Physicians’ ties to industry influence device choice in ICD implantation

Physicians who have financial relationships with biomedical manufacturers are up to 12 times more likely to use an implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy-defibrillator (CRT-D) from that company instead of another manufacturer, according to preliminary research presented Nov. 11 at the American Heart Association Scientific Sessions in Chicago.

A related abstract presented by the same research group offered a bit of good news amid those potential conflicts of interest: Patient outcomes didn’t appear to suffer, despite the apparent influence in device selection.

“I am reassured that the quality of care doesn’t differ based on whether or not you’ve received money from industry, but I am, to be honest, a little troubled by the implications of our finding that payments from industry really do influence device choice,” said Jeptha P. Curtis, MD, associate professor of medicine at Yale School of Medicine and the senior investigator for both studies.

“I don’t think there’s anything inherently wrong about relationships between physicians and the device industry, but I do think we really need to tread carefully in that space. The potential for the appearance of conflicts of interest is really significant and has the potential to undermine the faith that patients put in physicians.”

The Physician Payment Sunshine Act requires the public disclosures of payments from biomedical manufacturers to physicians. However, even though cardiologists have been shown to receive some of the highest payments among specialties, there is little research into how these relationships influence physician behavior.

Both studies used the National Cardiovascular Data Registry for ICDs to analyze device choices and intra- and post-procedural complications for operations performed by 4,096 physicians in 2014 or 2015.

The researchers found patients of physicians who received more than $100 per year from industry experienced complications at similar rates to patients of doctors with minimal or no financial ties to device manufacturers. The complication rates were 2.06 percent for those treated by industry-paid physicians and 2.1 percent for the other group, while in-hospital death rates were 0.32 percent and 0.24 percent, respectively.

Curtis and colleagues found physicians who accepted payments from manufacturers were slightly more likely to implant a CRT-D in eligible patients (24.42 percent versus 23.19 percent) but marginally less likely to discharge them on the “appropriate” medications of beta-blockers and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (84.17 percent versus 85.35 percent).

The differences were substantially greater when it came to device selection. Physicians who received the bulk of their payments from a given manufacturer were between 2.6 and 11.7 times more likely to implant a device from that company versus another, depending on the manufacturer.

The authors deidentified the companies—referring to them as Manufacturers A through D—but Curtis noted there was a dose-dependent relationship in terms of how likely doctors were to use that device. In other words, the greater the payments from that company to a physician, the more likely the physician would be to select its device. Similarly, the two companies that shelled out the most money each year had the greatest likelihoods of physicians choosing their products.

“This is all retrospective analysis and all we’re identifying are associations, so you have to take this with a grain of salt, but nevertheless we did see a very strong association and one that raises questions as to the appropriateness of these relationships and to what degree they are influencing physician choice,” Curtis said.

Curtis added that, even though payments from industry to medicine are posted for public viewing, it isn’t exactly easy for patients to access and interpret that data. He suggested hospitals improve transparency by requiring doctors to disclose financial relationships to patients before implanting a device from a manufacturer they’ve received money from.

“That seems practical and potentially important information for patients to know,” he said. “Similarly, I think hospital conflict of interest committees need to take their job very seriously because … the optics are not great. We want our medical decision-making to be made independently of any underlying relationship with industry and to be made solely with the interest of the patient at heart.”