Publications in HEPATOLOGY: Is there a pro-United States bias?
Authors: Patrick S. Kamath
Journal: Hepatology (2011)

International meetings have provided me with many opportunities to interact socially with investigators from different countries. The evening often follows the same script. Toward the end of the dinner, when tongues have been sufficiently loosened, the topic of conversation focuses on my role as an Associate Editor (AE) in HEPATOLOGY. The pointed question I am usually asked, depending on whom I am with, is "Why is HEPATOLOGY biased against Europeans, or against Asians?" To be fair, I too had some of these reservations about American journals, albeit not evidence-based, before I moved to the United States. Moreover, there have also been American authors who have indicated to me that they believe there is a pro-European bias in the decision-making process! In this Editorial, I hope to dispel any notion that there is a systematic bias in HEPATOLOGY either in favor of or against specific geographic regions of the world. AE, Associate Editor; SCI, Science Citation Index; US, United States. It is a well-known fact that manuscripts from developed countries are more likely to be published in international journals than manuscripts from developing countries.1 Other interesting suggestions are that there might be a gender bias in the refereeing process,2 and that submissions with more than four authors more likely to be published than papers with fewer authors. If the corresponding author is from the same country as that of the publishing journal, the acceptance rate is higher. However, the most common perception is that there is a bias in publication in favor of the United States. This perception exists despite the fact that there has been an increase in recent years in the number of articles published from non–United States (US) sources among medical journals published from the United States. Currently, approximately 25% of all manuscripts published in US journals originate from outside the United States. Being a native English speaker is associated with a higher acceptance rate of a manuscript in US journals. Among internal medicine journals, there is no difference in publication rates for manuscripts submitted from the United States or Canada, and these rates are slightly higher than those for Europe.3 The acceptance rates from other parts of the world are smaller. In fact, acceptance rates for English-speaking countries are more than twice the acceptance rates of non–English-speaking countries, emphasizing the importance of communicating easily in the English language. Potential reasons for lower publication rates from developing countries include difficulty writing in English and submission of best manuscripts to national rather than US journals, although there is no evidence that this is the case. Some studies have been conducted to identify quality characteristics associated with manuscripts accepted for publication.4 Such studies have confirmed that manuscripts are most likely to be published if they have high methodological quality. Randomized control studies are the most likely to be published, especially with descriptive or qualitative analytical methods and disclosure of any funding sources. Larger sample size also increases the chance of acceptance of publication. Spectacular results (large treatment effects, strong associations, and unusually novel or exciting findings) are preferentially published. Although difficult to ascertain, we do accept that there may be biases, in general, in favor of well-known researchers in the field who are more likely to get a pass than the less-recognized researcher. However, this bias is not based on country of origin, but rather reputation within the field. The American Association for the Study of Liver Diseases performed a survey of submitting authors to provide more insight into its academic journals. One important aspect of the report was this: Corresponding authors from Europe and Asia were more likely to believe the review process was biased, and there were a few suggestions that the process is discriminatory and/or that there is preferential treatment toward US manuscripts. Given concerns from submitting authors that HEPATOLOGY may be biased against non-US authors, rather than take umbrage, we performed an in-depth analysis of acceptance rates. But first, some details of how we at HEPATOLOGY have attempted to avoid bias. The first step is the assignment of the AE who will handle the manuscript. The AE not only has expertise and is familiar with the investigators and collaborations in the field, but is often requested by the submitting author. The AE reviews the paper and, if the paper is deemed to have merit, assigns it for review. The reviewers nominated are experts with a reputation for balanced and incisive reviews, and are not known to have an unhealthy rivalry with the submitting author. The submitting authors' list of preferred and nonpreferred reviewers is also considered when assigning reviewers. Names of six potential reviewers are submitted to the HEPATOLOGY Editorial Office, and the first three on that list are invited electronically and simultaneously. The first two who respond positively are assigned the manuscript for review. After both reviews are submitted, the decision regarding acceptance or rejection of the manuscript is made by the Editor and the AE, taking into consideration the reviewers' comments, as well as feedback from additional reviewers and the other AEs, on a case-by-case basis. The criteria for acceptance are two-fold: (1) Does the manuscript offer new insight into the understanding of the disease condition? (2) Does the manuscript have an impact on the management strategy for that condition? Even if a study is well done, if it is purely descriptive and likely to result only in a small advancement of knowledge, it is likely to be considered a low priority for publication. The presence of AEs—as well as a large number of reviewers—who are outside the United States goes a long way toward minimizing bias in publication, specifically bias in favor of submissions from the United States and against those from outside the United States. It is definitely possible that a well-done study that advances the science will still be rejected if it is poorly written. Under such circumstances, an important message may not be delivered, hence non–native English speakers are at a disadvantage. HEPATOLOGY currently receives nearly 1,700 submissions a year and has an acceptance rate of approximately 20% (Table 1). The journal staff and editors analyzed the acceptance rate according to country of submission. When a manuscript has multiple authors from different countries, the country of the corresponding author is considered the country of submission. Manuscripts were analyzed further based on the number of publications and acceptance rates. There is a statistically significant increase in acceptance rates with increasing number of submissions (Table 2). There is also a statistically higher acceptance rate for submissions from the United States compared with other English-speaking countries (for the purpose of this analysis, the United Kingdom, Canada, Australia, and New Zealand and South Africa), Europe, and Asia (Table 2). A summary of the number of manuscripts accepted per country is given in Table 3. Among countries that submitted more than 100 manuscripts in the 3-year period analyzed, the highest acceptance rate was Australia (50%), followed by Switzerland (46%) and the United States (45%). The conclusions drawn from these data suggest that the United States does have a higher rate of acceptance than Europe or Asia as a whole, but it also has the highest number of submissions. However, the United States has a lower acceptance rate of manuscripts than Switzerland or Australia. The Science Citation Index (SCI) ranks countries according to manuscripts published in the field of hepatology in any journal.5 Between 1996 and 2009, the highest numbers of publications related to hepatobiliary disease were from the United States : 5,123 publications, of which 4,159 are citable. Japan was next with 2,871 publications, of which 2,710 are citable. Of note, manuscripts from the United States in the field of hepatology were cited 145,795 times, followed by Japan, with 43,824 citations. Further analysis of the SCI document shows that there is good correlation between the resources a country devotes to research and the number of scientific publications. The number of publications from developing countries that have minimal investment in scientific research is usually exceedingly small. We hope these data support the position that the only reason a paper is published in HEPATOLOGY is that it significantly advances knowledge in the field. The data also strengthen the conclusion that investment in science pays off with better studies and a higher number of manuscripts submitted, which ultimately translates into a higher percentage of manuscripts accepted. Authors from developing countries should lobby their governments to increase their investments in scientific research. Perhaps more important is the need to communicate clearly in English. Non–native English speakers are encouraged to have their manuscript edited by a local expert in the English language before submitting manuscripts. A paper free of typographical errors also makes for easier reading. Meanwhile, HEPATOLOGY should and will continue to treat manuscripts fairly and endeavor to publish what is best in the field. Rejecting a worthy manuscript serves very little purpose and, in fact, works against the journal and could diminish its impact factor. HEPATOLOGY needs high-quality manuscripts. On a more personal level, I look forward to many more social interactions with my international friends, and hope that together we can improve the knowledge in the field of hepatology. I thank Terry Therneau for statistical assistance.