Conflict of interest in orthopaedic research. An association between findings and funding in scientific presentations

Spine surgeon conflict of interest disclosure discrepancies between a national conference and the open payments database

Background

Financial relationships between physicians and the medical device industry are common. These relationships can potentially influence research, education, and patient care. The purpose of this study was to evaluate inconsistencies between physician disclosures and the Open Payments database for a national spine conference.

Methods

Disclosures of participants in the 2023 North American Spine Society (NASS) conferences were compared with the Open Payments database. Discrepancies were noted whenever a participant had a company listing on their Open Payments page that was not reported in their disclosure in the NASS Disclosure Index. Simple statistics were reported as a frequency and percentage for categorical variables, and median and interquartile range (IQR) were used for continuous variables. Pearson correlations were run to investigate associations between the number of reportable companies, the number of discrepancies, and general payment amounts.

Results

A total of 432 participants met the inclusion criteria, with the majority having discrepancies between their self-reported disclosures and the Open Payments database (84.2%, N=364/432). Regarding surgeons with a discrepancy, 80.2% (N=292/364) failed to report payments of less than 1,000 USD. Physicians affiliated with a larger number of reportable companies were associated with an increased number of discrepancies (p<.001, R=0.832) and a greater general payment amount (p=.012, R=0.126).

Conclusions

Discrepancy rates between what surgeons disclosed at NASS 2023 and what companies reported to Open Payments were high. However, the majority of these discrepancies that the physicians failed to report were low in value, falling below 1,000 USD. As a potential means to mitigate these discrepancies, it is imperative that physicians review their Open Payments page prior to disclosure submission.

Industry Payments to Orthopaedic Surgeons: A Geospatial Analysis of the Open Payments Database

INTRODUCTION

There has been an increasing demand for transparency between industry and physicians. Several studies have evaluated the distribution of payment value and types to orthopaedic surgeons, but little is known about the spending patterns from an industry-centric perspective. The purpose of this study was to describe the payment patterns of top medical device companies in orthopaedics while presenting a geospatial analysis of these trends.

METHODS

The Open Payments database was assessed for all records of industry financial relationships with orthopaedic surgeons from 2015 to 2021. Value of financial relationships was expressed on a per orthopaedic surgeon basis, with the numerator representing total value of payments and denominator representing number of orthopaedic surgeons, and was geographically analyzed according to United States Census Divisions.

RESULTS

Based on averages during the study period, the top 10 paying companies were (1) DePuy, (2) Zimmer Biomet, (3) Stryker Corporation, (4) Arthrex, (5) SpineFrontier, (6) Medtronic, (7) Smith and Nephew, (8) Renovis Surgical Technologies, (9) NuVasive, and (10) Paragon 28. Payments in the South Atlantic ($6,854 ± $1,265) Division were significantly greater than all other eight divisions ( P < 0.001), with the next leading division being the Pacific Division ($4,114 ± $643). Five companies strongly favored one particular division, directing more than double the amount of payments to this division compared with the next leading division (SpineFrontier, 99% South Atlantic; Renovis Surgical Technologies, 81% Pacific; Paragon 28, 59% South Atlantic; NuVasive, 43% West North Central; DePuy, 35% South Atlantic). Only 3 of 10 companies were headquartered in the same division where most payments were made.

CONCLUSION

From 2015 to 2021, companies preferentially supported surgeons in certain geographic regions, irrespective of where they were headquartered in. Surgeons in the South Atlantic Division received significantly more payments than any other division by a wide margin.

Conflict of Interest Disclosure in American Arthroplasty Surgical Literature

Background

Relationships between industry and physicians are critical for innovation in the field of arthroplasty surgery. However, these relationships can present a conflict of interest (COI) for medical research and are required to be disclosed by most journals. The rate of accurate disclosures by physicians has not been studied in arthroplasty surgery.

Methods

The names of all authors publishing in The Journal of Arthroplasty and Arthroplasty Today between 2014 and 2018 were obtained from MEDLINE. Financial disclosure statements were obtained from the journal websites and manually compared against Open Payments. Statistical comparisons were made using chi-square testing with significance defined as P < .05.

Results

From 2014-2018, 3147 articles were published with 4038 authors meeting inclusion criteria. Of authors with financial disclosures, 2298 (57%) authors correctly disclosed. The total value of disclosed COI equaled $1.71 billion. The total value of undisclosed conflicts of interest equaled $334 million. For payments >$1,000,000 physicians disclosed accurately 86% of the time. For payments between $100 and $9999 physicians accurately disclosed 26% of the time. Senior authors disclosed correctly 72% of the time, which was significantly higher compared to middle and first authors.

Conclusions

There is a high prevalence of inaccurate disclosures in the field of arthroplasty surgery. This suggests a need to further educate early-career physicians on what constitutes a COI. Standardization of disclosure forms and verifications with the Open Payments Database can help increase the rate of accurate disclosures.

Industry affiliation influence on randomized controlled trials for platelet-rich plasma in the treatment of lateral epicondylitis: a systematic review

Background

Explicit funding and industry affiliation are believed to potentially impact medical research. There have been an increasing number of studies that have evaluated this relationship. The purpose of this study is to determine whether industry affiliation influences the outcomes of randomized controlled trials that investigate the effectiveness of platelet-rich plasma (PRP) in the treatment of lateral epicondylitis.

Methods

A search of PubMed, SPORTDiscus, and SCOPUS was performed using the search terms "lateral epicondylitis" and "platelet-rich plasma" as well as "tennis elbow" and "platelet-rich plasma." Only studies from 2010 to present were considered. Final texts were then analyzed for industry affiliation and treatment efficacy. When determining whether a study was industry-affiliated, explicit financial supporters of the study, stated conflicts of interest, American Academy of Orthopaedic Surgeons disclosures, and the Centers for Medicare and Medicaid Services open payments database were assessed. Study outcomes were categorized as favorable, analogous, or unfavorable based on achieving a statistically significant (P < .05) comparison between PRP and control.

Results

A total of 26 studies were used. Of these, 20 were industry nonaffiliated and 6 were industry affiliated. There were 15 studies (2 affiliated and 13 nonaffiliated) that reported PRP as favorable compared to the comparison (corticosteroid, analogous whole blood, or normal saline). The endpoints were 6 and 12 months after the use of PRP or the comparison. Quantitative data analysis yielded results that were not statistically significant between industry-nonaffiliated and affiliated groups. The P values for 6-month visual analog scale, 12-month visual analog scale, 6-month disabilities of the arm, shoulder, and hand, 12-month disabilities of the arm, shoulder, and hand, 6-month patient-related tennis elbow evaluation, and 12-month patient-related tennis elbow evaluation were 0.577, 0.635, 0.554, 0.465, 0.273, and 0.157, respectively.

Conclusion

Despite our results indicating that industry affiliation does not have an impact on outcomes of randomized controlled trials examining the treatment of lateral epicondylitis with PRP, it is important for future studies to evaluate affiliations when making treatment recommendations.

An In-Depth Analysis of Public and Private Research Funding in Orthopaedic Surgery from 2015 to 2021

BACKGROUND

Understanding the trends and patterns of research funding can aid in enhancing growth and innovation in orthopaedic research. We sought to analyze financial trends in public orthopaedic surgery funding and characterize trends in private funding distribution among orthopaedic surgeons and hospitals to explore potential disparities across orthopaedic subspecialties.

METHODS

We conducted a cross-sectional analysis of private and public orthopaedic research funding from 2015 to 2021 using the Centers for Medicare & Medicaid Services Open Payments database and the National Institutes of Health (NIH) RePORTER through the Blue Ridge Institute for Medical Research, respectively. Institutions receiving funds from both the NIH and the private sector were classified separately as publicly funded and privately funded. Research payment characteristics were categorized according to their respective orthopaedic fellowship subspecialties. Descriptive statistics, Wilcoxon rank-sum tests, and Mann-Kendall tests were employed. A p value of <0.05 was considered significant.

RESULTS

Over the study period, $348,428,969 in private and $701,078,031 in public research payments were reported. There were 2,229 unique surgeons receiving funding at 906 different institutions. The data showed that a total of 2,154 male orthopaedic surgeons received $342,939,782 and 75 female orthopaedic surgeons received $5,489,187 from 198 different private entities. The difference in the median payment size between male and female orthopaedic surgeons was not significant. The top 1% of all practicing orthopaedic surgeons received 99% of all private funding in 2021. The top 20 publicly and top 20 privately funded institutions received 77% of the public and 37% of the private funding, respectively. Private funding was greatest (31.5%) for projects exploring adult reconstruction.

CONCLUSION

While the amount of public research funding was more than double the amount of private research funding, the distribution of public research funding was concentrated in fewer institutions when compared with private research funding. This suggests the formation of orthopaedic centers of excellence (CoEs), which are programs that have high concentrations of talent and resources. Furthermore, the similar median payment by gender is indicative of equitable payment size. In the future, orthopaedic funding should follow a distribution model that aligns with the existing approach, giving priority to a nondiscriminatory stance regarding gender, and allocate funds toward CoEs.

CLINICAL RELEVANCE

Securing research funding is vital for driving innovation in orthopaedic surgery, which is crucial for enhancing clinical interventions. Thus, understanding the patterns and distribution of research funding can help orthopaedic surgeons tailor their future projects to better align with current funding trends, thereby increasing the likelihood of securing support for their work.

Financial Conflicts of Interest and Industry Funding are Associated With Conclusions Favorable to New Technologies: A Review of Published Economic Analyses in Hip and Knee Arthroplasty

BACKGROUND

New technologies in hip and knee arthroplasty are commonly evaluated using cost-effectiveness analyses and similar economic assessments. There is a wide variation in the methodology of these studies, introducing the potential for bias. The purpose of this study was to evaluate associations between potential financial conflicts of interest (COI) and the outcomes of economic analyses. We hypothesized that authors' COI and industry funding would be associated with conclusions favorable to a new technology.

METHODS

Economic analyses making cost-effectiveness or economic implementation claims on patient-specific instrumentation, robotics, and implants used in hip and knee arthroplasty published from 2010 to 2022 were identified. Papers were evaluated to determine if conclusions were favorable to the new technology being studied. Fisher's exact test was utilized to determine the relationship between the presence of COI and an article's conclusions.

RESULTS

Of 43 eligible articles, 76.7% were cost-effectiveness analyses, 23.2% were cost analyses, and 67.4% of articles had conclusions favorable to a technology. Of the 29 articles with favorable conclusions, 26 had an author with a financial COI (89.7%), and 14 had industry funding (48.3%). Of the 33 articles with a financial COI, 26 (78.8%) had favorable conclusions, and of the 16 articles with industry funding, 14 (87.5%) had favorable conclusions. Fisher's exact test revealed a statistically significant association between an article having favorable conclusions and the presence of an author's COI or industry funding (odds ratio, 13.5; 95% CI [confidence interval], 2.3 to 79.9; P = .003).

CONCLUSIONS

Financial COIs were present in 79.1% of lower extremity arthroplasty economic analyses on technologies and were associated with an article having conclusions favorable to the new technology. Surgeons and decision-makers should be aware of the variability and assumptions in these studies and the potential bias of the conclusions.

Industry affiliation does not predict outcomes of randomized controlled trials for mesenchymal stem cells in knee osteoarthritis

BACKGROUND

This research aims to determine the influence of industry on the outcomes of randomized controlled trials (RCTs) for Mesenchymal Stem Cell (MSC) treatments in knee osteoarthritis (OA).

METHODS

PubMed, Scopus, and Web of Science were searched from 2010 onwards using the terms "knee osteoarthritis" and "mesenchymal stem cells". After identifying relevant RCTs, studies were categorized as industry-affiliated or non-industry-affiliated. They were also classified as favorable if they achieved statistically significant (p < 0.05) results with MSC injections compared to control. Chi-squared tests were employed to analyze the relationship between industry affiliation and study outcome.

RESULTS

Post exclusion criteria, 38 studies were analyzed. Of these, there were 20 (52.6%) industry affiliated (IA) and 18 (47.4%) non-industry affiliated (NIA) studies. Among the 20 IA studies, 17 (85.0%) reported favorable outcomes for MSC treatment arm, with the remaining 3 (15.0%) showing analogous (no difference between treatment arms) results. For the 18 NIA studies, 15 (83.3%) were favorable, and 3 (16.6%) were analogous. No significant difference in outcomes was observed between IA and NIA studies (p = 0.888). Analysis of patient reported outcomes also revealed no significant difference. Of note, studies using allogeneic MSCs were more likely to be IA than studies using autologous MSCs (p = 0.005) CONCLUSION: This study demonstrated no strong association between industry affiliation and the outcomes of RCTs for MSC treatments in knee OA. Despite this, the potential influence of industry ties should always be considered when applying study findings to new treatment modalities for patient care.

Orthopedic Research Funding: Assessing the Relationship between Investments and Breakthroughs

Orthopedic research plays a crucial role in improving patient outcomes for musculoskeletal disorders. This narrative review explores the intricate interplay between funding patterns and the trajectory of breakthroughs achieved in this dynamic field. A meticulous search strategy identified studies illuminating the diverse sources of orthopedic research funding, including public funding (government agencies), philanthropic organizations, private sector investment, and international funding bodies. The review further delved into the spectrum of breakthroughs, encompassing fundamental scientific discoveries, technological advancements, and personalized medicine approaches. Public funding emerged as a significant pillar, supporting foundational research that lays the groundwork for future advancements. Philanthropic organizations addressed specific musculoskeletal disorders, often focusing on patient-centric applications. International funding bodies played a role in supporting research in low- and middle-income countries. Breakthroughs extended beyond cutting-edge prosthetics and minimally invasive surgeries, encompassing fundamental discoveries in areas like gene therapy and biomaterials science. Technological advancements included brain-computer interface prosthetics and 3D-printed implants. Personalized medicine offered the potential for tailored treatments based on individual needs and genetic profiles. This review underscores the complex interplay between funding patterns and breakthroughs in orthopedic research. A multifaceted approach is essential for continued progress. Fostering collaboration, optimizing funding models, and prioritizing both foundational and translational research hold the key to unlocking the true potential of orthopedic research and transforming the lives of patients suffering from musculoskeletal disorders.

Reporting Bias in Systematic Reviews and Meta-Analyses Related to the Treatment of Distal Radius Fractures: The Presence of Spin in the Abstract

BACKGROUND

Spin is a form of reporting bias which suggests a treatment is beneficial despite a statistically nonsignificant difference in outcomes. Our purpose was to define the prevalence of spin within the abstracts of distal radius fracture (DRF) systematic reviews (SRs) and meta-analyses (MA). We also sought to identify article characteristics that were more likely to contain spin.

METHODS

We performed a SR of multiple databases to identify DRF SRs and MAs. Articles were screened and analyzed by 3 reviewers. We recorded article and journal characteristics including adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, funding disclosures, methodologic quality (AMSTAR 2 instrument), impact factor, and country of origin. Presence of the 9 most severe types of spin in abstracts were recorded. Unadjusted odds ratios (ORs) were calculated to analyze the association between article characteristics and the presence of spin.

RESULTS

A total of 112 articles were included. Spin was present in 46% of abstracts, with type 1 spin ("conclusions not supported by findings") most frequent (19%). Spin was present in 43% of abstracts in PRISMA-adhering journals compared to 49% in journals that did not (OR = 0.79, 95% confidence interval [CI] = 0.37-1.68). For articles originating from China, spin was present in 61% of abstracts compared to 39% of abstracts from other countries (OR = 2.55, 95% CI = 1.13-5.75).

CONCLUSIONS

In addition to low article quality, there are high rates of spin within the abstracts of SRs and MAs related to treatment of DRF. Articles within journals that adhere to PRISMA do not appear to contain less spin.

Impact of Reporting Bias, Conflict of Interest, and Funding Sources on Quality of Orthopaedic Research

BACKGROUND

Influence of factors like reporting outcomes, conflicts of interest, and funding sources on study outcomes, particularly positive outcomes in orthopedics, remains underexplored. As transparency of partnerships in orthopaedic surgery through conflicts of interest statements has increased over the years, there has been a lack of focus on the value of these partnerships in influencing study outcomes. We aimed to investigate the associations between reporting outcomes, conflicts of interest, and sources of funding on study outcomes.

METHODS

We reviewed articles published in 1 year in The Journal of Bone and Joint Surgery, The American Journal of Sports Medicine, and The Journal of Arthroplasty. The abstracts were examined for appropriate inclusion, while the authors' names, academic degrees, funding disclosures, and departmental and institutional affiliations were redacted. There were a total of 1,351 publications reviewed from January 1, 2021 to December 31, 2021.

RESULTS

A significant association was found between positive outcomes and reported conflicts of interest (75% versus 25%, P < .001). Likewise, conflicts of interest showed significant association with industry-sponsored studies (88% versus 12%, P < .001) and evidence level > II (72% versus 28%, P < .001). Industry-sponsored research accounted for the highest percentage of studies involving a conflict of interest (88%) and level I studies (12%).

CONCLUSIONS

Conflicts of interest are significantly associated with positive outcomes in orthopaedics. Sponsored studies were more inclined to have conflicts of interest and accounted for the majority of level I studies.

2015-2021 Industry Payments to Pediatric Orthopaedic Surgeons: Analysis of Trends and Characteristics of Top-earning Surgeons

BACKGROUND

Analysis of industry payments to pediatric orthopaedic surgeons last occurred in 2017. We investigated payments to pediatric orthopaedic surgeons from 2015 to 2021 to understand surgeon characteristics associated with increased industry payments.

METHODS

Open Payments Database datasets from 2015 to 2021 were queried for nonresearch payments to pediatric orthopaedic surgeons. Annual aggregates and subcategories were recorded. For surgeons receiving payments in 2021, the Hirsch index (h-index), gender, and US census division were found using the Scopus database, Open Payments Database, and online hospital profiles, respectively. χ 2 , Fisher exact, Mann-Whitney U , and t tests were used to compare surgeons in the top 25%, 10%, and 5% payment percentiles to the bottom 75%, 90%, and 95%, respectively.

RESULTS

Payments rose 125% from 2015 to 2021. Education, royalties, and faculty/speaker increased most, while travel/lodging, honoraria, charitable contributions, and ownership interest decreased. Only royalties increased from 2019 to 2021. In 2021, of 419 pediatric orthopaedic surgeons receiving industry payments, men received greater median aggregate payments than women ($379.03 vs. $186.96, P =0.047). There were no differences in gender proportions between the top 75% and bottom 25% ( P =0.054), top 10% and bottom 90% ( P =0.235), and top 5% and bottom 95% ( P =0.280) earning comparison groups. The h-index was weakly positively correlated with industry payments ( rs =0.203, P <0.001). Mean h-indices in the 75th ( P <0.001, 95% CI: 2.62-7.65), 90th ( P =0.001, 95% CI: 3.28-13.03), and 95th ( P =0.005, 95% CI: 4.25-21.11) percentiles were significantly higher. Proportions of surgeons from the Middle Atlantic and West South Central in the 90th ( P =0.025) and 95th percentiles ( P =0.033), respectively, were significantly lower compared to all other regions. A higher proportion of surgeons from the Pacific were placed in the 90th ( P =0.004) and 95th ( P =0.024) percentiles.

CONCLUSIONS

Industry payments to pediatric orthopaedic surgeons rose from 2015 to 2021. Most categories fell from 2019 to 2021, which may be related to the SARS-CoV-19 pandemic. In 2021, though gender was not related to aggregate payment percentile, location in select US census divisions and h-index was.

LEVEL OF EVIDENCE

Level II-Retrospective study.

Social Media Influence and Gender Are Correlated with Industry Payments to Orthopaedic Sports Surgeons

Social media, specifically Twitter, has become an increasingly used tool in academic orthopaedic surgery to help surgeons connect with patients and peers. This study seeks to understand correlations among social medial influence, academic influence, and gender among academic orthopaedic sport surgeons. A list of all orthopaedic sports surgeons serving as faculty of sports fellowships in the United States was compiled, along with publicly available demographic information. Their Hirsh indices (h-indices) were obtained using the Scopus database. The Physician Payments Sunshine Act Web site was used to determine their industry payments from 2014 through 2020. The number of Twitter followers was used as a measure of social media influence. Multivariable linear regression models were employed to explore the associations between these parameters and industry payments. Of the 633 surgeons, 33% had a Twitter account. Surgeons with > 1,000 followers (7.3%) were awarded 186% more in nonresearch funding (p = 0.01) and had a higher probability of receiving industry research funding compared with those with no followers (p = 0.03). Sports surgeons had an average h-index of 16, with 44% having ≤ 20 publications and 21% having ≥ 100 publications. Surgeons with ≥ 100 publications were awarded 453% more in nonresearch funding (p = 0.001) and had a 32% higher probability of receiving industry research funding (p < 0.001) when compared with their colleagues with ≤ 20 publications. Female sports surgeons accounted for only 7.9% of surgeons included in the study, and were awarded 65% less in industry nonresearch funding compared with their male colleagues (p = 0.004) when controlling for other factors. Both number of publications and a high level of Twitter activity (> 1,000 followers) had the strongest associations with the quantity of industry nonresearch funding and the highest probability of industry research funding. Female sports surgeons received significantly less industry nonresearch funding compared with their male colleagues. Future studies further exploring gender disparities in industry funding for orthopaedic surgeons may be warranted. LEVEL OF EVIDENCE:  Prognostic, Level III.

Orthopedic surgeon-scientist representation is low among National Institutes of Health grants for rotator cuff research

Background

The purpose of this study is to characterize National Institutes of Health (NIH) funding for rotator cuff research and evaluate the impact of orthopedic surgeons on this portfolio.

Methods

The NIH's Research Portfolio Online Reporting Tools Expenditures and Results database was queried for "rotator cuff repair" or "rotator cuff tear" from the 2011 to 2021 fiscal years. Compound annual growth rates were calculated and grants were categorized by basic, clinical, or translational research. Funding totals were compared by Principal Investigator (PI) and grant characteristics.

Results

A total of 52 grants were awarded to 38 PIs between 2011 and 2021, totaling $40,156,859. Annual NIH funding for rotator cuff tear and rotator cuff repair increased by a Compound annual growth rate of 11.0% from 2011 to 2021, compared to 3.4% for the total NIH budget. Orthopedic surgeon-scientists received $9,208,212 (22.9%), most commonly through R01 (80.5%) and K08 (7.1%) mechanisms. No significant difference in funding was found by PI sex (P = .332), degree (P = .460), academic rank (P = .118), or researcher type (P = .227). Professors had a higher h-index than associate and assistant professors (P = .001). Orthopedic surgeon-scientists had a higher h-index (mean 36.3 ± 9.4) compared to clinician-scientists (mean 8.0 ± 1.4) and research-scientists (35.5 ± 40.7) (P = .044). Clinical topics receiving the highest funding were rehabilitation (23.9%), diagnosis, (22.3%) and surgical technique (14.8%). Orthopedic surgeon-scientists acquired funding for diagnosis (57.1%), rehabilitation (17.0%), and surgical technique (14.5%).

Discussion

While NIH funding for rotator cuff research is growing, orthopedic surgeon representation is low. Future studies should evaluate barriers to obtaining funding for orthopedic surgeon-scientists.

Battle of the titans: Survivorship analysis of the 3 most common types of uncemented femoral stems used across national registries

Background

Although many institutions utilize uncemented stems as routine in performing total hip arthroplasty (THA), many surgeons continue to rely on outcomes reported in the literature in the form of small cohorts and patient series when analyzing survivorship for specific implants. The purpose of this study was to identify and analyze the survivorship of the 3 most common uncemented stem types (as opposed to brands) used across multiple national joint registries.

Methods

A review of data available from all national joint registries was carried out in July 2022. Analysis of each individual registry and classified uncemented implants into the seven different uncemented stem types. The 3 most common stem types were identified, and average cumulative revision rates calculated. Metal on metal bearings surface implants were excluded from this study due to high revision rates across all implant types.

Results

Our detailed review identified 6 out of 13 (NJR, AOANJRR, LROI, EPRD, MARCQI and the NZJR) international registries reporting implant specific survivorship on uncemented femoral stems; including 960,328 uncemented stems across all registries. The most common type of stem used was type 3c, accounting for 61% (583,724), followed by type 1 stems with 23% (217,897) and type 2 stems with 8% (79,257). Cumulative revision rates at 13 years follow-up for these stems ranged from 6.9% to 7.9%.

Conclusion

Although all stem types have comparable revision rates across all registries, the most common uncemented stem reported was the type 3c, tapered rectangular fully coated stem. Furthermore, out of all type 3c, the Müller design philosophy with full hydroxyapatite coating seems to be the most sought after worldwide. In this study we can conclude, thus far, that there does not appear to clinical or statistical differences in revision rates between the different stem types.

Level of evidence

III.

Do Corporate Payments Influence Research Related to the Use of Acellular Dermal Matrices in Breast Surgery?

BACKGROUND

No study has assessed the impact of financial conflicts of interests (COIs) on the reporting of breast reconstruction outcomes with acellular dermal matrix (ADM) in peer-reviewed publications. The authors hypothesized that there is (1) an association between financial COIs and likelihood of studies reporting benefits in using ADM, and (2) inconsistent reporting of financial COIs.

METHODS

The PubMed database was used to identify articles that reported on the use of ADM in breast surgery in four leading plastic surgery journals from January of 2014 to December of 2019. Financial COIs for authors were determined using the open payments database.

RESULTS

Fifty-five articles were included. Twenty-four articles (43.6%) supported use of ADM, 12 (21.8%) did not promote ADM use, and 19 (34.5%) were neutral. Fifty-one studies (92.7%) had either a first or senior author with a COI, and authors with a COI more commonly reported positive outcomes ( P = 0.02). Studies with positive outcomes featured first authors who received significantly larger financial payments ($95,955 versus $15,642; P = 0.029) compared with studies with negative or neutral outcomes. Receiver operating characteristic curve demonstrated that studies with first authors receiving over $376.28 were more likely to report positive results. Eight senior authors and three first authors received greater than $500 from ADM producers yet did not report any financial disclosure.

CONCLUSIONS

Financial COI is associated with higher likelihood of studies reporting benefit of using ADM in breast surgery. There remains inconsistent reporting of COIs, and better oversight is needed to ensure unbiased publication on the use of ADM in breast surgery.

Funding has no effect on clinical outcomes of total joint arthroplasty emerging technologies: a systematic review of bibliometrics and conflicts of interest

Background

The use of new total joint arthroplasty technologies, including patient-specific implants/instrumentation (PSI), computer-assisted (CA), and robotic-assisted (RA) techniques, is increasing. There is an ongoing debate regarding the value provided and potential concerns about conflicts of interest (COI).

Methods

PRISMA guidelines were followed. PubMed, MEDLINE, and Web of Science databases were searched for total hip and knee arthroplasties, unicompartmental knee arthroplasties (UKA), PSI, CA, and RA. Bibliometric data, financial COI, clinical/functional scores, and patient-reported outcomes were assessed.

Results

Eighty-seven studies were evaluated, with 35 (40.2%) including at least one author reporting COI, and 13 (14.9%) disclosing industry funding. COI and industry funding had no significant effects on outcomes (P = 0.682, P = 0.447), and there were no significant effects of conflicts or funding on level of evidence (P = 0.508, P = 0.826). Studies in which author(s) disclosed COI had significantly higher relative citation ratio (RCR) and impact factor (IF) than those without (P < 0.001, P = 0.032). Subanalysis demonstrated RA and PSI studies were more likely to report COI or industry funding (P = 0.045). RA (OR = 6.31, 95% CI: 1.61–24.68) and UKA (OR = 9.14, 95% CI: 1.43–58.53) had higher odds of reporting favorable outcomes than PSI.

Conclusions

Author COIs (about 40%) may be lower than previously reported in orthopedic technologies/techniques reviews. Studies utilizing RA and PSI were more likely to report COI, while RA and UKA studies were more likely to report favorable outcomes than PSI. No statistically significant association between the presence of COIs and/or industry funding and the frequency of favorable outcomes or study level of evidence was found.

Level of evidence

Level V Systematic Review

Supplementary Information

The online version contains supplementary material available at 10.1186/s42836-022-00146-3.

Conflicts of interest among patients: do they exist and can they bias patient-reported outcome measures? A survey of shoulder and elbow patients

BACKGROUND

Potential conflicts of interest (COIs) are common among physicians and may bias physician-reported outcome assessment in orthopedic research. It is unclear whether patients have COIs and whether these COIs could affect patient-reported outcome measures (PROMs). The purposes of this study were to investigate (1) the existence of COIs among patients and (2) the potential of these COIs to bias PROMs with a pseudonymized survey among consecutive shoulder and elbow patients.

MATERIALS AND METHODS

Between February and May 2021, 144 shoulder and elbow patients who underwent consultation at our outpatient clinic were included in the survey study. Of these patients, 79.2% (n = 114) completed the 11-item questionnaire. Variables including sex, existence of chronic diseases, level of education, and economic status were also assessed to investigate any association between these variables and patients' perceptions of COIs.

RESULTS

Whereas 33.3% of respondents (n = 38) believe that COIs exist among patients and 28.1% (n = 32) believe that COIs could bias PROMs in general, fewer patients admit to personal COIs (24.6%, n = 28) and COIs biasing their self-assessment (23.7%, n = 27). Patients more frequently suggest COIs in their personal environment, such as among family members or friends (27.2%, n = 31), than in their own medical treatment. Financial factors such as sick pay (34.2%, n = 39) are thought to be the most likely reason for having COIs, followed by interpersonal reasons such as maintaining medical affection or bonds (29.8%, n = 34). Of respondents, 42.1% (n = 48) believe that sole usage of PROMs poses risks in treatment evaluation and only 21% (n = 24) consider PROMs reliable. In addition, 43% of respondents (n = 49) believe that patients should disclose COIs routinely in medical treatment. Multinomial logistic regression analysis revealed that wealthier patients are more likely to believe COIs could bias PROMs (odds ratio for poor vs. middle class, 0.23 [95% confidence interval, 0.053-0.963]; odds ratio for lower-middle class vs. middle class, 0.19 [95% confidence interval, 0.052-0.677]).

CONCLUSIONS

Although the majority of shoulder and elbow patients deny having self-experienced COIs and deny biased PROMs due to COIs in their own medical treatment, a considerable number of patients admit to having experienced both. Further studies might be justified to investigate the actual clinical relevance of patients' COIs and their impact on value-based health care.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Industry payments to spine surgeons from 2014 to 2019: trends and comparison of payments to spine surgeons versus all physicians

BACKGROUND CONTEXT

The ethics of industry payments to physicians and the potential impact on healthcare costs and research outcomes have long been topics of debate. Industry payments to spine surgeons are frequently scrutinized. Transparency of industry relationships with physicians provides insight into their possible impact on clinical decision-making and utilization of care.

PURPOSE

To analyze trends in medical industry payments to spine surgeons and all physicians from 2014 to 2019, and further evaluate whether specific payments to spine surgeons vary based on company size.

STUDY DESIGN/SETTING

Cross-sectional investigation of publicly reported Center for Medicare and Medicaid Services (CMS) Open Payments Database (OPD) POPULATION SAMPLE: All US providers listed as receiving industry payments with further evaluation of payments to neurosurgeons and orthopedic spine surgeons.

OUTCOME MEASURES

Main measures were the magnitude and trends of industry general and research payments and subcategories of general payments, such as royalty/license and consulting fees, to spine surgeons and comparison to all physicians over the six-year period. Variations in payment patterns among spine device manufacturers with the highest reported level of spine surgeon payments in 2019.

METHODS

From 2014 to 2019 publicly reported general and research industry payments in the CMS OPD were analyzed. Trends in payments to all physicians were compared to trends in payments to neurosurgeons and orthopedic spine surgeons. Trends in payment patterns among spine device manufacturers with the highest payments in 2019 were determined. Linear regression analysis was completed to find statistically significant outcomes.

RESULTS

Our investigation found an aggregate of $42,710,365,196 general and research payments reported to all physicians over the 6-year period, 2.6% ($1,112,936,203) of which went to spine surgeons. Industry general and research payments to spine surgeons decreased by 17.5% ($195,571,109, 2014; $161,283,683, 2019), while increasing by 8.7% ($6,706,208,391, 2014; $7,288,003,832, 2019) to all physicians. Industry research payments to spine surgeons were notably low each year and decreased to only 0.5% of research payments made to all physicians in 2019. Median payment received by spine surgeons as well as the overall distribution of payments to the 75th and 95th percentile significantly increased over the six-year period in comparison to the stable distribution of payments to all physicians. Top eight spine device manufactures with the highest level of spine surgeon payments accounted for 72.9% payments in 2014 but decreased payments by 17.6% to 2019 ($120,409,083.75, 2014; $99,283,264.49, 2019).

CONCLUSIONS

Industry general and research payments to all physicians increased from 2014 to 2019 but decreased to spine surgeons, largely due to decreasing payments from eight device manufacturers with the highest level of surgeon payments. A small subset of spine surgeons continues to receive increasing payments. The implications of decreasing investments in research by industry and of large payments made to a small group of spine surgeons bears cautious oversight, both for the future of the specialty and any impact on patient care outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Industry Payment Trends to Orthopaedic Surgeons From 2014 to 2018: An Analysis of the First 5 Years of the Open Payments Database

INTRODUCTION

The Open Payments Database (OPD) provides transparent reporting of all payments made to physicians from private industry. Previous studies have described the nature of these financial relationships using the first year of publicly available data. However, long-term trends of these relationships have not been well described. Therefore, we report on the value and distribution of payments within the OPD and analyze trends of payments made to orthopaedic surgeons from 2014 to 2018.

METHODS

The OPD was queried from 2014 to 2018. Payments within the database were categorized into (1) general payments, (2) research interests, and (3) ownership interests. We report on the number, value, and payment trends between private industry and all licensed orthopaedic surgeons who have completed residency training.

RESULTS

A total of 631,000 physicians and 23,859 orthopaedic surgeons were included, representing 79.8% of US board-certified orthopaedic surgeons (n = 29,908). Although orthopaedic surgeons received an average of 2.9% of the number of payments made annually, payments to orthopaedic surgeons represented 10.0% of the value of payments made to all physicians. From 2014 to 2018, payments to orthopaedic surgeons increased in both number and value, from 313,194 separate payments ($883.8 million) in 2014 to 335,815 separate payments ($958.6 million) in 2018. In 2018, the top 1% of orthopaedic surgeons (n = 239) accounted for 58.0% ($265.8 million) of all payments to the field. Despite representing only 2.4% of the number of general payments, royalties represented 68.9% ($290.4 million) of the value of general payments to orthopaedic surgeons. Payments for research and education both increased.

DISCUSSION

Industry payments to orthopaedic surgeons represent 10.0% of all physician payments, with increases in payments for research and education. Royalties represented most (68.9%) of the value of general payments made to orthopaedic surgeons. Transparency in physician payments from industry is essential to avoid conflicts of interest.

LEVEL OF EVIDENCE

Level III.

Is There an Association Between Authors' Conflicts of Interest and Outcomes in Clinical Studies Involving Autologous Chondrocyte Implantation?

BACKGROUND

Autologous chondrocyte implantation (ACI) is an increasingly popular technique for the treatment of articular cartilage defects. Because several companies have financial interests in ACI, it is important to consider possible conflicts of interest when evaluating studies reporting outcomes of ACI.

PURPOSE

To determine whether there is an association between authors' financial conflicts of interest and the outcomes of ACI studies.

STUDY DESIGN

Cross-sectional study.

METHODS

A search of PubMed and MEDLINE databases for "autologous chondrocyte implantation" was performed. Clinical studies published after 2012 through May 15, 2019, and in English were included. Studies were determined to have financial conflicts of interest if any contributing author had relevant conflicts, either self-reported in the published study's disclosures section or reported online in the American Academy of Orthopaedic Surgeons Disclosure database or the Centers for Medicare & Medicaid Services Open Payments database. The outcomes of each study were rated as favorable, equivocal, or unfavorable based on predefined criteria and then tested for association with conflicts of interest through use of the Fisher exact test.

RESULTS

A total of 79 studies met the inclusion criteria. Nearly all studies were of level 3 or 4 evidence. Conflicts of interest were established in 51.90% of studies (n = 41). Conflicts that were not self-reported by the authors were discovered in 18% of studies. The level of evidence was not associated with conflict of interest. No statistically significant difference was found in the rate of favorable outcomes between studies with conflicts (92.68%) and those with no conflicts (81.58%) (P = .126). Publications by US authors were more likely to have financial conflicts of interest (P = .003).

CONCLUSION

Favorable results were reported in a majority of studies involving ACI. No statistical association was found between the frequency of favorable outcomes and the presence of financial conflicts of interest, country of authorship, or level of evidence. There was a trend toward more favorable outcomes in studies with conflicts of interest. Additionally, nearly 20% of publications had possible conflicts found online that were not self-reported. It is critical for orthopaedic surgeons to judiciously evaluate published studies and consider financial conflicts of interest before performing ACI techniques on patients.

Nonsensus in the treatment of proximal humerus fractures: uncontrolled, blinded, comparative behavioural analysis between Homo chirurgicus accidentus and Macaca sylvanus

OBJECTIVE

To investigate the inter-rater reliability of Barbary macaques compared with an expert group of surgeons for the choice of treatment and predicted outcome of proximal humerus fractures.

DESIGN

Uncontrolled, blinded, comparative behavioural analysis.

SETTING

Germany and United States.

PARTICIPANTS

10 blinded experts in the field of orthopaedic trauma surgery (Homo chirurgicus accidentus), with special focus on upper extremity surgery from Germany and the US, and five Barbary macaques (Macaca sylvanus) from a semi-free range enclosure.

MAIN OUTCOME MEASURES

The reliability of agreement between raters assessed with Fleiss' ĸ.

RESULTS

Barbary macaques seem to have inferior inter-rater reliability in comparison with experts for choice of treatment (non-surgical v surgical), but for the geriatric age group most frequently affected by proximal humeral fractures, they performed similarly to the experts in their choices of treatment and choice of surgical procedure. Agreement about predicted outcome was poor among the macaques and slight among the experts. All experts almost always predicted the outcome incorrectly and tended to underestimate it. While only 4 (4.4%) of 90 experts' predictions were correct, 13 (28.9%) of 45 macaques' predictions were correct.

CONCLUSIONS

Consensus on treatment and expected outcomes of proximal humeral fractures is lacking even beyond the human species. Although Barbary macaques tend to predict the clinical outcome more accurately, their reliability to assist surgeons in making a consistent decision is limited. Future high quality research is needed to guide surgeons' decision making on the optimal treatment of this common injury.

Identifying competing interest disclosures in systematic reviews of surgical interventions and devices: a cross-sectional survey

Background

A competing interest is an important source of bias in research and disclosure is frequently employed as a strategy to manage it. Considering the importance of systematic reviews (SRs) and the varying prevalence of competing interests in different research fields, we conducted a survey to identify the range of competing interests in SRs assessing surgical interventions or devices and explored the association between the competing interest disclosures and authors’ conclusions.

Methods

We retrieved SRs of surgical interventions and devices published in 2017 via PubMed. Information regarding general characteristics, funding sources, and competing interest disclosures were extracted. We conducted a descriptive analysis of the studies’ characteristics and compared them between Cochrane SRs (CSRs) and non-Cochrane SRs using the Chi-square test. Results were expressed as odds ratio and their 95% confidence interval.

Results

One hundred fifty-five SRs published in 2017 were included in the study. More than half of the SRs (58.7%) reported their funding sources and 94.2% reported authors’ competing interest disclosures. Among 146 SRs that stated competing interest disclosures, only 35 (22.6%) SRs declared at least one author had a competing interest. More than 40 terms were used to describe competing interests. Cochrane SRs (CSRs) were more likely to provide a detailed description of competing interests compared to those in non-CSRs (48.0% versus 25.4%, P = 0.023). No association between positive conclusions and competing interest disclosures was found (P = 0.484, OR = 0.43, 95%CI: 0.08, 2.16). In the subgroup analyses, SRs stating no competing interest disclosure were more likely to report positive conclusions than those stating at least one type of competing interest, but the difference is not significantly different (P = 0.406, OR = 1.38, 95%CI: 0.64, 2.98).

Conclusion

In surgical SRs, there is a high percentage of competing interest disclosures but without detailed information. The identification and statement of competing interests with a detailed description, particularly the non-financial ones, needs improvement. Some efficient and effective methods/tools for identifying, quantifying, and minimizing potential competing interests in systematic reviews remains valuable.

Opinion leaders in the medical community attract more attention than randomized controlled trials in shoulder surgery

PURPOSE

The objective of this study was to determine whether opinion leaders in the medical community attract more attention than randomized controlled trials (RCT) in shoulder surgery.

METHODS

A PubMed search to retrieve all therapeutic and diagnosis RCT shoulder studies was carried out. Three opinion leaders were chosen from among the last ten presidents of the European Shoulder and Elbow Society based on the number of publications. Their studies were also retrieved from PubMed. The metrics of the studies were determined through ResearchGate and Web of Science. The year of publication, impact factor of the journal, level of evidence, number of citations, number of reads, research interest, and reported conflicts of interest were recorded for every study.

RESULTS

Two-hundred forty-five shoulder RCTs and 236 opinion leader studies met the inclusion criteria. The opinion leader studies were read significantly more times than the RCTs (p = 0.04). The mean impact factor for RCT studies was 2.84 (SD 3.9) while it was of 1.99 (SD1.14) in the opinion leader group (p < 0.001). Most of the studies of the opinion leaders were level IV (73.3%), while only 6.3% of their papers were categorized as levels I-II. Conflict of interest was present in 19.6% of the RCTs and in 32.2% of the opinion leader studies (p < 0.001).

CONCLUSION

The medical community pays more attention to opinion leader studies in shoulder surgery than to RCT studies even though RCTs are published in higher impact factor journals and opinion leader studies are mainly level IV evidence studies.

Reproducible research practices and transparency in reproductive endocrinology and infertility articles

OBJECTIVE

To analyse the published literature in reproductive endocrinology and infertility (REI) to examine the transparency and the use of reproducible research practices of the scientific literature and to identify possible avenues for improvement.

DESIGN

Meta-epidemiologic study. We examined the first 20 consecutive full-text original articles presenting primary data from five REI-specific journals for 2013 and for 2018, and eligible REI articles published in 2013-2018 in five high-impact general journals. Eligible articles were required to be full-text original articles, presenting primary data.

SETTING

Not applicable.

PATIENT(S)

Not applicable.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Each article was assessed for study type, trial registration, protocol and raw data availability, funding and conflict of interest declarations, inclusion in subsequent systematic reviews and/or meta-analyses, sample size, and whether the work claimed to be novel or replication. Sample sizes and citation counts also were obtained.

RESULT(S)

A total of 222 articles were deemed eligible; 98 from REI journals published in 2013, 90 from REI journals published in 2018, and 34 from high-impact journals. There were 37 studies registered, 15 contained a protocol, and two stated actively that they were willing to share data. Most studies provided a statement about funding and conflicts of interest. Two articles explicitly described themselves as replications. All randomized controlled trial published in REI journals were registered prospectively; many meta-analyses were not registered. High-impact journal articles had a greater median sample size and more citations and were more likely to be registered, to have a protocol, and to claim novelty explicitly when compared with REI 2013 and 2018 articles.

CONCLUSION(S)

Research in REI can be improved in prospective registration, routine availability of protocols, wider sharing of raw data whenever feasible, and more emphasis on replication.

Industry Consulting Payments to Orthopedic Surgeons Are Associated With Increased Publications

In accordance with the Physician Payment Sunshine Act, all industry payments to physicians in the United States have become publicly available. Previous research has indicated that orthopedic surgeons receive the greatest amount of industry compensation compared with other surgical subspecialists. However, the relationship between this compensation and research productivity is less clear. This study sought to investigate the relationship between consulting fees paid to orthopedic surgeons and academic productivity. Using the Centers for Medicare & Medicaid Services Open Payments Database, this study identified 2555 orthopedic surgeons who received at least one industry consulting fee in 2015. Physicians who received total consulting fees of at least $20,000 (US) were stratified into the high payment group. The number of publications and the h-index for each physician were used as metrics of scholarly impact. Mean publication number and h-index for the high payment group were compared with all other physicians in the sample using an independent-samples t test. A total of 2555 orthopedic surgeons received consulting payments totaling $62,323,143 in 2015. The mean consulting payment was $24,393 (SD, $45,465). The publication number was greater for the high payment group (mean, 61.6; SD, 135.6) compared with all other physicians in the sample (mean, 36.1; SD, 95.6). Additionally, the mean h-index for the high payment group was 13.7 (SD, 14.3) compared with 10.0 (SD, 11.6) for all other orthopedic surgeons. These findings indicate that the orthopedic surgeons who receive more in industry consulting fees are also those who contribute most substantially to the body of orthopedic literature. [Orthopedics. 2019; 42(3):137-142.].

Assessment of Pharmaceutical Company and Device Manufacturer Payments to Gastroenterologists and Their Participation in Clinical Practice Guideline Panels

IMPORTANCE

Payments from pharmaceutical and device manufacturers to physicians may influence the advice physicians give patients and peers.

OBJECTIVES

To investigate the nature and amounts of monetary and other benefits that gastroenterologists received and to determine the participation of those receiving benefits in the formulation of clinical practice guidelines.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed information from the Centers for Medicare & Medicaid Services Open Payments database, including all reports about payments that pharmaceutical and device manufacturers gave to adult or pediatric gastroenterologists in 2016. PubMed was used to examine the professional affiliations and publication records of top payment recipients. Panelists of clinical guidelines who also received personal financial rewards listed in the Open Payments database were identified.

MAIN OUTCOMES AND MEASURES

Payments made to gastroenterologists by pharmaceutical company and device manufacturers.

RESULTS

Of 15 497 gastroenterologists, 13 467 (86.9%) received a total of 432 463 payments accounting for a total expenditure of $67 144 862. Direct financial payments for consultations, talks, or other services were made to 2055 physicians and were responsible for 4.2% of payments (18 179 of 432 463), but for 62.7% of total expenditures ($42 086 207 of $67 144 862). Although a significant number of submissions were for food and beverages, they constituted only a small amount of total expenditure. For gastroenterologists treating adult patients, 10 products were linked to 63.8% of payments (11 221 of 17 588) related to direct financial rewards and 37.1% of the total expenditures ($24 892 643 of $67 144 862). Twenty-nine of 36 clinical practice guidelines included panelists who had received honoraria or consultation fees from industry sources, with amounts exceeding $10 000 in 8 of them (22%).

CONCLUSIONS AND RELEVANCE

Most gastroenterologists accept meals or gifts from industry, with 2055 of 15 497 gastroenterologists receiving direct payments and 8 of 36 clinical practice guidelines panelists having received more than $10 000. Considering the known impact of such benefits on prescribing patterns and other professional behaviors, policy makers should consider revising regulations governing interactions with industry and disclosure formats alerting others to their potential biasing impact.

Differences in Reported Outcomes in Industry-Funded vs Nonfunded Studies Assessing Thromboprophylaxis After Total Joint Arthroplasty

BACKGROUND

There are numerous studies discussing thromboprophylaxis after total joint arthroplasty (TJA), with varying conclusions. Patient inclusion criteria may be different for each study, which may lead to selection bias and misrepresentation of data. This study aimed to investigate if industry funding impacted patient demographics and overall reported outcomes of studies analyzing venous thromboembolism (VTE) prevention after TJA.

METHODS

Electronic searches were completed using Ovid, PubMed, and Embase databases. Studies were included if (1) they are published in the English language between 2000 and 2016; (2) they included patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA); and (3) they evaluated prevention and control of postoperative VTE with at least one of the following thromboprophylactic agents: aspirin, enoxaparin, dalteparin, dabigatran, apixaban, rivaroxaban, dabigatran, ximelagatran, fondaparinux, or coumadin. Data were extracted and analyzed via mixed-effect logistic regression.

RESULTS

Fifty-seven studies were included; 29 were industry funded, and 28, nonfunded. There were no significant differences between patient's age, body mass index, or revision exclusions between funded and nonfunded studies. Funded studies reported less pulmonary embolisms, fewer events of major bleeding, and significantly less 90-day mortality compared with nonfunded studies.

CONCLUSION

Industry-funded studies reported less pulmonary embolisms, major bleeding, and mortality compared with nonfunded studies. Detailed demographic data were missing from the literature, and we were unable to demonstrate the cause of different reported outcomes between industry-funded and nonfunded studies. Further investigations should be aimed toward understanding how funded studies report less adverse outcomes in analyzing VTE after TJA.

Analysis of the conflicts of interest disclosed by the program reviewers of the scoliosis research society (SRS) congresses, 2010-2014

BACKGROUND

Conflicts of interest (COI) between industry and surgeons frequently introduce biases into surgical research. The abstracts submitted for presentation in scientific congresses are usually vetted for any indication of commercial bias. Members of review program committees regularly have recognized qualifications, and therefore certain COI are unavoidable. This study aims to determine the prevalence and magnitude of possible COI among those responsible for the selection of presentations at two important international conferences on spine surgery during a five-year period.

METHODOLOGY

COI declarations by those responsible for the final programs of the annual SRS (Scoliosis Research Society) and IMAST (International Meeting of Advanced Spine Technologies) conferences from 2010 to 2014 were collected and analyzed from data published by the corresponding scientific programs. The SRS's disclosure index did not contain financial amounts; therefore, this aspect could not be analyzed.

RESULTS

Five scientific committees and 117 members (76 individuals) were studied. Of these 76, 41 (53.9%) participated in more than one conflict of interest (>1 COI). Scientific committee members were from 11 countries across 4 continents, but most were from the Unites States (76.9%). Of the 117 program reviewers, 65.8% declared >1 COI and 34.2% reported no COI. The 77 program reviewers who disclosed a potential COI declared a total of 273 COI (mean = 3.54 COI/member). Overall, 36.0%, 26.1%, 10.7%, and 10.7% of the COI corresponded to consultancies, research funds, bureau participation, and advisory board panel participation, respectively. Stockholder reimbursement corresponded to 8.8% of the disclosed COI, and financial or material support were mentioned in 7.4% of COI. Among the COI disclosures, 55 companies were mentioned, and 5 of the top 10 companies involved in spinal device markets were responsible for 65.2% of the COI.

CONCLUSIONS

More than two thirds of the members of the SRS and IMAST scientific committees reported COI. Consultancies and research grants account for two thirds of these. Most of the grants and major COI are related to the five companies leading the spinal implant market.

Plastic Surgeons' Perceptions of Financial Conflicts of Interest and the Sunshine Act

BACKGROUND

It is unknown whether recent legislation known as the Physician Payments Sunshine Act has affected plastic surgeons' views of conflicts of interest (COI). The purpose of this study was to evaluate plastic surgeons' beliefs about COI and their comprehension of the government-mandated Sunshine Act.

METHODS

Plastic surgeon members of the American Society of Plastic Surgeons were invited to complete an electronic survey. The survey contained 27 questions that assessed respondents' past and future receipt of financial gifts from industry, awareness of the Sunshine Act, and beliefs surrounding the influence of COI on surgical practice.

RESULTS

A total of 322 individuals completed the survey. A majority had previously accepted gifts from industry (n = 236; 75%) and would accept future gifts (n = 181; 58%). Most respondents believed that COI would affect their colleagues' medical practice (n = 190; 61%) but not their own (n = 165; 51%). A majority was aware of the Sunshine Act (n = 272; 89%) and supported data collection on surgeon COI (n = 224; 73%). A larger proportion of young surgeons believed patients would benefit from knowing their surgeon's COI (P = 0.0366). Surgeons who did not expect COI in the future believed financial COI could affect their own clinical practice (P = 0.0221).

CONCLUSIONS

Most plastic surgeons have a history of accepting industry gifts but refute their influence on personal clinical practice. Surgeon age and anticipation of future COI affected beliefs about the benefits of COI disclosure to patients and the influence of COI on surgical practice.

Cervical disc arthroplasty: do conflicts of interest influence the outcome of clinical studies?

BACKGROUND CONTEXT

Cervical disc arthroplasty (CDA) is an emerging technique for the treatment of cervical degenerative disease. Multiple studies have investigated the outcomes of CDA, particularly in comparison with cervical arthrodesis techniques such as anterior cervical discectomy and fusion (ACDF). As many entities have financial interests in CDA implants, it is imperative to consider the influence of conflicts of interest on the results of studies investigating the efficacy of CDA.

PURPOSE

This study aimed to determine if there is an association between the presence of conflicts of interest among study authors and the reported outcome of studies involving CDA.

STUDY DESIGN

This is a systematic review of clinical CDA publications until October 2016.

OUTCOME MEASURE

The outcome measures are presence of conflicts of interest, level of evidence, and outcome for all included studies.

METHODS

PubMed and MEDLINE databases were searched for articles presenting clinical, radiographic, and cost outcomes of CDA. Data extracted from each article included title, authors, publication year, level of evidence, prosthesis type, number of operative levels, presence of conflicts of interest, and outcome. Conflicts of interest were determined by the presence of any conflicts for any author within manuscript disclosure sections or through Open Payments reporting. Outcomes of each study were graded as either favorable, unfavorable, or equivocal. The presence of conflicts of interest was tested for an association with the level of evidence and study outcome using Pearson chi-square analysis, Fisher exact test, or logistic regression for categorical variables. The authors report no conflicts of interest directly related to this work, and have not received any funds in support of this work.

RESULTS

A total of 98 articles were included in this analysis. In total, 44.9% (44) of articles had the presence of a conflict of interest, whereas 55.1% (54) of articles did not. Conflicted studies were more likely to present level I evidence and less likely to present level IV evidence than non-conflicted studies (p<.001). Furthermore, conflicted studies were more likely to report favorable outcomes after CDA than non-conflicted studies (90.9% vs. 74.1%, p=.040).

CONCLUSIONS

The results of this study suggest that the majority of conflicted and non-conflicted studies report favorable results in patients undergoing CDA. However, conflicted studies were also more likely to report favorable outcomes compared with non-conflicted studies. Individual clinicians must critically review published studies for potential conflicts of interest before incorporating CDA into their practice.

Funding sources and financial disclosures, and their relationship to study outcomes and level of evidence in the Journal of Shoulder and Elbow Surgery

HYPOTHESIS/BACKGROUND

Concern exists regarding the reliability of published manuscripts due to influence of industry funding and author financial conflicts of interest (COI). We aim to determine whether COI affect the outcome of a research study or the level of evidence (LOE).

METHODS

We reviewed 244 consecutive original articles in Journal of Shoulder and Elbow Surgery from January 2014 to December 2014. Articles included only those available in the printed journal. For LOE, 178 articles from the Shoulder and Elbow section were used (basic science articles were excluded). COI was determined by comparing financial disclosures and stated funding sources to the study content.

RESULTS

COI were present in 44 of 244 articles (18%); of these, 24 (55%) had positive outcomes. Of the 200 without COI, 128 (64%) had positive outcomes. This difference in proportions was determined to be significant (P = .007). COI were present in 27 shoulder and elbow articles; of these, only 1 was LOE I or II (4%). Of the 151 without COI, 34 (23%) were LOE I or II. This difference in proportions was determined to be significant (P = .023).

CONCLUSION

We found that Journal of Shoulder and Elbow Surgery articles with COI are neither more likely to have positive outcomes nor higher LOE than those with no COI. Although the χ² analysis found a statistically significant relationship between COI and study outcomes, the study outcomes were more often positive in articles without COI. This is contrary to previously published analyses that found outcomes to be more positive in articles with COI.

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.

Bias in cervical total disc replacement trials

PURPOSE OF REVIEW

Cervical disc replacement (CDR) has emerged as a motion-preserving alternative to anterior cervical discectomy and fusion in selected cases. Despite favorable literature, CDR is not universally accepted because of concerns regarding bias in the existing literature. The purpose of this review is to identify the possible biases in the disc replacement literature.

RECENT FINDINGS

Recent studies that compare CDR and ACDF have demonstrated equivalent or superior outcomes, lower rates of secondary surgery, and equivalent safety at medium- and long-term follow-up. In our review, we identified four types of bias that may affect the CDR literature: publication bias, external validity, confounding bias, and financial conflicts of interest. Bias, whether intentional or unintentional, can impact the interpretation and outcome of CDR studies. Recognition of this issue is critical when utilizing the existing literature to determine the efficacy of CDR and designing future studies.

Industry sponsorship and research outcome

BACKGROUND

Clinical research affecting how doctors practice medicine is increasingly sponsored by companies that make drugs and medical devices. Previous systematic reviews have found that pharmaceutical-industry sponsored studies are more often favorable to the sponsor's product compared with studies with other sources of sponsorship. A similar association between sponsorship and outcomes have been found for device studies, but the body of evidence is not as strong as for sponsorship of drug studies. This review is an update of a previous Cochrane review and includes empirical studies on the association between sponsorship and research outcome.

OBJECTIVES

To investigate whether industry sponsored drug and device studies have more favorable outcomes and differ in risk of bias, compared with studies having other sources of sponsorship.

SEARCH METHODS

In this update we searched MEDLINE (2010 to February 2015), Embase (2010 to February 2015), the Cochrane Methodology Register (2015, Issue 2) and Web of Science (June 2015). In addition, we searched reference lists of included papers, previous systematic reviews and author files.

SELECTION CRITERIA

Cross-sectional studies, cohort studies, systematic reviews and meta-analyses that quantitatively compared primary research studies of drugs or medical devices sponsored by industry with studies with other sources of sponsorship. We had no language restrictions.

DATA COLLECTION AND ANALYSIS

Two assessors screened abstracts and identified and included relevant papers. Two assessors extracted data, and we contacted authors of included papers for additional unpublished data. Outcomes included favorable results, favorable conclusions, effect size, risk of bias and whether the conclusions agreed with the study results. Two assessors assessed risk of bias of included papers. We calculated pooled risk ratios (RR) for dichotomous data (with 95% confidence intervals (CIs)).

MAIN RESULTS

Twenty-seven new papers were included in this update and in total the review contains 75 included papers. Industry sponsored studies more often had favorable efficacy results, RR: 1.27 (95% CI: 1.17 to 1.37) (25 papers) (moderate quality evidence), similar harms results RR: 1.37 (95% CI: 0.64 to 2.93) (four papers) (very low quality evidence) and more often favorable conclusions RR: 1.34 (95% CI: 1.19 to 1.51) (29 papers) (low quality evidence) compared with non-industry sponsored studies. Nineteen papers reported on sponsorship and efficacy effect size, but could not be pooled due to differences in their reporting of data and the results were heterogeneous. We did not find a difference between drug and device studies in the association between sponsorship and conclusions (test for interaction, P = 0.98) (four papers). Comparing industry and non-industry sponsored studies, we did not find a difference in risk of bias from sequence generation, allocation concealment, follow-up and selective outcome reporting. However, industry sponsored studies more often had low risk of bias from blinding, RR: 1.25 (95% CI: 1.05 to 1.50) (13 papers), compared with non-industry sponsored studies. In industry sponsored studies, there was less agreement between the results and the conclusions than in non-industry sponsored studies, RR: 0.83 (95% CI: 0.70 to 0.98) (six papers).

AUTHORS' CONCLUSIONS

Sponsorship of drug and device studies by the manufacturing company leads to more favorable efficacy results and conclusions than sponsorship by other sources. Our analyses suggest the existence of an industry bias that cannot be explained by standard 'Risk of bias' assessments.

The quality of randomised controlled trials involving surgery from the hand to the elbow

Aims

Our purpose was to determine the quality of current randomised controlled trials (RCTs) in hand surgery using standardised metrics.

Materials and Methods

Based on five-year mean impact factors, we selected the six journals that routinely publish studies of upper extremity surgery. Using a journal-specific search query, 62 RCTs met our inclusion criteria. Then three blinded reviewers used the Jadad and revised Coleman Methodology Score (RCMS) to assess the quality of the manuscripts.

Results

Based on the Jadad scale, 28 studies were of high quality and 34 were of low quality. Methodological deficiencies in poorly scoring trials included the absence of rate of enrolment, no power analysis, no description of withdrawal or dropout, and a failure to use validated outcomes assessments with an independent investigator.

Conclusion

A large number of RCTs in hand, wrist, and elbow surgery were of suboptimal quality when judged against the RCMS and Jadad scales. Even with a high level of evidence, study design and execution of RCTs should be critically assessed. Methodological deficiencies may introduce bias and lead to statistically underpowered studies. Cite this article: Bone Joint J 2017;99-B:94–9.

Variable Reporting by Authors Presenting Arthroplasty Research at Multiple Annual Conferences

BACKGROUND

Prior studies have demonstrated discrepancies in financial conflict of interest (COI) disclosure among authors presenting research at multiple spine and sports medicine conferences. The purpose of this study was to quantify the variability of self-reported financial disclosures of individual authors presenting at multiple arthroplasty conferences during the same year.

METHODS

The author disclosure information published for the 2012 annual meetings of the American Academy of Orthopaedic Surgeons (AAOS), American Association of Hip and Knee Surgeons, the Hip Society, and the Knee Society were compiled. We tabulated the author disclosures, the number of companies/entities represented, and the types of disclosures reported. The disclosures made by authors presenting at more than one meeting were then compared for discrepancies.

RESULTS

Of the 209 authors who presented at both the AAOS and American Association of Hip and Knee Surgeons meetings, 79 (37.79%) demonstrated discrepancies in their disclosures with 7 (8.8%) reporting no disclosures to the AAOS. Of the 84 authors who presented at both the AAOS and Hip Society meetings, 1 (1.19%) had discrepancies in their disclosures. Of the 52 authors who presented at both the AAOS and Knee Society meetings, 2 (3.84%) had discrepancies in their disclosures.

CONCLUSION

There is variability in reported financial COIs by authors presenting at multiple arthroplasty conferences within the same year. Further work is warranted to improve transparency of COI disclosures among arthroplasty surgeons presenting research at national meetings.

Orthopaedic Surgeons Receive the Most Industry Payments to Physicians but Large Disparities are Seen in Sunshine Act Data

BACKGROUND

Industry payments made to physicians by drug and device manufacturers or group purchasing organizations are now reported to the Centers for Medicare and Medicaid Services (CMS) as a part of the Physician Payments Sunshine Act. Initial reports from the program show that orthopaedic surgeons lead all physician specialties in total and average industry payments. However, before further discussion of these payments and their implications can take place, it remains to be seen whether these figures are a true reflection of the field of orthopaedic surgery in general, rather than the result of a few outlier physicians in the field. In addition, the nature and sources of these funds should be determined to better inform the national dialogue surrounding these payments.

QUESTIONS/PURPOSES

We asked: (1) How do industry payments to orthopaedic surgeons compare with payments to physicians and surgeons in other fields, in terms of median payments and the Gini index of disparity? (2) How much do payments to the highest-receiving orthopaedic surgeons contribute to total payments? (3) What kind of industry payments are orthopaedic surgeons receiving? (4) How much do the highest-paying manufacturers contribute to total payments to orthopaedic surgeons?

MATERIALS AND METHODS

We reviewed the most recent version of the CMS Sunshine Act Open Payments database released on December 19, 2014, containing data on payments made between August 1, 2013 and December 31, 2013. Data on total payments to individual physicians, physician specialty, the types of payments made, and the manufacturers making payments were reviewed. The Gini index of statistical dispersion was calculated for payments made to orthopaedic surgeons and compared with payments made to physicians and surgeons in all other medical specialties. A Gini index of 0 indicates complete equality of payments to everyone in the population, whereas an index of 1 indicates complete inequality, or all income going to one individual.

RESULTS

A total of 15,376 orthopaedic surgeons receiving payments during the 5-month period were identified, accounting for USD 109,846,482. The median payment to orthopaedic surgeons receiving payments was USD 121 (interquartile range, USD 34-619). The top 10% of orthopaedic surgeons receiving payments (1538 surgeons) received at least USD 4160 and accounted for 95% of total payments. Royalties and patent licenses accounted for 69% of all industry payments to orthopaedic surgeons.

CONCLUSIONS

Even as a relatively small specialty, orthopaedic surgeons received substantial payments from industry (more than USD 110 million) during the 5-month study period. Whether there is a true return of value from these payments remains to be seen; however, future ethical and policy discussions regarding industry payments to orthopaedic surgeons should take into account the large disparities in payments that are present and also the nature of the payments being made. It is possible that patients and policymakers may view industry payments to orthopaedic surgeons more positively in light of these new findings.

LEVEL OF EVIDENCE

Level III, Economic and Decision Analysis.

Are Financial Conflicts of Interest for the Surgeon A Source of Concern for the Patient?

We surveyed 269 consecutive patients (81% response rate) with an anonymous questionnaire to assess their attitudes toward conflicts-of-interest (COIs) resulting from three financial relationships between orthopedic surgeons and orthopedic industry: (1) being paid as a consultant; (2) receiving research funding; (3) receiving product design royalties. The majority perceived these relationships favorably, with 75% agreeing that surgeons in such relationships are top experts in the field and two-thirds agreeing that surgeons engage in such relationships to serve patients better. Patients viewed surgeons who designed products more favorably than those who are consultants (P=0.03). The majority (74%) agreed that these COIs should be disclosed to patients. Given patients' desires for disclosure and their favorable perceptions of these relationships, open discussions about financial COIs is appropriate.

Strategies to improve the credibility of meta-analyses in spine surgery: a systematic survey

BACKGROUND CONTEXT

Meta-analyses are powerful tools that can synthesize existing research, inform clinical practice, and support evidence-based care. These studies have become increasingly popular in the spine surgery literature, but the rigor with which they are being conducted has not yet been evaluated.

PURPOSE

Our primary objectives were to evaluate the methodological quality (credibility) of spine surgery meta-analyses and to propose strategies to improve future research. Our secondary objectives were to evaluate completeness of reporting and identify factors associated with higher credibility and completeness of reporting.

STUDY DESIGN

This study is based on a systematic survey of meta-analyses.

OUTCOME MEASURES

We evaluated credibility according to the Users' Guide to the Medical Literature and completeness of reporting according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist.

METHODS

We systematically searched MEDLINE, EMBASE, and The Cochrane Library, and two reviewers independently assessed eligibility, credibility, and completeness of reporting. We used multivariable linear regression to evaluate potential associations. Interrater agreement was quantified using kappa and intraclass correlation (ICC) coefficients.

RESULTS

We identified 132 eligible meta-analyses of spine surgery interventions. The mean credibility score was 3 of 7 (standard deviation [SD], 1.4; ICC, 0.86), with agreement for each item ranging from 0.54 (moderate) to 0.83 (almost perfect). Clinical questions were judged as sensible in 125 (95%), searches were exhaustive in 102 (77%), and risk of bias assessments were undertaken in 91 (69%). Seven (5%) meta-analyses addressed possible explanations for heterogeneity using a priori subgroup hypotheses and 24 (18%) presented results that were immediately clinically applicable. Investigators undertook duplicate assessments of eligibility, risk of bias, and data extraction in 46 (35%) and rated overall confidence in the evidence in 24 (18%). Later publication year, increasing Journal Impact Factor, increasing number of databases, inclusion of Randomized Controlled Trials, and inclusion of non-English studies were significantly associated with higher credibility scores (p<.05). The mean score for reporting was 18 of 27 (SD, 4.4; ICC, 0.94).

CONCLUSIONS

The credibility of many current spine surgery meta-analyses is limited. Researchers can improve future meta-analyses by performing exhaustive literature searches, addressing possible explanations of heterogeneity, presenting results in a clinically useful manner, reproducibly selecting and assessing primary studies, addressing confidence in the pooled effect estimates, and adhering to guidelines for complete reporting.

Does Extended-Release Liposomal Bupivacaine Better Control Pain Than Bupivacaine After Total Knee Arthroplasty (TKA)? A Prospective, Randomized Clinical Trial

Liposomal bupivacaine periarticular injection (PAI) offers sustained bupivacaine release after TKA, but few prospective independent studies exist. In this prospective, blinded study, liposomal bupivacaine was randomized against bupivacaine and incorporated into a comprehensive multimodal pain management protocol. 111 primary TKAs were randomized to receive PAI: 58 patients received 266 mg (20cc) liposomal bupivacaine mixed with 75 mg (30cc) 0.25% bupivacaine, and 53 patients received 150 mg (60cc) 0.25% bupivacaine. Visual analog pain scores and narcotic use were determined. No pain score differences occurred between study and control patients: Day 1: 4.5/4.6 (P=0.73); Day 2: 4.4/4.8 (P=0.27); or Day 3: 3.5/3.7 (P=0.58). Narcotic use was similar during hospitalization, 51.8/54.2 (P=0.34). The study medication costs $285, and the control medication costs $2.80. This finding does not justify the routine use of liposomal bupivacaine.

Conflicts of interest in research: looking out for number one means keeping the primary interest front and center

Conflicts of interest represent circumstances in which professional judgments or actions regarding a primary interest, such as the responsibilities of a medical researcher, may be at risk of being unduly influenced by a secondary interest, such as financial gain or career advancement. The secondary interest may be financial or non-financial, and the resultant bias may be conscious or unconscious. The presence of conflicts of interest poses a problem for professional, patient, and public trust in research and the research enterprise. Effective means of identifying and managing conflicts are an important element in successfully achieving the goals of research. These strategies typically focus on the investigator and rely upon disclosure, which has substantial limitations. Additional management strategies include process-oriented steps and outcomes-oriented strategies. More attention to identifying and managing non-financial conflicts is needed. Future empirical research will be important for defining which conflicts need to be better addressed and how to achieve this goal.