The Cost of Surgeon-Industry Conflicts: Nothing Relevant to Disclose?

Commentary Orthopaedic surgeons frequently collaborate with the medical device industry to develop, update, and market products. When physicians partner with industry, we are considered to have a conflict of interest, which is often viewed as problematic and favoring industry. Studies of the pharmaceutical industry have indeed found a positive association between physicians receiving industry payments and prescribing of branded, higher-cost prescriptions1. Public perception and the media can scandalize physician-industry relationships by claiming that physicians receiving industry payments, in turn, skew research data or compromise quality and affordability of care. Alternatively, industry-sponsored physicians may be viewed in a positive light in the same way that we regard athletes who are sponsored by Adidas or Nike: as top performers or thought leaders. Health care is a highly regulated sector. The Patient Protection and Affordable Care Act requires pharmaceutical and medical device manufacturers to report all gifts and payments made to physicians as publicly available information. The aim of this regulation is to increase transparency, decrease cost, and improve patient care and trust. We know that many physicians receive industry payments or gifts in some form, but the question remains as to how this impacts the care that we provide2. In this excellent study by Wadhwa et al., the authors found there was not a significant association between physician payments and the cost of total joint arthroplasty (TJA) in patients with Medicare insurance. They performed a comparison examining the difference between surgeons receiving the lowest 5% of payments and those receiving the highest 5% of payments. Surgeons in the top 5% group had slightly higher operating costs for total hip arthroplasty (THA) (mean, $16,419 compared with $16,137) than surgeons receiving the lowest 5% of payments but lower operating costs for total knee arthroplasty (TKA) (mean, $6,609 compared with $6,728). The patients of surgeons in the top 5% group had a significantly shorter hospital length of stay after both THA and TKA, which, the authors note, is perhaps the most clinically meaningful finding of this study. This finding may be attributed to surgeon experience, novel techniques or technology, and streamlined protocols. These higher-earning surgeons were more likely to have been in practice longer, to work at larger academic hospitals, and to receive payments including royalties or ownership stakes. Should we be reassured that this study did not find a significant difference in surgical costs or outcomes based on industry payments to surgeons? Perhaps, but we should also note that this study only examined a 20% sample of Medicare beneficiaries and may not represent the impact that industry relationships have on surgical costs for patients with commercial insurance. Also consider that there is not a true control when nearly 98% of orthopaedic surgeons performing TJA receive at least some form of industry payment. TJA cannot be performed without implants, and surgeons will partner with implant companies and industry on some level. As noted in this study, there are different types of surgeon-implant company interactions, which range from sponsored educational events to royalties and ownership stakes. These different types of payments likely influence surgeons to variable degrees. If we villainize surgeon-industry relationships, I think we are missing opportunities for education and innovation. However, as we strive to provide high-quality, value-based care for patients, we must be aware of the factors that consciously or unconsciously influence our decisions. Wadhwa et al. have opened the door for ongoing study of the impact that surgeon-industry relationships have in TJA and orthopaedics. We should take this as an opportunity to self-regulate, be transparent with our reporting of conflicts of interests, and continue to be aware of and study the potential impact that our financial relationships with industry have.