This Viewpoint discusses the critical importance of continued funding for the intramural research program in the Department of Veterans Affairs.

With its advent in 2018, the publishers and editors of JAMA Network Open confronted the risky proposition as to whether a high-volume, open access journal could be successful while maintaining the same standards as the most highly respected medical journals.Now, 6 years on, the answer is clear.Submissions to the journal have grown steadily, reaching nearly 15 000 in 2023, 14% more than in 2022.The reach of the journal has become global.Two-thirds of submissions originate from 82 countries outside the United States, particularly China,

Last year was another tumultuous year, with the evolution of SARS-CoV-2, ongoing war and destruction in Ukraine, economic hardship throughout the world, mind-numbing recurrences of racial and ethnic violence, accumulating evidence of the devastating effects of climate change, and wide political and social divisions.At the same time, there have been positive developments regarding management of COVID-19, including new treatments for COVID-19 to replace ones no longer effective, increasing immunity among many populations from immunization and infection, and increasing recognition of the need to understand and treat post-COVID-19 condition symptoms.These circumstances and events have served to further energize the editors and staff of JAMA Network Open to pursue our mission "to improve health, health care, and health equity worldwide through open access dissemination of high quality, innovative, general medical research and commentary by and for a broad range of clinicians, researchers, policy makers, and public health and health care leaders."We remain deeply committed to addressing racism in medicine, health care, and society both in the US and abroad. 1,2Monica Vela, MD, joined us this year as JAMA Network Open Diversity, Equity, and Inclusion associate editor.In this role, she collaborates with the rest of the editors and with Preeti N. Malani, MD, MSJ, Director of Equity for the JAMA Network, to lead implementation of the journal's plan to improve diversity of our editors, authors, and reviewers; assist new authors in publishing their work; train the next generation of editors from diverse backgrounds; and publish the highest quality studies related to diversity, equity, and inclusion.][6][7][8][9][10] We received nearly 13 000 research manuscripts in 2022, an increase of 18% from 2021.We have also increased the number of published articles to approximately 8 per weekday, holding our acceptance rate at 15%.Approximately 3000 of these submissions were related to the COVID-19 pandemic, forcing us to be highly selective to ensure that those we now publish provide important new information.

ImportanceAlthough peer review is an important component of publication for new research, the viability of this process has been questioned, particularly with the added stressors of the COVID-19 pandemic.ObjectiveTo characterize rates of peer reviewer acceptance of invitations to review manuscripts, reviewer turnaround times, and editor-assessed quality of reviews before and after the start of the COVID-19 pandemic at a large, open-access general medical journal.Design, Setting, and ParticipantsThis retrospective, pre-post cohort study examined all research manuscripts submitted to JAMA Network Open between January 1, 2019, and June 29, 2021, either directly or via transfer from other JAMA Network journals, for which at least 1 peer review of manuscript content was solicited. Measures were compared between the period before the World Health Organization declaration of a COVID-19 pandemic on March 11, 2020 (14.3 months), and the period during the pandemic (15.6 months) among all reviewed manuscripts and between pandemic-period manuscripts that did or did not address COVID-19.Main Outcomes and MeasuresFor each reviewed manuscript, the number of invitations sent to reviewers, proportions of reviewers accepting invitations, time in days to return reviews, and editor-assessed quality ratings of reviews were determined.ResultsIn total, the journal sought review for 5013 manuscripts, including 4295 Original Investigations (85.7%) and 718 Research Letters (14.3%); 1860 manuscripts were submitted during the prepandemic period and 3153 during the pandemic period. Comparing the prepandemic with the pandemic period, the mean (SD) number of reviews rated as high quality (very good or excellent) per manuscript increased slightly from 1.3 (0.7) to 1.5 (0.7) (P < .001), and the mean (SD) time for reviewers to return reviews was modestly shorter (from 15.8 [7.6] days to 14.4 [7.0] days; P < .001), a difference that persisted in linear regression models accounting for manuscript type, study design, and whether the manuscript addressed COVID-19.Conclusions and RelevanceIn this cohort study, the speed and editor-reported quality of peer reviews in an open-access general medical journal improved modestly during the initial year of the pandemic. Additional study will be necessary to understand how the pandemic has affected reviewer burden and fatigue.

Priya Vart, PhD; Niels Jongs, PhD; David C. Wheeler, MD; Hiddo J. L. Heerspink, PhD; Anna Maria Langkilde, PhD; Glenn M. Chertow, MD, MPH

Rachel S. Goodman, MBA; J. Randall Patrinely, MD, MBA; Cosby A. Stone Jr, MD, MPH; Eli Zimmerman, MD; Rebecca R. Donald, MD; Sam S. Chang, MD, MBA; Sean T. Berkowitz, MD, MBA; Avni P. Finn, MD, MBA; Eiman Jahangir, MD, MPH; Elizabeth A. Scoville, MD, MSCI; Tyler S. Reese, MD; Debra L. Friedman, MD, MS; Julie A. Bastarache, MD; Yuri F. van der Heijden, MD, MPH; Jordan J. Wright, MD, PhD; Fei Ye, PhD; Nicholas Carter, MD; Matthew R. Alexander, MD, PhD; Jennifer H. Choe, MD, PhD; Cody A. Chastain, MD; John A. Zic, MD, MMHC; Sara N. Horst, MD, MPH; Isik Turker, MD, MSc; Rajiv Agarwal, MD; Evan Osmundson, MD, PhD; Kamran Idrees, MD, MSCI, MMHC; Colleen M. Kiernan, MD, MPH; Chandrasekhar Padmanabhan, MD; Christina E. Bailey, MD, MSCI; Cameron E. Schlegel, MD; Lola B. Chambless, MD; Michael K. Gibson, MD, PhD; Travis J. Osterman, DO, MS; Lee E. Wheless, MD, PhD; Douglas B. Johnson, MD, MSCI

Systematic reviews and meta-analyses are valuable tools for understanding existing-and shaping future-medical research.The concepts of systematic reviews and meta-analysis were introduced more than 40 years ago and adopted into mainstream medical research shortly thereafter. 1,2When well performed, including the choice of a relevant topic, systematic reviews and meta-analyses can provide useful insights into disease diagnosis, epidemiology, treatment effects (including benefits and harms), and aspects of study design or populations that might be associated with (and possibly influence) treatment effectiveness or other outcomes, including adverse events.These effects may become apparent in a meta-analysis when not readily evident from individual small studies.Nearly half a century later, these objectives remain central, although additional applications and more rigorous methods have been developed. 3wever, as noted in a commentary by Berlin et al, 4 there is great variability in the quality of published meta-analyses, particularly with regard to whether they were conducted in a transparent, reproducible, and valid manner.In this vein, there are numerous existing guidance documents relating to the conduct or reporting of systematic reviews and meta-analyses, eg, the Cochrane Handbook and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. 5,6other issue is the massive increase in meta-analyses and systematic reviews published during the past 3 decades, many of which are likely redundant or misleading. 7This trend presents a challenge for the editors of JAMA Network Open in terms of the volume of systematic reviews and meta-analyses, including network meta-analyses, that are routinely submitted.In 2021, there were 655 meta-analyses and 175 systematic reviews submitted, with 56 (9%) and 29 (17%) accepted, respectively.Although we have not established explicit standards for determining whether a submitted systematic review or meta-analysis should be accepted, the editors of JAMA Network Open have implicitly developed criteria by which to judge these submissions.The issues extend beyond methodological rigor, which is a fundamental requirement, to include the crucial questions of what makes the meta-analysis important and interesting.To clarify our expectations, and in the process, improve the chance that a manuscript might be considered further, we ask that authors of meta-analyses and systematic reviews to address a series of key questions in their cover letter:• Why is a new meta-analysis or network meta-analysis needed?What do we not already know that the current analysis can address?A meta-analysis that addresses an egregious error in a prior analysis and makes this correction the focus of the report may be appropriate for JAMA Network Open, particularly if it relates to an important clinical question with public health implications.• What meta-analyses on this topic have been conducted during the last 5 years, and how do the studies included in the current submission compare with those included in prior meta-analyses and/or network meta-analyses?There must be a compelling rationale to publish this type of replicative research in JAMA Network Open.An incremental update of existing meta-analyses would receive a lower priority and probably is better suited to other venues for living and dynamic reviews. 8• Does the meta-analysis address a secondary question (eg, using metaregression to evaluate factors that might modify treatment effectiveness, risk factors in a subgroup of special interest)?These often represent novel questions and are a higher priority for JAMA Network Open.• Is the systematic review or meta-analysis unique?The first meta-analysis on a topic, even if the results merely show that there is very little literature on a given topic, can be of some value and

Last year when we wrote in our 2020 year in review 1 about how the pandemic had upended everyone's lives, we were hopeful that the pandemic might soon be brought under control with the advent of very effective vaccines and a year of rapid-paced learning on how to reduce risk of severe illness and death.Unfortunately, but perhaps not altogether unexpectedly, the frustratingly rapid adaptability of this pathogen, combined with the unpredictability of human behavior, made SARS-CoV-2 one of the dominant topics for health and health care again in 2021.Another theme that was woven into many of the manuscripts submitted to JAMA Network Open and those we published was the effect of systemic racism on health and health care.In recognition of growing importance of this topic in medicine and society, the editors of the journal engaged in a year-long process to examine how we could more effectively address this issue.Among several outcomes of these discussions was an editorial 2 outlining our views and plans for the future.In addition, we revised our mission statement: "The mission of JAMA Network Open is to improve health, health care, and health equity worldwide through open access dissemination of high quality, innovative, general medical research and commentary by and for a broad range of clinicians, researchers, policy makers, and public health and health care leaders."The journal had issued a call for articles in August 2020 on the prevention and effects of systematic racism on health 3 and has continued to contribute to this scientific discussion with more than 300 studies and commentaries

Frederick P. Rivara, MD, MPH; Steven M. Bradley, MD, MPH; Daniel V. Catenacci, MD; Angel N. Desai, MD; Ishani Ganguli, MD, MPH; Sebastien J. P. A. Haneuse, PhD; Sharon K. Inouye, MD, MPH; Elizabeth A. Jacobs, MD, MAPP; Kristin Kan, MD, MPH, MSc; Howard S. Kim, MD, MS; Arden M. Morris, MD, MPH; Olugbenga Ogedegbe, MD, MS, MPH; Eli N. Perencevich, MD, MS; Roy H. Perlis, MD, MSc; Elizabeth Powell, MD, MPH; Gordon D. Rubenfeld, MD, MSc; Lawrence N. Shulman, MD; N. Seth Trueger, MD, MPH; Stephan D. Fihn, MD, MPH

Baptiste Vasey, MMed; Stephan Ursprung, MMed; Benjamin Beddoe, BSc; Elliott H. Taylor, BSc; Neale Marlow, MBBS; Nicole Bilbro, MD; Peter Watkinson, MD; Peter McCulloch, MD

The ability of latent class models to identify clinically distinct groups among high-risk patients has been demonstrated, but it is unclear how healthcare data can inform group-specific intervention design. Examine how utilization patterns across latent groups of high-risk patients provide actionable information to guide group-specific intervention design. Cohort study using data from 2012 to 2015. Participants were 934,787 patients receiving primary care in the Veterans Health Administration, with predicted probability of 12-month hospitalization in the top 10th percentile during 2014. Patients were assigned to latent groups via mixture-item response theory models based on 28 chronic conditions. We modeled odds of all-cause mortality, hospitalizations, and 30-day re-hospitalizations by group membership. Detailed outpatient and inpatient utilization patterns were compared between groups. A total of 764,257 (81.8%) of patients were matched with a comorbidity group. Groups were characterized by substance use disorders (14.0% of patients assigned), cardiometabolic conditions (25.7%), mental health conditions (17.6%), pain/arthritis (19.1%), cancer (15.3%), and liver disease (8.3%). One-year mortality ranged from 2.7% in the Mental Health group to 14.9% in the Cancer group, compared to 8.5% overall. In adjusted models, group assignment predicted significantly different odds of each outcome. Groups differed in their utilization of multiple types of care. For example, patients in the Pain group had the highest utilization of in-person primary care, with a mean (SD) of 5.3 (5.0) visits in the year of follow-up, while the Substance Use Disorder group had the lowest, with 3.9 (4.1) visits. The Substance Use Disorder group also had the highest rates of using services for housing instability (25.1%), followed by the Liver group (10.1%). Latent groups of high-risk patients had distinct hospitalization and utilization profiles, despite having comparable levels of predicted baseline risk. Utilization profiles pointed towards system-specific care needs that could inform tailored interventions.

This Viewpoint proposes strategies the Veterans Affairs (VA) health care system can pursue to shore up its mission in response to declining numbers of veterans and impending budget constraints, including accelerating a transition to value-based care, optimization of infrastructure, and strengthening engagement with employees and the public.