Public concern over conflicts of interest may trail perception

Intensified scrutiny over physician-industry conflicts of interest (COIs) shows no sign of abating. Government policy makers, medical societies, and industry representatives are continuing efforts to define improper relationships, so that those who engage in them can be punished.

Yet for all the effort and attention expended in the name of protecting the public, a paradox has arisen, say the authors of a paper presented Thursday by Christian P. DiPaola, MD: the public has barely been consulted, and when it has, it has indicated less apprehension over conflict issues than those in government and even in medicine.

Evidence exists showing that a majority of patients do not believe that surgeon-industry conflicts of interest affect patient care, the authors note, “yet government officials and certain societies, acting on behalf of the public, would suggest otherwise.”

Their survey sought to gauge the attitudes and perceptions of the public regarding surgeon-industry consulting relationships. They specifically tried to explore opinions on how surgeons should be paid in consultation agreements and how those agreements should be regulated.

Probably the most prominent finding from the 610 respondents is that more than 80 percent say that their care will be improved (46.4 percent) or not affected (34.1 percent) if their surgeon is a consultant “to help design/improve a surgical device.” When asked about royalties, almost 40 percent of respondents said that patient care would be adversely affected if a surgeon received such payments for a device that would be implanted by that surgeon. But when royalties are paid only on devices implanted by other surgeons, less than a quarter (24.6 percent) showed concern that quality of care would be worse.

Of the 19.5 percent of respondents who felt that surgeon consulting with industry is unethical, only 61 percent said this practice would have a negative impact on the quality of healthcare. A full 91 percent of respondents said it was important for surgeons to disclose consulting agreements regarding devices in their surgery, and 60 percent thought it was appropriate for surgeons to disclose consulting arrangements with all patients regardless of the planned usage of such devices in their own surgery.

When questioned about who should be involved in regulation of COI, a majority of respondents (64.3 percent) said that a combination of physicians, hospitals/universities, government, and company representatives was desirable. Just over a third (34.9 percent) said that medical professional societies run by doctors should have the most control over COI regulation; this was almost twice the next most frequent specific choice (government, 17.9 percent), although 32.7 said “not sure.”

Asked which entity should not be involved in regulation of COI, a combined 70.2 percent chose to exclude either medical company representatives (44.9 percent) or government officials (26.3 percent).

The surveyed participants were more elderly, female, and educated than the general US population, and 40 percent had a history of or planned to have surgery involving an implantable device.

Discussing the results, the authors note that the general population appears to agree with the Academy’s consensus statement that the enhancement of patient care will continue to require orthopaedic surgeons to collaborate productively with industry in development of new technology and techniques.

“The data provided by this study offers evidence into society’s opinions with regard to the complex issue of surgeon-industry COI,” the authors conclude. “Public opinion is necessary to allow doctors, hospitals, universities, politicians, and industry to form appropriate evidence-based guidelines. By studying the patient preference component of evidence-based medicine, we have generated useful information that we propose be used as a basis for ‘evidence-based government.’”

The coauthors of the study are Charles G. Fisher, MD; Hongbin Zhang, MSc, MEng; Vanessa K. Noonan, PhD; Chris Bailey, MD, MHSc; and Marcel F. S. Dvorak, MD.

Disclosure information: Dr. DiPaola—Medtronic, DePuy, Allen Medical Systems; Dr. Fisher—Medtronic, Nuvasive, DePuy; Dr. Bailey—Stryker, Medtronic; Dr. Dvorak—Medtronic, Synthes, DePuy, Arcus, Thieme. The other authors report no conflicts.

Prepared by Terry Stanton, senior science writer, AAOS Now.