Industry Financial Relationships in Neurosurgery in 2015: Analysis of the Sunshine Act Open Payments Database

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.

Neurotrauma Surveillance in National Registries of Low- and Middle-Income Countries: A Scoping Review and Comparative Analysis of Data Dictionaries

BACKGROUND

Injury is a major global health problem, causing >5 800 000 deaths annually and widespread disability largely attributable to neurotrauma. 89% of trauma deaths occur in low- and middle-income countries (LMICs), however data on neurotrauma epidemiology in LMICs is lacking. In order to support neurotrauma surveillance efforts, we present a review and analysis of data dictionaries from national registries in LMICs.

METHODS

We performed a scoping review to identify existing national trauma registries for all LMICs. Inclusion/ exclusion criteria included articles published since 1991 describing national registry neurotrauma data capture methods in LMICs. Data sources included PubMed and Google Scholar using the terms "trauma/neurotrauma registry" and country name. Resulting registries were analyzed for neurotrauma-specific data dictionaries. These findings were augmented by data from direct contact of neurotrauma organizations, health ministries, and key informants from a convenience sample. These data were then compared to the World Health Organization (WHO) minimum dataset for injury (MDI) from the international registry for trauma and emergency care (IRTEC).

RESULTS

We identified 15 LMICs with 16 total national trauma registries tracking neurotrauma-specific data elements. Among these, Cameroon had the highest concordance with the MDI, followed by Colombia, Iran, Myanmar and Thailand. The MDI elements least often found in the data dictionaries included helmet use, and alcohol level. Data dictionaries differed significantly among LMICs. Common elements included Glasgow Coma Score, mechanism of injury, anatomical site of injury and injury severity scores. Limitations included low response rate in direct contact methods.

CONCLUSION

Significant heterogeneity was observed between the neurotrauma data dictionaries, as well as a spectrum of concordance or discordance with the MDI. Findings offer a contextually relevant menu of possible neurotrauma data elements that LMICs can consider tracking nationally to enhance neurotrauma surveillance and care systems. Standardization of nationwide neurotrauma data collection can facilitate international comparisons and bidirectional learning among healthcare governments.

Industry Payments to Pain Medicine Physicians: An Analysis of the Centers for Medicare and Medicaid Services Open Payments Program

OBJECTIVE

To analyze industry payments to pain medicine physicians in the United States.

DESIGN

Retrospective cohort study using publicly available databases.

SUBJECTS

The study includes U.S. pain medicine physicians (PMPs) with reports in the Open Payments program from 2013 to 2018.

METHODS

The Centers for Medicare and Medicaid Services Open Payments program was analyzed for general, investment, and ownership payments to PMPs reported from 2013 to 2018. The nature, type, and geographic variation of payments were analyzed.

RESULTS

The main findings of the study are as follows: 1) Payments made to PMPs constituted a small proportion of the payments made to all physicians in the United States, and the number of transactions and the total dollar amount seem to have decreased from 2016 to 2018. 2) The median number of payments among physicians with reported payments was around 4 (interquartile range: 18), and the majority of them were under $20. 3) The majority of payments were for in-kind items and services (85%) and were made for food and beverages (91%), travel and lodging (5.5%). 4) Some of the ownership and investment interest payments exceeded $500,000. 5) The top five drugs associated with physician payments included medications with opioids. 6) A very small minority of payments were made for entertainment or gifts. 7) A third of PMPs with reports had payments reported under more than one taxonomy.

CONCLUSIONS

Overall payments made to PMPs seem to be decreasing since 2016. The majority of the payments are made for the food, beverage, and travel categories. Public and physician awareness of the Open Payments system reports is essential to promote transparency and to minimize adverse effects of financial relationships on patient care.

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.

Industry-Sponsored Research Payments in Neurosurgery-Analysis of the Open Payments Database From 2014 to 2018

BACKGROUND

The Open Payments Database (OPD) started in 2013 to combat financial conflicts of interest between physicians and medical industry.

OBJECTIVE

To evaluate the first 5 yr of the OPD regarding industry-sponsored research funding (ISRF) in neurosurgery.

METHODS

The Open Payments Research Payments dataset was examined from 2014 to 2018 for payments where the clinical primary investigator identified their specialty as neurosurgery.

RESULTS

Between 2014 and 2018, a $106.77 million in ISRF was made to 731 neurosurgeons. Fewer than 11% of neurosurgeons received ISRF yearly. The average received $140 000 in total but the median received $30,000. This was because the highest paid neurosurgeon received $3.56 million. A greater proportion ISRF was made to neurosurgeons affiliated with teaching institutions when compared to other specialties (26.74% vs 20.89%, P = .0021). The proportion of the total value of ISRF distributed to neurosurgery declined from 0.43% of payments to all specialties in 2014 to 0.37% in 2018 (P < .001), but no steady decline was observed from year to year.

CONCLUSION

ISRF to neurosurgeons comprises a small percentage of research payments made to medical research by industry sponsors. Although a greater percentage of payments are made to neurosurgeons in teaching institutions compared to other specialties, the majority is given to neurosurgeons not affiliated with a teaching institution. A significant percentage of ISRF is given to a small percentage of neurosurgeons. There may be opportunities for more neurosurgeons to engage in industry-sponsored research to advance our field as long as full and complete disclosures can always be made.

Telemedicine in cardiac procedures: considerations for a remote future

PURPOSE OF REVIEW

Present a review of relevant literature and suggest a framework for discussion of the considerations affecting the evolution and adoption of Telerobotic Support and Telerobotic Collaboration in the practice of cardiac procedural medicine.

RECENT FINDINGS

Recent medical practice has undergone remarkable transformation in the adoption of telemedicine. This evolution has been accelerated by the COVID-19 (SARS-CoV-2) pandemic and has largely been focused on outpatient medicine. Clinical studies and opinion articles have highlighted benefits including reduced costs, increased patient engagement, and saved time, while also raising concerns regarding privacy, care quality and data security. Early and current efforts implementing remote procedural medicine have not only demonstrated technical success but also highlighted the many issues that must be resolved before acceptance as a major aspect of everyday patient care.

SUMMARY

It is inevitable that remote technologies will play an increasing role in procedural medicine as they have in outpatient clinical medicine. Thoughtful participation by physicians in the evolution of these technologies and their modes of use will be necessary to maximize the benefits to our patients and healthcare systems.

Industry Payments to Orthopedic Spine Surgeons Reported by the Open Payments Database: 2014-2017

STUDY DESIGN

This was a retrospective study of publicly available data.

OBJECTIVE

The objective of this study was to characterize and assess trends in Open Payments Database (OPD) industry payments reported to orthopedic spine surgeons from 2014 to 2017.

SUMMARY OF BACKGROUND DATA

There have been a lack of studies characterizing OPD industry payments to orthopedic spine surgeons over the 4 full years of data available.

MATERIALS AND METHODS

General industry payments made to orthopedic spine surgeons from 2014 to 2017 were characterized by year with analysis of: number of compensated surgeons, median payment per surgeon, top strata of compensated surgeons, and subtype (ie, food/beverage). Research and Ownership Payments were characterized by median payment per surgeon. Mann-Whitney U tests were used to compare payments.

RESULTS

For General Payments, the number of compensated orthopedic spine surgeons increased from 1539 in 2014 to 1673 in 2017. Later year median General Payments per surgeon were compared with the 2014 median ($1051): 2015 ($1070: P=0.375), 2016 ($1263: P=0.012), and 2017 ($978: P=0.561). In 2014, the top 10% of compensated orthopedic spine surgeons received 89% of the total General compensation to orthopedic spine surgeons, top 5% received 79%, and the top 1% received 55%. The median General Payment for these 3 top strata remained similar over the 4 years evaluated (P>0.05). For subtype analyses, the median aggregate General Payment for "education" increased (P=0.002) across the years. Finally, it was determined that the median payment per surgeon for Research and Ownership Payment categories remained stable across the time period (P>0.05).

CONCLUSIONS

Many expected industry payments to surgeons to decrease under public scrutiny of the OPD, but the present study showed no net change in median payment (General, Research, and Ownership) over the years studied. In the age of greater transparency, these findings shed insight into the orthopedic spine surgeon-industry relationship.

LEVEL OF EVIDENCE

Level III.

Dissecting the Financial Relationship Between Industry and Academic Neurosurgery

BACKGROUND

Established by the Centers for Medicare and Medicaid Services (CMS), the Open Payments Database (OPD) has reported industry payments to physicians since August 2013.

OBJECTIVE

To evaluate the frequency, type, and value of payments received by academic neurosurgeons in the United States over a 5-yr period (2014-2018).

METHODS

The OPD was queried for attending neurosurgeons from all neurosurgical training programs in the United States (n = 116). Information from the OPD was analyzed for the entire cohort as well as for comparative subgroup analyses, such as career stage, subspecialty, and geographic location.

RESULTS

Of all identified neurosurgeons, 1509 (95.0%) received some payment from industry between 2014 and 2018 for a total of 106 171 payments totaling $266 407 458.33. A bimodal distribution was observed for payment number and total value: 0 to 9 (n = 438) vs > 50 (n = 563) and 0-$1000 (n = 418) vs >$10 000 (n = 653), respectively. Royalty/License was the most common type of payment overall (59.6%; $158 723 550.57). The median number (40) and value ($8958.95) of payments were highest for mid-career surgeons. The South-Central region received the most money ($117 970 036.39) while New England received the greatest number of payments (29 423). Spine surgeons had the greatest median number (60) and dollar value ($20 551.27) of payments, while pediatric neurosurgeons received the least (8; $1108.29). Male neurosurgeons received a greater number (31) and value ($6395.80) of payments than their female counterparts (11, $1643.72).

CONCLUSION

From 2014 to 2018, payments to academic neurosurgeons have increased in number and value. Dollars received were dependent on geography, career stage, subspecialty and gender.

Characteristics of Reported Industry Payments to Neurosurgeons: A 5-Year Open Payments Database Study

OBJECTIVE

The aim of this study was to characterize the payments made by medical industry to neurosurgeons from 2014 to 2018.

METHODS

A retrospective study was performed from January 1, 2014 to December 31, 2018 of the Open Payments Database. Collected data included the total number of industry payments, the aggregate value of industry payments, and the mean value of each industry payment made to neurosurgeons per year over the 5-year period.

RESULTS

A total of 105,150 unique surgeons, with 13,668 (12.99%) unique neurosurgeons, were identified to have received an industry payment during 2014-2018. Neurosurgeons were the second highest industry-paid surgical specialty, with a total 421,151 industry payments made to neurosurgeons, totaling $477,451,070. The mean average paid amount per surgeon was $34,932 (±$936,942). The largest proportion of payments were related to food and beverage (75.5%), followed by travel and lodging (14.9%), consulting fees (3.5%), nonconsulting service fees (2.1%), and royalties or licensing (1.9%), totaling 90.4% of all industry payments to neurologic surgeons. Summed across the 5-year period, the largest paid source types were royalties and licensing (64.0%; $305,517,489), consulting fees (11.8%; $56,445,950), nonconsulting service fees (7.3%; $34,629,109), current or prospective investments (6.8%, $32,307,959), and travel and lodging (4.8%, $22,982,165).

CONCLUSIONS

Our study shows that over the most recent 5-year period (2014-2018) of the Centers for Medicare and Medicaid Services Open Payments Database, there was a decreasing trend of the total number of payments, but an increasing trend of the total amount paid to neurosurgeons.

A Five-Year Analysis of Industry Payments to Sleep Neurologists From 2014 Through 2018

Background and objectives 

Sleep medicine has been one of the fastest-growing medical fields in recent years. The industry plays a big role in developing new medications and devices for both diagnosis and treatment of sleep-related problems. We analyzed payments made by industry to physicians from 2014 through 2018 based on the Open Payments Program data.

Methods

Centers for Medicare and Medicaid Services Open Payment Program and American Board of Psychiatry and Neurology databases were explored to elicit financial relationships between industry and sleep neurologists.

Results

Payments made by industry to sleep neurologists have been steadily increasing from 2014 through 2018. Approximately 16% to 22% of sleep certified neurologists received payments from industry during the study period. Interestingly, the payments made to the top 10% of the sleep physicians contributed approximately 85% to 96% of the total payments. The top two categories to which the highest payments were made were compensation for services and royalty and/or licensing fees. Silenor® (doxepin), Xyrem® (sodium oxybate), Aptiom® (eslicarbazepine acetate), Belsomra® (suvorexant), and Fycompa® (perampanel) were most of the drugs, which made the highest payments, that got approved by the Food and Drug Administration in the last decade.

Conclusions 

It seems that the industry is spending significant amounts of money in educating the physicians and in marketing the newer drugs. This analysis of the data on payments from industry is very useful in identifying any potential conflicts of interest from physicians. Further analyses are needed to study the trends of physician practice behavior and decision making.

Patents and Innovation Among Neurosurgeons from the American Association of Neurological Surgeons

Objective Neurosurgeons have taken on the role of innovators, continuing to move the field forward over the centuries. More recently, innovation has taken the form of new technological devices and therapeutics, which require patenting. The aim of this study is to identify major areas of innovation in the field of neurosurgery by evaluating patent records. Methods This study quantifies the number of patents the American Association of Neurological Surgeons (AANS) neurosurgeons hold across different subspecialties. The United States Patent and Trademark Office (USPTO) patent database was queried using the names of 7,293 AANS members who filed patents between 1976 and 2019. Results A total of 346 (4.7%) AANS neurosurgeons hold a total of 1,025 patents. The number of patents held by each neurosurgeon ranged from one to 109. The areas that patents were filed under include cellular and genetic science (40), drug delivery (45), image guidance (82), neuromodulation (52), pain (7), peripheral nerve stimulation (24), spine (398), surgical devices (148), trauma (16), tumor (78), vascular (67), and other (68). No patents were filed under pediatrics (0). The fields with the greatest number of filed patents are spine, instruments/devices, and image guidance. Conclusion Given the technical nature of the field of neurosurgery, instruments and devices that improve localization, visualization, targeting, and spinal reconstruction are often in demand. Furthermore, since the rates of spinal procedures and implants continue to increase, higher patenting may be motivated by the opportunity to develop new products that can result in royalty payments to neurosurgeons. The advent of new technologies undoubtedly continues to push the field of neurosurgery forward.

Industry Payments to Pediatric Orthopaedic Surgeons Reported by the Open Payments Database: 2014 to 2017

BACKGROUND

The Open Payments Database (OPD), mandated by the Sunshine Act, is a national registry of physician-industry transactions. Payments are reported as either General, Research, or Ownership payments. The current study aims to investigate trends in OPD General payments reported to pediatric orthopaedic surgeons from 2014 to 2017.

METHODS

General industry payments made to pediatric orthopaedic surgeons (as identified by OPD) were characterized by median payment, payment subtype, and census region. As fewer Research and Ownership payments were made, only payment totals for these categories were determined. General payment data were analyzed for trends using the nonparametric Mann-Whitney U test.

RESULTS

For General payments, there was an increase in the number of compensated pediatric orthopaedists from 2014 to 2017 (324 vs. 429). Of those compensated, there was no significant change in median payment per compensated surgeon ($201 vs. $197; P=0.82). However, a large percentage of total General payment dollars in pediatric orthopaedics were made to the top 5% of compensated pediatric orthopaedists each year (average 71% of total General industry compensation). For this top 5% group, median General payment per compensated surgeon increased from 2014 ($14,624) to 2017 ($32,752) (P=0.006). A significant increase in median subtype aggregate payment per surgeon was observed in the education (P<0.001) and royalty/license (P=0.031) subtypes; a significant decrease was observed for travel/lodging payments (P=0.01). Midwest pediatric orthopaedists received the highest median payment across all years studied. Few payments for research and ownership were made to pediatric orthopaedists. Four-year aggregate payment totals were $18,151 and $3,223,554 for Research and Ownership payments, respectively.

CONCLUSIONS

Many expected payments to surgeons to decrease when put under the public scrutiny of the OPD. Not only was this decrease not observed for General payments to pediatric orthopaedic surgeons during the 2014 to 2017 period, but also the median General payment to the top 5% increased. These findings are important to note in the current era of increased transparency.

LEVEL OF EVIDENCE

Level III.

Association between physician characteristics and payments from industry in 2015-2017: observational study

OBJECTIVE

To investigate the association between physician characteristics and the value of industry payments.

DESIGN

Observational study.

SETTING AND PARTICIPANTS

Using the 2015-2017 Open Payments reports of industry payments linked to the Physician Compare database, we examined the association between physician characteristics (physician sex, years in practice, medical school attended and specialty) and the industry payment value, adjusting for other physician characteristic and institution fixed effects (effectively comparing physicians practicing at the same institution).

MAIN OUTCOME MEASURES

Our primary outcome was the value of total industry payments to physicians including (1) general payments (all forms of payments other than those classified for research purpose, eg, consulting fees, food, beverage), (2) research payments (payments for research endeavours under a written contract or protocol) and (3) ownership interests (eg, stock or stock options, bonds). We also investigated each category of payment separately.

RESULTS

Of 544 264 physicians treating Medicare beneficiaries, a total of $5.8 billion in industry payments were made to 365 801 physicians during 2015-2017. The top 5% of physicians, by cumulative payments, accounted for 91% of industry payments. Within the same institution, male physicians, physicians with 21-30 years in practice and physicians who attended top 50 US medical schools (based on the research ranking) received higher industry payments. Across specialties, orthopaedic surgeons, neurosurgeons and endocrinologists received the highest payments. When we investigated individual types of payment, we found that orthopaedic surgeons received the highest general payments; haematologists/oncologists were the most likely to receive research payments and surgeons were the most likely to receive ownership interests compared with other types of physicians.

CONCLUSIONS

Industry payments to physicians were highly concentrated among a small number of physicians. Male sex, longer length of time in clinical practice, graduated from a top-ranked US medical school and practicing certain specialties, were independently associated with higher industry payments.

Characteristics of Industry Payments to Ophthalmologists in the Open Payments Database

Importance

An increased awareness of the interactions between the medical industry and health care professionals may lead to lower health care costs and more effective health care practices.

Objective

To assess the characteristics of industry payments made to ophthalmologists between 2013 and 2017.

Design, Setting, and Participants

This analysis included data reported in the June 29, 2018, update of the Centers for Medicare & Medicaid Services Open Payments Database (OPD). The OPD contains public records of industry payments made to physicians and teaching hospitals from August 1, 2013, to December 31, 2017, as reported by the medical industry. All general or research payments distributed to US ophthalmologists and contained in the OPD were included in this study. Data are summarized by practitioner, manufacturer, payment category, and geographic location.

Main Outcomes and Measures

Main outcomes were the distribution, quantity, and value of payments made to ophthalmologists practicing in the United States or US territories. The financial characteristics of payment category, manufacturer, product, and location were also assessed.

Results

This analysis revealed that the OPD showed industry reporting a total of 20 943 ophthalmologists receiving 736 517 payments worth $543 679 603.53 (1.67% of all industry-reported funds in the OPD). The median payment value was $22.44. Most payments were for food and beverages (581 588 [78.96%]), whereas most funds were allocated toward research ($310 142 151.88 [57.05%]) and consulting fees ($73 565 327.71 [13.51%]). The median payout to each ophthalmologist was $637.75 (interquartile range, $167.33-$2065.54). California was the highest-grossing state, receiving $101 135 980.34 (18.60%) of all payments. Fifteen companies were responsible for 87.68% of all funds distributed ($476 719 470.11) and were mostly involved in the production of pharmaceutical agents (anti-vascular endothelial growth factor agents, glaucoma eyedrops, and ocular lubricants) and surgical devices (cataract and glaucoma).

Conclusions and Relevance

Although there is no way to know the veracity of these reports, the findings suggest the financial ophthalmologist-industry relationship is substantial. These relationships may be adding to health care costs and affecting the quality of care, although those associations were not evaluated in this study.