Surgeon-industry conflict of interest: survey of North Americans' opinions regarding surgeons consulting with industry

Evaluation of Conflict of Interest in Consulting Fee Payments in Plastic Surgery and Related Specialties

BACKGROUND

The Physician Payments Sunshine Act was enacted to increase transparency regarding physician and industry financial interests. Consulting fee payments constitute a large proportion of these financial relationships. The authors hypothesized that there are discrepancies among industry-derived consulting payments to medical and surgical specialties. The purpose of this study was to evaluate the distribution of consulting fee payments to plastic surgery and related specialties.

METHODS

This cross-sectional study used the publicly available Centers for Medicare & Medicaid Services Open Payments Program database for 2018. Consulting fee payments to physicians practicing in dermatology, internal medicine, neurosurgery, orthopedic surgery, otolaryngology, and plastic surgery were isolated and analyzed to identify discrepancies in consulting payments among these specialties and within plastic surgery.

RESULTS

A total of $250,518,240 was paid in consulting fees to specialties analyzed, with the largest average payment made to orthopedic surgeons and neurosurgeons. Nearly half of physicians were paid at least $5000 for consulting fees in 2018. Most payments were not associated with contextual information. Among U.S. plastic surgeons, 4.2% held financial relationships with corporations and were likely to be paid more when consulting for small companies.

CONCLUSIONS

Consulting payments make up a large proportion of payments included in the Open Payments Database. Although sex, state, company type, and sole proprietorship did not correlate with higher pay, plastic surgeons who consulted for small companies were paid more per payment than those working for large companies. Future studies are warranted to determine whether these industry financial relationships impact physician behavior.

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.

Awareness and Perceptions among Members of a Japanese Cancer Patient Advocacy Group Concerning the Financial Relationships between the Pharmaceutical Industry and Physicians

Objectives: Awareness and perceptions of financial conflicts of interest (FCOI) between pharmaceutical companies (Pharma) and healthcare domains remain unclear in Japanese cancer patient communities. This study aimed to assess awareness (RQ1), the influence of FCOI on physician trustworthiness (RQ2), and their perception (RQ3) among the Japanese cancer patient advocacy group members. Methods: A cross-sectional study using a self-administered survey was conducted with a Japanese cancer patient advocacy group between January and February 2019. The main outcome measures included awareness and perceptions of physician–Pharma interactions, their impact on physician trustworthiness, and attitudes towards FCOI among medical and other professions. Furthermore, we performed thematic analyses on the comments which responders provided in the surveys. Results: Among the 524 contacted members, 96 (18.3%) completed the questionnaire, including 69 (77.5%) cancer patients. In RQ1, most of the respondents were aware of physician–Pharma interactions, although the extent differed based on the nature of the interaction. Furthermore, the respondents mainly considered these interactions influential on clinical practice (RQ2) and agreed to the need for further regulation of physician–Pharma interactions (QR3). In qualitative analyses (n = 56), we identified the 4 following themes: perception towards the FCOI (Theme 1), concerns about the respondent’s treatment (Theme 2), reason of physician–Pharma interactions (Theme 3), and possible solutions from the patient perspective (Theme 4). Conclusions: Most respondents were generally aware of physician–Pharma-associated FCOI and perceived them negatively. Additionally, participants appeared supportive of further FCOI regulation to protect patient-centred care. Abbreviations: FCOI—financial conflicts of interest; United States—US; Pharma—pharmaceutical companies; RQ—research question.

Industry Payments Among Appropriate Use Criteria Voting Panels: An Open Payments Analysis

BACKGROUND

Although multiple studies have consistently demonstrated that orthopaedic surgeons receive greater transfers of value than other specialties, the industry payments of providers who are involved in the formation of practice guidelines have not been thoroughly explored. Therefore, the purpose of our analysis was to evaluate the industry payments of the authors of the Appropriate Use Criteria (AUC) from the American Academy of Orthopaedic Surgeons (AAOS).

METHODS

The publicly available AAOS web portal (OrthoGuidelines.org) was queried for all AUCs that had been released between January 1, 2013, and December 31, 2019, regarding the management of musculoskeletal pathologies. A cross-sectional analysis of the Centers for Medicare & Medicaid Services (CMS) Open Payments database was conducted to determine the number and total value of industry payments to AUC voting committee members during the year of voting for the AUC. Industry payments for each orthopaedic surgeon voting member were compared with payments received by orthopaedic surgeons nationwide who received any payment within the same year. The proportion of orthopaedic surgeon voting members who received any industry payment was compared with the proportion of orthopaedic surgeons nationwide who received payments.

RESULTS

Our analysis included a total of 18 different AUCs with 216 voting members, 157 of whom were orthopaedic surgeons. Of the orthopaedic surgeon voting members, 105 (67%) received industry payments, a rate roughly comparable with the national average among orthopaedic surgeons (74%). For 7 of 18 AUCs (39%), the median payment per orthopaedic surgeon voting member was above the median among orthopaedic surgeons receiving payments nationwide that year. Qualitatively, orthopaedic surgeon voting members were more likely to receive payments in the form of royalties, licenses, or speaking fees than orthopaedic surgeons nationwide.

CONCLUSIONS

AUC voting members receive payments at frequencies and magnitudes that are roughly comparable with orthopaedic surgeons nationwide. Whether voting panel members receiving payments at these rates is ideal or is in the best interest of patients is a policy decision for the AAOS and society at large. Our study confirms that payments are common and, thus, continued vigilance is justified.

Industry Payments to Plastic Surgeons: What Has Changed Over the Last 6 Years Following Implementation of the Physician Payments Sunshine Act?

BACKGROUND

The Open Payments Program, as designated by the Physician Payments Sunshine Act, is the single largest repository of industry payments made to licensed physicians within the United States. Though sizeable in its dataset, the database and user interface are limited in their ability to permit expansive data interpretation and summarization.

OBJECTIVES

The authors sought to comprehensively compare industry payments made to plastic surgeons with payments made to all surgeons and all physicians to elucidate industry relationships since implementation.

METHODS

The Open Payments Database was queried between 2014 and 2019, and inclusion criteria were applied. These data were evaluated in aggregate and for yearly totals, payment type, and geographic distribution.

RESULTS

A total 61,000,728 unique payments totaling $11,815,248,549 were identified over the 6-year study period; 9089 plastic surgeons, 121,151 surgeons, and 796,260 total physicians received these payments. Plastic surgeons annually received significantly less payment than all surgeons (P = 0.0005). However, plastic surgeons did not receive significantly more payment than all physicians (P = 0.0840). Cash and cash equivalents proved to be the most common form of payment; stock and stock options were least commonly transferred. Plastic surgeons in Tennessee received the most in payments between 2014 and 2019 (mean $76,420.75). California had the greatest number of plastic surgeons who received payments (1452 surgeons).

CONCLUSIONS

Plastic surgeons received more in industry payments than the average of all physicians but received less than all surgeons. The most common payment was cash transactions. Over the past 6 years, geographic trends in industry payments have remained stable.

Is there an indication for surgery in patients with spinal deformities? - A critical appraisal

Background

High-quality evidence exists to support physiotherapy and brace treatment for scoliosis and other spinal deformities. However, according to previous systematic reviews, it seems that no evidence exists for surgery. Nevertheless, the number of research articles focussing on spinal surgery highly exceeds the number of articles focussing on conservative treatment.

Objective

The purpose of this study is to conduct an updated search for systematic reviews providing high-quality evidence for spinal surgery in patients with spinal deformities.

Method

A narrative review including PubMed and the Cochrane database was conducted on April 12, 2020, with the following search terms: (1) spinal deformities, surgery, systematic review and outcome; (2) kyphosis, surgery, systematic review and outcome; (3) Scheuermann's disease, surgery, systematic review and outcome, and (4) scoliosis, surgery, systematic review and outcome.

Results

No reviews containing prospective controlled or randomised controlled studies were found providing evidence for surgery.

Conclusions

A general indication for spine surgery just based on the Cobb angle is not given. In view of the long-term unknown variables and the possible long-term complications of such treatment, a surgical indication for patients with spinal deformities must be reviewed on an individual basis and considered carefully. A current systematic review appears necessary in order to be able to draw final conclusions on the indication for surgery in patients with spinal deformities.

Clinical implications

In view of the increasing number of surgeons with an affiliation to industry, the indication for surgery needs to be given by independent conservative specialists for spinal deformities in order to provide an objective recommendation.

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.

Perceptions of Financial Conflict of Interest and Knowledge of the Sunshine Act Among Orthopedic Surgery Patients

The orthopedic surgical specialty is strongly tied to partnerships with industry that have fostered innovation and greatly enhanced patient care. A substantial number of orthopedic surgeons currently receive some form of industry support. These relationships are highly scrutinized because they present the possibility of both personal and financial conflicts of interest (COI). The authors examined orthopedic patients' awareness of existing regulation and perceptions of financial COI by performing a prospective survey-based study of patients seen in an academic orthopedic department. Data were collected during 1 year, in a cross-section of hospital-based and community clinical settings. The authors collected 513 surveys during a 1-year period between 4 clinical locations. Of all respondents, 55% were unconcerned regarding gifts or direct compensation their physicians received from industry, and only 16% were very or extremely concerned regarding these benefits. Patients' opinions regarding possible influence of benefits were similarly ambivalent, with 54% of patients minimally or not at all concerned regarding the potential influence of industry gifts or compensation. Seventy-six percent of patients had never heard of the Sunshine Act, and only 3% indicated that they were aware of the legislation and its intention. The income of the respondents and their level of education were positively correlated with increased concern about handling of COI, as well as knowledge regarding the Sunshine Act. These data suggest that orthopedic surgery patients are widely unconcerned regarding physician COI, but specific subsets of patients may be more likely to have concerns regarding these relationships. [Orthopedics. 2021;44(5):e682-e686.].

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

PURPOSE

The purpose of the present study is to investigate trends in overall payments to orthopaedic sports medicine surgeons reported by the Open Payments Database (OPD) over the 6 full years of available data (2014-2019).

METHODS

A retrospective review of industry payments to United States sports medicine trained orthopaedic surgeons from 2014 to 2019 was performed using the Centers for Medicare and Medicaid Services OPD. Total payments and subtype payments were analyzed for yearly trends. Regional analysis was also performed. The primary outcome was the overall trend in total median payments (defined as the median total payments per surgeon per year), which was assessed via the Jonckheere-Terpstra test. Descriptive statistics include medians with interquartile ranges. P values < .05 were considered statistically significant.

RESULTS

From 2014 to 2019, there were a total of 1,941,772 payments to 12,816 sports medicine orthopaedic surgeons. The median payments to surgeons demonstrated a significant upward trend (P < .001). The total number of payments (r = 0.002; P = .99) did not significantly correlate with changing year. The top 5 compensated surgeons received 45.8% of all industry contributions with a median total payment of $9,210,974.06 (interquartile range: 25,029,951.46). The majority of industry contributions in the top 5 earners were attributed to royalties and licenses (98.7%). Across the study period, 89.4% of the total orthopaedic sports medicine surgeons received a yearly total payment less than $10,000, which made up 8.3% of the total industry payment sum. Those receiving a yearly total payment greater than $500,000 accounted for 0.3% of surgeons but received 53.4% of the sum payments. We found a yearly increasing trend in payments in all regions including the Midwest, South, Northeast, and West (P < .001, P < .001, P < .001, and P = .006).

CONCLUSION

Despite the transparency of reporting mandated by the Sunshine Act, orthopaedic sports medicine surgeons have continued to maintain industry relationships with a notable disparity in distribution.

CLINICAL SIGNIFICANCE

Our analysis suggests continued relationships among sports medicine surgeons and industry. Future research is needed to determine how this impacts medical practice in the United States.

Addressing Conflicts of Interest in Health and Medicine: Current Evidence and Implications for Patient Decision Aid Development

BACKGROUND

More stringent policies for addressing conflicts of interest have been implemented around the world in recent years. Considering the value of revisiting conflict of interest quality standards set by the International Patient Decision Aid Standards (IPDAS) Collaboration, we sought to review evidence relevant to 2 questions: 1) What are the effects of different strategies for managing conflicts of interest? and 2) What are patients' perspectives on conflicts of interest?

METHODS

We conducted a narrative review of English-language articles and abstracts from 2010 to 2019 that reported relevant quantitative or qualitative research.

RESULTS

Of 1743 articles and 118 abstracts identified, 41 articles and 2 abstracts were included. Most evidence on the effects of conflict of interest management strategies pertained only to subsequent compliance with the management strategy. This evidence highlighted substantial noncompliance with prevailing requirements. Evidence on patient perspectives on conflicts of interest offered several insights, including the existence of diverse views on the acceptability of conflicts of interest, the salience of conflict of interest type and monetary value to patients, and the possibility that conflict of interest disclosure could have unintended effects. We identified no published research on the effects of IPDAS Collaboration conflict of interest quality standards on patient decision making or outcomes.

LIMITATIONS

Because we did not conduct a systematic review, we may have missed some evidence relevant to our review questions. In addition, our team did not include patient partners.

CONCLUSIONS

The findings of this review have implications for the management of conflicts of interest not only in patient decision aid development but also in clinical practice guideline development, health and medical research reporting, and health care delivery.

Review of Industry Payments to General Orthopaedic Surgeons Reported by the Open Payments Database: 2014 to 2019

Introduction:

The Physician Payments Sunshine Act was placed into law in 2010 in an effort to create transparency between physicians and industry. Along with many other specialties, orthopaedic surgeons have long worked intimately with medical industry companies. This study aimed to evaluate trends in industry payments to general orthopaedic surgeons from 2014 to 2019.

Methods:

A retrospective review of the Center of Medicare and Medicaid Services' Open Payments Database was done to identify all industry payments to all general orthopaedic surgeons (ie, not subspecialty affiliated) from 2014 to 2019. The researchers analyzed total payments and subtype payments for yearly trends, and a regional analysis was done. The primary outcome was the overall trend in total median payments, which was assessed through the Jonckheere-Terpstra test. Descriptive statistics include medians with interquartile ranges. P < 0.05 was considered statistically significant.

Results:

Between 2014 and 2019, a total of 1,330,543 payments totaling $1.79 billion dollars was paid to 108,041 general orthopaedic surgeons. During this time, the number of surgeons receiving payments increased with a significant uptrend in median payments per surgeon (P < 0.001; Table 1). The top 25% percentile of general orthopaedic surgeons received >95% of payments, whereas the bottom 25% received <0.1%. The general payment types all saw significant increases (P < 0.001) between 2014 and 2019, with the exception of “Ownership or Investment Interests” (P = 0.657) and “Royalty or License” (P = 0.517). Significant regional uptrends in median industry payments were also seen in the Midwest, Northeast, South, and West (P < 0.001). Four of the top five orthopaedic industry companies made payment increases between 2014 and 2019.

Conclusion:

Industry payments to general orthopaedic surgeons between 2014 and 2019 have increased with a considerable disparity in payments among the top-paid orthopaedic surgeons.

Shoulder surgeon perspective of surgical device representatives: a multinational survey

Background

This study aimed to determine the working relationships of shoulder surgeons and surgical device representatives, and benefits or detractors to the operating environment.

Methods

An electronic survey was distributed to all members of the Codman Shoulder Society, an international group of fellowship-trained shoulder surgeons.

Results

The response rate was 44% (59 of 134). Mean yearly case volume was estimated as 253.3 ± 126.7, with 205.7 ± 119.6 cases having a surgical device representative present (81.2%). Among respondents, 41.1% (23 of 56) expressed wishes for the increased presence of device representatives during cases. A majority, 78.6% (44 of 56), felt that the presence of a device representative improved the efficiency of the operating room, with 7.3% (4 of 55) identifying an inability to use certain equipment without instruction. Valued qualities of device representatives were identified as attentiveness, organized, knowledgeable, honest, and available, whereas qualities not valued were pushiness/salesmanship, unpreparedness, disengagement, and disorganized. Median working time with the same representative was 5 years (0.5-20 years) with 94.4% (53 of 56) of respondents identifying desire for familiarity. A large proportion, 42.9% (24 of 56), identified changing their implants based on qualities of device representatives. Only 26.8% (15 of 56) felt that the presence of a device representative should be disclosed to a patient.

Conclusions

High-volume shoulder surgeons partially dictate the use of surgically implanted devices and make decisions based on valued or disvalued surgical device representative traits. Working relationships between the shoulder surgeon and device representatives proceed longitudinally and are significant in establishing long-term company relationships.

All Disclosure is Good Disclosure: Patient Awareness of the Sunshine Act and Perceptions of Surgeon-Industry Relationships

STUDY DESIGN

This was a prospective study.

OBJECTIVE

To determine patient awareness of surgeon-industry relationships, how these relationships affect patient perceptions of surgeons, and which relationships cause the greatest concern to patients.

SUMMARY OF BACKGROUND DATA

The prevalence of orthopedic surgeon-industry relationships led to the establishment of a national database of physician-industry interaction [Open Payments Database (OPD)] as part of the Physician Payments Sunshine Act (PPSA).

MATERIALS AND METHODS

A 10-item questionnaire was administered to patients before their first evaluation. Two questions asked about awareness of the surgeon's industry relationships and of the OPD. One question evaluated the importance of surgeon-industry relationships of patients when choosing a provider. Six questions assessed patient perception of specific types of surgeon-industry relationships. Lastly, each patient ranked specific types of surgeon-industry relationships (1-most concerning to 6-least/not concerning). The distribution of patient-perceptions was compared using a Friedman 2-way analysis of variance by Ranks test. Distributions across awareness were compared using a Kruskal-Wallis test.

RESULTS

A total of 205 patients completed the survey. A majority of patients were unaware of their surgeons' relationships with industry and the existence of the OPD. However, most patients considered surgeon-industry relationships an important, very important or most important part of choosing their physician. There were significant differences in how industry relationships affected patient perceptions. Research funding had the most positive impact on perception. Financial ownership was reported to be the most concerning relationship followed by royalty payments and consulting.

CONCLUSIONS

Our results suggest that despite a lack of awareness, most patients consider surgeon-industry relationships an important factor in choosing their doctor. Patients generally report a more positive view of surgeons that have active relationships with industry. These results emphasize the value of disclosure for surgeons; it provides transparency and improves their standing amongst a majority of their patients.

Disclosures Undisclosed

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) Open Payments public database, resulting from the Physician Payments Sunshine Act of 2010, was designed to increase transparency of physicians' financial relationships with pharmaceutical manufacturers. We compared physician-reported conflict-of-interest (COI) disclosures in journal articles with this database to determine any discrepancies in physician-reported disclosures.

METHODS

COIs reported by authors from 2014 through 2016 were analyzed in 3 journals: Foot & Ankle International (FAI), The Journal of Bone & Joint Surgery (JBJS), and The Journal of Arthroplasty (JOA). Payment information in the CMS Open Payments database was cross-referenced with each author's disclosure statement to determine if a disclosure discrepancy was present.

RESULTS

We reviewed 3,465 authorship positions (1,932 unique authors) in 1,770 articles. Within this sample, 7.1% of authorships had a recorded undisclosed COI (disclosure discrepancy), and 13.2% of articles had first and/or last authors with a disclosure discrepancy. Additionally, we saw a great variation in the percentage of authorships with disclosure discrepancies among the journals (JBJS, 2.3%; JOA, 3.6%; and FAI, 23.7%).

CONCLUSIONS

Discrepancies exist between payment disclosures made by authors and those published in the CMS Open Payments database. Although the percentage of articles with these discrepancies varies widely among the journals that were analyzed in this study, no trend was found when analyzing the number of discrepancies over the 3-year period.

CLINICAL RELEVANCE

COI disclosures are important for the interpretation of study results and need to be accurately reported. However, COI disclosure criteria vary among orthopaedic journals, causing uncertainty regarding which conflicts should be disclosed.

They Know How to Work It, That’s Their Focus in Life: The Complex Role of Industry Representatives in Surgical Innovation

Relationships between health care providers and industry can generate conflicts of interest with their attendant harms. However, the types of relationships that involve conflicts of interest have often been understood narrowly as material ones between individual clinicians and industry. In research we undertook with surgical teams, we found the role of industry representatives has become normalized in the context of surgical innovation. In this article, we report the findings of our study and unpack the features of both surgery and innovation which contribute to the scope and normalization of industry involvement. We argue that these relationships generate significant ethical challenges and conclude by commenting on how our conceptualization of the situation might inform change.

Factors Associated With Financial Relationships Between Spine Surgeons and Industry: An Analysis of the Open Payments Database

STUDY DESIGN

A retrospective review of Centers for Medicare and Medicaid Services Database.

OBJECTIVE

Utilizing Open Payments data, we aimed to determine the prevalence of industry payments to orthopedic and neurospine surgeons, report the magnitude of those relationships, and help outline the surgeon demographic factors associated with industry relationships.

SUMMARY OF BACKGROUND DATA

Previous Open Payments data revealed that orthopedic surgeons receive the highest value of industry payments. No study has investigated the financial relationship between spine surgeons and industry using the most recent release of Open Payments data.

METHODS

A database of 5898 spine surgeons in the United States was derived from the Open Payments website. Demographic data were collected, including the type of residency training, years of experience, practice setting, type of medical degree, place of training, gender, and region of practice. Multivariate generalized linear mixed models were utilized to determine the relationship between demographics and industry payments.

RESULTS

A total of 5898 spine surgeons met inclusion criteria. About 91.6% of surgeons reported at least one financial relationship with industry. The median total value of payments was $994.07. Surgeons receiving over $1,000,000 from industry during the reporting period represented 6.6% of the database and accounted for 83.5% of the total value exchanged. Orthopedic training (P < 0.001), academic practice setting (P < 0.0001), male gender (P < 0.0001), and West or South region of practice (P < 0.0001) were associated with industry payments. Linear regression analysis revealed a strong inverse relationship between years of experience and number of payments from industry (r = -0.967, P < 0.0001).

CONCLUSION

Financial relationships between spine surgeons and industry are highly prevalent. Surgeon demographics have a significant association with industry-surgeon financial relationships. Our reported value of payments did not include ownership or research payments and thus likely underestimates the magnitude of these financial relationships.

LEVEL OF EVIDENCE

3.

Effects of Conflicts of Interest on Practice Patterns and Complication Rates in Spine Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

We sought to determine whether financial relationships with industry had any impact on operative and/or complication rates of spine surgeons performing fusion surgeries.

SUMMARY OF BACKGROUND DATA

Recent actions from Congress and the Institute of Medicine have highlighted the importance of conflicts of interest among physicians. Orthopedic surgeons and neurosurgeons have been identified as receiving the highest amount of industry payments among all specialties. No study has yet investigated the potential effects of disclosed industry payments with quality and choices of patient care.

METHODS

A comprehensive database of spine surgeons in the United States with compiled data of industry payments, operative fusion rates, and complication rates was created. Practice pattern data were derived from a publicly available Medicare-based database generated from selected CPT codes from 2011 to 2012. Complication rate data from 2009 to 2013 were extracted from the ProPublica-Surgeon-Scorecard database, which utilizes postoperative inhospital mortality and 30-day-readmission for designated conditions as complications of surgery. Data regarding industry payments from 2013 to 2014 were derived from the Open Payments website. Surgeons performing <10 fusions, those without complication data, and those whose identity could not be verified through public records were excluded. Pearson correlation coefficients and multivariate regression analyses were used to determine the relationship between industry payments, operative fusion rate, and/or complication rate.

RESULTS

A total of 2110 surgeons met the inclusion criteria for our database. The average operative fusion rate was 8.8% (SD 4.8%), whereas the average complication rate for lumbar and cervical fusion was 4.1% and 1.9%, respectively. Pearson correlation analysis revealed a statistically significant but negligible relationship between disclosed payments/transactions and both operative fusion and complication rates.

CONCLUSION

Our findings do not support a strong correlation between the payments a surgeon receives from industry and their decisions to perform spine fusion or associated complication rates. Large variability in the rate of fusions performed suggests a poor consensus for indications for spine fusion surgery.

LEVEL OF EVIDENCE

3.

Potential Financial Conflict of Interest Among Physician Editorial Board Members of Orthopaedic Surgery Journals

BACKGROUND

The practice of medicine is based on evidence from peer-reviewed literature. As can occur with author-related funding, the integrity of the process by which manuscripts are reviewed, edited, and approved for publication may be at risk due to financial conflict of interest. The purpose of our study was to assess potential financial conflict of interest among physician editorial board members of orthopaedic surgery journals.

METHODS

We identified the physician editorial board members of 15 orthopaedic surgery journals and searched the 2014 payments that were archived in the Centers for Medicare & Medicaid Services Open Payments system (mandated by the Physician Payments Sunshine Act). Total dollar values were calculated and tabulated in a multilevel fashion: nothing reported, >$0 and ≤$10,000, >$10,000, >$250,000, and >$950,000.

RESULTS

We identified 908 physician editors of 15 orthopaedic surgery journals. Something of financial value was received by 78% (712 of 908) of these individuals. Rates of editorial board potential financial conflict of interest for individual journals ranged from 4% to 73% in the >$10,000 category. At the >$250,000 mark, rates ranged from 0% (2 journals) to 31%. When applying the >$950,000 criterion, physician potential conflict of interest ranged from 0% (5 journals) to 13%.

CONCLUSIONS

Editor-related potential financial conflicts of interest exist in the orthopaedic surgery journals that we analyzed. These potential financial conflicts could possibly impact reviews.

Knowledge, Beliefs and Attitudes of Patients and the General Public towards the Interactions of Physicians with the Pharmaceutical and the Device Industry: A Systematic Review

OBJECTIVE

To systematically review the evidence on the knowledge, beliefs, and attitudes of patients and the general public towards the interactions of physicians with the pharmaceutical and the device industry.

METHODS

We included quantitative and qualitative studies addressing any type of interactions between physicians and the industry. We searched MEDLINE and EMBASE in August 2015. Two reviewers independently completed data selection, data extraction and assessment of methodological features. We summarized the findings narratively stratified by type of interaction, outcome and country.

RESULTS

Of the 11,902 identified citations, 20 studies met the eligibility criteria. Many studies failed to meet safeguards for protecting from bias. In studies focusing on physicians and the pharmaceutical industry, the percentages of participants reporting awareness was higher for office-use gifts relative to personal gifts. Also, participants were more accepting of educational and office-use gifts compared to personal gifts. The findings were heterogeneous for the perceived effects of physician-industry interactions on prescribing behavior, quality and cost of care. Generally, participants supported physicians' disclosure of interactions through easy-to-read printed documents and verbally. In studies focusing on surgeons and device manufacturers, the majority of patients felt their care would improve or not be affected if surgeons interacted with the device industry. Also, they felt surgeons would make the best choices for their health, regardless of financial relationship with the industry. Participants generally supported regulation of surgeon-industry interactions, preferably through professional rather than governmental bodies.

CONCLUSION

The awareness of participants was low for physicians' receipt of personal gifts. Participants also reported greater acceptability and fewer perceived influence for office-use gifts compared to personal gifts. Overall, there appears to be lower awareness, less concern and more acceptance of surgeon-device industry interactions relative to physician-pharmaceutical industry interactions. We discuss the implications of the findings at the patient, provider, organizational, and systems level.

Industry Ties in Otolaryngology

Objective

To characterize nonresearch payments made by industry to otolaryngologists in order to explore how the potential for conflicts of interests varies among otolaryngologists and compares between otolaryngologists and other surgical specialists.

Study Design

Retrospective cross-sectional database analysis.

Setting

Open Payments program database recently released by Centers for Medicare and Medicaid Services.

Subjects

Surgeons nationwide who were identified as receiving nonresearch payment from industry in accordance with the Physician Payment Sunshine Act.

Methods

The proportion of otolaryngologists receiving payment, the mean payment per otolaryngologist, and the standard deviation thereof were determined using the Open Payments database and compared to other surgical specialties. Otolaryngologists were further compared by specialization, census region, sponsor, and payment amount.

Results

Less than half of otolaryngologists (48.1%) were reported as receiving payments over the study period, the second smallest proportion among surgical specialties. Otolaryngologists received the lowest mean payment per compensated individual ($573) compared to other surgical specialties. Although otolaryngology had the smallest variance in payment among surgical specialties (SD, $2806), the distribution was skewed by top earners; the top 10% of earners accounted for 87% ($2,199,254) of all payment to otolaryngologists. Otolaryngologists in the West census region were less likely to receive payments (38.6%, P < .001).

Conclusion

Over the study period, otolaryngologists appeared to have more limited financial ties with industry compared to other surgeons, though variation exists within otolaryngology. Further refinement of the Open Payments database is needed to explore differences between otolaryngologists and leverage payment information as a tool for self-regulation.