The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 17

The Orthopaedic Forum | September 05, 2012

The Fate of Manuscripts Rejected by The Journal of Bone and Joint Surgery (American Volume)

Kanu Okike, MD, MPH¹; Mininder S. Kocher, MD, MPH²; Benedict U. Nwachukwu, BA³; Charles T. Mehlman, DO, MPH⁴; James D. Heckman, MD⁵; Mohit Bhandari, MD, MSc⁶

¹ Department of Orthopaedic Surgery, Massachusetts General Hospital/Brigham and Women’s Hospital, 55 Fruit Street, Boston, MA 02114. E-mail address: okike@post.harvard.edu
² Department of Orthopaedic Surgery, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115
³ Harvard Medical School, 260 Longwood Avenue, Boston, MA 02115
⁴ Division of Pediatric Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, Ohio 45229
⁵ The Journal of Bone and Joint Surgery, 20 Pickering Street, Needham, MA 02492
⁶ Department of Orthopaedic Surgery, Hamilton General Hospital, 237 Barton Street, East Hamilton, ON L8L 2X2, Canada

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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am, 2012 Sep 05;94(17):e130 1-9. doi: 10.2106/JBJS.L.00078

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Abstract

Background:

Of the many manuscripts that are submitted to The Journal of Bone and Joint Surgery (American Volume) (JBJS-A) for publication, the majority are not accepted. However, little is known about the outcome of these rejected submissions. To determine the fate of studies rejected by JBJS-A, we conducted a follow-up investigation of all clinical and basic science manuscripts that were submitted to The Journal between January 2004 and June 2005 but were not accepted.

Methods:

For each rejected manuscript, data were extracted on a wide variety of scientific and nonscientific characteristics, which were plausibly related to subsequent publication. PubMed searches were conducted to determine which manuscripts achieved full publication within five years, and logistic regression was used to identify the factors associated with publication. To further elucidate the factors associated with publication, a survey was administered to the corresponding author of each rejected manuscript.

Results:

At five years following rejection by JBJS-A, 75.8% (696 of 918) of manuscripts had reached full publication. In the multivariate analysis, factors associated with a higher likelihood of subsequent publication included grade of initial review by JBJS-A (p = 0.029), disclosure of a for-profit or nonprofit conflict of interest (p = 0.028 and 0.027, respectively), and a greater number of prior publications in frequently cited orthopaedic journals by the corresponding author (p < 0.0001). Manuscripts were less likely to reach full publication if the corresponding author was from Asia or the Middle East (p = 0.004) or was a woman (p = 0.003). Among survey respondents who indicated that their study had not yet reached full publication, the most commonly cited reason was lack of time (reported by 51.4% of respondents [thirty-eight of seventy-four]).

Conclusions:

Most manuscripts (75.8%) not accepted by JBJS-A were published elsewhere within five years of rejection. The factors predictive of subsequent publication were primarily investigator-related as opposed to study-related. Given this low threshold for eventual publication, readers are encouraged to use criteria other than inclusion in the PubMed database to identify high-quality papers.

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Introduction

Introduction | Materials and Methods | Results | Discussion | Acknowledgements

Given that The Journal of Bone and Joint Surgery (American Volume) (JBJS-A) is currently the most frequently cited journal in the field of orthopaedics¹, there are many researchers who initially submit their work to The Journal for publication. However, nearly 80% of submissions are subsequently rejected^2,3 for a variety of reasons, including level of interest and space constraints.

The fate of rejected manuscripts has previously been studied in a number of nonsurgical fields, including internal medicine⁴, dermatology⁵, radiology^6-8, and occupational medicine⁹. However, to our knowledge, no prior study has examined the outcome of manuscripts rejected by a journal in a surgical field. Therefore, the fate of manuscripts rejected by a prominent orthopaedic journal such as JBJS-A remains unknown.

The primary purpose of this study was to determine the proportion of manuscripts rejected by JBJS-A that achieves full publication within five years. Secondary research questions centered on the time to publication, the characteristics of the publishing journals, the manuscript factors associated with eventual publication, and the reasons for nonpublication.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | Acknowledgements

Study Sample

As part of a prior study^2,3, all 1181 clinical and basic science manuscripts submitted to JBJS-A between January 1, 2004 and June 30, 2005 were analyzed. Eight studies for which abstracts were unavailable were excluded, leaving 1173 manuscripts available for analysis. Data were extracted on a wide variety of scientific factors, including study type, subspecialty field, level of evidence, prospectiveness, blinding, controlling, sample size, direction of study findings, and grade of initial review by JBJS-A. Data were also extracted on a number of nonscientific factors, including conflict-of-interest disclosure, study location, primary language in the country of the corresponding author, the sex of the corresponding author, and the number of prior publications by the corresponding author in the five most frequently cited orthopaedic journals at the time of manuscript submission: JBJS-A, JBJS (British Volume [JBJS-B]), Clinical Orthopaedics and Related Research, Spine, and the Journal of Orthopaedic Research (please see prior publications for a detailed description of these methods^2,3). Of the 1173 manuscripts examined in these prior studies, 255 (21.7%) were accepted, and 918 (78.3%) were rejected; this latter group served as the sample for this study.

Search Method and Characteristics of Eventual Publication

For each of the 918 rejected manuscripts, the PubMed database was queried to identify any articles published in the five years following rejection. These searches were initially conducted on the basis of the corresponding author’s name, followed by the names of first author, second author, last author, and other authors. Search results were then compared with the manuscript in question on the basis of title and abstract content. Manuscripts for which no subsequent publication could be identified with these methods were classified as having not achieved full publication within five years. To prevent bias against manuscripts rejected later in the study period, we used a firm five-year cutoff (i.e., articles identified in the PubMed database that were published more than five years after the original rejection were also classified as having not achieved full publication within five years).

For manuscripts that did result in subsequent publication, we recorded the date of publication, which allowed for the calculation of publication delay (defined as the amount of time elapsed between rejection by JBJS-A and eventual publication by another journal). We also recorded the name of the publishing journal, which allowed for the determination of the journal impact factor in the year of publication (reported annually by the ISI Web of Knowledge, Journal Citation Reports Science Edition [from 2004 to 2010]^1,10-15), as well as the journal type (general orthopaedic, subspecialty orthopaedic, or nonorthopaedic). For the purposes of this study, journals categorized as “general orthopaedic” were divided into high-impact general orthopaedic journals (impact factor >1.0) and low-impact general orthopaedic journals (impact factor ≤1.0).

Survey

To further elucidate the factors associated with publication, a survey was e-mailed to the corresponding author of each rejected manuscript. The authors were asked a variety of questions regarding the initial submission of the manuscript, the manner in which the reviewer and editor comments were utilized, the details of subsequent submissions to other journals, and the current status of the study (published or unpublished). The authors of manuscripts that had not yet reached full publication were also queried regarding the reasons for nonpublication.

Ethics

Beginning on January 1, 2004, all authors submitting their work to JBJS-A for publication were informed that “The Journal shall have the right to use (and to permit others to use) the Data in reviewing and/or editing the Work and for any other purpose other than the creation or publication of any other work based exclusively on the Data.” The review and analysis of submitted manuscripts is permitted according to this statement. Approval was obtained from the McMaster University Research Ethics Board for the administration of the survey.

Statistical Analysis

To determine the factors associated with publication, logistic regression was performed. Factors found to be significant in the univariate analysis were retained in the multivariate model. In the multivariate analysis, multiple logistic regression was used to adjust for all variables simultaneously. Associations were estimated on the basis of odds ratios (ORs) and 95% confidence intervals (CIs). The factors predictive of publication were also analyzed with the Cox proportional hazards survival analysis (which also takes into account publication delay), but the results did not differ substantively from the logistic regression (data not shown). P < 0.05 was considered significant, and all tests were two-sided. Statistical analysis was performed with use of SAS (Version 9; SAS Institute, Cary, North Carolina).

Source of Funding

There was no external funding source for this study.

Results

Introduction | Materials and Methods | Results | Discussion | Acknowledgements

There were 918 rejected manuscripts included in this study, consisting of 603 clinical studies and 315 nonclinical studies. The majority of manuscripts received an initial grade of “reject” (92.3%; 847 of 918), while a small number were rejected after an initial grade of “revise and resubmit” (7.7%; seventy-one of 918). Level of evidence was generally low by our assessment, with more than half of the graded clinical studies providing Level-IV evidence (52.1%; 314 of 603). Conflicts of interest were disclosed by 31.0% of the studies (235 of 757), with nonprofit sources being slightly more common than for-profit sources (Table I).

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TABLE I Baseline Characteristics of the Rejected Manuscripts

Variable	No. (%)
Study type
Clinical	603 (65.7%)
Nonclinical	315 (34.3%)
Subspecialty field
Adult reconstruction hip	118 (12.9%)
Adult reconstruction knee	74 (8.1%)
Foot and ankle	39 (4.3%)
Hand and wrist	22 (2.4%)
Pediatric orthopaedics	49 (5.3%)
Practice management	16 (1.7%)
Rehabilitation medicine	4 (0.4%)
Shoulder and elbow	78 (8.5%)
Sports medicine and arthroscopy	35 (3.8%)
Spine	54 (5.9%)
Tumor and metabolic disease	45 (4.9%)
Trauma	77 (8.4%)
Basic science	307 (33.4%)
Level of evidence*
I	78 (12.9%)
II	45 (7.5%)
III	113 (18.7%)
IV	314 (52.1%)
N/A	53 (8.8%)
Prospective
No	397 (43.3%)
Yes	521 (56.8%)
Blinding
No	894 (97.4%)
Yes	24 (2.6%)
Controlling
No	550 (59.9%)
Yes	368 (40.1%)
Sample size
Small (1-15)	160 (17.4%)
Medium (16-99)	438 (47.7%)
Large (100 or more)	246 (26.8%)
Not reported	74 (8.1%)
Study findings
Positive	488 (53.2%)
Neutral	98 (10.7%)
Negative	83 (9.0%)
N/A	249 (27.1%)
Initial grade
Reject	847 (92.3%)
Revise and resubmit	71 (7.7%)
Conflict of interest†
None	522 (69.0%)
Nonprofit	144 (19.0%)
For-profit	116 (15.3%)
Study location
United States	420 (45.8%)
Canada	39 (4.3%)
Europe and Australia	278 (30.3%)
Latin America, the Caribbean, and Africa	9 (1.0%)
Asia and the Middle East	172 (18.7%)
Language
Non-English	355 (38.7%)
English	563 (61.3%)
Sex of corresponding author
Male	801 (87.3%)
Female	88 (9.6%)
Unknown	29 (3.2%)
Number of prior publications in frequently cited orthopaedic journals by the corresponding author
None (0)	298 (32.5%)
Some (1-9)	414 (45.1%)
Many (10 or more)	206 (22.4%)
Published within five years of rejection by JBJS-A
Yes	696 (75.8%)
No	222 (24.2%)
Total	918 (100.0%)

*Clinical studies only.
†Excludes studies for which conflict-of-interest information was missing (N = 161). Twenty-five studies disclosed both for-profit and nonprofit conflicts of interest. N/A = not applicable.

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TABLE I Baseline Characteristics of the Rejected Manuscripts

Variable	No. (%)
Study type
Clinical	603 (65.7%)
Nonclinical	315 (34.3%)
Subspecialty field
Adult reconstruction hip	118 (12.9%)
Adult reconstruction knee	74 (8.1%)
Foot and ankle	39 (4.3%)
Hand and wrist	22 (2.4%)
Pediatric orthopaedics	49 (5.3%)
Practice management	16 (1.7%)
Rehabilitation medicine	4 (0.4%)
Shoulder and elbow	78 (8.5%)
Sports medicine and arthroscopy	35 (3.8%)
Spine	54 (5.9%)
Tumor and metabolic disease	45 (4.9%)
Trauma	77 (8.4%)
Basic science	307 (33.4%)
Level of evidence*
I	78 (12.9%)
II	45 (7.5%)
III	113 (18.7%)
IV	314 (52.1%)
N/A	53 (8.8%)
Prospective
No	397 (43.3%)
Yes	521 (56.8%)
Blinding
No	894 (97.4%)
Yes	24 (2.6%)
Controlling
No	550 (59.9%)
Yes	368 (40.1%)
Sample size
Small (1-15)	160 (17.4%)
Medium (16-99)	438 (47.7%)
Large (100 or more)	246 (26.8%)
Not reported	74 (8.1%)
Study findings
Positive	488 (53.2%)
Neutral	98 (10.7%)
Negative	83 (9.0%)
N/A	249 (27.1%)
Initial grade
Reject	847 (92.3%)
Revise and resubmit	71 (7.7%)
Conflict of interest†
None	522 (69.0%)
Nonprofit	144 (19.0%)
For-profit	116 (15.3%)
Study location
United States	420 (45.8%)
Canada	39 (4.3%)
Europe and Australia	278 (30.3%)
Latin America, the Caribbean, and Africa	9 (1.0%)
Asia and the Middle East	172 (18.7%)
Language
Non-English	355 (38.7%)
English	563 (61.3%)
Sex of corresponding author
Male	801 (87.3%)
Female	88 (9.6%)
Unknown	29 (3.2%)
Number of prior publications in frequently cited orthopaedic journals by the corresponding author
None (0)	298 (32.5%)
Some (1-9)	414 (45.1%)
Many (10 or more)	206 (22.4%)
Published within five years of rejection by JBJS-A
Yes	696 (75.8%)
No	222 (24.2%)
Total	918 (100.0%)

At five years following rejection by JBJS-A, 75.8% (696 of 918) of the manuscripts had reached full publication. These publications occurred at a median of 19.5 months following rejection, with an average of 21.6 months and a standard deviation of 10.8 months. The majority of studies were published between twelve and thirty-six months following rejection, with relatively few studies published prior to twelve months or after thirty-six months (Fig. 1).

Fig. 1

Percentage of rejected studies published over time.

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The 696 subsequent publications occurred in 122 different journals. One hundred and ninety studies (27.3% of 696) were subsequently published in eight high-impact general orthopaedic journals, including Clinical Orthopaedics and Related Research (n = 77), JBJS-B (n = 48), the Journal of Orthopaedic Research (n = 28), and Acta Orthopaedica (n = 24). Seventy-eight studies (11.2% of 696) were subsequently published in seventeen low-impact general orthopaedic journals, including International Orthopaedics (n = 21) and Orthopedics (n = 12). Three hundred and one studies (43.2% of 696) were subsequently published in twenty-eight orthopaedic subspecialty journals, including the Journal of Arthroplasty (n = 69), Spine (n = 23), the Journal of Shoulder and Elbow Surgery (n = 22), The American Journal of Sports Medicine (n = 21), The Journal of Hand Surgery (American Volume) (n = 20), the Journal of Pediatric Orthopaedics (n = 19), the Journal of Orthopaedic Trauma (n = 18), Foot and Ankle International (n = 17), and Arthroscopy (n = 16). The remaining 127 studies (18.2% of 696) were subsequently published in sixty-nine nonorthopaedic journals, the most common of which were The Journal of Trauma and Acute Care Surgery (n = 17) and Injury (n = 8).

Studies published in high-impact general orthopaedic journals appeared in the literature the fastest after rejection (median, 17.2 months; mean, 19.1 months; standard deviation, 9.3 months), followed by nonorthopaedic journals (median, 19.2 months; mean, 21.6 months; standard deviation, 12.0 months), subspecialty orthopaedic journals (median, 19.9 months; mean, 21.8 months; standard deviation 9.7 months), and low-impact general orthopaedic journals (median, 27.6 months; mean, 27.6 months; standard deviation, 13.5 months) (Fig. 2).

Fig. 2

Number of studies published over time, by publishing journal type.

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In the multivariate analysis, manuscripts that received an initial grade of “revise and resubmit” were more likely to be published at five years than studies that received an initial grade of “reject” (88.7% compared with 74.7%, OR 2.40, 95% CI 1.09 to 5.28, p = 0.029). Manuscripts that disclosed a for-profit conflict of interest were more likely to be published than manuscripts that did not disclose a conflict (87.9% compared with 73.4%, OR 2.06, 95% CI 1.08 to 3.91, p = 0.028), as were manuscripts that disclosed a nonprofit conflict of interest (84.0% compared with 73.4%, OR 1.80, 95% CI 1.07 to 3.04, p = 0.027). Compared with manuscripts from the United States, manuscripts from Asia and the Middle East were less likely to be published at five years (65.1% compared with 81.2%, OR 0.40, 95% CI 0.22 to 0.74, p = 0.004). Manuscripts with female corresponding authors were also less likely than those with male corresponding authors to achieve full publication within five years (61.4% compared with 78.0%, OR 0.47, 95% CI 0.28 to 0.78, p = 0.003). The publication history of the corresponding author also emerged as a significant predictor, as the rates of publication following rejection were 62.8% for authors without any prior publications in frequently cited orthopaedic journals, 80.2% (OR 2.63, 95% CI 1.81 to 3.82, p < 0.0001) for authors who had between one and nine such publications, and 85.5% (OR 3.56, 95% CI 2.15 to 5.90, p < 0.0001) for authors with ten or more such publications (Table II).

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TABLE II Rates of Publication by Covariate

		Univariate		Multivariate
	Publication Rate	OR (95% CI)	P Value	OR (95% CI)	P Value
Study type
Clinical	74.3% (448/603)	1.00	---	N/A	N/A
Nonclinical	78.7% (248/315)	1.28 (0.92-1.77)	0.1368
Subspecialty field
Adult reconstruction hip	79.7% (94/118)	1.00	---	1.00	---
Adult reconstruction knee	74.3% (55/74)	0.74 (0.37-1.47)	0.3889	0.87 (0.42-1.83)	0.7199
Foot and ankle	71.8% (28/39)	0.65 (0.28-1.49)	0.3083	0.75 (0.31-1.82)	0.5201
Hand and wrist	72.7% (16/22)	0.68 (0.24-1.93)	0.4687	0.85 (0.28-2.62)	0.7761
Pediatric orthopaedics	73.5% (36/49)	0.71 (0.33-1.54)	0.3816	0.72 (0.31-1.69)	0.4552
Practice management	81.3% (13/16)	1.11 (0.29-4.20)	0.8818	1.13 (0.28-4.62)	0.8685
Rehabilitation medicine	50.0% (2/4)	0.26 (0.03-1.91)	0.1832	0.26 (0.03-2.22)	0.2189
Shoulder and elbow	69.2% (54/78)	0.57 (0.30-1.11)	0.0984	0.77 (0.38-1.56)	0.4683
Sports medicine and arthroscopy	77.1% (27/35)	0.86 (0.35-2.14)	0.7478	1.06 (0.41-2.77)	0.8988
Spine	79.6% (43/54)	1.00 (0.45-2.22)	0.9962	1.11 (0.47-2.63)	0.8082
Tumor and metabolic disease	64.4% (29/45)	0.46 (0.22-0.99)	0.0461	0.55 (0.25-1.25)	0.1534
Trauma	75.3% (58/77)	0.78 (0.39-1.55)	0.4758	1.05 (0.50-2.20)	0.8929
Basic science	78.7% (284/361)	0.93 (0.55-1.58)	0.7934	1.21 (0.68-2.16)	0.5157
Level of evidence*
I	78.2% (61/78)	1.00	---
II	71.1% (32/45)	0.69 (0.30-1.59)	0.3788	N/A	N/A
III	75.2% (85/113)	0.85 (0.43-1.68)	0.6331
IV	73.9% (232/314)	0.79 (0.44-1.43)	0.4327
Prospective
No	74.1% (294/397)	1.00	---	N/A	N/A
Yes	77.2% (402/521)	1.18 (0.87-1.60)	0.2768
Blinding
No	76.0% (679/894)	1.00	---	N/A	N/A
Yes	70.8% (17/24)	0.77 (0.32-1.88)	0.5644
Controlling
No	73.8% (406/550)	1.00	---	N/A	N/A
Yes	78.8% (290/368)	1.32 (0.96-1.81)	0.0843
Sample size†
Small (1-15)	76.9% (123/160)	1.00	---	N/A	N/A
Medium (16-99)	73.7% (323/438)	0.85 (0.55-1.29)	0.4366
Large (100 or more)	80.5% (198/246)	1.24 (0.76-2.01)	0.3827
Study findings‡
Positive	74.8% (365/488)	1.00	---	N/A	N/A
Negative or neutral	76.8% (139/181)	1.11 (0.75-1.67)	0.594
Initial grade
Reject	74.7% (633/847)	1.00	---	1.00	---
Revise and resubmit	88.7% (63/71)	2.66 (1.26-5.65)	0.0107	2.40 (1.09-5.28)	0.0292
Conflict of interest§
None	73.4% (383/522)	1.00	---	1.00	---
Nonprofit	84.0% (121/144)	1.70 (1.05-2.76)	0.0321	1.80 (1.07-3.04)	0.027
For-profit	87.9% (102/116)	2.40 (1.33-4.32)	0.0035	2.06 (1.08-3.91)	0.028
Study location
United States	81.2% (341/420)	1.00	---	1.00	---
Canada	84.6% (33/39)	1.27 (0.52-3.15)	0.5992	1.49 (0.56-3.99)	0.4229
Europe and Australia	73.4% (204/278)	0.64 (0.45-0.92)	0.015	0.93 (0.54-1.60)	0.7881
Latin America, the Caribbean, and Africa	66.7% (6/9)	0.46 (0.11-1.89)	0.284	0.47 (0.10-2.25)	0.3441
Asia and the Middle East	65.1% (112/172)	0.43 (0.29-0.64)	<0.0001	0.40 (0.22-0.74)	0.0037
Language
Non-English	71.3% (253/355)	1.00	---	1.00	---
English	78.7% (443/563)	1.49 (1.10-2.02)	0.0108	0.72 (0.43-1.20)	0.2075
Sex of corresponding author#
Male	78.0% (625/801)	1.00	---	1.00	---
Female	61.4% (54/88)	0.45 (0.28-0.71)	0.0006	0.47 (0.28-0.78)	0.0033
Number of prior publications in frequently cited orthopaedic journals by the corresponding author
None (0)	62.8% (187/298)	1.00	---	1.00	---
Some (1-9)	80.2% (320/399)	2.40 (1.71-3.38)	<0.0001	2.63 (1.81-3.82)	<0.0001
Many (10 or more)	85.5% (189/221)	3.51 (2.25-5.46)	<0.0001	3.56 (2.15-5.90)	<0.0001

*Clinical studies only. Also excludes fifty-three studies with level of evidence graded as “N/A.”
†Excludes seventy-two studies for which sample size was not reported.
‡Excludes 249 studies for which the direction of study findings was “N/A.”
§Excludes 161 studies for which conflict-of-interest information was missing.
#Excludes twenty-nine studies for which gender was unknown. OR = odds ratio, CI = confidence interval, and N/A = not applicable.

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TABLE II Rates of Publication by Covariate

		Univariate		Multivariate
	Publication Rate	OR (95% CI)	P Value	OR (95% CI)	P Value
Study type
Clinical	74.3% (448/603)	1.00	---	N/A	N/A
Nonclinical	78.7% (248/315)	1.28 (0.92-1.77)	0.1368
Subspecialty field
Adult reconstruction hip	79.7% (94/118)	1.00	---	1.00	---
Adult reconstruction knee	74.3% (55/74)	0.74 (0.37-1.47)	0.3889	0.87 (0.42-1.83)	0.7199
Foot and ankle	71.8% (28/39)	0.65 (0.28-1.49)	0.3083	0.75 (0.31-1.82)	0.5201
Hand and wrist	72.7% (16/22)	0.68 (0.24-1.93)	0.4687	0.85 (0.28-2.62)	0.7761
Pediatric orthopaedics	73.5% (36/49)	0.71 (0.33-1.54)	0.3816	0.72 (0.31-1.69)	0.4552
Practice management	81.3% (13/16)	1.11 (0.29-4.20)	0.8818	1.13 (0.28-4.62)	0.8685
Rehabilitation medicine	50.0% (2/4)	0.26 (0.03-1.91)	0.1832	0.26 (0.03-2.22)	0.2189
Shoulder and elbow	69.2% (54/78)	0.57 (0.30-1.11)	0.0984	0.77 (0.38-1.56)	0.4683
Sports medicine and arthroscopy	77.1% (27/35)	0.86 (0.35-2.14)	0.7478	1.06 (0.41-2.77)	0.8988
Spine	79.6% (43/54)	1.00 (0.45-2.22)	0.9962	1.11 (0.47-2.63)	0.8082
Tumor and metabolic disease	64.4% (29/45)	0.46 (0.22-0.99)	0.0461	0.55 (0.25-1.25)	0.1534
Trauma	75.3% (58/77)	0.78 (0.39-1.55)	0.4758	1.05 (0.50-2.20)	0.8929
Basic science	78.7% (284/361)	0.93 (0.55-1.58)	0.7934	1.21 (0.68-2.16)	0.5157
Level of evidence*
I	78.2% (61/78)	1.00	---
II	71.1% (32/45)	0.69 (0.30-1.59)	0.3788	N/A	N/A
III	75.2% (85/113)	0.85 (0.43-1.68)	0.6331
IV	73.9% (232/314)	0.79 (0.44-1.43)	0.4327
Prospective
No	74.1% (294/397)	1.00	---	N/A	N/A
Yes	77.2% (402/521)	1.18 (0.87-1.60)	0.2768
Blinding
No	76.0% (679/894)	1.00	---	N/A	N/A
Yes	70.8% (17/24)	0.77 (0.32-1.88)	0.5644
Controlling
No	73.8% (406/550)	1.00	---	N/A	N/A
Yes	78.8% (290/368)	1.32 (0.96-1.81)	0.0843
Sample size†
Small (1-15)	76.9% (123/160)	1.00	---	N/A	N/A
Medium (16-99)	73.7% (323/438)	0.85 (0.55-1.29)	0.4366
Large (100 or more)	80.5% (198/246)	1.24 (0.76-2.01)	0.3827
Study findings‡
Positive	74.8% (365/488)	1.00	---	N/A	N/A
Negative or neutral	76.8% (139/181)	1.11 (0.75-1.67)	0.594
Initial grade
Reject	74.7% (633/847)	1.00	---	1.00	---
Revise and resubmit	88.7% (63/71)	2.66 (1.26-5.65)	0.0107	2.40 (1.09-5.28)	0.0292
Conflict of interest§
None	73.4% (383/522)	1.00	---	1.00	---
Nonprofit	84.0% (121/144)	1.70 (1.05-2.76)	0.0321	1.80 (1.07-3.04)	0.027
For-profit	87.9% (102/116)	2.40 (1.33-4.32)	0.0035	2.06 (1.08-3.91)	0.028
Study location
United States	81.2% (341/420)	1.00	---	1.00	---
Canada	84.6% (33/39)	1.27 (0.52-3.15)	0.5992	1.49 (0.56-3.99)	0.4229
Europe and Australia	73.4% (204/278)	0.64 (0.45-0.92)	0.015	0.93 (0.54-1.60)	0.7881
Latin America, the Caribbean, and Africa	66.7% (6/9)	0.46 (0.11-1.89)	0.284	0.47 (0.10-2.25)	0.3441
Asia and the Middle East	65.1% (112/172)	0.43 (0.29-0.64)	<0.0001	0.40 (0.22-0.74)	0.0037
Language
Non-English	71.3% (253/355)	1.00	---	1.00	---
English	78.7% (443/563)	1.49 (1.10-2.02)	0.0108	0.72 (0.43-1.20)	0.2075
Sex of corresponding author#
Male	78.0% (625/801)	1.00	---	1.00	---
Female	61.4% (54/88)	0.45 (0.28-0.71)	0.0006	0.47 (0.28-0.78)	0.0033
Number of prior publications in frequently cited orthopaedic journals by the corresponding author
None (0)	62.8% (187/298)	1.00	---	1.00	---
Some (1-9)	80.2% (320/399)	2.40 (1.71-3.38)	<0.0001	2.63 (1.81-3.82)	<0.0001
Many (10 or more)	85.5% (189/221)	3.51 (2.25-5.46)	<0.0001	3.56 (2.15-5.90)	<0.0001

To further elucidate the factors associated with publication, we administered a survey to the corresponding author of each rejected manuscript. The response rate of the survey was 55.2% (507 of 918). Nearly all respondents indicated that JBJS-A was the first journal to which they had submitted their manuscript (95.5%; 484 of 507). More than two-thirds of respondents indicated that they had revised their manuscript based on the reviews provided by JBJS-A (70.8%; 359 of 507), including 38.7% (196 of 507) who had revised their study “a little,” 22.1% (112 of 507) who had revised their study “a moderate amount,” and 10.1% (fifty-one of 507) who had revised their study “a lot” based on the reviews. Investigators who indicated that they had revised their manuscript based on the reviews provided by JBJS-A were found to have a higher rate of subsequent publication compared with those who indicated that they had not used the reviews (82.6% [295 of 357] compared with 75.0% [111 of 148]; p = 0.049).

Following rejection, most respondents (72.4%; 367 of 507) indicated that their study had been submitted to one additional journal, 12.2% (sixty-two of 507) reported that their study had been submitted to two additional journals, and 5.7% (twenty-nine of 507) stated that their study had been submitted to three or more additional journals. Forty-three respondents (8.5% of 507) indicated that their manuscript had not been resubmitted to a journal for publication. Of the seventy-four respondents who indicated that their study had not yet been published, the most commonly reported reason was lack of time (reported by 51.4% of respondents; thirty-eight of seventy-four). The other reported reasons for nonpublication are presented in Table III.

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TABLE III Reasons for Nonpublication

Reason for Nonpublication	No. of Responses*(%)
Lack of time	38 (51.4%)
Lack of interest by journals	17 (23.0%)
Other papers with similar findings already published	9 (12.2%)
Difficulty with coauthors	7 (9.5%)
Publication not worth the trouble	7 (9.5%)
Results not important enough	7 (9.5%)
Lack of funds or other resources	7 (9.5%)
Poor methodology	4 (5.4%)
Performing additional data collection	4 (5.4%)
Statistical analysis not positive	0 (0.0%)
Other	12 (16.2%)
Total	74 (100.0%)

*Several authors gave multiple reasons for nonpublication.

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TABLE III Reasons for Nonpublication

Reason for Nonpublication	No. of Responses*(%)
Lack of time	38 (51.4%)
Lack of interest by journals	17 (23.0%)
Other papers with similar findings already published	9 (12.2%)
Difficulty with coauthors	7 (9.5%)
Publication not worth the trouble	7 (9.5%)
Results not important enough	7 (9.5%)
Lack of funds or other resources	7 (9.5%)
Poor methodology	4 (5.4%)
Performing additional data collection	4 (5.4%)
Statistical analysis not positive	0 (0.0%)
Other	12 (16.2%)
Total	74 (100.0%)

*Several authors gave multiple reasons for nonpublication.

Discussion

Introduction | Materials and Methods | Results | Discussion | Acknowledgements

In this observational study, we found that 75.8% (696 of 918) of manuscripts not accepted by JBJS-A were published elsewhere in the five years following rejection. To the best of our knowledge, this rate of publication after rejection by a scientific journal is higher than any value previously reported in the literature. Three prior studies conducted in the fields of occupational and environmental medicine⁹, radiology⁸, and internal medicine⁴ utilized similar durations of follow-up, and documented publication rates of 54% in four to six years, 64% in four to four and one-half years, and 69% in five to six years, respectively. Among prior studies that utilized a shorter duration of follow-up, the documented rates of publication were 41% in two to three years⁵, 56% in three to four years⁶, and 58% in three to four years⁷. The reasons for the high rate of publication documented in our study are unknown, but may relate to the fact that JBJS-A is a highly selective journal, or that this is the first such study to be conducted in a surgical field. It is also possible that these findings were the result of the persistence of orthopaedic researchers, as the mean time from rejection until subsequent publication averaged 21.6 months in our study as compared with fifteen to eighteen months in prior reports^4,6-8.

While, to our knowledge, no study has previously examined the subsequent publication rate of manuscripts rejected by an orthopaedic journal, several prior studies have investigated the publication rate of abstracts presented at an orthopaedic meeting. In these studies, the publication rate was found to range from 34% to 58% among abstracts presented at an annual meeting of the American Academy of Orthopaedic Surgeons^16-21, and from 41% to 67% among abstracts presented at a subspecialty meeting^22-32. The publication rate documented in our study was higher than all of these prior reports, which may be because manuscripts submitted to JBJS-A are further along in the research process or otherwise of higher quality than abstracts presented at an orthopaedic meeting.

To our knowledge, no prior study in any field of medicine has sought to systematically analyze the factors associated with publication following rejection by a scientific journal. In our study, we assessed a variety of scientific and nonscientific factors to determine their influence on publication following rejection by JBJS-A. In the multivariate analysis, the initial grade assigned to the manuscript by JBJS-A reviewers and editors emerged as a significant predictor of publication following rejection. In addition, investigators who revised their manuscripts based on the reviewer and editor comments provided by JBJS-A were also found to have a higher rate of publication. These are findings that lend face validity to the peer review process.

In our study, most of the factors associated with publication following rejection were investigator-related as opposed to study-related. A greater number of prior publications in frequently cited orthopaedic journals by the corresponding author was associated with an increased likelihood of subsequent publication, which could have been a result of the greater research skill, experience, or persistence of these researchers. Manuscripts written by individuals from Asia or the Middle East were less likely to achieve full publication, which could have been a result of the preferential publication of these studies in non-English journals that were less likely to be indexed on PubMed. However, survey respondents identified only ten additional articles that were published in journals not indexed on PubMed (representing 2.3% of the 429 published articles identified by the 507 survey respondents).

We also found that manuscripts whose corresponding authors were women were less likely to reach full publication. Given that women account for less than 5% of authors in the orthopaedic literature³³, determining the reasons for this finding is important. While the possibility of sex bias in the peer review process cannot be excluded³⁴, a prior study examining the editorial review process at JBJS-A found that manuscripts submitted by female and male corresponding authors were accepted at similar rates (24.1% compared with 22.0%, adjusted OR 1.31, p = 0.283)³. Instead, it may be that non-journal-related factors are contributing to the observed discrepancies in publication rates. There are a wide variety of barriers that women may face in the practice of academic medicine, including sexism in the medical workplace, lack of effective mentors, lack of institutional support, and the constraints of traditional gender roles^35-38. Additional research is required to identify and address any factors that may be impeding women in the publication of orthopaedic research.

In the multivariate analysis, disclosure of a conflict of interest (either for-profit or nonprofit) was also associated with a significantly higher likelihood of subsequent publication. This finding has been reported previously in other fields, including follow-up investigations of studies identified at the time of institutional review board approval³⁹ or presentation at a scientific meeting⁴⁰. While it is possible that the receipt of external funding promotes publication directly, less than 10% of survey respondents (seven of seventy-four) in our study indicated that a lack of funds or other resources may have contributed to their failure to publish. Instead, other mechanisms may be responsible. Given that many journals derive a substantial portion of their income from the advertisements, reprints, and supplements purchased by industry, the possibility of undue influence has been raised^41-43. Alternatively, it may be that conflict-of-interest disclosure is serving only as a marker for other factors that promote publication. For example, since grants are often awarded on a competitive basis, it is possible that studies with nonprofit disclosures may be of higher quality. Similarly, the tendency for industry to collaborate with prominent researchers may mean that investigators who disclose for-profit conflicts of interest are more skilled or experienced in the performance of research. However, additional research is required before definitive conclusions can be drawn.

Our survey of investigators whose manuscripts did not achieve full publication identified several reasons for nonpublication, the most common of which was lack of time. While no prior study, to the best of our knowledge, has examined the reasons for nonpublication following rejection by a scientific journal, prior investigators have done so for unpublished research identified anecdotally by prominent researchers⁴⁴ as well as for unpublished studies identified at the time of institutional review board approval or National Institutes of Health (NIH) funding³⁹, or abstract presentation^40,45,46. Within the field of orthopaedics, Sprague et al.⁴⁶ conducted a follow-up study of 306 abstracts that were presented at an annual meeting of the American Academy of Orthopaedic Surgeons but did not go on to full-text publication. In this study, the most commonly identified reason for nonpublication was also lack of time (46.5%; thirty-three of seventy-one), followed by ongoing research related to the study (31.0%; twenty-two of seventy-one), responsibility for manuscript preparation belonging to a coauthor (19.7%; fourteen of seventy-one), difficulties with coauthors (16.9%; twelve of seventy-one), pursuit of publication having a low priority (12.7%; nine of seventy-one), and a perception that the study was unlikely to be accepted by a journal (12.7%; nine of seventy-one)⁴⁶.

Our study benefited from the fact that we were able to follow up on a large sample of rejected manuscripts and systematically analyze the factors associated with subsequent publication, which, to the best of our knowledge, has not been reported previously in the literature. However, our study also had its limitations. We determined subsequent publication by searching PubMed, which could have missed studies that had changed substantially since the time of submission to JBJS-A and articles that were published in journals not indexed by this database. However, the survey administered to corresponding authors identified only five additional publications in journals indexed by PubMed and ten additional publications in journals not indexed by PubMed (which represented 0.7% and 1.4% of the 696 publications identified, respectively). In our analysis of the factors predictive of subsequent publication, the sex of the corresponding author was assigned on the basis of first name, which could have led to misclassification in the case of authors with names commonly associated with the opposite sex. Given that information on conflicts of interest was self-reported, it is possible that some conflicts were underreported⁴⁷. With regard to the survey, it was limited by the fact that investigators were asked to remember events that had occurred up to five years prior, which could have resulted in recall bias. In addition, our survey was limited by the fact that the response rate was only 55%; however, we were still able to obtain responses from over 500 orthopaedic researchers.

From our study, it can be concluded that a scientific manuscript, once prepared in a style that is acceptable for peer review by a top-tier orthopaedic surgery journal, has a high likelihood of being published in a journal indexed in PubMed. Of the 1173 manuscripts submitted to JBJS-A during the time period examined, a total of 82.1% (963) subsequently appeared in a PubMed-indexed journal, including 255 published in JBJS-A, 696 published in a different journal within five years of rejection, and twelve published in a different journal at more than five years following rejection. Of those manuscripts that did not go on to publication, the most common reasons appeared to be investigator-related as opposed to study-related. The high rate of subsequent publication suggests that the threshold for acceptance may be low, and readers should be aware that orthopaedic articles indexed in PubMed may vary greatly in terms of quality. To identify papers that are of high quality, readers are encouraged to use criteria other than mere inclusion in the PubMed database, such as study methodology and/or level of evidence.

Acknowledgements

Introduction | Materials and Methods | Results | Discussion | Acknowledgements

Note: The authors gratefully acknowledge the invaluable assistance of Cathy Griffin.

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Topics

rejection (psychology) ; procedure on joint

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Kanu Okike, Mininder S. Kocher, Benedict U. Nwachukwu, Charles T. Mehlman, James D. Heckman, Mohit Bhandari; The Fate of Manuscripts Rejected by The Journal of Bone and Joint Surgery (American Volume). The Journal of Bone & Joint Surgery. 2012 Sep;94(17):e130 1-9.

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