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Everhart AO. Time to publication of cost-effectiveness analyses for medical devices. THE AMERICAN JOURNAL OF MANAGED CARE 2023; 29:265-268. [PMID: 37229785 PMCID: PMC10214008 DOI: 10.37765/ajmc.2023.89359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES Academic researchers and physicians have called for greater use of cost-effectiveness analyses in informing treatment and reimbursement decisions. This study examines the availability of cost-effectiveness analyses for medical devices, in terms of both the number of studies and when studies are published. STUDY DESIGN Analysis of the number of years between FDA approval/clearance and publication for cost-effectiveness analyses of medical devices in the United States published between 2002 and 2020 (n = 86). METHODS Cost-effectiveness analyses of medical devices were identified using the Tufts University Cost-Effectiveness Analysis Registry. Studies in which the model and manufacturer of the medical device used in the intervention were identifiable were linked to FDA databases. Years between FDA approval/clearance and publication of cost-effectiveness analyses were calculated. RESULTS A total of 218 cost-effectiveness analyses of medical devices in the United States published between 2002 and 2020 were identified. Of these studies, 86 (39.4%) were linked to FDA databases. Studies examining devices approved via premarket approval were published a mean of 6.0 years after the device received FDA approval (median, 4 years), whereas studies examining devices that were cleared via the 510(k) process were published a mean of 6.5 years after the device received FDA clearance (median, 5 years). CONCLUSIONS There are few studies describing the cost-effectiveness of medical devices. Most of these studies' findings are not published until several years after the studied devices received FDA approval/clearance, meaning that decision makers will likely not have evidence of cost-effectiveness when making initial decisions related to newly available medical devices.
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Affiliation(s)
- Alexander O Everhart
- Harvard-MIT Center for Regulatory Science, Harvard Medical School, Harvard University, 200 Longwood Ave, Armenise Bldg, Room 109, Boston, MA 02115.
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Wachholz PA, Stein AT, Melo DOD, Mello RGBD, Florez ID. Recommendations for the development of Clinical Practice Guidelines. GERIATRICS, GERONTOLOGY AND AGING 2022. [DOI: 10.53886/gga.e0220016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Clinical practice guidelines are statements that include recommendations intended to optimize patient care, are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options, and ensure that the best available clinical knowledge is used to provide effective and quality care. They can reduce inappropriate care and variability in clinical practice and can support the translation of new research knowledge into clinical practice. Recommendations from clinical practice guidelines can support health professionals by facilitating the decision-making process, empowering them to make more informed health care choices, clarifying which interventions should be priorities based on a favorable trade-off, and discouraging the use of those that have proven ineffective, dangerous, or wasteful. This review aims to summarize the key components of high-quality and trustworthy guidelines. Articles were retrieved from various libraries, databases, and search engines using free-text term searches adapted for different databases, and selected according to author discretion. Clinical practice guidelines in geriatrics can have a major impact on prevention, diagnosis, treatment, rehabilitation, health care, and the management of diseases and conditions, but they should only be implemented when they have high-quality, rigorous, and unbiased methodologies that consider older adult priorities and provide valid recommendations.
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Yang Y, Ma Y, Lu J, Zhang Q, Guan K, Liu K, Kang J, Du S, Tang S, Liu X, Zhang A, Schadendorf D, Agarwala SS, Zhang X. Evaluation of the reporting quality of clinical practice guidelines on melanoma using the RIGHT checklist. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1172. [PMID: 34430613 PMCID: PMC8350697 DOI: 10.21037/atm-21-2603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 06/28/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND The International Reporting Items for Practice Guidelines in Healthcare (RIGHT) instrument was launched in 2016 to improve the reporting of clinical practice guidelines (CPGs). We aimed to systematically evaluate the reporting quality of CPGs on melanoma using RIGHT. METHODS We systematically searched electronic databases, guideline databases and medical society websites until November 2020 to identify guidelines for melanoma published since 2018. The reporting quality of included guidelines was assessed by calculating the percentages of the 35 items of the RIGHT checklist that were appropriately reported. We stratified the results by selected characteristics to describe the correlation of these factors with reporting quality. RESULTS A total of 20 guidelines were identified and analyzed. The mean reporting rate was greater than 50% in five of the seven domains of the RIGHT checklist; the remaining two domains (Other information, Review and quality assurance) both had a mean reporting rate of 35.0%. The mean overall reporting rate was 63.7%. No CPG considered equity, feasibility or acceptability of the recommendations (item 14c), and only one CPG described the role of funders (item 18b). Guidelines that reported funding or were published in higher-impact journals tended to have a higher reporting quality, whereas the reporting rate in the one included Chinese-language CPG was low. CONCLUSIONS Reporting quality of melanoma CPGs tends to be relatively good. The CPGs developed in China were however an exception. The use of the 2016 RIGHT tool in guideline development should be encouraged to support rigorous and transparent reporting.
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Affiliation(s)
- Yongjie Yang
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Yanfang Ma
- School of Chinese Medicine of Hong Kong Baptist University, Hong Kong, China
| | - Jingli Lu
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Qiwen Zhang
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Kelei Guan
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Kefeng Liu
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Jian Kang
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Shuzhang Du
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Shu Tang
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Xuehui Liu
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Ailing Zhang
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital Duisburg-Essen, Essen, Germany
| | | | - Xiaojian Zhang
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, China
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Flemming J, Chojecki D, Tjosvold L, Paulden M, Armijo-Olivo S. Quality of reporting of economic evaluations in rehabilitation research: a systematic review. Disabil Rehabil 2020; 44:2233-2240. [PMID: 33126829 DOI: 10.1080/09638288.2020.1830441] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The quality of reporting of health economic evaluations for rehabilitation services has been questioned, limiting the ability to provide accurate recommendations for health decisions. PURPOSE To document current overall reporting quality of the published literature for economic evaluations of rehabilitation services using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), and to identify factors that could influence the quality of reporting. DATA SOURCES Electronic literature searches were performed using MEDLINE and the NHS Economic Evaluations Database via the Cochrane Library. STUDY SELECTION Prospective rehabilitation economic evaluation articles from 2013 to 2020 were selected. DATA EXTRACTION Data were extracted by one reviewer and independently verified by a second reviewer. DATA SYNTHESIS/RESULTS Title and abstracts of 3,454 papers were reviewed. 204 papers were selected for a full text screening. From those, 129 potential papers were identified to be included in this study. LIMITATIONS Only two databases were used in data collection, and papers were selected from 2013 to 2020 only. CONCLUSIONS Inconsistent reporting in health economic evaluations of rehabilitation services has continued, despite the availability of the CHEERS checklist. The methods of the analyzed studies were frequently under-reported, thereby creating challenges in determining whether the results reported were valid.IMPLICATIONS FOR REHABILITATIONVariable quality of reporting has been identified in rehabilitation research assessing cost-effectiveness.To grow as an area of expertise, the field of rehabilitation must produce research demonstrating its cost-effectiveness.Both rehabilitation clinicians and funders would benefit from full and transparent information to identify optimal solutions for effective and efficient care.
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Affiliation(s)
- Julie Flemming
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Dagmara Chojecki
- Institute of Health Economics (IHE), Edmonton, AB, Canada.,University of Alberta, Edmonton, AB, Canada
| | - Lisa Tjosvold
- Institute of Health Economics (IHE), Edmonton, AB, Canada.,University of Alberta, Edmonton, AB, Canada
| | - Mike Paulden
- School of Public Health, University of Alberta, Edmonton Clinic Health Academy, Edmonton, AB, Canada
| | - Susan Armijo-Olivo
- Faculty of Business and Social Sciences, University of Applied Sciences, Osnabrück, Germany.,Faculty of Rehabilitation Medicine, Corbett Hall, Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada.,Institute of Health Economics, Edmonton, AB, Canada
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Voigt C, Silbert S, Widen RH, Marturano JE, Lowery TJ, Ashcraft D, Pankey G. The T2Bacteria Assay Is a Sensitive and Rapid Detector of Bacteremia That Can Be Initiated in the Emergency Department and Has Potential to Favorably Influence Subsequent Therapy. J Emerg Med 2020; 58:785-796. [DOI: 10.1016/j.jemermed.2019.11.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 10/01/2019] [Accepted: 11/23/2019] [Indexed: 11/25/2022]
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Most guideline organizations lack explicit guidance in how to incorporate cost considerations. J Clin Epidemiol 2019; 116:72-83. [DOI: 10.1016/j.jclinepi.2019.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 07/26/2019] [Accepted: 08/14/2019] [Indexed: 11/21/2022]
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Kovacs E, Wang X, Strobl R, Grill E. Economic evaluation of guideline implementation in primary care: a systematic review. Int J Qual Health Care 2019; 32:1-11. [DOI: 10.1093/intqhc/mzz059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 04/29/2019] [Accepted: 07/01/2019] [Indexed: 12/15/2022] Open
Abstract
Abstract
Purpose
To review the economic evaluation of the guideline implementation in primary care.
Data sources
Medline and Embase.
Study selection
Electronic search was conducted on April 1, 2019, focusing on studies published in the previous ten years in developed countries about guidelines of non-communicable diseases of adult (≥18 years) population, the interventions targeting the primary care provider. Data extraction was performed by two independent researchers using a Microsoft Access based form.
Results of data synthesis
Among the 1338 studies assessed by title or abstract, 212 qualified for full text reading. From the final 39 clinically eligible studies, 14 reported economic evaluation. Cost consequences analysis, presented in four studies, provided limited information. Cost-benefit analysis was reported in five studies. Patient mediated intervention, and outreach visit applied in two studies showed no saving. Audit resulted significant savings in lipid lowering medication. Audit plus financial intervention was estimated to reduce referrals into secondary care. Analysis of incremental cost-effectiveness ratios was applied in four studies. Educational meeting evaluated in a simulated practice was cost-effective. Educational meeting extended with motivational interview showed no improvement; likewise two studies of multifaceted intervention. Cost-utility analysis of educational meeting supported with other educational materials showed unfavourable outcome.
Conclusion
Only a minor proportion of studies reporting clinical effectiveness of guideline implementation interventions included any type of economic evaluation. Rigorous and standardized cost-effectiveness analysis would be required, supporting decision-making between simple and multifaceted interventions through comparability.
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Affiliation(s)
- Eva Kovacs
- Institute for Medical Information Processing, Biometrics and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
- German Center for Vertigo and Balance Disorders, Faculty of Medicine, University Hospital, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
| | - Xiaoting Wang
- Institute for Medical Information Processing, Biometrics and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
| | - Ralf Strobl
- Institute for Medical Information Processing, Biometrics and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
| | - Eva Grill
- Institute for Medical Information Processing, Biometrics and Epidemiology, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
- German Center for Vertigo and Balance Disorders, Faculty of Medicine, University Hospital, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
- Munich Center of Health Sciences, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany
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Pliakos EE, Andreatos N, Tansarli GS, Ziakas PD, Mylonakis E. The Cost-Effectiveness of Corticosteroids for the Treatment of Community-Acquired Pneumonia. Chest 2018; 155:787-794. [PMID: 30448195 DOI: 10.1016/j.chest.2018.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/12/2018] [Accepted: 11/05/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The use of corticosteroids as adjunct treatment for community-acquired pneumonia (CAP) is associated with potential clinical benefits. The aim of this study was to evaluate the cost-effectiveness of this approach. METHODS We constructed a decision-analytic model comparing the use of corticosteroids + antibiotics with that of placebo + antibiotics for the treatment of CAP. Cost-effectiveness was determined by calculating deaths averted and incremental cost-effectiveness ratios. Uncertainty was addressed by plotting cost-effectiveness planes and acceptability curves for various willingness-to-pay thresholds. RESULTS In the base-case analysis, corticosteroids + antibiotics resulted in savings of $142,795 per death averted. In the probabilistic analysis, at a willingness to pay of $50,000, corticosteroids + antibiotics had a 86.4% chance of being cost-effective compared with placebo + antibiotics. In cost-effectiveness acceptability curves, the corticosteroids + antibiotics strategy was cost-effective in 87.6% to 94.3% of simulations compared with the placebo + antibiotics strategy for a willingness to pay ranging from $0 to $50,000. In patients with severe CAP (Pneumonia Severity Index classes IV/V) the corticosteroids + antibiotics strategy resulted in savings of $70,587 and had a 82.6% chance of being cost-effective compared with the placebo + antibiotics strategy. CONCLUSIONS The use of corticosteroids + antibiotics is a cost-effective strategy and results in considerable health care cost-savings, especially among patients with severe CAP (Pneumonia Severity Index classes IV/V).
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Affiliation(s)
- Elina Eleftheria Pliakos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Nikolaos Andreatos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Giannoula S Tansarli
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Panayiotis D Ziakas
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI.
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Manquen J, Combs T, Mazur-Mosiewicz A, Sanders D, Schiesel M, Gordon J, Farabough M, Vassar M. A review of research efforts to address the 2008 ACEP guideline for mild traumatic brain injury. Am J Emerg Med 2018; 37:73-79. [PMID: 29776825 DOI: 10.1016/j.ajem.2018.04.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/25/2018] [Accepted: 04/26/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND The objective of this study was to evaluate the temporal relationship between clinical practice guideline development and subsequent research performed, with the goal of providing more data on areas of sparse evidence that serve to underlie guideline recommendations. We aimed to assess the quality of current research efforts to address the American College of Emergency Physicians guideline and to provide suggestions for future research of mild traumatic brain injury. METHODS We identified clinical practice guideline recommendations with low levels of underlying evidence and searched ClinicalTrials.gov and the World Health Organization's International Clinical Trial Registry Portal to determine whether subsequent research has reflected an effort to address guideline recommendations. RESULTS Few currently registered clinical trials attempt to focus on clinical practice guideline recommendations where the basis of evidence is weak, and even fewer might benefit future iterations of the guideline due to multiple problems in study design and reporting. CONCLUSIONS The amount of research dedicated to investigation of mild traumatic brain injury continues to be sparse and of poor quality. Study results should always be posted, even if the null hypothesis is confirmed. Efforts to improve the evidence base of a guideline should be realized by designing studies that directly assess and speak to the questions posed by guideline authors.
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Affiliation(s)
- Jack Manquen
- Oklahoma State University Center for Health Sciences, College of Osteopathic Medicine, 1111 West 17th Street, Tulsa, OK 74107, United States.
| | - Tyler Combs
- Oklahoma State University Center for Health Sciences, College of Osteopathic Medicine, 1111 West 17th Street, Tulsa, OK 74107, United States.
| | - Anya Mazur-Mosiewicz
- Oklahoma State University Center for Health Sciences, Department of Behavioral Sciences, 1111 West 17th Street, Tulsa, OK 74107, United States.
| | - Donald Sanders
- Oklahoma State University Medical Center, Department of Emergency Medicine, 744 W 9th St., Tulsa, OK 74127, United States.
| | - Michael Schiesel
- Oklahoma State University Medical Center, Department of Emergency Medicine, 744 W 9th St., Tulsa, OK 74127, United States.
| | - Joshua Gordon
- Oklahoma University Medical Center, Department of Anesthesiology, 700 NE 13th St., Oklahoma City, OK 73104, United States.
| | - Michelle Farabough
- Oklahoma State University Center for Health Sciences, 1111 West 17th Street, Tulsa, OK 74107, United States.
| | - Matt Vassar
- Oklahoma State University Center for Health Sciences, Department of Behavioral Sciences, 1111 West 17th Street, Tulsa, OK 74107, United States.
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Andreatos N, Zacharioudakis IM, Zervou FN, Muhammed M, Mylonakis E. Discrepancy between financial disclosures of authors of clinical practice guidelines and reports by industry. Medicine (Baltimore) 2017; 96:e5711. [PMID: 28079800 PMCID: PMC5266162 DOI: 10.1097/md.0000000000005711] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
There is a substantial effort to increase the accuracy of conflicts of interest (COI) reporting, and reduce the influence of COI between physicians and industry, especially as it relates to clinical practice guidelines.We used the newly implemented Open Payments dataset to evaluate the accuracy of COI disclosures of authors of clinical practice guidelines that were either newly published or revised within 2014 and were included in the National Guideline Clearinghouse (NGC) website (maintained by the U.S. Department of Health and Human Services). Authors were considered as having inaccurate COI disclosure if they had not reported all companies from which they had received funds >$5000 in the 12 months preceding the guideline's publication.We identified 223 guidelines that were either newly published (109/223; 48.9%) or revised (114/223; 51.1%) within 2014 and were included in the NGC website. Among the 1329 guideline authors with available Open Payments data, 523 received >$5000 from at least 1 healthcare-associated entity. However, only 56 out of the 523 authors (10.7%) were found to have accurate COI disclosure. The percentage of authors with accurate COI disclosure in revised guidelines was significantly lower than in newly published guidelines (6.8% vs 14.3%; P < 0.01) and was also found to differ between specialties. Furthermore, authors were less likely to inaccurately disclose "research payments" (37/49, 75.5%) compared to "general payments" (488/559, 87.3%, P = 0.02) as well as "other/associated research funding" (430/506, 85.0%, P = 0.08). No statistically significant association was detected between funding amount and disclosure accuracy.The majority of guideline authors lacked significant COIs, but among authors that received significant funds from at least 1 healthcare-associated entity the frequency of accurate disclosure was low. These findings indicate that the current process of disclosing COIs may be suboptimal and a proactive approach should be adopted in order to minimize COI reporting discrepancies. Furthermore, every effort should be undertaken to ensure the completeness and accuracy of the data recorded in the Open Payments database.
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Affiliation(s)
- Nikolaos Andreatos
- Division of Infectious Disease, Rhode Island Hospital
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ioannis M. Zacharioudakis
- Division of Infectious Disease, Rhode Island Hospital
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Fainareti N. Zervou
- Division of Infectious Disease, Rhode Island Hospital
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Maged Muhammed
- Division of Infectious Disease, Rhode Island Hospital
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Eleftherios Mylonakis
- Division of Infectious Disease, Rhode Island Hospital
- Warren Alpert Medical School of Brown University, Providence, RI, USA
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