Corruption or coincidence? Physicians use cardiac devices made by manufacturers who pay them the most

Financial transactions between physicians and medical device manufacturers are common, and new research indicates that physicians are “substantially more likely” to use cardiac devices made by the manufacturer that pays them the most.

Is this a genuine cause for alarm? Or just the way this particular cookie happened to crumble?

The study, published in full in JAMA, explored that very question.

“The fundamental concern about physician payments is that such payments may change how physicians select treatment options and that their choices may not necessarily be consistent with the best interests of the patient,” wrote lead author Amarnath R. Annapureddy, MD, of Yale-New Haven Hospital in New Haven, Connecticut, and colleagues. “Studies have reported that payments to physicians were associated with a greater likelihood of prescriptions of branded medications over generic medications. However, investigators have not explored whether associations exist between payments from device manufacturers and device selection.”

Annapureddy et al. examined data from more than 145,000 patients who received an implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy-defibrillator (CRT-D) from  2016 to 2018. More than 4,000 physicians were included in the study, and 94% of them had received payments from at least one device manufacturer. The median payment received was $1,211.

Of the physicians who did receive payments, 8% received payments from a single manufacturer, 17% received payments from two manufacturers, 37% received payments from three manufacturers and 37% received payments from all four manufacturers tracked for this analysis.

Overall, the team found, somewhere between 38.5% and 54.7% of patients received ICDs and CRT-Ds made by the manufacturer that provided their physician with the largest payments. A vast majority of those patients—96% to be exact—underwent implantations at a hospital where devices made by more than one manufacturer were available.

One key point, the authors emphasized, is that the rates of in-hospital mortality or complications did not appear to be impacted by the presence of payments. However, the data still provides reasons to be concerned about the decision-making processes of some physicians.

“This study’s findings raise the possibility that payments from device manufacturers may influence the physician’s choice in selection of a manufacturer’s device,” the authors wrote. “However, this may not be the only contributing factor. Physicians who perform ICD or CRT-D implantations may develop a preference for a specific line of products based on years of experience and familiarity. Working with a small number of devices may improve efficiency of clinical care, particularly in the outpatient setting.”

Annapureddy and colleagues noted that their study did have certain limitations, including one important point about the timing of these payments.  

“Due to the observational, cross-sectional nature of the data, this study could not ascertain whether implanting the devices preceded or followed a physician’s receipt of payments,” they wrote. “Thus, it remains uncertain whether payments led to the selection of a particular device or rewarded specific behaviors, or, contrarily, were unrelated to physician practice patterns. Therefore, findings identify associations but no temporality or causality.”

The team concluded that “the presence of payments” does not appear to be a “reliable marker for in-hospital care,” but also called for additional research into this area.

The full study is available here.