Effect of financial relationships on the behaviors of health care professionals: a review of the evidence

Assessing oncology providers attitudes and practices toward nonformulary drugs and mapping current obstacles in Saudi Arabia

Introduction

Formulary drug list is a continually updated list of medications routinely stocked by hospitals and other healthcare facilities and deemed effective, safe, and cost saving. Non-formulary drug (NFD) refers to medications not on the formulary, due to cost or lack of clinical data. This study aimed to examine the processing of NFD requests by oncology providers (OPs) in Saudi Arabia.

Method

A cross-sectional survey in Saudi oncology centers gathered perspectives of healthcare practitioners, mainly oncology pharmacists and physicians, on NFDs and request processes, aiming to understand variations, reasons for NFDs, and suggestions for an improved, unified NFDs request algorithm.

Result

A total of 93 physicians and pharmacists responded, 57 % were pharmacists, 43 % were physicians, and 94.6 % worked in the governmental sector. Around 31.2 % reported that it takes one week to receive a decision on their NFD request, while 28 % reported it takes two weeks to one month. Furthermore, 35.5 % of participants reported that the complete NFD process, from the initial order placement to the receipt of medications, spans a duration of 2-4 months, while 8.6 % noted a longer duration exceeding six months. The participants reported that the most common obstacles while requesting NFD were procurement delays and lengthy processing times. Additionally, 26.9 % agreed that formulary restrictions hindered medical care and 40.3 % reported delays in patient care. While 33.8 % were forced to use fewer effective options, and 22.1 % referred patients to palliative care.

Conclusion

The current practice of NFDs has negative consequences on cancer patient outcomes due to delays in patient care or the use of less effective drugs. Thus, we recommend having a national NFD access program.

Clinical evaluation of marketed and non-marketed orthodontic products: are researchers now ahead of the times? A meta-epidemiological study

BACKGROUND

The advertisement and adoption of untested orthodontic products is common. This study aimed to provide an update regarding the prevalence of clinical trials in orthodontics evaluating commercially marketed products. Associations between marketed/non-marketed products and study characteristics such as direction of effect, declaration of conflict of interest and industry sponsorship were evaluated. In addition, within the marketed products associations between direction of effect and study characteristics were explored.

MATERIAL AND METHODS

Electronic searching of a single database (Medline via PubMed) was undertaken to identify Randomized controlled trials (RCTs) published over a 5-year period (1st January 2017 to 31st December 2021). Descriptive statistics and associations between trial characteristics were explored.

RESULTS

196 RCTs were analysed. RCTs were frequently published in Angle Orthodontist (18.4%), American Journal of Orthodontics and Dentofacial Orthopedics (14.8%) and European Journal of Orthodontics (13.3%). 65.3% (128/196) of trials assessed marketed products after their introduction. The majority of trials assessed interventions to improve treatment efficiency (33.7%). Growth modification appliances were typically analysed in non-marketed compared to marketed products. An association between the type of product (marketed vs non-marketed) and both the declaration of conflict of interest and industry sponsorship was detected. For individual RCTs assessing marketed products either a positive effect (45.3%) or equivalence between interventions or between intervention and untreated control (47.7%) was evident. In 27% of these trials either no conflict of interest or industry funding was not clearly declared. Within the marketed products, no association between the direction of the effect and conflict of interest or funding was detected.

CONCLUSIONS

The analysis of marketed orthodontic products after their introduction is still common practice. To reduce research waste, collaboration prior to the licensing and marketing of orthodontic products between researchers, industry and manufacturers is recommended.

Health Care Clinicians and Product Promotion by Industry

Medical pharmaceutical and device manufacturers are essential in making products that benefit patients, and collaboration between health care clinicians and the industry is necessary for the design and manufacture of these medical products. However, health care clinicians must recognize that their duties and the interests of the industry may at times diverge. Relationships with the industry, even seemingly minor ones, have the potential to shape the decisions made on behalf of patients. The marketing divisions of pharmaceutical and medical device firms view health care clinicians as targets of their efforts, and some of the interactions that occur between the industry and health care clinicians have the potential to alter decision making in ways that may not necessarily benefit patients. Health care clinicians have an ethical duty to recognize situations and marketing strategies that are designed to influence their choice of diagnostic and therapeutic options for their patients. At a minimum, health care clinicians should be aware of the techniques used to attempt to alter their behavior and guard against them.

Health Care Clinicians and Product Promotion by Industry

Medical pharmaceutical and device manufacturers are essential in making products that benefit patients, and collaboration between health care providers and industry is necessary in the design, testing, and manufacture of these medical products. However, health care providers must recognize that their duties and the interests of industry may, at times, diverge. Relationships with industry, even seemingly minor ones, have the potential to shape the decisions made on behalf of patients. The marketing divisions of pharmaceutical and medical device firms view health care providers as a target of their efforts, and some of the interactions that occur between industry and health care providers have the potential to alter decision making in ways that may not necessarily benefit patients. Health care providers have an ethical duty to recognize situations and marketing strategies that are designed to influence their choice of diagnostic and therapeutic options for their patients. Health care providers should be aware of the techniques used to attempt to alter their behavior and guard against them.

A Guide to Industry Payments and an Algorithm for Their Management

BACKGROUND

The Open Payments database was created to increase transparency of industry payment relationships within medicine. The current literature often examines only 1 year of the database. In this study, the authors use 5 years of data to show trends among industry payments to plastic surgeons from 2014 to 2018. In addition, the authors lay out the basics of conflict-of-interest reporting for the new plastic surgeon. Finally, the authors suggest an algorithm for the responsible management of industry relationships.

METHODS

This study analyzed nonresearch payments made to plastic surgeons from January 1, 2014, to December 31, 2018. Descriptive statistics were calculated using R Statistical Software and visualized using Tableau.

RESULTS

A total of 304,663 payments totaling $140,889,747 were made to 8148 plastic surgeons; 41 percent ($58.28 million) was paid to 50 plastic surgeons in the form of royalty or license payments. With royalties excluded, average and median payments were $276 and $25. The average yearly total per physician was $2028. Of the 14 payment categories, 95 percent of the total amount paid was attributable payments in one of six categories. Seven hundred thirty companies reported payments to plastic surgeons from 2014 to 2018; 15 companies (2 percent) were responsible for 80 percent ($66.34 million) of the total sum paid. Allergan was responsible for $24.45 million (29.6 percent) of this amount.

CONCLUSIONS

Although discussions on the proper management of industry relationships continue to evolve, the data in this study illustrate the importance of managing industry relationships. The simple guidelines suggested create a basis for managing industry relationships in the career of the everyday plastic surgeon.

Mapping conflict of interests: scoping review

OBJECTIVE

To identify all known ties between the medical product industry and the healthcare ecosystem.

DESIGN

Scoping review.

METHODS

From initial literature searches and expert input, a map was created to show the network of medical product industry ties across parties and activities in the healthcare ecosystem. Through a scoping review, the ties were then verified, cataloged, and characterized, with data abstracted on types of industry ties (financial, non-financial), applicable policies for conflict of interests, and publicly available data sources.

MAIN OUTCOME MEASURES

Presence and types of medical product industry ties to activities and parties, presence of policies for conflict of interests, and publicly available data.

RESULTS

A map derived through synthesis of 538 articles from 37 countries shows an extensive network of medical product industry ties to activities and parties in the healthcare ecosystem. Key activities include research, healthcare education, guideline development, formulary selection, and clinical care. Parties include non-profit entities, the healthcare profession, the market supply chain, and government. The medical product industry has direct ties to all parties and some activities through multiple pathways; direct ties extend through interrelationships among parties and activities. The most frequently identified parties were within the healthcare profession, with individual professionals described in 422 (78%) of the included studies. More than half (303, 56%) of the publications documented medical product industry ties to research, with clinical care (156, 29%), health professional education (145, 27%), guideline development (33, 6%), and formulary selection (8, 1%) appearing less often. Policies for conflict of interests exist for some financial and a few non-financial ties; publicly available data sources seldom describe or quantify these ties.

CONCLUSIONS

An extensive network of medical product industry ties to activities and parties exists in the healthcare ecosystem. Policies for conflict of interests and publicly available data are lacking, suggesting that enhanced oversight and transparency are needed to protect patient care from commercial influence and to ensure public trust.

Study of the Correlation Between the Ratio of Diastolic to Systolic Durations and Echocardiography Measurements and Its Application to the Classification of Heart Failure Phenotypes

Background

This study aimed to investigate the correlation between the ratio of diastolic to systolic durations (D/S) and echocardiographic parameters of patients with chronic heart failure (CHF) and evaluate whether the D/S can be used as a supplementary biomarker for the classification of heart failure (HF) phenotypes.

Methods

In total, 122 CHF patients with a left ventricular ejection fraction (LVEF) <40%, 40%≤LVEF<50%, or ≥50% were categorized as having HF with a reduced ejection fraction (HFrEF) (N=32), HF with a mid-range ejection fraction (HFmrEF) (N=21) or HF with a preserved ejection fraction (HFpEF) (N=69), respectively. All patients underwent echocardiography for assessment of nineteen structural and functional echocardiographic parameters and digital phonocardiography for the measurement of D/S. Spearman correlation was used to analyse the associations between the D/S and echocardiographic parameters. Multivariate logistic regression analysis was performed to examine the associations between the D/S and HF phenotypes, and receiver operating characteristic (ROC) curve analysis was employed to evaluate the predictive value of the D/S in the classification of HF phenotypes.

Results

The D/S values of patients with HFrEF, HFmrEF and HFpEF were 1.32±0.06, 1.44±0.11 and 1.54±0.08, respectively, which were significantly different (All P<0.05). A close correlation between the D/S and LVEF was found (r=0.777, P<0.001). The multivariate analysis indicated that the D/S was an independent risk factor for CHF phenotypes (OR=4.927, 95% CI 2.532-9.587; P<0.001). The area under the ROC curve for distinguishing between HFmrEF and HFpEF using the D/S was 0.764 (95% CI 0.707-0.845; P < 0.001) and that for distinguishing between HFmrEF and HFrEF using the D/S was 0.821 (95% CI 0.755-0.882; P < 0.001).

Conclusion

The D/S was significantly associated with LVEF, and as LVEF decreased, the D/S tended to decrease, which could also serve as a noninvasive supplementary indicator for detecting systolic and diastolic dysfunction.

Conflict of interest disclosure in orthopaedic and general surgical trauma literature

SIGNIFICANCE

Financial relationships between industry and physicians are a key aspect for the advancement of surgical practice and training, but these relationships also result in a conflict of interest with respect to research. Financial payments to physicians are public within the United States in the Open Payments Database, but the rate of accurate financial disclosure of payments has not previously been studied in trauma surgery publications.

OBJECTIVE

To determine the rate of accurate financial disclosure in major surgical trauma journals compared with the Open Payments Database.

MATERIALS AND METHODS

The names of all authors publishing in The Journal of Orthopaedic Trauma, Injury, and The Journal of Trauma and Acute Care Surgery between 2015 and 2018 were obtained from MEDLINE. Non-physicians, physicians outside of the United States, physicians without payments in the Open Payments Database, and physicians with payments types of only "Food and Drink" were excluded. Financial disclosure statements were obtained from the journal websites and manually compared against Open Payments Database entries the year prior to submission and during the year of submission up until 3 months prior to publication for each individual physician. Main outcomes were accuracy of disclosure published with each article, total amount of payments received (disclosure or undisclosed), surgical subspecialty of the reporting physician. Statistical comparisons were made using Chi-square testing with significance defined as p<0.05.

RESULTS

Between 2015 and 2018, 5070 articles were published involving 28,948 authors. 2945 authors met inclusion criteria. 490 authors accurately disclosed their financial relationships with industry (16.6%). The median value of undisclosed payments was $22,140 [IQR $6465, $77,221] which was significantly less than the medial value of disclosed payment of $66,433 [IQR $24,624, $161,886], p<0.001 Orthopaedic surgeons disclosed at a higher rate (26.3%, 479/1818) than general surgeons (4.8%, 47/971), p<0.001.

CONCLUSIONS

Physician-industry relationships are key for advancing surgical practice and providing training to physicians. These relationships are not inherently unethical, but there is consistently high inaccuracy of financial disclosure across multiple trauma surgery journals which may indicate the need for further education on financial disclosures during surgical training or active obtainment of publicly available financial disclosures by journals.

Assessment of Self-Reported Financial Conflicts of Interest in Vascular Surgery Studies

INTRODUCTION

With increased collaboration between surgeons and industry, there has been a push towards improving transparency of conflicts of interest (COI). This study aims to determine the accuracy of reporting of COIs among studies in major vascular surgery journals.

METHODS

A literature search identified all comparative studies published from January 2018 - December 2018 from three major United States vascular surgery journals (Journal of Vascular Surgery, Vascular and Endovascular Surgery, and Annals of Vascular Surgery). Industry payments were collected using the Centers for Medicare & Medicaid Services (CMS) Open Payments database. COI discrepancies were identified by comparing author declaration statements with payments found for the year of publication and year prior.

RESULTS

A total of 239 studies (1642 authors) were identified. Two hundred twenty-one studies (92%) and 669 authors (63%) received undisclosed payments when utilizing a cut-off payment amount of $250. In 2018, 10,778 payments (totaling $22,174,578) were made by 145 companies. Food and beverage payments were the most commonly reported transaction (42%), but accounted for only 3% of total reported monetary values. Authors who accurately disclosed payments received significantly higher median general payments compared to authors who did not accurately disclose payments ($56,581 [IQR: $2441 - $100,551] vs $2,361 [IQR: $525 - $9,699], p < .001). When stratifying by dollar-amount discrepancy, the proportions of authors receiving undisclosed payments decreased with increasing payment thresholds. Multivariate analysis demonstrated that first and senior authors were both significantly more likely to have undisclosed payments (OR 2.0, 95% CI 1.1-3.6 and OR 2.9, 95% CI 1.6-5.2, respectively).

CONCLUSIONS

There is a significant discordance between self-reported COI in vascular surgery studies compared to payments received in the CMS Open Payments database. This study highlights the need for increased efforts to both improve definitions of what constitutes a relevant COI and encourage a standardized reporting process for vascular surgery studies.

Industry payments and physicians prescriptions: Effect of a payment restriction policy

The pharmaceutical industry spends billions of dollars every year for marketing its products to US health care providers. This study investigates the association between industry marketing payments and physicians' prescription in New York and Massachusetts, and examines the effect of the Massachusetts payment restriction policy on this association in comparison with the New York State that has no payment restriction policy. Three panel data models (fixed effects regression (FE), first difference regression (FD), and first difference with lagged independent variable (LFD)) were used to establish the association accounting for unobserved confounders and reverse causality. The main indicator is the total amount of industry payments for meals, drug samples, consulting fees, etc. (excluding research funding, and ownership). Dependent variables are a) yearly days' supply of Medicare Part D prescriptions, b) yearly costs of prescribed prescriptions. Secular time trends, as well as differences between the two states were controlled in all models. All three panel models showed significant positive association between industry payments and physician prescriptions. Particularly, these models show that in the base year (2014), a 1% increase in the annual industry payments was associated with (0.01%-0.04%) increase in days' supply of medication, and (0.01%-0.05%) increase in prescription costs for NYS providers. Moreover, FE and FD models show that compared to NYS physicians, the association of industry payments with days' supply and costs of Medicare Part D prescriptions was (0.01%-0.02%) smaller for MA physicians. Because of the smaller sample size and lower power, the LFD model did not detect a significant difference between the NYS and MA providers. The findings of this study provide additional evidence that industry payments are associated with increases in the volume and cost of Medicare prescriptions. Moreover, these findings provide preliminary evidence that payment restriction policies negatively moderate this association, which calls for further research.

Industry Payments by Allergan, Inc to Plastic Surgery and Related Specialties in 2018

In 2014, payments to medical providers from drug/device manufacturers were made public through the Open Payments Database. Although previous studies have used the Open Payments Database to describe relationships between specialties and industry, few have evaluated specific companies and the effect of their contributions. As a large contributor to industry payments in plastic surgery, Allergan, Inc represents a significant source of potential financial conflicts of interest in the field. In this study, we aimed to describe the quantity, type, and specific products associated with Allergan's payments to both plastic surgeons and physicians of other specialties. In 2018, Allergan paid a total of $48,484,163 in 397,225 payments to 90,386 physicians. Psychiatry and neurology received $11,867,861 in payments, the largest of any specialty, whereas internal medicine received the largest number of individual payments. Plastic surgeons made the most per physician ($3025). Most payments made to plastic surgeons were categorized as "gifts." Payments made in relation to Botox were predominantly made to neurologists, whereas most payments attributed to Natrelle breast implants were made to plastic surgeons (74.4%). Surprisingly, 18.2% of Natrelle payments were made to family medicine physicians. Further study is needed to fully understand the implications of the financial contributions revealed in this study.

Prognostic Gene Expression Profiling in Cutaneous Melanoma: Identifying the Knowledge Gaps and Assessing the Clinical Benefit

Importance

Use of prognostic gene expression profile (GEP) testing in cutaneous melanoma (CM) is rising despite a lack of endorsement as standard of care.

Objective

To develop guidelines within the national Melanoma Prevention Working Group (MPWG) on integration of GEP testing into the management of patients with CM, including (1) review of published data using GEP tests, (2) definition of acceptable performance criteria, (3) current recommendations for use of GEP testing in clinical practice, and (4) considerations for future studies.

Evidence Review

The MPWG members and other international melanoma specialists participated in 2 online surveys and then convened a summit meeting. Published data and meeting abstracts from 2015 to 2019 were reviewed.

Findings

The MPWG members are optimistic about the future use of prognostic GEP testing to improve risk stratification and enhance clinical decision-making but acknowledge that current utility is limited by test performance in patients with stage I disease. Published studies of GEP testing have not evaluated results in the context of all relevant clinicopathologic factors or as predictors of regional nodal metastasis to replace sentinel lymph node biopsy (SLNB). The performance of GEP tests has generally been reported for small groups of patients representing particular tumor stages or in aggregate form, such that stage-specific performance cannot be ascertained, and without survival outcomes compared with data from the American Joint Committee on Cancer 8th edition melanoma staging system international database. There are significant challenges to performing clinical trials incorporating GEP testing with SLNB and adjuvant therapy. The MPWG members favor conducting retrospective studies that evaluate multiple GEP testing platforms on fully annotated archived samples before embarking on costly prospective studies and recommend avoiding routine use of GEP testing to direct patient management until prospective studies support their clinical utility.

Conclusions and Relevance

More evidence is needed to support using GEP testing to inform recommendations regarding SLNB, intensity of follow-up or imaging surveillance, and postoperative adjuvant therapy. The MPWG recommends further research to assess the validity and clinical applicability of existing and emerging GEP tests. Decisions on performing GEP testing and patient management based on these results should only be made in the context of discussion of testing limitations with the patient or within a multidisciplinary group.

Does the "Morning Morality Effect" Apply to Prehospital Anaesthesiologists? An Investigation into Diurnal Changes in Ethical Behaviour

The “morning morality effect”—the alleged phenomenon that people are more likely to act in unethical ways in the afternoon when they are tired and have less self-control than in the morning—may well be expected to influence prehospital anaesthesiologist manning mobile emergency care units (MECUs). The working conditions of these units routinely entail fatigue, hunger, sleep deprivation and other physical or emotional conditions that might make prehospital units predisposed to exhibit the “morning morality effect”. We investigated whether this is in fact the case by looking at the distribution of patient transports to hospital with and without physician escort late at night at the end of the shift as a surrogate marker for changing thresholds in ethical behaviour. All missions over a period of 11 years in the MECU in Odense were reviewed. Physician-escorted transports to hospital were compared with non-physician-escorted transports during daytime, evening, and night-time (which correlates with time on the 24 h shifts). In total, 26,883 patients were transported to hospital following treatment by the MECU. Of these, 27.4% (26.9%–27.9%) were escorted to the hospital. The ratio of patient transports to hospital with and without physician escort during the three periods of the day did not differ (p = 1.00). We found no evidence of changes in admission patterns over the day. Thus, no evidence of the expected “morning morality effect” could be found in a prehospital physician-manned emergency care unit.

Medical, pharmacy and nursing students in the Baltic countries: interactions with the pharmaceutical and medical device industries

BACKGROUND

Interactions between pharmaceutical and medical device industries and students can lead to commercial influences on educational messages, with a potential to bias future treatment choice. This is the first study in the Baltic countries describing exposure and attitudes of medical, pharmacy and nursing students towards cooperation with industry.

METHODS

A cross-sectional on-line survey of current medical, pharmacy and nursing students (n = 918) in three Baltic countries was carried out.

RESULTS

We found that most students participate in events organized or sponsored by industry and accept a range of gifts and benefits. Students in the Baltic countries consider cooperation with industry important; at the same time, most do not feel that they have sufficient training on how to ethically interact with pharmaceutical and medical device companies and believe that these interactions can influence their prescribing or dispensing patterns. There is a tendency to rationalize cooperation with industry by referring to the current economic situation and patient benefits. Pharmacy students have higher rates of participation and they accept gifts and other benefits more often than nursing or medical students; therefore, they are likely to be more vulnerable to potential industry influence.

CONCLUSIONS

The findings highlight the need to include topics on ethics and conflicts of interests in cooperation with industry in curriculum of health care students in Baltic countries. Without proper training, students continue to be at risk to industry influence and may develop habits for their further practice differing from evidence-based practice in prescribing and dispensing of medicines, as well as use of medical devices.

Association Between Reimbursement Incentives and Physician Practice in Oncology: A Systematic Review

Importance

Significant controversy exists regarding whether physicians factor personal financial considerations into their clinical decision making. Within oncology, several reimbursement policies may incentivize physicians to increase health care use.

Objective

To evaluate whether the financial incentives presented by oncology reimbursement policies affect physician practice patterns.

Evidence Review

Studies evaluating an association between reimbursement incentives and changes in reimbursement policy on oncology care delivery were reviewed. Articles were identified systematically by searching PubMed/MEDLINE, Web of Science, Proquest Health Management, Econlit, and Business Source Premier. English-language articles focused on the US health care system that made empirical estimates of the association between a measurement of physician reimbursement/compensation and a measurement of delivery of cancer treatment services were included. The Risk of Bias in Non-Randomized Studies of Interventions tool was used to assess risk of bias. There were no date restrictions on the publications, and literature searches were finalized on February 14, 2018.

Findings

Eighteen studies were included. All were observational cohort studies, and most had a moderate risk of bias. Heterogeneity of reimbursement policies and outcomes precluded meta-analysis; therefore, a qualitative synthesis was performed. Most studies (15 of 18 [83%]) reported an association between reimbursement and care delivery consistent with physician responsiveness to financial incentives, although such an association was not identified in all studies. Findings consistently suggested that self-referral arrangements may increase use of radiotherapy and that profitability of systemic anticancer agents may affect physicians' choice of drug. Findings were less conclusive as to whether profitability of systemic anticancer therapy affects the decision of whether to use any systemic therapy.

Conclusions and Relevance

To date, this study is the first systematic review of reimbursement policy and clinical care delivery in oncology. The findings suggest that some oncologists may, in certain circumstances, alter treatment recommendations based on personal revenue considerations. An implication of this finding is that value-based reimbursement policies may be a useful tool to better align physician incentives with patient need and increase the value of oncology care.

How might financial pressures have impacted brachytherapy? A proposed narrative to explain the declines in cervical and prostate brachytherapy utilization

Rates of brachytherapy administration in the United States have declined for both cervical and prostate cancers, and we argue that the available facts suggest financial considerations are a major contributor to this issue. In this narrative, we discuss financial pressures that have existed for cervical and prostate brachytherapy and how they may have influenced their declining usage, consider other proposed influences, and provide suggestions for future research to understand the scope of the issue.

Industry payments to physician journal editors

Background

Open Payments is a United States federal program mandating reporting of medical industry payments to physicians, increasing transparency of physician conflicts of interest (COI). Study objectives were to assess industry payments to physician-editors, and to compare their financial COI rate to all physicians within the specialty.

Methods and findings

We performed a retrospective analysis of prospectively collected data, reviewing Open Payments from August 1, 2013 to December 31, 2016. We reviewed general payments (“… not made in connection with a research agreement”) and research funding to “top tier” physician-editors of highly-cited medical journals. We compared payments to physician-editors and physicians-by-specialty. In 35 journals, 333 (74.5%) of 447 “top tier” US-based editors met inclusion criteria. Of these, 212 (63.7%) received industry-associated payments in the study period. In an average year, 141 (42.3%) of physician-editors received any direct payments to themselves including general payments and research payments, 66 (19.8%) received direct payments >$5,000 (National Institutes of Health threshold for a Significant Financial Interest) and 51 (15.3%) received >$10,000. Mean annual general payments to physician-editors was $55,157 (median 3,512, standard deviation 561,885, range 10–10,981,153). Median general payments to physician-editors were mostly higher compared to all physicians within their specialty. Mean annual direct research payment to the physician-editor was $14,558 (median 4,000, range 15–174,440). Mean annual indirect research funding to the physician-editor’s institution (highly valued by academic leaders such as departmental chairs and deans) was $175,282 (median 49,107, range 0.18–5,000,000). The main study limitation was difficulty identifying physician-editors primarily responsible for making manuscript decisions.

Conclusions

A substantial minority of physician-editors receive payments from industry within any given year, sometimes quite large. Most editors received payment of some kind during the four-year study period. Given the extent of editors’ influences on the medical literature, more robust and accessible editor financial COI declarations are recommended.

A Proposal to Address NFL Club Doctors' Conflicts of Interest and to Promote Player Trust

How can we ensure that players in the National Football League receive excellent health care they can trust from providers who are as free from conflicts of interest as realistically possible? NFL players typically receive care from the club's own medical staff. Club doctors are clearly important stakeholders in player health. They diagnose and treat players for a variety of ailments, physical and mental, while making recommendations to the player concerning those ailments. At the same time, club doctors have obligations to the club, namely to inform and advise clubs about the health status of players. While players and clubs share an interest in player health-both of them want players to be healthy so they can play at peak performance-there are several areas where their interests can diverge, and the divergence presents legal and ethical challenges. The current structure forces club doctors to have obligations to two parties-the club and the player-and to make difficult judgments about when one party's interests must yield to another's. None of the three parties involved should prefer this conflicted approach. We propose to resolve the problem of dual loyalty by largely severing the club doctor's ties with the club and refashioning that role into one of singular loyalty to the player-patient. The main idea is to separate the roles of serving the player and serving the club and replace them with two distinct sets of medical professionals: the Players' Medical Staff (with exclusive loyalty to the player) and the Club Evaluation Doctor (with exclusive loyalty to the club). We begin by explaining the broad ethical principles that guide us and that help shape our recommendation. We then provide a description of the role of the club doctor in the current system. After explaining the concern about the current NFL player health care structure, we provide a recommendation for improving this structure. We then discuss how the club medical staff fits into the broader microenvironment affecting player health.

Multiple constraints compromise decision-making about implantable medical devices for individual patients: qualitative interviews with physicians

Background

Little research has examined how physicians choose medical devices for treating individual patients to reveal if interventions are needed to support decision-making and reduce device-associated morbidity and mortality. This study explored factors that influence choice of implantable device from among available options.

Methods

A descriptive qualitative approach was used. Physicians who implant orthopedic and cardiovascular devices were identified in publicly available directories and web sites. They were asked how they decided what device to use in a given patient, sources of information they consulted, and how patients were engaged in decision-making. Sampling was concurrent with data collection and analysis to achieve thematic saturation. Data were analyzed using constant comparative technique by all members of the research team.

Results

Twenty-two physicians from five Canadian provinces (10 cardiovascular, 12 orthopedic; 8, 10 and 4 early, mid and late career, respectively) were interviewed. Responses did not differ by specialty, geographic region or career stage. Five major categories of themes emerged that all influence decision-making about a range of devices, and often compromise choice of the most suitable device for a given patient, potentially leading to sub-optimal clinical outcomes: lack of evidence on device performance, patient factors, physician factors, organizational and health system factors, and device and device market factors. In the absence of evidence from research or device registries, tacit knowledge from trusted colleagues and less-trusted industry representatives informed device choice. Patients were rarely engaged in decision-making. Physician preference for particular devices was a barrier to acquiring competency in devices potentially more suitable for patients. Access to suitable devices was further limited to the number of comparable devices on the market, local inventory and purchasing contract specifications.

Conclusions

This study revealed that decision-making about devices is complex, cognitively challenging and constrained by several factors limiting access to and use of devices that could optimize patient outcomes. Further research is needed to assess the impact of these constraints on clinical outcomes, and develop interventions that optimize decision-making about device choice for treating given patients.

Electronic supplementary material

The online version of this article (10.1186/s12911-017-0577-3) contains supplementary material, which is available to authorized users.

Should disclosure of conflicts of interest in medicine be made public? Medical students' views

CONTEXT

Conflicts of interest (CoIs) are considered to be ubiquitous in health care and biomedicine. The disclosure of relevant interests is a first step in managing conflicts, although its usefulness is contested. Although several countries have mandated the public disclosure of doctors' financial relationships with the pharmaceutical industry, little is known about medical students' understanding of mandatory public disclosure.

METHODS

Six 90-minute focus groups were conducted with medical students in New South Wales, Australia. Participants ranged from first- to final-year students. Students were asked about their understanding and experiences of CoIs and, more specifically, for their views on and experiences of disclosure in medical education, mandatory disclosure and public registers. Qualitative data analysis was based on a framework approach.

RESULTS

Participants were generally not supportive of mandatory public disclosure of financial relationships with industry, principally because of concerns about privacy, control over disclosure, and others' (mis)interpretations of disclosures. Further, they did not know how to assess the disclosures presented to them as part of their medical education and described a wide range of reactions to disclosed information.

CONCLUSIONS

This study suggests that students are currently not well prepared for mandatory public disclosure of CoIs. The subsequent discussion draws on Bourdieu's doxa to highlight assumptions of altruism in medicine, assumptions that are potentially in tension with recent events that have exposed doctors to moral scrutiny by the public. Medical students could be better prepared for future obligations by encouraging disclosures, and contextualising and helping students to interpret them. Disclosure as a box-ticking exercise is unlikely to achieve goals implied by transparency, but a more reflective approach may assist both scrutinisers and the scrutinised.

Social preferences of future physicians

This paper advances scientific understanding of social preference—a topic of longstanding cross-disciplinary interest—by studying the preferences of future physicians. In making treatment decisions, physicians make fundamental tradeoffs between their own (financial) self-interest, patient benefit, and stewardship of social resources. These tradeoffs affect patient health, adoption of new scientific medical technologies, and the equity and efficiency of our health care system. Understanding physicians’ decisions about these tradeoffs requires understanding the social preferences that are behind them. Our main finding that future physicians are substantially less altruistic and more efficiency focused than the average American challenges notions of physician altruism, the fundamental feature of medical professionalism, and has potential implications for policy in a host of health care areas.

We measure the social preferences of a sample of US medical students and compare their preferences with those of the general population sampled in the American Life Panel (ALP). We also compare the medical students with a subsample of highly educated, wealthy ALP subjects as well as elite law school students and undergraduate students. We further associate the heterogeneity in social preferences within medical students to the tier ranking of their medical schools and their expected specialty choice. Our experimental design allows us to rigorously distinguish altruism from preferences regarding equality–efficiency tradeoffs and accurately measure both at the individual level rather than pooling data or assuming homogeneity across subjects. This is particularly informative, because the subjects in our sample display widely heterogeneous social preferences in terms of both their altruism and equality–efficiency tradeoffs. We find that medical students are substantially less altruistic and more efficiency focused than the average American. Furthermore, medical students attending the top-ranked medical schools are less altruistic than those attending lower-ranked schools. We further show that the social preferences of those attending top-ranked medical schools are statistically indistinguishable from the preferences of a sample of elite law school students. The key limitation of this study is that our experimental measures of social preferences have not yet been externally validated against actual physician practice behaviors. Pending this future research, we probed the predictive validity of our experimental measures of social preferences by showing that the medical students choosing higher-paying medical specialties are less altruistic than those choosing lower-paying specialties.

Bringing Transparency to Medicine: Exploring Physicians' Views and Experiences of the Sunshine Act

The Physician Payments Sunshine Act (PPSA) requires health care product manufacturers to report to the federal government payments more than $10 to physicians. Bringing unprecedented transparency to medicine, PPSA holds great potential for enabling medical stakeholders to manage conflicts of interest (COI) and build patient trust-crucial responsibilities of medical professionalism. The authors conducted six focus groups with 42 physicians in Chicago, IL, San Francisco, CA, and Washington, DC, to explore attitudes and experiences around PPSA. Participants valued the concept of transparency but were wary of the law's design and consequences. They downplayed PPSA's potential and felt it undermined public trust. Showing broad unawareness of COI, they dismissed the notion of industry influence and welcomed company "perks." Misapprehensions may leave physicians unprepared to advance the opportunities PPSA holds for professionalism. The authors offer recommendations for government and medicine to improve physicians' and other stakeholders' understandings and use of the data.

Variability in conflict of interest disclosures by physicians presenting trauma research

AIM

To quantify the variability of financial disclosures by authors presenting orthopaedic trauma research.

METHODS

Self-reported authorship disclosure information published for the 2012 American Academy of Orthopaedic Surgeons (AAOS) and Orthopaedic Trauma Association (OTA) meetings was compiled from meeting programs. Both the AAOS and OTA required global disclosures for participants. Data collected included: (1) total number of presenters; (2) number of presenters with financial disclosures; (3) number of disclosures per author; (4) total number of companies supporting each author; and (5) specific type of disclosure. Disclosures made by authors presenting at more than one meeting were then compared for discrepancies.

RESULTS

Of the 5002 and 1168 authors presenting at the AAOS and OTA annual meetings, respectively, 1649 (33%) and 246 (21.9%) reported a financial disclosure (P < 0.0001). At the AAOS conference, the mean number of disclosures among presenters with disclosures was 4.01 with a range from 1 to 44. The majority of authors with disclosures reported three or more disclosures (n = 876, 53.1%). The most common cited disclosure was as a paid consultant (51.5%) followed by research support (43.0%) and paid speaker (34.8%). Among the 256 physicians with financial disclosures presenting at the OTA conference, the mean number of disclosures was 4.03 with a range from 1 to 22. Similar to the AAOS conference, the majority of authors with any disclosures at the OTA conference reported three or more disclosures (n = 140, 54.7%). Most authors with a disclosure had three or more disclosures and the most common type of disclosure was paid consulting. At the OTA conference, the most commonly cited form of disclosure was paid consultant (54.3%) followed by research support (46.1%) and paid speaker (42.6%). Of the 346 researchers who presented at both meetings, 112 (32.4%) authors were found to have at least one disclosure discrepancy. Among authors with a discrepancy, 36 (32.1%) had three or more discrepancies.

CONCLUSION

There were variability and inconsistencies in financial disclosures by researchers presenting orthopaedic trauma research. Improved transparency of conflict of interest disclosures is warranted among trauma researchers presenting at national meetings.

"We can't get along without each other": Qualitative interviews with physicians about device industry representatives, conflict of interest and patient safety

Objectives

Physician relationships with device industry representatives have not been previously assessed. This study explored interactions with device industry representatives among physicians who use implantable cardiovascular and orthopedic devices to identify whether conflict of interest (COI) is a concern and how it is managed.

Design

A descriptive qualitative approach was used. Physicians who implant orthopedic and cardiovascular devices were identified in publicly available directories and web sites, and interviewed about their relationships with device industry representatives. Sampling was concurrent with data collection and analysis. Data were analyzed and discussed using constant comparative technique by all members of the research team.

Results

Twenty-two physicians (10 cardiovascular, 12 orthopedic) were interviewed. Ten distinct representative roles were identified: purchasing, training, trouble-shooting, supplying devices, assisting with device assembly and insertion, supporting operating room staff, mitigating liability, conveying information about recalls, and providing direct and indirect financial support. Participants recognized the potential for COI but representatives were present for the majority of implantations. Participants revealed a tension between physicians and representatives that was characterized as “symbiotic”, but required physicians to be vigilant about COI and patient safety, particularly because representatives varied regarding disclosure of device defects. They described a concurrent tension between hospitals, whose policies and business practices were focused on cost-control, and physicians who were required to comply with those policies and use particular devices despite concerns about their safety and effectiveness.

Conclusions

Given the potential for COI and threats to patient safety, further research is needed to establish the clinical implications of the role of, and relationship with device industry representatives; and whether and how hospitals do and should govern interaction with representatives, or support their staff in this regard.

A new survey to evaluate conflict of interest policies at academic medical centers

Background

A majority of academic medical centers (AMCs) have now adopted conflict of interest policies (COI) to address relationships with pharmaceutical and device industries that can increase the risk of bias in patient care, education and research. However, AMCs may have little information on the impact of their policies. This paper provides a new method, which is a free, publicly-available survey, to fill this information gap and improve COI programs at AMCs.

Methods & findings

The survey, piloted in three AMCs and designed in collaboration with national conflicts of interest policy experts, covers a range of universal compliance-related concerns, which allows institutions to tailor questions to align with their own policies and culture. The survey was low-burden, and provided important data for these AMCs to evaluate their policies. A descriptive analysis of the pooled pilot site data (n = 1578) was performed, which found that a majority of respondents did not have financial ties with industry and a majority was satisfied with specific COI policies at their institutions. The analysis also showed that the survey is sensitive to differences that AMCs will find meaningful. For instance, individuals with industry ties were significantly more likely than individuals without ties to think that COI policies unnecessarily hindered interactions with industry (p = .004), were ineffective at reducing harm to patients (p < .001), and were ineffective in reducing bias in medical education (p>.001).

Conclusion

The survey is now free and publicly available for use by any institution. AMCs can use the results to update and refine policies, and to provide ongoing education regarding existing policies.

Debates about Conflict of Interest in Medicine: Deconstructing a Divided Discourse

The pharmaceutical industry plays an increasingly dominant role in healthcare, raising concerns about "conflicts of interest" (COI) on the part of the medical professionals who interact with the industry. However, there is considerable disagreement over the extent to which COI is a problem and how it should be managed. Participants in debates about COI have become entrenched in their views, which is both unproductive and deeply confusing for the majority of medical professionals trying to work in an increasingly commercialized environment. We used a modified meta-narrative review method to analyse debates about COI in the academic and grey literature. We found two Discourse Models: The Critical Discourse Model sees COI in health and biomedicine as a major problem that both can and should be addressed, while the Defensive Discourse Model argues that current efforts to control COIs are at best unnecessary and at worst harmful. Each model is underpinned by profoundly differing views about how society should be organized-in particular whether market forces should be encouraged or curtailed-and how the dangers associated with market forces should be managed. In order to make any headway, academics and policymakers must recognize that these debates are underpinned by profoundly differing worldviews.

Association Between Financial Conflicts of Interests and Supportive Opinions for Erectile Dysfunction Treatment

A conflict of interest (COI) is a situation in which a person has competing loyalties or interests that make it difficult to fulfil his or her duties impartially. Conflict of interest is not categorically improper in itself but requires proper management. A SCOPUS literature search was performed for publications on the efficacy/safety of Phospho-Di-Esterase Inhibitors (PDEIs) for treating erectile dysfunction. A categorization tool (CoOpCaT) was used to review and classify the publications as supportive/not-supportive for the discussed active ingredient and reporting or not reporting a COI for that specific drug or for the remaining PDEIs (i.e. competitors). Multivariable binary logistic regression was performed. In the 419 selected records the prevalence of supportive opinions was higher when a COI for the index label was declared. The CoOpCaT showed good internal consistency, discriminative validity and intra/inter-rater agreement. The strongest predictor for a supportive opinion was the total number of financial COIs for the index label. A mild protective effect of the total number of financial COIs for any competitor label was noted. Financial COIs have frequently been associated with bias, and the measures currently adopted to restrain it lack effectiveness. Some evidence for monitoring and/or compensating this bias is reported here, but the ultimate solution remains distant.

Abortion and compelled physician speech

Informed consent mandates for abortion providers may infringe the First Amendment's freedom of speech. On the other hand, they may reinforce the physician's duty to obtain informed consent. Courts can promote both doctrines by ensuring that compelled physician speech pertains to medical facts about abortion rather than abortion ideology and that compelled speech is truthful and not misleading.

Physician-industry collaboration: conflicts of interest and the imputation of motive

Policies about physicians' involvement with pharmaceutical companies spawn contradictory ideas. One set of policies aims to stimulate collaboration between private companies and publicly employed researchers to spur innovation and economic growth, another addresses what is seen as the problem of physicians' conflicts of interest stemming from industry collaboration. This article explores how these contradictory policies interact with everyday practice in clinical hypertension research in Denmark. I argue that 'corporate' and 'academic' research is entangled as physicians participate in industry trials to pursue their own research. Building on document analysis, observations of contract research, and interviews with clinician researchers and industry executives, I show how the establishment of industry 'ties' can serve as a way for physicians to navigate the constraints of research infrastructures and live up to intergenerational norms that knit the medical collective together. I discuss how this entanglement shapes medical research in ways that may run counter to the aims of medical innovation policies and that conflicts of interest policies do little to address. I conclude that appreciation of the ways in which economic and moral valuations come together is necessary to understand the conditions for medical research in an intertwined public-private research environment.

Disclosing conflicts of interest in patient decision aids

Background

In 2005, the International Patient Decisions Aid Standards (IPDAS) Collaboration developed quality criteria for patient decisions aids; one of the quality dimensions dealt with disclosure of conflicts of interest (COIs). The purposes of this paper are to review newer evidence on dealing with COI in the development of patient decision aids and to readdress the theoretical justification and definition for this quality dimension.

Methods

The committee conducted a primary systematic literature review to seek published research addressing the question, "What is the evidence that disclosure of COIs in patient decision aids reduces biased decision making?" A secondary literature review included a systematic search for recent meta-analyses addressing COIs in other spheres of health care, including research and publication, medical education, and clinical care.

Results

No direct evidence was found addressing this quality dimension in the primary literature review. The secondary review yielded a comprehensive Institute of Medicine report, as well as four relevant meta-analyses addressing disclosure of COIs in health care. They revealed a broad consensus that disclosure of COIs is desirable in such areas as research publication, guideline development, medical education, and clinical care.

Conclusions

The committee recommends the criteria that are currently used to operationally define the quality dimension “disclosing conflicts of interest” be changed as follows (changes in italics):

Does the patient decision aid:

• report prominently and in plain language the source of funding to develop or exclusively distribute the patient decision aid?

• report prominently and in plain language whether funders, authors, or their affiliations, stand to gain or lose by choices patients make after using the patient decision aid?

Furthermore, based on a consensus that simple disclosure is insufficient to protect users from potentially biased information, the committee recommends that the IPDAS Collaboration consider adding the following criterion when the IPDAS consensus process is next conducted: “Does the patient decision aid:

• report that no funding to develop or exclusively distribute the patient decision aid has been received from commercial, for-profit entities that sell tests or treatments included as options in the patient decision aid?”

Is it really all about the money? Reconsidering non-financial interests in medical research

Concern about financial conflicts crowds out sufficient consideration of other interests that may bias research conduct. Regulations, institutional policies, and guidance from professional bodies and medical journals all primarily focus on financial ties. But why? Economic gain is not the only powerful influence. This article argues that we under-prioritize non-financial interests in the regulation of medical research. It critiques the usual reasons given for regulating financial and non-financial interests differently - that the interests contrast in terms of tangibility, that financial interests are optional, and that financial interests can be efficiently carved out as a discrete area of focus. Moreover, disparate regulatory treatment seems inattentive to the very similar social and psychological forces that animate the bias effect of both financial and non-financial interests and fails to account for how financial and non-financial interests synergistically interact. Under-prioritization of non-financial interests threatens to erode public trust and creates negative spillover effects that weaken financial conflicts regulation. Optimal regulation requires a more integrated, balanced, and proportionate response to secondary interests in medical research.