This systematic review with scientometric analysis is the first study to identify trends, themes, and contributors of the most cited A.C.C.M. research. Anesthesia and Analgesia (15.5%) had the most articles among the 116 studies. The first African journal, South African Medical Journal (6.9%), ranked third. The Southern African Journal of Anaesthesia and Analgesia (1.7%) was the first specialty African journal in eleventh place ex aequo. Epiu I had the greatest number of first author articles (2.6%), and the African Surgical Outcomes Study by Biccard et al. [7] was among the most influential papers. Dubowitz et al. [12] had the highest H-index among the references of the most cited articles.
Citations
Top-cited A.C.C.M. articles had lower scientometric measures than similar research from other regions.[5] Citation metrics are influenced by the time since publication and visibility. Most top-cited A.C.C.M. articles were published in 2013 or later, and a significant proportion of articles were published in prominent journals. For example, the most cited article, published in The Lancet, totaled 87 citations in two years.[7] The impressive citation metrics can be attributed to its publication in a high-impact factor journal but equally to its relevance and novelty. Biccard et al. [7] led the largest multicentre prospective study of 7-day postoperative mortality in Africa (25 African countries, 247 hospitals, and 11 422 patients), and they identified perioperative disparities between surgical specialties and African regions.[7] This African research collaborative set a precedent for high-impact clinical research in Africa, and we anticipate there will be similar initiatives and publications in the next few years.
Collaborations between African authors and institutions were less common than non-African and African collaborations. A.C.C.M. research collaborations will benefit greatly from partnering with African authors and institutions that have experience publishing high-impact research. These include Lugazia E (Tanzania), Zoumenou E (Benin), Tindimwebwa J (Uganda), Elobu AE (Uganda), Kibwana S (Ethiopia), Rukewe A (Nigeria), Sama HD (Togo), and Biccard B (South Africa).
While most first authors of top-cited A.C.C.M. articles were affiliated with African institutions, non-African academic institutions had more top-cited articles and greater citation metrics than African academic institutions. This observation is consistent with other reports. Global North researchers and institutions have higher citation metrics than Global South researchers and institutions.[13, 14] Moreover, African researchers have smaller scholarly outputs within the Global South than their counterparts from the other regions.[15, 16] The growth of scholarly productivity in Africa is stunted by numerous factors. Lack of funding and administrative support is the most commonly cited barriers to scholarly productivity in Africa.[17] These barriers forestall the design and publication of quality (large sample, multicentric, prospective, randomized, and blinded) research on the continent.[4, 5] Another consequence of the lack of funding is decreased visibility. Open access increases article visibility and citation; however, open-access publication costs in some high-impact factor journals can be prohibitive.[16, 17, 18] Fortunately, an increasing number of high-impact factor journals offer open access fee waivers to authors from low-income countries and reductions for authors from lower- and upper-middle-income countries.[19] African authors who cannot afford these costs either opt for a subscription-based journal or a less expensive journal.[18]
The majority of top-cited A.C.C.M. articles were published in non-African journals. Local journals have lower or no publication fees but tend to have smaller readerships and impact factors.[19] As a result, African authors often have to choose between decreased visibility and expensive fees. Authors can increase their articles' visibility by designing and disseminating visual abstracts, organizing journal clubs, and writing op-eds on their manuscripts.[18, 20, 21] Local journals should encourage A.C.C.M. authors to organize the post-publication activities mentioned above by providing toolkits and post-publication services.
Keywords
The theme of the most cited A.C.C.M. research is transitioning from critical care to anesthesia. This transition is demonstrated in Fig. 5 by the blue (older) sepsis-related keywords to the yellow (newer) anesthesia keywords. Sepsis is the most common cause of death from infectious diseases, and Africa has an enormous burden of infectious diseases.[22–24] In particular, the African region is among the most affected by the human immunodeficiency virus and Mycobacterium tuberculosis, the first and second causes of sepsis in Africa, respectively.[23, 25] Moreover, sepsis is responsible for USD 10-469 billion in financial loss among African families and states.[26] Despite the considerable clinical and financial burden of sepsis in Africa, it remains under-reported and under-researched.[22] The nodes of sepsis were smaller and less connected than those of anesthesia. Given the burden of sepsis and a limited number of top-cited sepsis-related articles, we suggest that A.C.C.M. stakeholders promote more novel and collaborative sepsis research.
This scientometric analysis equally highlights the need to increase the visibility of articles on other aspects of critical medicine. For example, research on the other components of the care continuum such as surveillance, prevention, prehospital care, and rehabilitation.
Although the terms "global health," "low-income countries," and "developing countries" were prominent, there was no noticeable "global anesthesia" node. It appears that global anesthesia research is accessible in Africa, but the term "global anesthesia" is not commonly used. Global anesthesia is a growing field that studies and advocates universal access to safe, timely, and affordable anesthesia care.[27, 28] 2010 was a marquee year for global anesthesia as Dubowitz et al. highlighted specialist workforce shortage in low-and middle-income countries and its impact on patient outcomes.[29] In the same year, McQueen published two articles on global anesthesia.[30, 31] While the three global anesthesia articles were not focused on African anesthesia, they inspired research in the region. Dubowitz et al. 's high H-index supports this claim among the 116 articles. A decade after the seminal global anesthesia studies publication, the term does not figure among the most influential keywords in African anesthesia research. Further research is needed to understand this phenomenon.
Biccard et al. [32] have proposed an agenda for A.C.C.M. research composed of ten priorities. Four of the ten priorities are health systems research, and only two are clinical: A.C.C.M. education, service delivery, peripartum hemorrhage, non-technical skills, infrastructure, context-specific evidence-based practice, economic analyses, information management, quality improvement, and perioperative outcomes.[32] Other than perioperative outcomes (represented by the keywords "mortality" and "surgery"), the remaining research priorities set by Biccard et al. [32] do not appear among the most cited African A.C.C.M. studies.
Contributions of non-African research institutions
The U.S.A. and the U.K. contributed significantly to the most-cited A.C.C.M. research. In addition, institutions from these countries were central to collaborations between African and non-African academic institutions. On the one hand, this finding highlights the benefit and magnitude of collaboration between Global North and African institutions. On the other hand, it draws attention to the lower representation of African researchers and institutions among the most cited A.C.C.M. studies. 55.1% of first authors were affiliated with an African institution. This proportion is greater than that reported in a recent systematic review of global health research in Africa. Hedt-Gauthier et al. found that 68.3% of papers had a collaborator from the Global North, and only 23.0% of first authors were local researchers.[33] As we promote greater representation of local authors in A.C.C.M. research, we must avoid practices such as gift authorship that will undermine African researchers' contributions. African researchers should be involved early on in A.C.C.M. collaborative research so they can contribute significantly and deserve first and last authorship positions.
Limitations
There are several limitations to the present study. First, the definition of African A.C.C.M. research excludes articles by African researchers on the practice of Anesthesia abroad. Including such studies would have been difficult and incomplete because of the inability to identify African researchers if they have a foreign affiliation. The publication focuses on A.C.C.M. practice in a non-African region. Next, few African journals can be found on the major search databases. As a result, we might have missed a significant proportion of articles on local practice. However, we wish to note that articles that are not found in one of the standard databases are less likely to have citation data.