Annual payment trends from 2014 to 2022
After excluding several
general-payment categories for acquisition, debt forgiveness, and
long-term medical supply or device loans from GPEOR, the time series
analyses showed that per-physician GPEOR significantly decreased by
4.4% (95% CI: -5.7% to -3.3%, p<0.001), while there was no
significant change in the number of endocrinologists receiving GPEOR
between 2014 and 2019 (Supplemental Material 5). As compared to
2014-2019, the number of endocrinologists accepting GPEOR significantly
decreased by more than half and per-physician GPEOR also decreased by
approximately 20% during the COVID-19 pandemic period (2020-2022).
There were slight increasing trends in both the number of
endocrinologists receiving GPEOR and per-physician GPEOR increased
between 2020 and 2022, although the number of endocrinologists receiving
GPEOR (4358) and total amounts of GPEOR ($37.2 million) in 2022 were
still substantially under those (5034 and $68.9 million) in 2019.
Median per-physician associated research payments were the lowest in
2021 at $40,300 (IQR: $7,715–$179,700) and there were no significant
trends in per-physician annual associated research payments before
(2014-2019) and during the COVID-19 pandemic (2020-2022) (Supplemental
Material 5). The time series analyses showed the number of
endocrinologists receiving associated research payments decreased
between 2014 and 2019 and showed more marked decreases at the beginning
of the COVID-19 pandemic (2020). The number of endocrinologists
receiving direct research payments also decreased at the beginning of
the COVID-19 pandemic: however generally there were no significant
changes in per-physician direct research payments over the study period.
Discussion
This study sheds light on physician-industry financial relationships in
the field of endocrinology reported under the Sunshine Act in the US.
The study analyses show that US endocrinologists received a total of
$2.06 billion from 891 pharmaceutical and medical device companies
during the 9 years between 2014 and 2022, and most industry payments
were made for research purposes. Although
50.5% to 68.0% of all
endocrinologists received at least one GPEOR each year, less than 10%
of endocrinologists received associated research funding each year.
Per-physician annual general payments decreased by 4.4% between 2014
and 2019. Industry general payments were disproportionately distributed
to a small number of endocrinologists. Although prior studies have
investigated the financial relationships between physicians and
healthcare industries in specialties, few have been conducted in
endocrinology.
The study found that endocrinologists received high median general
(non-research) payments in the healthcare industry, especially compared
to other specialists and primary care physicians (4,16,25,28,29). This
is consistent with a previous three-year analysis by Inoue et al. (28).
According to a previous study by Tringale et al. (4), primary care
physicians, who care for and manage most diabetes and obesity patients,
received $179 in median per-physician general payments in 2015. The
prevalence of obesity and diabetes in the US have increased over the
past several decades (6,30). Additionally, a previous study by Inoue et
al. reporting approximately 92% of all general payments related to
non-insulin glucose-lowering therapies such as sodium glucose
co-transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor
agonists (GLP-1RAs) in the US were paid for these same two classes of
medications (31).
The study found that large GPEOR were disproportionately concentrated
among a few endocrinologists. Only 1% (80 endocrinologists) of
physicians received 29.1%-38.3% of all GPEOR in endocrinology each
year. As shown in previous studies (20,21,29), the healthcare industry
made large consulting, speaking, and research payments to physicians
with substantial clinical or research experience, often called “key
opinion leaders” (KOLs) (32). KOLs frequently hold influential
positions such as professional medical association leaders,
clinical-practice guideline authors, and academic journal editors
(16,33,34).
This study showed that more than 80% of GPEOR were made for food and
beverage in the number of payments and about 10% of GPEOR paid to the
top 10% endocrinologists were provided for travel and lodging. However,
industry sponsorship for the sole purpose of travel, accommodation and
meals associated with attending international or national conferences is
not allowed in the US. Thus, reported travel expenses likely primarily
reflect participation in company-sponsored consulting meetings, advisory
boards, investigator meetings, rather than the provision of funds that
did not involve a formal company activity.
The author recognize that the receipt of industry-sponsored research
payments does not necessarily increase the risk of a biased outcome due
to a conflict of interest. Industry-sponsored research expenses should
be considered separately from general payments. The analysis shows that
healthcare companies invested substantial amounts in research payments
in the field of endocrinology. Although previous studies only analyzed
research payments paid directly to individual physicians (16,28), this
study included all research payments made to endocrinologists and their
institutions, including research payments for trials where the principal
investigators were endocrinologists. These estimates give a more
comprehensive evaluation of industry research investment in
endocrinology (18,19).
Research payments were distributed to only 6.0% to 9.3% of all
endocrinologists each year and 15.3% over nine-years in the US, and
per-physician research payments were substantially higher than other
specialists (15,17,18,35-38). However, these payments should be viewed
with caution because they include research costs at a time when many
studies of SGLT2 inhibitors and GLP-1RAs were ongoing and nearly all of
these funds were paid directly to institutions. An important caveat is
also that the costs of trial medications sponsored by government
organizations such as the National Institutes of Health NIH would have
been included in the breakdown of research payments to principal
investigators even though the medications were donated to the government
organizations as part of a research agreement. The study was unable to
discern which these may have been from the publicly available data. The
high research payments in endocrinology indicate that companies are
focused on this area. Prior work has suggested that industry-sponsorship
can influence the outcome and interpretation of clinical trial findings
(39,40).