The Influence of the Sunshine Act on Industry Payments to United States Orthopaedic Sports Medicine Surgeons

Industry Payments to Foot and Ankle-Trained Orthopedic Surgeons: An Analysis of the Open Payments Database From 2014 to 2019

Introduction The authors examined if the transparency in industry payments to foot and ankle-trained orthopedic surgeons resulted in the following changes to the (1) median general payments to surgeons, (2) trend in median payments to surgeons across all subcategory payments, and (3) trend in median payments to surgeons in 11 regions of the United States. Methods A retrospective review of the Centers for Medicare and Medicaid Services (CMS) and Open Payments Database (OPD) was performed to identify all industry payments made by drug and medical device companies to orthopedic surgeons (N = 3,835) between January 1, 2014, and December 31, 2019. Descriptive statistics were calculated, and trend analyses in annual payments, number of payments to surgeons per year, payment subtypes, and regional distributions were analyzed. Results A total of 53,280 payments totaling $53,454,850.56 were made to orthopedic foot and ankle surgeons between 2014 and 2019. Mean and median payments were $1,003.28 and $60.19, respectively. Statistically significant differences in mean payment amounts were observed by year (p = 0.001) with a highly statistically significant, strong increase in the number of payments made over the six-year period (r = 0.97, p < 0.001). The greatest increases in median individual payments were observed for gifts (277.1%; r = 0.18, p = 0.05), education (250.6%; r = 0.17, p < 0.001), and royalties and licensing (72.1%; r = 0.05, p = 0.04). Statistically significant increasing trends in median payments over time were observed for the Northeast (p < 0.001) and South regions (p < 0.001). Discussion The results of this study demonstrate the increase in payments made across the six-year time period. The study demonstrates that there is a shift in the type of payments from speaker fees, entertainment, and lodging to education, gifts, honoraria, royalties, and consulting. Conclusion Since the OPD release, no significant decrease was identified in the financial relationship between foot and ankle surgeons and the industry; rather, an increase was observed. This increase in education, royalties, and consulting shows that more foot and ankle surgeons are getting involved in the industry, contrary to expectations. The partnership between industry and physicians can help to improve innovation and bring new ideas to the future of orthopedics.

Contemporary Analysis of Inconsistencies Between Physician-reported Disclosures at the AAOS Annual Meeting and Industry-reported Financial Disclosures in the Open Payments Database

Introduction:

Healthcare regulators and patients are increasingly interested in financial transparency between physicians and the industry because of concerns of bias.

Methods:

Disclosures for every first and last author with a medical degree from the United States associated with a poster or podium presentation at the American Academy of Orthopaedic Surgeons (AAOS) 2019 Annual Meeting were identified. Author characteristics were collected. AAOS disclosures were then compared with disclosures from the Open Payments Database to determine whether any inconsistencies existed.

Results:

In total, 2,503 AAOS presenters were identified, and 1,380 authors met the inclusion criteria. Using AAOS disclosures as the standard comparator, 482 authors (35%) had an inconsistency in any category between AAOS disclosures and the Open Payments Database. Inconsistency rates for each category were 8% for royalties, 10% for speaker's fee, 15% for paid consultant, 16% for research, 14% for stocks, and 1% for other financial support.

Discussion:

Although the inconsistency rate for each category has improved over the years, the overall inconsistency rate between physician-reported disclosures at a recent AAOS Annual Meeting and industry-reported relationships reported in the Open Payments Database was still 35%.

Industry Payments Among Editorial Board Members of Orthopaedic Journals: An Open Payments Analysis From 2014 to 2019

INTRODUCTION

Although industry payments to physicians and surgeons remain a subject of controversy, relationships between industry and orthopaedic surgeons continue to grow. Notably, recent analyses have demonstrated significant increases in the rate and magnitude of payments among orthopaedic surgeons, despite the passing of the Physician Payments Sunshine Act in 2010. Given the concerns regarding how these relationships may affect the peer-review process, our analysis aimed to evaluate how payments among editorial board members of orthopaedic journals have changed over a contemporary time frame.

METHODS

The Clarivate Analytics Impact Factor tool was used to identify all orthopaedic journals with a 2019 impact factor of ≥1.5. Editorial board members from these respective journals were identified from each journal's website. Subsequently, the Open Payments database by the Centers for Medicare and Medicaid Services was queried to identify industry payments received by these board members between 2014 and 2019. The quantity and magnitude of payments were then evaluated and compared over this study period. All monetary values were adjusted for inflation.

RESULTS

A total of 18 orthopaedic journals were included in our analysis. Of the 1,519 editorial board members identified, 711 (46.81%) received some form of industry payment in 2019. The total, average, and median payments over this study period decreased for 6 (31.6%), 7 (36.8%), and 8 of the included journals (44.44%), respectively. Six hundred twenty board members had higher average payments in 2019 than in 2014.

CONCLUSION

Our analysis demonstrated high rates of industry payments among editorial board members of high-impact orthopaedic journals. In addition, we demonstrated marked growth in the total, average, and median magnitude of these payments since the inception of the Open Payments database. Our findings encourage a continued need for transparency in related payments to ensure a fair and unbiased peer-review process, one that is separated from undue industry influence.

Academic Influence as Reflected by h Index Is Not Associated With Total Industry Payments but Rather With National Institutes of Health Funding Among Academic Orthopaedic Sports Medicine Surgeons

PURPOSE

(1) To compare the total number and dollar amount of industry funding and National Institutes of Health (NIH) funding to academic orthopaedic sports medicine surgeons and (2) to examine the impact of academic influence on industry funding and NIH funding to academic orthopaedic sports medicine surgeons.

METHODS

Academic orthopaedic sports medicine surgeons were identified using faculty web pages. Academic influence was approximated by a physician's Hirsch index (h index) and number of publications and obtained from the Scopus database. Total industry payments were acquired through the Open Payments Database, and NIH funding was determined from the NIH website. Statistical analysis was performed using Mann-Whitney U test and Spearman correlations with significance set at P < .05.

RESULTS

Physicians who received industry research payments and NIH funding had a significantly higher mean h index and more mean total publications than physicians who did not receive industry research payments and NIH funding. There were no significant differences in h index (P = .374) or number of publications (P = .126) between surgeons receiving industry nonresearch funding and those who did not. h Index and number of publications were both weakly correlated with the amount of industry research and nonresearch funding.

CONCLUSION

Although academic influence is associated with industry research funding and NIH funding, there is no association between measures of academic influence and total industry and industry nonresearch payments. Combined with the weak associations between academic influence and the amount of industry payments, academic influence does not appear to be a major determinant of industry funding to academic orthopaedic sports medicine surgeons.

CLINICAL RELEVANCE

Surgeons should be cognizant of potential conflicts with industry, but the relationship between academic sports medicine surgeons and industry may be less subject to bias than previously believed.

The Role of Advanced Academic Degrees in Orthopaedic Sports Medicine Faculty

Background:

Limited knowledge exists on the role of advanced academic degrees within faculty positions in orthopaedic sports medicine.

Purpose:

To 1) provide an assessment of the baseline demographics of advanced degrees among orthopaedic sports medicine faculty and 2) examine the impact of advanced degrees on research productivity and career attainment of orthopaedic sports medicine faculty.

Study Design:

Cross-sectional study; Level of evidence, 4.

Methods:

Orthopaedic sports medicine academics were identified using faculty listings on websites of the 200 orthopaedic surgery residency programs during the 2020-2021 academic year. Advanced degrees were defined as those additional to the primary medical degree (Doctor of Medicine [MD] or Doctor of Osteopathic Medicine [DO]). Outcome measures included timing of advanced degree obtainment, residency program rankings, research productivity, and current academic rank and leadership roles. Statistical analysis was performed using chi-square and Mann-Whitney U tests to determine the association of advanced degrees on outcome measures.

Results:

In total, 911 orthopaedic sports medicine faculty members were identified, of whom 100 had an advanced degree. The most common advanced degrees were Master of Science (MS/MSc; 38%), Doctor of Philosophy (PhD; 23%), and Master of Business Administration (MBA; 13%). The presence of an advanced degree was associated with greater research productivity, including higher h-index and number of publications, as well as more editorial board positions on orthopaedics journals ( P < .001). Advanced degrees were not significantly associated with attending a higher ranked orthopaedic surgery residency program, current academic rank, or leadership roles. At the institutional level, orthopaedic sports medicine programs that employed faculty with an advanced degree had a higher residency program ranking and the presence of a sports medicine fellowship was more likely ( P < .05).

Conclusion:

Advanced degrees in orthopaedic sports medicine were associated with greater faculty research engagement and employment at a higher ranked institution; they were not associated with matching to a highly ranked orthopaedic surgery residency program, higher faculty rank, or academic leadership roles.

Orthopaedic Trauma Surgeons' Financial Relationships With Industry: An Analysis of the Sunshine Act Reporting of Physician Open Payments From 2014 to 2019

INTRODUCTION

Orthopaedic trauma surgeons have an intricate relationship with the medical device industry. In the past decade, legislation has created transparency of monetary exchanges between physicians and industry. In 2013, the Physician Payments Sunshine Act was passed and ultimately led to the creation of the Open Payments Database. The purpose of this study was to evaluate trends in industry payments to orthopaedic trauma surgeons.

METHODS

A retrospective review of the Centers for Medicare & Medicaid Services' Open Payments Database was conducted for general industry payments to orthopaedic trauma surgeons from 2014 to 2019. Total payments and subtype payments were analyzed for yearly trends. All payments were converted to 2019 US dollars to adjust for inflation. Descriptive statistics included analysis of payments, number of surgeons, types of payments, top contributing companies, and regional comparisons. Trends were assessed through the Jonckheere-Terpstra test. Statistical significance was defined at P < 0.05.

RESULTS

From 2014 to 2019, 45,312 individual payments were given to orthopaedic trauma surgeons (N = 3208) accounting for a total of $41,376,397.85 (USD), with a mean of $919.54 per payment. Increased trends were noted for median annual payments, number of payments, and number of surgeons receiving payments. Compared with 2014 ($460.91), median payments were increased by 90.9% in 2016 ($879.85), 102.6% in 2018 ($933.81), and 178.6% in 2019 ($1284.06). Payment subtypes that demonstrated increasing median payments included consulting fees (P = 0.028); education (P < 0.001); entertainment, food, and beverage (P < 0.001); and travel (P = 0.019). Decreases in median payments were seen in royalties (P = 0.044) and grant funding (P < 0.001). Regional comparisons demonstrated increasing trends in median payments in the midwest (P = 0.011), south (P < 0.001), and west (P = 0.003), but not in the northeast (P = 0.081).

DISCUSSION

In our study, we found that industry payments to orthopaedic trauma surgeons were increasing markedly between 2014 and 2019, particularly among consulting fees, education, entertainment, food and beverage, and travel.

Industry Payments to Adult Reconstruction-Trained Orthopedic Surgeons: An Analysis of the Open Payments Database From 2014 to 2019

BACKGROUND

In recent time, there has been an increased push toward transparency in industry funding toward physicians. The Physician Payments Sunshine Act called for the creation of the Open Payments Database managed by the Centers for Medicare & Medicaid Services. To our knowledge, there have been no studies evaluating the trends in payments among adult reconstruction fellowship-trained orthopedic surgeons. The purpose of this study is to investigate trends in all payments to adult reconstruction-trained orthopedic surgeons from 2014 to 2019. Secondary outcomes included evaluating trends in yearly subpayment categories, regional variations, as well as characterizing the top 5 industry companies.

METHODS

A review of the Centers for Medicare & Medicaid Services Open Payments Database was performed to identify all payments to adult reconstruction-trained orthopedic surgeons. A total of 94,265 payments were made to 4911 surgeons accounting for a total of $258,865,231.20 during the study period. Our primary outcome was to assess the trend in median payment per year to individual surgeons. Secondary outcomes included evaluating payment trends with respect to subtype, location as defined by United States Census regions, as well as specifics concerning the top 5 companies.

RESULTS

Over the study period, there was a nonsignificant increasing trend in median payment per surgeon (r = 0.49, P = .096). However, there was also a significantly increasing trend in the number of payments per year (r = 0.83, P = .014), as well as the number of surgeons receiving payments (r = 0.88, P = .019). With respect to subcategory payments, there were significantly increasing trends in the median payment per surgeon for education (1054%, r = 0.942, P < .001) and entertainment/food and beverage expenses (20.2%, r = 0.49, P = .020), as well as a significantly decreasing trend for median honoraria payments per surgeon (20.2%, r = -0.04, P = .005). No significant regional trends were identified. Of the top 5 companies, one demonstrated a significantly decreasing trend in median payment per surgeon (21.6%, r = -0.109, P < .001), whereas the others remained unchanged.

CONCLUSION

In this study, we found a nonsignificant increasing trend in payments to adult reconstruction-trained surgeons as well as an increasing number of surgeons receiving payments. There were increasing trends in median payment per surgeon for education and entertainment expenses, but a decreasing trend for honoraria payments. No significant regional trends were identified. The majority of the top 5 companies had nonsignificant trends in their payments. Further studies are needed to characterize the disclosure of payments and the impact of industry payments on clinical outcomes.

LEVEL OF EVIDENCE

IV.