When Did Wolters Kluwer Financial Services Release Hecmorms

INTRODUCTION

Industry payments to physicians are of wide and current interest in the US healthcare customs. They include monetary payments (eg, paid invitee speakers) or items of value (eg, physician lunches) that medical device and pharmaceutical manufacturers requite to physicians, md groups, and hospitals.^¹ Considering of the nature of these payments, there is upstanding business organization regarding their influence, particularly their potential to incentivize practices such every bit physician kickbacks and overprescribing.^{^two} Despite these concerns, industry-doc relationships are commonplace in today'southward Us healthcare system, with 94% of physicians reporting some class of financial incentive from an industry analogue.^³

To bring transparency to doctor-industry relationships, the Centers for Medicare and Medicaid Services (CMS) implemented the Open Payments Plan (OPP) in 2014. Every bit a office of this program, which was spearheaded under the Physician Payments Sunshine Act (Section 2006 of the Affordable Care Act), medical device and pharmaceutical manufacturers are at present required to submit tape of any fiscal incentive given to physicians, md groups, and hospitals to CMS.^{^four} These information are in plough made available to the public by CMS.

Since the inception of the plan, studies in many medical specialties and subspecialties have been conducted to quantify and qualify md-industry relationships.^{^5-8} Because of the substantial pharmaceutical demands of transplant patients and evolving nature of medical devices and drug utilization by surgeons preoperatively, intraoperatively, and postoperatively, industry involvement in transplantation is apparent. Equally of 2017, the US transplantation market size was estimated at $three.half dozen billion United states of america Dollar and is expected to continually increment over the adjacent decade.^{^ix} Relationships between transplant surgeons and manufacture accept been briefly examined in a previous study, which characterized the first v mo of information afterwards the establishment of OPP in 2014.^¹⁰ Ahmed et al institute that physicians receiving consulting fees had higher h indices, a measure of research impact, that liver transplant centers receiving >$1000 annually had higher patient volumes, and that kidney transplant centers receiving >$1000 annually treated more patients who utilized private insurance or self-pay and clearly stated that supplementary longitudinal investigation of OPP was necessary to further understand the link betwixt industry and transplant surgeons. This report aims to expand upon these findings by characterizing trends in industry payments made to transplant surgeons over the past half-dozen y of OPP information.

MATERIALS AND METHODS

The report sample included all physicians who received at least one nonresearch payment as transplant surgeons to the OPP. Additionally, in order to capture transplant surgeons who may exist listed nether their pipeline specialty, the American Society of Transplant Surgeons member directory equally of Jan 2021 was queried. All members were searched in the OPP database, and payments from fellow member physicians categorized under Urology, Surgery, Pediatric Urology, and Pediatric Surgery were included. Physicians identified as residents in the American Society of Transplant Surgeons fellow member directory were excluded from analysis. This written report was exempt from institutional review board approval because it is an analysis of publicly available data. All analyses were conducted using Tableau Software and Stata Statistical Software, version 14.2.

Data Sources

Data from 2014 to 2019 were obtained from the publicly available OPP database available on the CMS website (http://www.cms.gov/openpayments). Md payment data were aggregated inside and across study years using the unique CMS physician identifier. Data on transplant volume by the Organ Procurement and Transplant Network (OPTN) region for intestine, kidney, liver, pancreas, and dual kidney and pancreas transplantation were likewise extracted from the OPTN website.

Summary statistics were used to characterize and compare payments made to all transplant surgeons across and within report years, and study years were compared using analysis of variance testing. As some payment entries in the CMS database included multiple number of payments, summary statistics for in total and for each study year were calculated using the number of entries in the CMS database as the number of payments rather than the number of payments included in total amount variable, as this encompassed consulting fees and other recurring payments in 1 unique entry. Summary statistics detailing the number of entries for each payment category is reported in the Nature of Payments department. To account for aggrandizement, all dollar amounts were adjusted to 2019 U.s. Dollar using yearly consumer price indices.

Nature of Payments

The OPP variable Nature of Payment or Transfer of Value was used in club to characterize and compare the distribution of payments inside and across study years. Payment types included compensation for services other than consulting, including serving as kinesthesia or equally a speaker at a venue other than a continuing teaching program; compensation for serving equally kinesthesia or every bit a speaker for an accredited or certified continuing education plan; bounty for serving equally faculty or as a speaker for a nonaccredited and noncertified continuing education program; consulting; electric current or prospective buying or investment interest; education; entertainment; food and potable; gift; grant; honoraria; royalty or license; and travel and lodging. The total amount of payments in each category across each report year and in full was quantified.

Geographic Distribution

To analyze the geographic distribution of payments, individual payments were aggregated at the state level using the Recipient State variable from the OPP and the results visualized using a rut map. Payments were further sorted into eleven OPTN regions, visualized via heat map, and compared across regions. Payments were analyzed beyond all study years and within each report year. Payments past OPTN regions were further analyzed by transplant volume. Transplant volume caseloads including intestine, kidney, liver, pancreas, and dual kidney and pancreas transplantation for each of the 11 OPTN regions were obtained, and total payment per transplant was calculated. Number of transplant surgeons receiving payment per region and average payment per transplant surgeon for each region were also calculated.

Acme Payers and Earners

To identify and characterize the major contributors in nonresearch payments to transplant surgeons, the top xxx industry payers to transplant surgeons by total amount were as well identified. The total amount in payments for each of the elevation 30 industry payers was and then summarized and visualized past payment category.

To characterize the potential earnings of transplant surgeons from manufacture payments, the superlative 50 transplant surgeons past total payment amount across the study period were identified by their unique CMS identifier and their earnings summarized. The identifiers associated with these transplant surgeons were so removed for privacy reasons. Total corporeality of payments for each of the top 50 surgeons were then further broken down into payment category and visualized.

RESULTS

In total, payments totaling $15 661 536 were made to 1335 transplant surgeons over the study period. The mean payment was $436.90 (SD, $1760), and the median payment was $52.94 (interquartile range [IQR], $xviii.29–$159.eighty). The highest payment made to a transplant surgeon over the study period was $101 846.00. Full amount of payments did non demonstrate a discernible tendency over the report flow. The highest total amount of payments was made in 2015, at $iii 137 981, whereas the lowest payment twelvemonth was 2017 at $2 306 299. Hateful payments ranged from $401.33 (SD, $1576.seventy) in 2016 to $496.05 (SD, $1970.x) in 2015. Analysis of variance between years demonstrated a meaning deviation in mean total amount of payments across study years (P < 0.001).

Nature of Payments

Of the $15 661 536 in total payments, compensation for services other than consulting, including serving equally faculty or as a speaker at a venue other than a continuing education program, comprised the largest amount in total payment over the study period, at $4 907 236 (31.3%), followed past consulting fees at $4 102 693 (26.2%), travel and lodging at $3 181 480 (20.3%), food and beverage at $i 317 375 (8.4%), instruction at $ane 233 141 (7.9%), compensation for serving as faculty or as a speaker for a nonaccredited and noncertified continuing education program at $425 432 (2.vii%), and honoraria at $401 804 (ii.half dozen%), with all other categories comprising the remaining $85 712 (0.6%). When analyzed over the study menstruum, payments from the top 3 categories comprised the pinnacle 3 total amounts for all written report years (Figure 1).

FIGURE one.:
Breakup of total payments by nature of payment for each year of the written report period in 2019 USD. USD, United states of america Dollar.

Current or prospective buying or investment interest had the largest median payment at $3038 (IQR, $2661–$3038; n = 24) paid to 1 transplant surgeon, followed by compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing teaching program, with a median of $2700 (IQR, $2106–$3728; n = 1653) paid to 145 transplant surgeons, compensation for serving as kinesthesia or as a speaker for a nonaccredited and noncertified standing teaching program with a median of $2697 (IQR, $2697–$2800; northward = 141) to 28 transplant surgeons, compensation for serving as faculty or as a speaker for an accredited or certified continuing education programme with a median of $2429 (northward = 1) to 1 transplant surgeon, and consulting fee with a median of $2268 (IQR, $675–$4172; north = 1115) to 240 transplant surgeons. Notably, nutrient and beverage comprised the highest number of payments (due north = 24 193) with a median of $25 (IQR, $15–$90) made to 1257 transplant surgeons. Further details of payment breakdown can be found in Tabular array ane.

TABLE 1. - Breakdown of payment categories by number of payments, median payment, number of transplant surgeons receiving payment, and mean payment per surgeon in 2019 USD

Nature of payment	Total corporeality, $	No. of Payments	Median Payment, $ (IQR)	No. of transplant surgeons receiving payment, %	Mean payment per surgeon, $
Current or prospective buying or investment interest	70 747	24	3038 (2661–3038)	1	seventy 747.00
Bounty for services other than consulting, including serving as faculty or every bit a speaker at a venue other than a continuing education programme	iv 907 236	1653	2700 (2106–3728)	145	33 843.01
Bounty for serving equally faculty or equally a speaker for a nonaccredited and noncertified continuing education program	425 432	141	2697 (2697–2800)	28	15 194.00
Compensation for serving as kinesthesia or every bit a speaker for an accredited or certified standing education plan	2429	1	2429 (2429–2429)	1	2429.00
Consulting fee	four 102 693	1115	2268 (675–4172)	240	17 094.55
Honoraria	401 804	162	2159 (972–3510)	69	5823.25
Royalty or license	8796	9	765 (661–1393)	ii	4398.00
Grant	489	two	244 (232–257)	two	244.fifty
Travel and lodging	three 181 480	7493	228 (66–489)	538	5913.53
Education	1 233 141	1225	97 (18–1080)	426	2894.70
Entertainment	1100	17	52 (13–102)	12	91.67
Gift	8817	21	46 (11–336)	14	629.79
Nutrient and potable	i 317 375	23 983	25 (fifteen–90)	1257	1048.03

IQR, interquartile range; USD, United states Dollar.

Geographic Distribution

Geographic distribution of median payments by state across study years is presented in Figure 2.

Transplant surgeons from Maryland received the highest median payment at $175.70, followed by Minnesota, Missouri, Arizona, and Illinois in the top 5 highest. Payments by OPTN region are shown in Figure 3 and Tabular array 2. When analyzed by OPTN region, transplant surgeons in region seven followed by region 8 received the highest median payments. Notably, region 5 had the highest transplant volume over the study menstruum, followed past regions 3, 2, 4, and 11 (Table 2). When payments were analyzed by transplant volume, region 9 demonstrated the highest total payment corporeality per transplant at $183, followed by region viii at $130 and region v at $111. Region i had the everyman full payment corporeality per transplant at $33 (Tabular array 2).

TABLE 2. - Total payment by Organ Procurement and Transplant Network region with median payment, transplant volume, payment per transplant, number of transplant surgeons receiving payment per region, and payment per transplant surgeon

Recipient state (group)	States in Region	Total amount of payment, $ (%full)	No. of payments	Median payment, $ (IQR)	Total number of transplants	Boilerplate payment per transplant performed, $	No. of transplant surgeons receiving payment	Average payment per transplant surgeon, $
Region ane	CT, ME, MA, NH, RI, Eastern VT	229 779 (ane.47%)	916	42 (19–125)	6911	33.25	83	2768.42
Region ii	DE, DC, MD, NJ, PA, WV, Northern VA	ii 108 229 (13.46%)	4135	58 (xviii–196)	21 296	99.00	227	9287.35
Region 3	AL, AK, FL, GA, LA, MS, PR	2 189 540 (xiii.98%)	5691	42 (17–136)	24 451	89.55	207	ten 577.49
Region four	OK, TX	981 906 (6.27%)	3959	23 (16–113)	16 848	58.28	141	6963.87
Region 5	AZ, CA, NV, NM, UT	3 058 327 (19.53%)	6479	50 (19–157)	27 563	110.96	228	13 413.71
Region half-dozen	AK, HI, ID, MT, OR, WA	206 188 (ane.32%)	978	39 (19–118)	5659	36.44	53	3890.34
Region 7	IL, MN, ND, SD, WI	1 234 498 (7.88%)	2394	91 (25–284)	xiv 818	83.31	154	8016.22
Region 8	CO, IA, KS, MO, NE, WY	1 425 607 (9.1%)	2522	86 (21–264)	eleven 001	129.59	107	13 323.43
Region 9	NY, Western VT	2 152 415 (thirteen.74%)	3582	74 (xx–227)	11 766	182.94	138	xv 597.21
Region 10	IN, MI, OH	i 113 508 (vii.11%)	2690	70 (19–174)	15 010	74.18	167	6667.71
Region eleven	KY, NC, SC, TN, VA	960 204 (six.13%)	2494	70 (18–155)	16 745	57.34	150	6401.36
Other	USVI	1334 (0.01%)	6	75 (69–102)	NA	NA	3	444.67

IQR, interquartile range; NA, non bachelor.

Effigy 3.:
Geographic distribution of median payments to transplant surgeons past the Organ Procurement and Transplant Network (OPTN) region. For the purposes of this study, Vermont was included in region nine, and Virginia was included in region 11, as it was not feasible to separate these groups into 2 regions. Map calibration is from $0 to $100 and is in 2019 USD. USD, United States Dollar.

Top Payers and Earners

The total amount of payments categorized past nature of payments made by the top thirty industry payers is shown in Figure 4. The industry payer with the largest total amount paid over the study period was Intuitive Surgical, Inc., at $1 901 546, followed by Gilead Sciences, Inc., at $ane 188 143 and Novartis Pharmaceuticals at $1 091 238. The top thirty payers contributed approximately 80% of the total payments received over the study period.

Figure four.:
Total amount of payments from top 30 manufacture payers over the study menstruum with breakdown past nature of payment. Companies entered with dissimilar international subsidiaries were kept split for the purpose of this analysis. All reported amounts are in 2019 USD. USD, U.s. Dollar.

The superlative 50 highest earning transplant surgeons in total amount of industry payments over the study period are shown in Figure 5. The highest earning transplant surgeon earned $861 647 over the written report menstruum, with the largest share received for education, at $462 811. The 2nd through sixth highest earners all received over $500 000 in industry payments during the study period.

Figure five.:
Total amount of payments to tiptop 50 transplant surgeons over the written report period with breakup by nature of payments. Physician identifiers were removed for privacy purposes. All amounts are reported in 2019 USD. USD, Usa Dollar.

DISCUSSION

Since 2014, the Sunshine Act has brought greater transparency to physician-industry relationships across all medical specialties. Ahmed et al provided a cursory introduction to transplant physician-industry relationships based on the first 5 mo of data after the establishment of the Sunshine Deed. This written report builds on these findings by being the first to characterize payments fabricated to transplant surgeons longitudinally from 2014 to 2019.

These findings should be considered in the context of some existing literature suggesting that any class of manufacturer compensation, from the largest sum of compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education to food and drink, may exist related in some manner to the utilization of said manufacturer'south products.^{^11-13} The challenge behind the doc-manufacture relationship is elucidating which forms and manners of physician compensation drive positive innovation and give-and-take and which may be indirectly complicating patient care. Although the Sunshine Act and respective OPP were formed to shed light on these relationships and make bounty publicly available, the causal link betwixt physicians and industry is far from understood. The Sunshine Act allows the public to quantify payments made to physicians since 2013, but without much more than information than the payment type and exact dollar corporeality provided by OPP, qualifying and understanding the exact impact of manufacture-physician relationships is rather difficult. Further enquiry is imperative to empathize these complex relationships.

Understanding the results of this study may exist helpful to policymakers by providing a more transparent paradigm of industry-transplant surgeon relationships in the United States. Although the OPP program does brand all payments public, at that place is piddling done by the program to qualify and organize the nature of these payments. This study, and others like information technology in specialties other than transplant surgery, supplements the data provided by the OPP program and provides a more well-rounded characterization that may exist useful in related decision-making. The results should be considered heavily, used in conjunction with other studies, and drive further inquiry into the exact nature of transplant-specific industry-surgeon relationships, but by themselves exercise not warrant farther policies on manufacture-physician relationships in the United States.

Comparison to Other Subspecialties

A total of $15 661 536 were made to 1335 transplant surgeons over the study period. The mean payment was $436.90 (SD, $1760) and the median payment was $52.94 (IQR, $xviii.29–$159.80). This median value is slightly larger than the median value for some medical specialties including a median $15 to urologists and $38.eleven to orthopedic surgeons just less than other medical specialties such every bit plastic surgeons with a median of $115.^⁵ ^, ^{^fourteen} ^, ^¹⁵ Utilizing a written report examining all physician payments from 2014 to 2018 past Marshall et al, payments to transplant surgeons compute to <0.two% each year of the study and just under 0.four% of the market of payments to all surgeons in each year.^{^sixteen}

Agreement Payment Types

Transplant surgeons received a broad range of payment types, with near of the payments falling nether a few main categories. Compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a standing education program, comprised the largest amount in total payment over the written report flow, at $iv 907 236 (31.3%), followed by consulting fees at $4 102 693 (26.2%) and travel and lodging at $3 181 480 (20.3%). These categories remained the top 3 payment categories over the entire study period. Compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a standing education, is a wide category that encompasses payments that are made to physicians for speaking, training, or educational purposes that practice not count toward continuing education.^¹⁷ For instance, a pharmaceutical company may recoup a transplant physician to speak, at a conference or private event, on the benefits of using a drug in patient care. Consulting fees are compensation for utilizing the physicians' medical expertise for research and development of a certain drug or device. For example, a company may pay a transplant medico to help in technology a medical device to gear up a common surgical complication or to pattern a clinical trial for a new drug. Food and beverage comprised the highest number of payments (n = 24 193) with a median of $25 (IQR, xv–90) made to 257 transplant surgeons, or ≈94% of transplant surgeons.

Pinnacle Payers

Both the number of companies making payments to transplant surgeons and the number of transplant surgeons receiving payments are heavily skewed, with a minority of companies making a large sum of payments and a minority of physicians receiving a big sum of payments. Only 15 companies made over $200 000 in payments to physicians. Similarly, only fourteen of 1335 transplant physicians received over $200 000 in industry payments. Only 3 companies (Intuitive Surgical, Inc.; Gilead Sciences, Inc.; and Novartis Pharmaceuticals) made over $ane meg in payments to physicians. Intuitive Surgical, Inc., which led in total payments with $ane 901 546 in industry payments, is the company behind Da Vinci Surgical Systems, the leading robotic surgical engineering science assuasive surgeons to complete a variety of circuitous surgical procedures using a minimally invasive arroyo. Robotic approaches to solid organ transplantation take yielded positive patient outcomes and decreased recovery times, leading to increased utilization across the field.^{^xviii} ^, ^{^nineteen} Although Intuitive Surgical, Inc., does not release case volumes specific to transplant surgery or other subspecialties, the utilization of the Da Vinci Surgical System has increased in general over the study period, with the use of robotic surgery in all surgical procedures increasing from 1.8% in 2012 to 15.1% in 2015.^²⁰ The vast majority of Intuitive Surgical'due south payments, over $ane million, were used for education of the company's products, presumably the Da Vinci Surgical System. The impact of advancing this robotic technology within the field and improving outcomes for transplant patients should be considered when characterizing Intuitive Surgical's payments into the industry. Gilead Sciences, Inc.; and Novartis Pharmaceuticals are too instrumental within the field of transplant as each produces several widely used transplantation-related medications. Gilead Sciences, Inc., produces several antivirals (Sovaldi, Veklury, Truvada, etc) useful in treating patients with chronic weather such equally hepatitis B, hepatitis C, and HIV both before and after liver transplant.^¹² Novartis Pharmaceuticals, specifically its subsidiary Sandoz, produces several essential drugs for transplantation such equally cyclosporine.^²¹ Many of the companies that reported payments to US transplant physicians under the Sunshine Human activity like Intuitive Surgical, Inc.; Gilead Sciences, Inc.; and Novartis Pharmaceuticals are foundational, or at the very least supplemental, to the transplant industry as it currently exists.

Geographic Distribution

Transplant physicians in 2 states, New York and California, at $2 058 965 and $ii 467 630, respectively, received the largest total amounts of payments over the study period and comprised near a third (30.iii%) of full payment corporeality for all states combined. When compiled into regions based on OPTN region, region five (AZ, CA, NV, NM, and UT) comprised 19.iii% of total payments at 2 889 993, followed past region 3 (AL, AK, FL, GA, LA, MS, and PR), which comprised 14.one% of full payments at $ii 107 355, and then region ix (NY and Western VT), which comprised 13.8% of total payments at $2 060 345. Yet, when looking at the median payment made past each OPTN region, region 7 (IL, MN, ND, SD, and WI) had the highest median payment of $91 (IQR, 25–284)‚ followed by region 8 (CO, IA, KS, MO, NE, and WY) at $86 (IQR, 21–264). Regions ix–11 and the U.s. Virgin Islands all had median payments in the range of $seventy–$75. This suggests that although regions v and iii may accept comprised the largest percentage of manufacture payments in the OPTN, this is probable considering of the larger transplant volumes (24 451 and 27 563 transplants, respectively) and the accompanying larger amount of manufacture payments in these regions.

Written report Limitations

The findings of this study should exist considered in the context of a few limitations. First and foremost, the Sunshine Act/OPP collects information that is self-reported from medical device and pharmaceutical manufacturers. Of undetermined significance, the accuracy of reporting to the OPP has been consistently called into question since the plan'south conception, with substantial literature pointing out inaccuracy and underreporting of manufacture payments.^{^22-24} It is as well important to consider that both physicians and companies can dispute payments made public past the Sunshine Deed, so some payments may be withheld considering of ongoing disputes. Consideration should too be made for miscategorization bias (ie, miscategorizing a payment type or a physician'south specialty type as a transplant surgeon) and for the Hawthorne issue over the written report period (ie, a doctor recognizes their received payments are publicly available and behaves differently accordingly). Lastly, because of the multispecialty practice of many transplant surgeons, the full corporeality of payments for transplant-related services may also be overestimated and must be considered when interpreting these results.

CONCLUSIONS

There is a considerable financial relationship between medical device and pharmaceutical manufacturers and transplant surgeons. This study is the first to characterize this relationship over the start vi y of the Sunshine Act, showing its numerical relationship and delving into the $fifteen 661 536 in industry payments made to 1335 transplant surgeons over the report menses. Further studies are needed assessing the impact of industry payments on transplant surgeons' beliefs with respect to prescribing or utilization of diverse medical supplies and devices.

DATA AVAILABILITY STATEMENT

Data from 2014 to 2019 were obtained from the publicly available Open up Payments Program database available on the Centers for Medicare and Medicaid Services website (http://www.cms.gov/openpayments).

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