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Anesth Analg 2003;96:513-517
© 2003 International Anesthesia Research Society

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH

Declining Proportion of Publications by American Authors in Major Anesthesiology Journals

Joseph W. Szokol, MD*,{dagger}, Glenn S. Murphy, MD*,{dagger}, Michael J. Avram, PhD{dagger}, Martin Nitsun, MD*,{dagger}, Theodore M. Wynnychenko, MD*,{dagger}, and Jeffery S. Vender, MD*,{dagger}

Departments of Anesthesiology, *Evanston Northwestern Healthcare, Evanston; and {dagger}Northwestern University Feinberg School of Medicine, Chicago, Illinois

Address correspondence and reprint requests to Joseph W. Szokol, MD, Department of Anesthesiology, Evanston Northwestern Healthcare, 2650 Ridge Ave., Evanston, IL 60201. Address e-mail to szokol{at}kellogg.northwestern.edu


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
A decline in the proportion of articles published by American authors in medical journals has been reported. We therefore sought to determine whether the contributions of authors from the United States to the three leading anesthesia journals changed between the years 1980 to 2000. The journals Pain, Anesthesiology, and Anesthesia & Analgesia were selected for evaluation on the basis of their respective impact factors. All clinical studies and basic science studies published in the years 1980, 1985, 1990, 1995, and 2000 were evaluated. The country of origin of the lead author of each article was determined by two of the investigators. {chi}2 Tests and least squares linear regression analyses were used to determine associations between the source of publication (United States or abroad) and year of publication. The proportion of American publications in the leading anesthesia specialty journals was found to be decreasing over the period 1980–2000 because of an increase in the rate of publication from abroad that is disproportionate to the increase in the total number of publications in the journals over that time. The reasons for changes in anesthesia-related publications by American authors were not established by this study. The authors speculate that multiple factors are involved, including an increased emphasis on clinical care over research because of economic constraints, American publication in journals other than the leading specialty journals, and the increased quality of submissions from abroad.

IMPLICATIONS: In the period 1980–2000, there was an increase in the number of research articles published in the three main anesthesia journals: Anesthesiology, Anesthesia & Analgesia, and Pain. Despite this increase in research activity, there was a significantly disproportionate decrease in the United States versus non-US authorship.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
Many factors affect scholarly productivity. Among the most important of these are financial support and investigator availability. In the last 2 decades of the 20th century, there has been a decreasing reimbursement rate from Medicare to hospitals for medical services, and the development of an academic manpower crisis within the anesthesiology specialty.

In 1990, Stossel and Stossel (1) reported a decline in the proportion of articles published by American authors in leading clinical research journals in the period 1978–1988. The declining rate of United States (US) publication in journals, including New England Journal of Medicine, Lancet, and the Journal of Clinical Investigation, was interpreted as reflecting a decline in the amount of high-quality research originating in the US. The authors noted that the decreased rate of publication coincided with a decreased growth of funding of American clinical research by the National Institutes of Health.

There is currently a shortage in anesthesiology manpower that is reflected in the number of faculty positions open in academic medical centers throughout the US. A Society of Academic Anesthesiology Chairs/Association of Anesthesiology Program Directors survey in August 2000 found that 91.5% of academic departments needed additional anesthesiologists [an average of 4.0 open positions per academic department (2)], whereas 66.5% of departments needed additional certified registered nurse anesthetists coverage. Not only are there more unfilled academic positions, but also those anesthesiologists practicing at academic centers are forced to spend more time performing clinical duties, as a result of which they have less time to devote to teaching and research activities.

In the present study, our purpose was to evaluate the contribution of American academic anesthesia programs to the body of anesthesia literature by determining the pattern of publication of both clinical and basic science articles from US authors in leading anesthesiology specialty journals between 1980 and 2000.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
To determine whether there has been a change in anesthesia-related publications by US authors over the last 20 yr of the 20th century, the publications in the 3 leading American anesthesia journals were examined. The Institute for Scientific Information ranks journals on the basis of the number of articles that are later cited in the medical literature. The "impact factor," a ratio of the number of citations to the citable items published recently, serves as an objective way to rank journals within a specialty such as anesthesiology. Table 1 lists the top 10 anesthesia journals and their respective impact factors. Three journals, Pain, Anesthesiology, and Anesthesia & Analgesia, were chosen for this study based on both their impact factors and the fact that all three are published in the US (www.jcrweb.com).


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  		Table 1. A List of the Top 10 Most Significant Anesthesia-Related Journals in 2000 and Their Respective Impact Factors (http://jcrweb.com/jcr_summary_list.pl)
 
Publications in 1980, 1985, 1990, 1995, and 2000 were evaluated to determine whether there was a trend in the contribution of US authors to the journals selected. All publications were examined by at least two authors. The origins of both clinical studies and basic science studies were determined; editorials, review articles, letters, abstracts, and case reports were excluded from analysis. Once it was ascertained that the article was a clinical article or a basic science article, the country of origin of the lead author was determined. If the institution of the lead author was within the US, the article was categorized as of US origin; otherwise, it was categorized as "other." When there was any disagreement as to either the nature of the article (clinical versus basic science) or to the institution of the lead author, a third author of our study was consulted to help settle the dispute.

Using least squares linear regression analysis, correlations were sought between the total number or the number of basic science or clinical articles or the proportion of basic science or clinical publications from the US or abroad published in each journal at 5-yr intervals from 1980 (year 0) to 2000 (year 20) and time (in years). The number of clinical or basic science articles originating from the US or abroad and the number of clinical and basic science articles published were compared within journals for each of the 5 yr studied by using 5 x 2 {chi}2 tests. When differences were detected, all possible post hoc comparisons were performed by using 2 x 2 {chi}2 tests with the Yates correction for continuity and the Bonferroni correction of the criterion for rejection of the null hypothesis to compensate for the application of multiple tests to the same data. The overall two-tailed criterion for rejection of the null hypothesis was P < 0.05.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
The number of clinical and basic science articles published in Pain, Anesthesiology, and Anesthesia & Analgesia at 5-yr intervals from 1980 to 2000 are listed in Table 2. Figure 1 represents in graphic form the increase over time of the relative contributions to the journals studied. The total number of articles published in the 3 journals increased linearly with time, with adjusted r2s ranging from 0.902 to 0.999 (Table 3). The number of clinical studies published in the 3 journals increased linearly with time, with adjusted r2s ranging from 0.885 to 0.911, but the number of basic science articles published increased linearly with time only in Pain, with an adjusted r2 of 0.938. The mix of basic science and clinical studies published within journals differed only in the journal Pain between the years 1980 and 1985 and the year 2000 (Table 2).


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  		Table 2. The Number of Clinical and Basic Science Articles Published in the Three Leading Anesthesiology Specialty Journals at Five-Year Intervals from 1980 to 2000
 


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  		Figure 1. The three studied journals and their respective changes in the number of articles published over the 20-yr period of study. US = United States, A&A = Anesthesia & Analgesia.

 

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  		Table 3. Correlation Between the Total Number or the Number of Basic Science or Clinical Articles Published in the Three Leading Anesthesiology Specialty Journals at Five-Year Intervals from 1980 (Year 0) to 2000 (Year 20) and Time (in Years)
 
The {chi}2 test revealed no statistically significant association between the source of basic science publication and the year of publication in the journal Pain (Table 4). An association between the source of basic science publication and the year of publication was observed when the source of publication of basic science articles in 2000 was compared with the source of publications in all other years studied in both Anesthesiology and Anesthesia & Analgesia, with a smaller proportion of basic science publications originating in the US in 2000 than in any other year in both journals (P < 0.05). In addition, the proportion of basic science studies published in Anesthesia & Analgesia originating from the US in 1995 was less than that published in 1985 (P < 0.05).


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  		Table 4. The Number of Clinical and Basic Science Articles Published from the US or Abroad in the Three Leading Anesthesiology Specialty Journals at Five-Year Intervals from 1980 to 2000
 
In the journal Pain, the {chi}2 test revealed that the proportions of clinical studies originating from the US in both 1990 and 2000 were less than they were in 1980 (P < 0.05) (Table 4). American authors published a smaller proportion of clinical studies in Anesthesiology in 2000 than they did in 1980, 1985, and 1995 (P < 0.05). The proportion of clinical studies published in Anesthesia & Analgesia from the US decreased from 1980 to all other years studied (P < 0.05) and was less in 2000 than it was in all other years studied (P < 0.05).

Because the number of articles published in the three journals increased with time, correlations were sought between the proportion of basic science or clinical articles published from the US or abroad and time. Only the proportion of clinical articles originating in the US that were published in Anesthesia & Analgesia changed with time in a statistically significant manner (adjusted r2 = 0.892, P < 0.05), decreasing from 86% in 1980 to 34% in 2000, with a corresponding increase in the proportion of clinical articles originating from abroad.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
In 1980, American authors contributed between 76% and 86% of both basic science and clinical articles to Anesthesiology and Anesthesia & Analgesia (Table 4). By 2000, American contributions decreased to between 34% and 44% of both basic science and clinical articles in both journals, proportions that were significantly different from those observed in nearly every other year studied.

American contributions of clinical articles to Pain decreased precipitously and significantly from 66% of the total in 1980 to 36% in 1990 and to 30% in 2000. In contrast, US basic science contributions to Pain increased progressively, but not significantly, from 23% in 1980 to 40% in 2000.

The most extreme evidence of a change in the representation of publications originating from the US is the linear decrease in the proportion of clinical reports in Anesthesia & Analgesia from 86% in 1980 to 34% in 2000. Similar linear decreases in the representation of US basic science and clinical publications in Anesthesiology, basic science publications in Anesthesia & Analgesia, and clinical publications in Pain were not observed. However, given that the American publication rate in 2000 differed from those observed in nearly every other year studied in Anesthesiology and Anesthesia & Analgesia, there may be a linear trend toward decreased representation of publications originating in the US that did not reach statistical significance because data were not collected for each of the years from 1980 to 2000 or that will reach statistical significance if the trend continues.

The present study was designed to study publication characteristics in leading anesthesia specialty journals between 1980 and 2000 as rigorously as possible whereas minimizing the likelihood of a type II error caused by correction of the criterion for rejection of the null hypothesis in an effort to minimize the likelihood of a type I error. Thus, we elected to study publication characteristics at 5-year intervals because this would allow us to set the criterion for rejection of the null hypothesis for each application of a post hoc 2 x 2 {chi}2 analysis at P < 0.005 to provide an overall criterion of P < 0.05. A disadvantage of this approach is that it may have resulted in the detection of differences that are attributable to abnormal publication blips rather than true differences. Alternatively, this approach may not have provided sufficient data to detect significant changes with time in the linear regression analysis that may have been detected had data been obtained for all 21 years of the period being studied.

The decline in the dominance of US investigators in research publications in leading medical journals is not unique to the field of anesthesiology. As already mentioned, in 1990, Stossel and Stossel (1) reported a decline in the proportion of articles published by American authors in leading clinical research journals in the period 1978–1988 that coincided with a decreased growth of National Institutes of Health funding of American clinical research. A study by Nahrwold et al. (3) compared major surgical journals in the years 1983 and 1993 and found that the total number of US research papers in the journals examined decreased significantly during this decade. The authors speculated on multiple reasons for this dramatic decline in US surgical research, including the increasing demands to generate funds through clinical practice, the inhibition of quality research by more stringent institutional review board requirements, issues regarding informed consent, and lack of access to qualified research coordinators. The authors further speculated that lack of governmental and private funding may also have had a role.

Why would the representation of publications in the leading anesthesiology specialty journals originating from the US decrease from 1980 to 2000? There are no data in our study to address this question, but there are data and information available at large that fuel the following speculations.

Academic medical centers are beleaguered by decreasing government reimbursement, a rigorous regulatory environment, and an increasing emphasis of clinical care over research because of shrinking profit margins. The field of anesthesiology may be most affected by these changes for several reasons, including an increasing volume of surgical procedures, a nationwide manpower shortage, reimbursement by governmental payers that is significantly less that of other medical specialties [the Medicare Fee Schedule undervalues anesthesia work by between 30% to 56% (4)], and decreased research funding from all sources including corporate, governmental, and institutional.

Other specialties facing similar constraints have had diminished academic productivity. For example, academic radiology departments have found that an increase in clinical volume decreases research activity. Taylor (5) examined this correlation and found that a 17% increase in the number of clinical examinations interpreted by a radiologist per full time employee led to a decrease in peer-reviewed publications by 69%.

The shortfall in anesthesia providers may contribute to less research activity in a variety of ways. For example, as already noted, with an average of 4.0 open positions per academic department, anesthesiologists practicing at academic centers are forced to spend more time performing clinical duties and less time performing teaching and research activities. In addition, given the national shortage of anesthesia providers, academic anesthesiologists, including accomplished researchers, are attracted into more lucrative private practice and industrial positions.

The shortfall in anesthesia care providers is expected to continue for years to come. Schubert et al. (6) extrapolated demand based on number of surgical procedures, growth in ambulatory and office-based surgery, advances in surgical technology, increased off-site anesthesia, growing interest in pain medicine and intensive care medicine, growing procedure rates for elderly patients, and the advancing age of the general population. These assumptions led to a presumed annual growth rate of 1.5%–3%. The authors concluded that there is presently a 3.6%–10.9% shortage of anesthesiologists, or approximately 1200–3800 anesthesiologists.

How did we arrive at such a shortage? During the mid-1990s, there was a perceived notion that there was a glut of graduating anesthesiology residents. The number of residents in anesthesiology residency programs peaked in 1994, with a total of 5868 (7). Because of both the perception that there was a surplus of anesthesiologists and an emphasis on the future need for primary care providers, this number decreased dramatically to a low of 3672 in 1998. Not only was there a decline in the total number of graduating residents, but also there was an even larger decrease in the number of American medical graduates; international medical graduates (IMG) represented 58% of the 1999 class. Many of these IMGs elect to return to their country of origin to practice or their visa status may force them to leave the US. The decline in residents in anesthesiology rebounded in the year 2001 with a total number of 4636 with 41% being IMGs. The number of certified registered nurse anesthetists being certified also decreased slightly during this time as well, from 1082 in 1995 to 997 in the year 2000 (7).

Other explanations for our results include the possibility that American anesthesiology investigators are choosing to publish high quality articles in journals other than the leading specialty journals. For example, there may have been a change in the quality and complexity of American anesthesiology basic science research between 1980 and 2000, leading many American anesthesiology investigators to publish in the higher impact factor basic science journals. Alternatively, American anesthesiology clinical investigators may be choosing to publish in the new anesthesia subspecialty journals that have been created over the past two decades without consideration of their impact factor. These possibilities were not evaluated in our study but merit further consideration.

The results of the present study suggest that, absent changes in editorial policies favoring the publication of articles submitted from abroad, the quality of research being conducted in anesthesiology departments abroad has improved greatly between 1980 and 2000, leading to their increased representation in the 3 journals examined. This study did not evaluate the number of submissions to the three journals (because these data are not within the public domain). It may be that the number of US submissions has not changed relative to those from abroad whereas the number accepted for publication has because of the increased quality of submissions from abroad.

It is important to note that the decrease in American publication in the highest impact anesthesiology journals is only in the proportion of articles published in those journals. Between 1980 and 2000, the number of articles published in Anesthesiology, Anesthesia & Analgesia, and Pain increased as much as fourfold (Table 2), whereas the number of US publications remained relatively unchanged or increased (Fig. 1 and Table 4). The reason the proportion of publications in the leading anesthesia specialty journals originating from the US is decreasing, therefore, is that the number of articles originating from abroad have increased at a rate that is disproportionate to the increase in the total number of publications in the journals.


   Footnotes
 
No financial support from foundations, institutions, pharmaceutical, or other private companies was involved in this work.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Stossel TP, Stossel SC. Declining American representation in leading clinical-research journals. N Engl J Med 1990; 322: 739–42.[Abstract]
  2. Tremper KK, Barker SJ, Gelman S, et al. Surviving the storm: the financial environment of academic anesthesia. SAAC/AAPD Executive Summary, Oct 2000.
  3. Nahrwold DL, Pereira SG, Dupuis J. United States research in major surgical journals is decreasing. Ann Surg 1995; 222: 263–9.[ISI][Medline]
  4. Lubarsky DA, Reves JG. Using Medicare multiple results in disproportionate reimbursement for anesthesiologists compared to other physicians. J Clin Anesth 2000; 12: 238–41.[Medline]
  5. Taylor GA. Impact of clinical volume on scholarly activity in an academic children’s hospital: trends, implications, and possible solutions. Pediatr Radiol 2001; 31: 786–9.[Medline]
  6. Schubert A, Eckhout G, Cooperider T, Kuhel A. Evidence of a current and lasting national anesthesia personnel shortfall: scope and implications. Mayo Clin Proc 2001; 76: 995–1010.[ISI][Medline]
  7. Grogono A. Residency composition and numbers graduating from residencies and nurse anesthesia schools. ASA Newslett 2001; 65: 19–23.
Accepted for publication September 30, 2002.




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This Article
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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press