Saturday, January 12, 2019

In case you didn’t know, over a third of ER docs are industry puppets

I am a close follower of the Emergency Medicine Literature of Note blog. The author, Ryan Radecki, takes a skeptical approach to surrogate endpoints and is generally careful to avoid conclusions that over reach the data.

He seems to have violated his own rules, however, in his approach to this report on industry gifts to physicians. From the paper:


Characterize the frequency and magnitude of all categories of publicly reported financial payments made to emergency physicians (EPs) in the United States (U.S.) in 2017.


This cross-sectional study of the 2017 Centers for Medicare and Medicaid Services Open Payments Database was exempt from Institutional Review Board Review. We calculated descriptive statistics of the frequency, type, and amount (medians) of general, research, and ownerships transactions made to EPs from industry, described regional differences of median payments to EPs, and characterized the drugs or devices most commonly associated with transactions.


In 2017, among 40,899 practicing U.S. EPs, 14,447 (35.4%) received 51,870 general payments from industry totaling $12,870,832. The median per-physician payment was $18.30 (interquartile range [IQR], $13.63–$60.90). The most frequent transaction was food and beverage (89.6%), though most payments by dollar amount were related to speaker and consulting fees (74.5%). Antithrombotics were the most frequently drug or device associated with transactions. Only 35 (0.08%) and 20 (0.05%) EPs had research and ownership relationships with industry, respectively. A significant difference was observed in median payments per physician across all U.S. Census regions (p  less than 0.01) except when comparing Northeast and West (p = 1.00).


Over one-third of U.S. EPs had general payments from industry in 2017, while less than 1% of EPs had either research and ownership payments during this time period. Consistent with previous research, most payments to EPs are of low monetary value. Antithrombotics remain the most frequent drug associated with payments to EPs.

The vast majority of the gifts were small: lunches and dinners. There’s been quite a bit of research showing that even small gifts such as these influence physicians, largely out of their awareness. The problem with this research, extensive as it is, is that it is based on soft surrogate endpoints. Virtually nothing is known about the extent of the influence, let alone any downstream effects that might impact patient outcomes, for good or harm.

But Radecki’s post says this:

It’s CMS Open Payments Database time again, updated for 2017. Sadly, it turns out you or at least one of your closest colleagues is a witting or unwitting puppet of the pharmaceutical industry: a full 35.4% of practicing U.S. emergency physicians received payments from industry last year.

Clearly out of keeping with his usually cautions approach. Doesn’t the issue deserve more nuance?

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