A Scientometric Analysis of Research Productivity in Clinics and Hospitals from Five Latin American Countries

In university hospitals, clinical care, teaching and research are the pillars of their missions. Scientometrics play a key role in the analysis of scientific productivity of researchers, laboratories or countries. However, there are no published articles about bibliometric studies of the scientific production of healthcare institutions in Latin America. To carry out a scientometric analysis of leading clinics and hospitals from five Latin American countries. We focused on five Latin American countries with the largest scientific production: Argentina, Brazil, Chile, Colombia and Mexico. We examined available information for international publications, citations, registered clinical trials, networks of collaborations and patent applications. The institutions with the highest numbers of published articles are: Hospital de Clínicas de Porto Alegre (Brazil), Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (Mexico), Instituto Nacional De Cardiología Ignacio Chávez (Mexico) and Hospital Italiano de Buenos Aires (Argentina). Highly cited articles, networks of collaborations and patents applications were also identified. Scientometric analysis of health research around the globe has been quite helpful, in terms of identification of priorities for funding and support. The higher scientific productivity for some of these Latin American institutions might be explained partially by their higher levels of collaborations with colleagues in institutions in high-income countries, which usually have larger funding. We provide several recommendations for strengthening clinical research in this world region.


INTRODUCTION
Historically, clinics and hospitals have played an important role in medical research, facilitating the study of patients' illnesses, in addition to the analysis of pharmacological and surgical interventions, among others. [1]In university hospitals, clinical care, teaching and research are the pillars of their missions. [2]he evolution of medical science places hospitals and clinics as necessary centers for the development of clinical research projects. [3] recent decades, multiple methodological approaches in the field of scientometrics, particularly bibliometrics, have been developed and implemented around the world. [4,5]Scientometrics play a key role in the analysis of scientific productivity of researchers, laboratories or countries. [4]It has been used extensively, in several fields, for the analysis of multiple bibliometric indicators, such as number of articles published in international journals, features of highly cited papers and collaboration networks. [4] the fields of medicine and related health sciences, there are available articles about the bibliometric analysis of areas such as public and global health and biotechnology in Latin America. [6,7]owever, there are no published articles about bibliometric studies of the scientific production of healthcare institutions in Latin America.In the current work, we carried out a scientometric analysis of leading clinics and hospitals from five Latin American countries.

METHODOLOGY
In this work, we used previously published methods for scientometric analysis, [7,8] which involve data collection from major bibliographic and patent databases and analysis with validated software for this type of studies. [5,7] focused on five Latin American countries with the largest scientific production: Argentina, Brazil, Chile, Colombia and Mexico. [9]In those countries, the main clinics and hospitals were Tocora, et al.: Scientometric Analysis of clinics in Latin America identified from several available rankings (such as the one from the América Economia magazine) and the Scimago Institutions Ranking. [19]In Mexico, clinical institutions were identified on the websites of the Mexican national institutes of health and of the main healthcare organization in the country (Instituto Mexicano del Seguro Social).Scientific articles indexed in Scopus and PubMed databases [11] were identified through simple searches and the use of the Boolean operator OR.Highly cited articles for the included institutions were found in the Scopus database.The numbers of patent applications [12] for the included clinics and hospitals and recorded in Scopus and Google Patents [11] databases were consulted.Numbers of observational and experimental studies enlisted in the ClinicalTrials.govregistry [13] were identified.The information was retrieved from the different sources limited by time until December 2020.Word clouds were generated for the titles of the most cited articles and for the patents found for the selected institutions.The software tool VosViewer 1.6.17 [14]was used for the data visualization of publication networks, based on fractional counting.

RESULTS
The search algorithms for each database are presented in supplementary Table S1.Scientific articles were identified for authors with affiliations with hospitals and clinics in Argentina, Brazil, Chile, Colombia and Mexico.There was a higher number of documents identified through Scopus compared to PubMed, where Mexico and Brazil ranked first and second, respectively (Figure 1).
Regarding the articles identified in PubMed (   As can be seen in Table 1, for the studies registered on ClinicalTrials.gov, the largest number corresponded to Brazil   A review of all the studies registered on clinicaltrials.govfor the included institutions (Table 2) displays that they were mainly intervention studies (n=1681), in phase 3 (n=838), completed (n=438) or active in the recruitment phase (n=438) and funded by industry (n=1043) or other institutions (n=748).
In terms of collaborations in publications, Figure 2 shows the co-authorship networks, weighted by documents or citations for the selected institutions in the five countries and Figure 3 shows the co-authorship networks for each country.These bibliometric analyses show an asymmetry of profiles of collaborations among countries, with some countries with higher levels of joint publications between scientists and institutions, in addition to the existence of several subnetworks of collaborations at the Latin American level.
In the context of the international scientific impact of publications, Table 3 presents an overview of selected highly cited papers for healthcare institutions in the five countries.It highlights that highly cited papers were published in high-impact journals, as results of participations in large international collaborations, led by scientists in the United States or in Europe.
For an examination of technological advances protected by intellectual property, Table 4 shows an analysis of patent applications for the selected healthcare institutions, highlighting a heterogeneity for this indicator of innovation and technological development, with some institutions having an important number of patents and other clinics and hospitals without it.
In order to visualize the most common themes, a word cloud for the highly cited articles of the selected institutions shows a high representation of papers about the global burden of disease, cancer and published in open access journals (Figure S1).In addition, a word cloud for the patents highlights a role of technological advances related to the development of novel methods and devices for use in clinical settings (Figure S2).

DISCUSSION
This is the first scientometric study of clinics and hospitals in Latin America.In the current study, we carried out a scientometric analysis of leading healthcare institutions in five Latin American countries.We identified the profiles of international publications, citations, registered clinical trials, networks of collaborations and patent applications.We found that Brazil and Mexico have the healthcare institutions with the largest scientific productivity and that international collaborations play an important role in publications in high-impact journals, in addition to observing a heterogeneity between countries and institutions in the examined parameters.
Comparing our findings with previous scientometric studies in Latin America, in other related fields, highlight several common issues: Chinchilla-Rodríguez et al. [6] carried out an analysis of bibliometric (in public health), socioeconomic and health indicators for ten Latin American countries.They found that Brazil and Mexico were the two countries with the highest scientific output in public health, which is in concordance with our current findings.León-de la O et al. [7] did an analysis of publications in the field of health biotechnology for six Latin American countries.They observed that there was an important role of international collaborations, and that Brazil and Mexico were the top countries in scientific production in health biotechnology, which is in agreement with our results.Forero et al. carried out [8] a scientometric analysis for neurosciences in five Latin American countries and also found that Brazil and Mexico were the top producers of articles in this field.
From an international perspective, scientometric analysis of health research around the globe has been quite helpful, [15,16] in terms of identification of priorities for funding and support. [17]reviously, Chen et al. analyzed the publication trends in healthcare science and services research in China [18] and Muneem et al. compared the scientific productivity between a hospital medical and a college of medicine in the United States. [19]e higher scientific productivity for some of these institutions, such as the Mexican hospitals, might be explained partially by their higher levels of collaborations with colleagues in institutions in the United States, which usually have larger funding [20] Moses et al. identified that, in comparison to North America and Europe, Latin America has a relatively low funding for medical research and that in those countries with high levels of scientific productivity, private institutions provide a large amount of funding for medical research. [20]Public and private funding for further longitudinal research studies, such as large cohorts [21] (including community-based research) and clinical trials, [20] is of particular relevance in Latin American countries, in addition to the support for strengthening the technological innovations in healthcare. [7] examination of highly cited papers from these healthcare institutions suggests that collaborations with international centers facilitate the publication in high-impact journals, taking into account the asymmetric dynamics of scientific publishing, including citations, in the life sciences between world regions. [22,23]n analysis of registered clinical trials highlights a key role of funding by global pharmaceutical companies, taking into account the current needs of large financial and logistic support for multicentric randomized trials. [24,25]An exploration of patent applications shows that some institutions have a higher level of   advance in this type of technological products, which involve particular types of previous funding and innovation capacity. [26,27] interesting topic that needs to be studied in further detail in future works is the correlation between scientific productivity and the quality of healthcare provided in clinics and hospitals. [28,29]n this context, lessons learned in healthcare institutions in high-income countries would be of interest to apply in clinics and hospitals in resource-limited regions.In terms of research collaborations between scientists in the Global North and the Global South, several recommendations have been provided, in order to facilitate the consolidation of appropriate scientific networks and to avoid "helicopter research". [30,31]34] A key aspect in leading hospitals is the close relationship with   major local medical schools, which have important infrastructure for research, including MSc and PhD level scientists. [2,9]Several articles have described the advantages of programs focused on advances training in research methods and scientific writing for members of clinical institutions in resource-limited countries. [35,36]A potential and recent aspect of health research in Latin American institutions involves the adequate use of novel Artificial Intelligence (IA) tools, [37] including the local challenge of the need of having automated resources for identifying IA-generated texts. [38,39] high-quality clinical research involves a major investment in availability of researchers, protected time for research for clinical specialists is a key need in hospitals interested in increasing its productivity. [2,3,9,33]In addition, creation of additional academic programs focused on clinical research is a major need in some of these Latin American countries [9,40] Limitations of the current study involves the focus on the most scientifically productive institutions in the five selected Latin American countries and the main use of international databases.

CONCLUSION
This is the first scientometric study of clinics and hospitals from several Latin American countries.For a number of selected clinics and hospitals in five countries (Argentina, Brazil, Chile, Colombia and Mexico), we identified the profiles of international publications, citations, registered clinical trials, networks of collaborations and patent applications.In addition, we proposed several suggestions for strengthening research and innovation in healthcare institutions in Latin American countries.

Figure 1 :
Figure 1: Geographical locations of hospitals and clinics and articles published by country.

Figure 2 :
Figure 2: Co-authorship networks for hospitals and clinics in Argentina, Brazil, Chile, Colombia and Mexico.A: weighted by documents B: weighted by citations.

Table 1 : Clinical trials registered in ClinicalTrials.gov and articles indexed in PubMed by hospital and country.
Tocora, et al.: Scientometric Analysis of clinics in Latin America

Table 3 : Selected highly cited papers by healthcare institution.
Tocora, et al.: Scientometric Analysis of clinics in Latin America