The Role of Sponsored Supplements in a Peer-Reviewed Journal

Over the course of my tenure as Editor-in-Chief of Aesthetic Surgery Journal, I’ve been asked several times by fellow Editorial Board members and readers whether I feel that publishing sponsored supplements is in the best interest of the Journal. Some of my esteemed colleagues have suggested that these article collections—which appear in a separate insert mailed with the main issue, address a specific clinical topic or product, and are industry-funded—give a false impression of partiality or endorsement on the Journal’s part, thereby effectively compromising scientific objectivity. On the other side of the coin, I receive regular notes from readers who have found clinical value in our supplements, including the special issue titled “Acellular Dermal Matrix: Fundamentals and Expanding Applications in Plastic Surgery,”1 published with our September 2011 issue. Although I certainly understand the concern of those who feel that sponsorship inherently affects author neutrality, I am confident in our strict peer review process and proud of the content that we’ve published in the main issues and our supplements. I’d like to share with you some of the reasons why I believe that our method of manuscript evaluation and disclosure ensures that the sponsored supplements that we publish are as useful and scientifically rigorous as possible. First, it is important to understand the mechanism by which supplements come to be published by a journal. This happens in one of three ways: (1) an industry sponsor works with investigators/authors to prepare a series of articles on its product and contacts journals in a relevant subspecialty to gauge interest after the material is complete; (2) the Editorial Board of a journal determines that the readership would benefit from focused discussion on a certain topic, invites authors to write manuscripts, and seeks sponsorship from one or several companies after the material is complete; or (3) a sponsor approaches a journal’s publisher (or vice versa) with a topic idea and a proposed budget, and the articles are written after an agreement has been reached. Each of the four supplements published in the last three years has fallen into the third category. This distinction is essential because it provides the Editorial Board with complete control over the content of the supplement. In fact, I am adamant that the following clauses be included in every contract signed between our publisher and a supplement sponsor: “All editorial control (including selection and revision of the Contributions) for the Supplement will be the sole responsibility of the Journal Editor or guest editor,” and “The Journal Editor shall retain editorial approval of the content of the Supplement; manuscripts selected for publication shall be of the highest standards in terms of scientific scholarship and pedagological value.” I request a full summary of the proposed material (with potential titles for each paper) from the sponsor and make a decision about whether the content would be useful to, would be of interest to, and would have educational value for our readership. This editorial control includes what becomes, in effect, a divorce of interests between the sponsor and the Journal after the contract is signed. At that point, decisions about funding are made. I personally select a guest editor who is unaffiliated (financially and otherwise) with the sponsor. In only one instance has a guest editor been found to have ties to the sponsoring company; this was a matter of error, rather than deceit, and the guest editor willingly stepped down from the position prior to peer review of the articles. After a guest editor has been selected, I suggest or approve a list of authors, whom the guest editor contacts directly and invites to write articles on specific clinical topics related to the technique, device, or product being discussed. Although the authors are made aware that their article, if accepted, will be printed in a supplement sponsored by the manufacturer, they are asked to write impartially, and they are encouraged to discuss competing products freely. The authors themselves may work directly with the sponsor and/or a paid medical writer as they compose the articles, but they are informed that all manuscripts will undergo a thorough, meticulous, and stringent peer review process—the same peer review process to which all manuscripts submitted to the main journal are subjected. At no time is the sponsor, guest editor, or author under the impression that funding is a guarantee of acceptance. With regard to peer review, I generally work with the guest editor to select a core group of eight to 10 reviewers who are experts in the technology being discussed in the supplement articles. The only way in which the peer review process differs between the main journal and a supplement is that I ask this core group to review all the articles for the supplement, rather than inviting a different set of reviewers for each manuscript. I believe that this gives the reviewers themselves, the guest editor, and the Editorial Board a comprehensive picture of how the supplement functions as a whole. I make every effort to select impartial reviewers who are not affiliated with the sponsor in any way, paid or unpaid. Reviewers, like authors, are asked to disclose any real or potential conflicts of interest, and I reserve the right to recuse any reviewer whose impartiality might be compromised. Aesthetic Surgery Journal accepts very few articles outright, and this remains true (perhaps even more so) for supplements. Like manuscripts for the main issue, articles for supplements are often returned to the authors for revision. During this phase, authors may be asked to make various improvements to increase the scientific relevance of the article (and the overall supplement). Reviewer suggestions may include items such as requesting that the authors conduct additional research into the existing literature to support their clinical experience or asking that they expand their discussion to include other products on the market. I take the task of peer review very seriously, as do the reviewers and supplement guest editors, and we are explicit with authors—and any medical writers assisting them with the revisions—that we cannot accept any article that displays unwarranted bias or slanted reporting. Perhaps the most important component of publishing any medical article, especially one that appears in a sponsored supplement, is disclosure. I addressed this issue in two editorials (“Disclosing Conflicts of Interest to Maintain Ethical Integrity”2 and “Ghostwriting: Stringent Disclosure Policies Take Aim at Authorship Abuses”3), both of which stressed that we, as medical professionals, are responsible for ethical disclosure of our conflicts of interest at every available opportunity. In the latter of those editorials,2 I briefly addressed the issue of sponsored supplements, which I am obviously discussing at length here. Regardless of the part of the Journal in which an article is published, full and accurate disclosure remains one of my highest priorities. As I said previously, “The [conflict of interest] inherent in any kind of academic study can impact our ability to write, review, edit, and read the results without bias,” but “if the potential predispositions are clearly outlined from the start, we can weigh their impact against the science itself and arrive at a fair conclusion about each article.” If you examine the acellular dermal matrix supplement as an example, you will notice that LifeCell’s sponsorship is disclosed on the cover, directly underneath the supplement’s title. An astute reader later wrote me to point out that no information was included on the guest editor, but this was a publishing error, rather than a routine practice; normally, each supplement features the guest editor’s name on the cover, along with the title and sponsor. In that case, Dr. Joseph M. Serletti was our guest editor, and his disclosure information was included in the introduction, which begins on page 5S. Likewise, disclosure and funding information is included for each author in each article. While many of the authors in this particular supplement were associated with LifeCell, information was included about many other acellular dermal matrix products currently on the market. When provided with disclosure and conflict-of-interest details about the supplement as a whole, each author, and the guest editor, I feel confident that our readers can weigh the value of the clinical information against any potential bias and decide for themselves if they believe that the scientific recommendations contained in the supplement have value for their own practices. You might still be asking, why print these supplements at all if there is any question about their ethical impact? First of all, it allows us to offer material about one subject to our readers in a concise package. Our 2010 supplement on nonsurgical facial rejuvenation4 and a previous one on Dysport dosing5 have both become touchstones for clinicians because they contain the most up-to-date, relevant, practical information about those topics in one place. Second, the supplement format allows us to place information about sponsorship prominently. Whereas it might escape a reader’s notice in one article in the main journal, we are able to display the conflict-of-interest information prominently on the cover, the front matter, and the final page of each article in a supplement. It is worth noting that the delicate issues surrounding sponsored supplements are not unique to Aesthetic Surgery Journal or even to the cosmetic surgery subspecialty. Several scientific articles,6,7 editorials,8,9 and news articles10,11 have addressed this issue across the medical field. In an effort to clarify the issue, the International Committee of Medical Journal Editors published a list of uniform requirements for supplements, theme issues, and special series.12 While I will not reprint the full list here, I encourage all of our readers, authors, reviewers, and editors to familiarize themselves with the requirements. Since the Journal adheres to both the letter and the spirit of these guidelines, I believe that reading them will reassure those with doubts about the veracity of our sponsored supplements and reaffirm the judgment of those who already acknowledge their clinical value. The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.