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Preprints Make Research More Accessible, But Use Among Health Services Researchers is Low

Until recently, there were no preprint servers for medical and health sciences. In this post, Harlan Krumholz and Joseph Ross, co-founders of medRxiv, describe the benefits of preprints and highlight features of their preprint server for health sciences launched in June 2019.

Photo of academic journals on a shelf.

In the field of health services research, research does not age well. The relevance of scholarly contributions is often related to their timeliness. In some cases, delays in dissemination can delay actions to address inequities, poor quality care, or even harmful care. One way to address this is for the health services research community to consider using preprints to disseminate research.

For those who are unfamiliar, a preprint server is a platform to post preliminary versions of research articles, before they undergo formal peer review, to enable prompt sharing across the community, solicit feedback, and encourage debate. The content is archived so it is publicly available and searchable. Updated versions of articles may be uploaded, but all versions remain available to allow readers to view the postings’ history.

Peer Review is Deliberative, but Slow

Our research often languishes in peer review purgatory for years. When we rely on peer review publication to disseminate scientific research, we are accepting that there will frequently be prolonged delays that may relegate contributions to irrelevance by the time they are published. Delays are due in part to the time required to improve the study and address peer review comments, but also to the time required to identify a journal willing to publish the study. In one example among many, our team submitted a paper for which the initial review took almost six months. Despite many communications with the journal, the decision remained pending a year later, when we withdrew the paper and published it elsewhere. A moment had passed during which the paper could have informed discussion and contributed to ongoing policy debate.

The slow, deliberative peer review process is common in other areas of science. Many fields have arrived at the solution to post articles before peer review so that the community can provide feedback and to foster collaboration. This approach is normative practice in the biological sciences, health economics, data science, and so many other fields. In fact, in these fields, if you rely solely on the article of record in peer review to disseminate your work, you will be at a competitive disadvantage.

Preprints Make Research More Accessible

The goal of a preprint platform is to make early reports of research available, before peer review, in the same way that we do at scientific meetings or local research-in-progress gatherings. Preprints are archived at a point in time and widely available for comment. This allows us to track progress through versions, and even compare peer-reviewed publications with the initial submissions. We can also complement brief presentations at scientific meetings with more in-depth material that can be accessed over time.

Preprints make research articles citable by other investigators earlier and allow for posting of content that may be hard to publish but important to disseminate, such as:

  • studies confirming established findings in new settings,
  • quality innovations,
  • replicating secondary data analysis research findings, and
  • inconclusive or pilot trial results.

Most preprint servers have no firewall and are open to all readers. Most importantly, preprints enable rapid feedback, with discussion of the research, either directly with the investigators or through online platforms, including the comments section of preprint servers, Twitter, blogs, or other social media services.

Introducing a Preprint Server for Health Services Research

Until recently, there were no preprint servers for medical and health sciences, but in June 2019, a collaboration of individuals representing the BMJ, Cold Spring Harbor Laboratories and Yale University launched medRxiv (pronounced “med archive”), a freely accessible, online preprint platform designed to bring preprints to medical and health science research. Several other preprint servers are also available for health researchers, such as the Open Science Framework and Research Square, as well as NBER’s Working Paper listing for health economists.

Submitted papers that meet established requirements—a list of authors and affiliations, study abstract, statement of ethical oversight, and when applicable, clinical trial registration number—are usually available online within three days. About one in five submitted papers is declined for not being within the platform’s scope, which is intended to feature reports of research—not editorials or narrative reviews—or for not complying with preprint policies. Content that may cause harm if misinterpreted may also be declined, deemed better to disseminate after peer review. medRxiv states clearly that the content is not peer-reviewed and should be handled with that in mind, along with a caution that posted papers should not be considered established knowledge.

To date, medRxiv hosts nearly 25,000 preprints, with at least one-third receiving comments on medRxiv or attention in scientific circles through Twitter or other social media. But the use among health services researchers is still low. See below for a breakdown of preprints from the first two years:

Subject Area

Number of Preprints & Percentage of Total

Health Economics

205 (0.9%)

Health Informatics

632 (2.9%)

Health Policy

351 (1.6%)

Health Systems & Quality Improvement

237 (1.1%)

We have no doubt that the health services research community believes its work is timely and consequential. For that reason, we should favor sharing research early and often, maximizing its potential to inform policy and use to improve patient care. While some researchers may be hesitant to preprint for fear of jeopardizing publication, many journals allow preprinted research articles to be considered for publication. Indeed a recent assessment published in JAMA found that only one of the 100 top-ranked clinical journals prohibited pre-prints. The onus is on journals to best serve the research community, and it is our view that they should support preprints as they do scientific presentations at scientific meetings. And it is up to the research community not to have a small number of journals dictate the way that science can be disseminated.

We hope that the health services research community will find medRxiv useful, volunteer to help improve it, and comment on the work that others submit. It holds the promise of more rapid dissemination of our work, as a complement to peer review, and a way to enhance peer feedback on work before there is a publication of record.

Editor’s Note: Embracing innovation in the scientific process is a strategic priority for AcademyHealth. Last month, AcademyHealth’s Paradigm Project convened a group of experts to discuss how to apply open science to health services research. A full meeting summary is forthcoming, but you can find Dr. Lisa Simpson’s reflections on the meeting here.

Harlan Krumholz Headshot

Harlan Krumholz, M.D., S.M.

Director - Center for Outcomes Research and Evaluation (CORE)

Harlan Krumholz, MD, SM, is the director of the Yale New Haven Hospital Center for Outcomes Research and Evalu... Read Bio

Joseph Ross

Joseph Ross, M.D., M.H.S.

Professor of Medicine (General Medicine) and of Public Health (Health Policy and Management) - Yale School of Medicine

Joseph S. Ross, M.D., M.H.S., is a Professor of Medicine (General Medicine) and of Public Health (Health Polic... Read Bio

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