper. These were identified by Medical Subject Heading (MeSH) terms, which are standardized labels created and assigned by trained National Library of Medicine staff for the purpose of identifying articles by their subject matter. [9,27,28] MeSH terms used to identify articles included the following: stroke; cerebral infarction; brain infarction; brain stem infarctions; infarction, anterior cerebral artery; infarction, middle cerebral artery; infarction, posterior cerebral artery; cerebrovascular disorders. Additionally, only articles that had one of these terms flagged as a major topic of the paper were included. MEDLINE indexes the department, institution, city, state, and country of the first author, which were used to assign country of origin and clinical specialty. Only articles defined as "journal articles" were included in this study. Research methodology tags were analyzed. A full description of the methodological tags can be found on the National Library of Medicine website. [29] Articles that were both clinical trials and multicenter studies were given the additional designation of multicenter trial. Finally, journal articles that had no additional specialized tags were labeled as unspecified general research. Journal Impact Factor (JIF) data was obtained from Thompson Scientific. [44] Articles were assigned the JIF of the journal in which they were published in the year of publication, after which the mean JIF values were calculated. Analysis of focus by topic was performed by grouping MeSH terms according to associated general stroke topics, rehabilitation and stroke sequelae, medical and surgical therapy, diagnostic tools, and miscellaneous topics including articles regarding registries, questionnaires, patient education, etc.
Individual growth rates of each subject were then calculated using linear regression. The remaining growth patterns were studied using least squares linear and nonlinear regression analysis, as appropriate, utilizing R statistical software (Windows version 2.6.2, R Foundation for Statistical Computing, Vienna, Austria). The standard exponential growth equation, articles = Ne rt , was used as the basis for exponential regression, where articles refers to the number of published articles, N represents a constant, r represents the growth rate, and t represents time in years (with the year 1996 = 0). The standard logistic growth equation is: articles = a/(1 + Be −rt ), where a represents the asymptotic maximum number of articles, B and r represent constants that affect the contour of the growth curve, e the mathematical constant, and t represents time in years (1996 = 0). P ≤ 0.05 was used as the threshold for significance. Akaike's information criterion was used as a measure of goodness of fit of the three models, with the best fit determined by the lowest value. [1]

Articles identified
Between 1996 and 2008, a total of 32,309 articles from 2824 distinct journals were identified. Of these articles, 28,682 (88.8%) had an identified country of origin, with articles originating from a total of 103 countries. Leading contributors included the United States with 8795 articles (27.2% of the world total), Japan with 2757 articles (8.5%), and the United Kingdom with 2629 articles (8.1%). Total publication counts for the leading 20 producers in the stroke literature by methodology can be found in Figure 1. With regards to article type, the largest subcategory of articles was unspecified general research (14,209,44.0%). Review articles and clinical trials numbered 5932 (18.4%) and 2934 (9.1%) articles, respectively [ Table 1]. The journal that published the most articles was Stroke (3109), followed by Neurology (957), Cerebrovascular Diseases (816), and Archives in Physical Medicine and Rehabilitation (469).

Geographic research growth and relative contribution
Globally, the number of publications grew at a linear rate Of the top five nations, Canada had the highest rate of growth, which followed an exponential model at 11.3% (P < 0.001). China had the largest proportional growth during this period of 1000%. The absolute, relative, and proportional growth rates of top five contributors are detailed in Figure 2.
With regards to relative global contribution, the United States rose from 26.3 to 27.8% between 1996 and 2008. Of the remaining top five contributors, increases were also seen in Germany and Canada, rising from 5.0 to 6.0% and from 2.2 to 4.2%, respectively. Conversely, relative contribution from Japan decreased from 11.7 to 7.2%. The United Kingdom remained relatively unchanged from 6.8 to 6.5%.

Study methodology by geography and growth
Globally, the top three nations in clinical trials were the United States (24.2% of worldwide total), the United Kingdom (11.5%), and Germany (9.1%). However, the top three nations in randomized controlled trials (RCTs) were the United States (25.1%), the United Kingdom (15.6%), and China (7.6%). The leaders in review articles included the United States (36.1%), the United Kingdom (10.7%), and Japan (5.1%). Lastly, the leaders in case reports included the United States (124.5%), Japan (14.8%), and Germany (4.9%) [ Figure 1]. National focus varied by country. Within the United States, clinical trials represented 8.1% of articles of which 56.2% were RCTs. Review and case reports represented 24.4 and 12.2% of published articles, respectively. In contrast, review and case reports from Japan represented 10.9 and 23.5%, respectively. Of the clinical trials produced in Japan, 23.0% were RCTs. Higher proportions of clinical trials were seen in the United Kingdom (12.9%) and Germany (13.1%). Lastly, of top 10 nations, China had the greatest relative national focus on clinical trials at 15.1% of which 81.1% represented RCTs.
With respect to growth in productivity according to methodology, review articles and case reports grew linearly at 41.7 and 17.1 articles per year, respectively (both P < 0.001). Clinical trials and RCTs both followed exponential growth patterns, measuring 7.7 and 10.6% per year, respectively (both P < 0.001).

Specialty influence
With regards to specialty contribution, 19,475 (60.3%) first authors were assignable to a specific medical specialty. Leading contributors included neurology (27.7%), internal medicine (6.3%), physical medicine and rehabilitation (PMR) (5.8%), diagnostic radiology (4.4%), and neurological surgery (3.9%). Interestingly, the largest rate of proportional growth was seen in PMR (42-236 articles), which was followed by neurology (362-1009 articles). This was further magnified when examining clinical trials and RCTs in which PMR grew from 4 to 51 articles and from 2 to 35 articles, respectively. This was followed by neurology which grew from 28 to 87 articles in clinical trials and from 16 to 41 articles in RCTs [ Figure 3].

NIH funding
Of   Figure 4].

Subject analysis
The greatest overall growth rate was displayed by general, uncategorizable stroke research (303 articles/year), though this only represented a rate of increase of ~17% of 1996 productivity levels. The greatest increases compared to 1996 levels, however, were seen in rehabilitation-related papers (33%, 89 articles/year) and epidemiology and public health related papers (41%, 11 articles/year). Lower proportional growth rates were found in medical/surgical therapy related stroke research (25%, 67 articles/year), stroke etiology and prevention research (16%, 50 articles/ year), and stroke diagnosis research (14%, 22 articles/year) [ Figure 5].

Worldwide productivity
The United States was the leading single nation contributor during the study period, contributing to 27.2% of all articles. However, this figure is considerably lower when comparing United States productivity across multiple disciplines. Specifically, contribution of the United States in science and other medical specialties has reportedly ranged between 40 and 60%. [34,35] These findings imply a greater globalization of strokerelated research. This phenomenon of increasing internationalization has also been well established in science and medicine and has manifested itself by a progressive decline in relative contribution from the United States within surgery, radiology, interventional radiology, and other medical subspecialties. [6,10,12,18,23,[35][36][37]45] Specifically, between 1991 and 2000, relative contribution of the United States to basic science and clinical articles declined from 69.7 to 58.3% and from 60.0 to 52.1%, respectively. [34] Given this decline, it is remarkable that the United States has maintained its relative global contribution in stroke publications and grown from 26.3 to 27.8% over the last decade. Although this growth and sustained research productivity from the United States is likely multifactorial, one possible reason is the development of novel initiatives in infrastructure to focus stroke   [3,4] Thus, a relatively lower number of publications may stem from a smaller workforce and the demands of clinical needs at the expensive of time for research, which has been previously suggested in other literature. [38] An alternative view is that a growth of only 1.5% is too small considering the SPOTRIAS support and ratio of neurologists, and may point to needs of increasing funding and better use of our resources.
When examining the productivity of other countries, we observed that Canada had the highest proportional growth of top five contributing nations and that China had the highest proportional growth of all nations. These data likely reflect several potential etiologies. With respect to Canada, one explanation includes its changing infrastructure in stroke research. In 1999, the Canadian Stroke Network (CSN) was founded and in 2001 the Registry of the Canadian Stroke Network (RCSN) was established. [7] This registry provided investigators with a clinical database to assess outcomes and delivery of care, and established comprehensive stroke centers to increase the efficiency in treating patients with acute ischemic stroke. This registry had collected information from over 50,000 strokes within Canada by 2008, representing a large database for investigators. [8] Regarding China, a large proportional growth of research has also been displayed in other clinical areas. [18] This has been attributed to changing research infrastructure, increasing government funding, and the growing incentives and pressures amongst Chinese authors. [17,39,48] These factors may also be responsible for its robust number of RCTs (7.6% of the world total), despite being the 12th highest national contributor (3.0%). Additionally, given that China has the largest number of stroke deaths in the world, there could also be a greater priority placed on stroke research. [48] Study methodology During the study period, the percentage of studies that were clinical trials (9.1%) and RCTs (4.9%) was slightly higher when compared to other topics and specialties, such as interventional oncology, cardiovascular medicine, and neurosurgical research. [5,12,22] Additionally, we observed that RCTs grew at an exponential rate of 10.6% annually. While multifactorial, the previously mentioned infrastructure developments in stroke centres and research, as well as the sustained growth of clinical trials may have played a substantial and positive role in stroke declining to the fourth leading cause of death within the United States. [46] While these are impressive achievements, nearly a third of literature published worldwide was in the form of case reports and review articles. This emphasis on case reports and review articles has been seen in other specialties. [18] One possibility for this disproportionately low number of clinical trials may stem from the difficulty of enrolling patients in acute stroke trials during an acute stroke setting. [41] Furthermore, the costs of a clinical trial are significantly higher than case series, reports, and review papers. In Canada, the cost of obtaining consent for stroke studies was estimated to be approximately $520,000 US dollars, which accounts for 25% of the RCSN's budget. [47] Additionally, these barriers have led to selection bias by excluding non-native speaking patients. [47] With regards to potential therapeutic drugs in the United States, the federal government allows for waivers of consent in life-threatening emergencies; however, these are seldom used. [21,33,50] Overall, there is still much room to improve the efficiency and dedication to clinical trials. One unanswered question is how these barriers to clinical trials affect the development and testing of interventional devices, all of which are more recently playing a very important role in ischemic stroke treatment.

Specialty influence
Over the last decade, mortality from stroke has decreased. Despite this, stroke has remained the leading cause of disability, resulting in a greater demand for stroke rehabilitation research. [20,49] This need has reflected itself with a rise in RCTs within stroke rehabilitation. [43] This was also evident in our analysis. Specifically, despite neurology department's dominance in the number of stroke-related publications, PMR had the largest proportional growth of overall publications and RCTs. This growth will likely continue and hopefully limit the impact of stroke-related disability.

Influence of funding
Examining the US articles specifically, 32.2% of published articles received NIH funding, with a high proportion of those being clinical trials including RCTs and multicenter trials, which is unsurprising given the high cost associated with running clinical trials. [24] Additionally, the relative contribution of NIH-funded publications increased nearly 5% during the study period. However, stroke research remains underfunded when examining its burden on mortality and disability. [15,16,19] In the mid-1990s, the Institute of Medicine set a goal that disease-specific research funding should be comparable to burden of disease on society. [15,16] In 2006, stroke research was underfunded by approximately 20% less than expected on this basis. [50] Although this study did not examine funding patterns outside the US, a lack of funding in stroke research relative to other disease processes has been observed in Europe as well. [30,31] These findings are alarming given that the importance of funding and its positive association with research productivity has been previously established. [22] Limitations When interpreting the results of this study, several limitations should be kept in mind. First, this study is limited to only articles indexed within MEDLINE, which does not encompass all types of research. Nonetheless, MEDLINE is a comprehensive resource that includes 17.4 million articles from over 5200 journals in 37 languages. [25,26] There is also a possible bias within MEDLINE toward English language and Western journals. Lastly, using the first author's affiliation can be potentially problematic in instances where authors from different institutions or clinical departments co-author a paper. Using only the first author's affiliation may underweigh the contribution of other authors if they tend to systematically be non-first authors. On the other hand, giving non-first authors equal credit may overweigh the contribution of certain specialties, such as statisticians. Evidence has shown that first authors account for a preponderance of work and are most deserving of credit. [11,40] Weighing these factors, it was decided that using the first author's affiliation was the best compromise.

CONCLUSION
In conclusion, there is an unprecedented sustained growth in productivity for stroke research in the United States. Research within stroke has also seen a steady increase in the number of clinical trials, especially by pain management and rehabilitation.