Abstract / Summary
Abstract Background Strengthening Primary Health Care (PHC) is a global policy priority, and measurement is increasingly positioned as a strategic lever for learning, quality improvement and reform. Yet the use of indicators and performance data for learning in primary care settings remains inconsistent, and what enables data to translate into improvement is poorly understood. Aim To synthesise empirical evidence on how quality, safety and performance indicators are implemented and used in primary care, and to identify the barriers and facilitators shaping their sustained use. Methods MEDLINE, EMBASE, and Scopus were searched from 1 January 2014 to 4 June 2025. Empirical studies from high-income countries examining the use or implementation of quality, safety, or performance indicators in primary care were eligible. Data were analysed using descriptive synthesis and inductive thematic analysis of barriers and facilitators across studies. Reporting followed PRISMA guidelines. Results Twenty-six studies from nine countries were included: United States (n = 6, 23%), United Kingdom (n = 6, 23%), Canada (n = 4, 15%), Netherlands (n = 3, 12%), Australia (n = 2, 8%), Japan (n = 2, 8%), and Belgium, Germany and Sweden (n = 1 each, 4%). Study designs included mixed methods (n = 13, 50%), qualitative (n = 12, 46%) and quantitative (n = 1, 4%). Six interdependent themes shaped indicator use: clinical relevance and improvement value (23 of 26 studies); alignment with practice priorities and improvement goals (25 of 26); alignment with policies, financial incentives and system partners (15 of 26); digital and data enablement for improvement (24 of 26); practice infrastructure and adaptive capacity (13 of 26); and leadership and continuous learning culture (22 of 26). Successful use of indicators also required convergence across three meta-conditions: value, fit and alignment, supported by organisational enablers and by meso-level actors whose bridging and brokering work activated these conditions. Conclusion Indicator-based improvement in primary care gained traction not through the indicators themselves, but when value, fit and alignment converged across clinical practice and the wider system, brokered into place by the actors who worked between them. Strengthening these mutually reinforcing conditions, rather than addressing isolated barriers, offers a more realistic path towards effectively embedding and sustaining indicator use and advancing primary care as a Learning Health System.