MILITARY MEDICINE, 179, 12:1469, 2014
Patient Perceptions of Surgeon-Industry Relations in a Military Setting CPT Dionisio Ortiz III, MC USA; Lt Col Joel Jenne, USAF MC
ABSTRACT Background: Investigations into the financial relationships between orthopedic surgeons and device manufacturers have recently been investigated. Despite these investigations, the public appears to maintain trust and confidence that their surgeons are acting in patients’ best interest. However, patient perceptions of these relationships have not been investigated in a military treatment setting. We surveyed patients’ perception of the surgeon-industry relationship in a single military treatment facility. Methods: From March 2012 to March 2013, we surveyed 282 pre operative and postoperative spine and arthroplasty patients in a single military treatment facility. Patients were eligible if they were adult TRICARE beneficiaries being followed in one of those clinics and within the age requirements. Results: Most patients were aware of private industry involvement in the manufacture of orthopedic implants (77%). Most patients thought that it was beneficial for surgeons to serve in an advisory role to device companies (81%) and most (65%) felt that the relationship was appropriate and beneficial for patient care. A minority (29%) felt their surgeon should receive payment for this role. Conclusion: Most patients in the military setting had a positive view of the relationship that their surgeons had with industry, which is reflective of data obtained in the civilian literature.
BACKGROUND The relationships between surgeons and medical device industry have been well scrutinized in recent years, causing many professional organizations to adopt standards of profes sionalism to help ensure the professional relationships between surgeon and industry are appropriate. Much of this was in response to a Department of Justice investigation in the early 21st century regarding orthopedic industry-surgeon relation ships and payments.1 For example, the American Academy of Orthopedic Surgeons (AAOS) adopted and published their standards of professionalism in 2007.2 Since then, the AAOS and the North American Spine Society (NASS) have subse quently published position statements regarding physicianindustry relationships.3'4 Much of this has been in response to a U.S. Senate inves tigation on the relationships between surgeons and the medical device industry that raised questions about the legitimacy of consultant fees and grants for continuing education.5 Some of the data presented has led to new policies regarding disclosure of financial interests and relationships with medical device companies to patients and colleagues receiving continuing edu cation. This has helped to manage potential conflicts of interest, which could improperly influence medical decision making. Researchers have sought to determine how patients feel about these relationships and published data on orthopedic patients is limited. There are two major published studies on orthopedic patients, one on spine surgery patients by Khan et al,6 and one on hip and knee arthroplasty patients by Camp et al.7 Both studies demonstrated that patients are not over whelmingly concerned with financial relationships between surgeons and industry, but agree that disclosure of financial
interests is important. To date, these questions have not been addressed within the military health system. Given that we work in a system that is funded by govern ment appropriations, and many surgeons performing orthopedic surgeries in our system are active duty military officers, we sought to determine the position of patients within the mili tary health system regarding disclosure of financial relation ships with industry, receipt of compensation, and the process behind how a surgeon in the military health system chooses a particular implant, including views on the role of the govern ment in choosing implants. We hypothesize that patients in the military health system will have similarly favorable per ceptions of surgeons potential conflicts of interest, but may overestimate the influence of the government on implant choices of individual surgeons. MATERIALS AND METHODS Study Patients From March 2012 to March 2013, patients visiting the spine surgery clinic and joint arthroplasty clinic at a single military teaching hospital (San Antonio Military Medical Center, San Antonio, TX) completed self-administered questionnaires. In total, four surgeons (two arthroplasty and two spine) con tributed patients to this study. None of the surgeons had finan cial relationships with manufacturers. All patients who were 18 or older, were TRICARE beneficiaries (active or retired military and their dependents), and were being evaluated in the spine or total joint clinic were included. Civilian trauma patients being cared for in these clinics were excluded. Questionnaire Design
San Antonio Military Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, TX, 78234-6200. doi: 10.7205/MILMED-D-14-00207
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Our survey questionnaire was developed based on a previ ously published survey8 exploring physician-industry rela tionships in a civilian practice setting, with permission from
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Patient Perceptions o f Surgeon-Industry Relations in a Military Setting
the original authors. Questions in the original survey that were not relevant to a military-based population were removed, and demographic questions related to military sta tus (active, retired, or dependent) were added to the survey. Additionally, questions were added regarding patients per ceived role of the government in choosing surgical implants, given the nature of the military health care system. The final questionnaire contained a total of 37 items within the follow ing domains: patient awareness of surgeon-industry relation ships, opinions regarding reimbursement from industry, the role of government in choosing implants, trust in the surgeon to choose the best implant, demographic information, and whether or not the patient had a spinal or joint implant at the time of the survey. Survey Administration Patients attending the spine and total joint clinics at the San Antonio Military Medical Center were asked by clinic personnel to complete the self-administered questionnaire. Every patient who met inclusion criteria was invited to partic ipate. Patients were informed that participation was voluntary, that their surgeon would not know if they had participated, that the survey was completely anonymous, and that their choice to participate or to not participate would not affect their care in any way. Although one of the participating surgeons (J.J.) is an author of the study, he was not directly involved in the recruiting of patients. Consent to participate was demonstrated by the patients completing the survey. This questionnaire has been used in previous studies,8 and was written in a way as to be clear and comprehensible by the study population. There was no financial incentive for participation. The San Antonio Military Medical Center Institutional Review Board approved the protocol and the questionnaire. Statistical Analysis The survey results were summarized based on the percentage of patients who responded to each question. Univariate anal ysis was performed to describe frequencies of response to each question. For bivariate analysis, Likert scales were col lapsed into three response categories (“agree,” “no opinion,” and “disagree”). Source of Funding No external funding sources were utilized for this study. RESULTS
Patient Characteristics Demographic data for our patient population are summarized in Table I. The majority of patients in the cohort were male (59%). The age profile represented an overall younger popu lation than published civilian data on patients who undergo total joint arthroplasty9 or spine surgery.10 The distribution of education reveals a higher percentage of college and
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TA B LE 1.
Patient Demographic and Clinical Data
Characteristic Gender Male Female Age (Year) 79 Military Status Active Duty Enlisted Officer Retired Dependent Level of Education Less Than High School High School College Graduate/Professional Employed in Health Care Profession Yes Physician Nurse Other No Had Prior Total Joint or Spine Surgery Yes At Military Treatment Facility At Civilian Hospital No
Number (%) 166 (59) 116(41) 111 (40) 62 (22) 70 (26) 25 (9) 8(3) 83 125 63 108 88
(30) (66) (34) (38) (32)
2(1) 67 (24) 139(50) 72 (26) 69 (25) 5(7) 19 (28) 45 (65) 212 (75) 158(53) 177 (80) 44 (20) 138 (47)
Totals may vary because of missing data or patient refusal. Percentages may not total 100 because of rounding.
advanced degrees compared with the general population based on 2010 census data.11 Among the active duty and retired military population, a higher proportion of officers in our cohort (34%) than in the general military population was noted. About half of the patients had prior spine or joint replacement surgery and half were new patients presenting either for initial evaluation or established patients being managed nonoperatively. Patient Awareness and Perception of Physicianindustry Relationship Data regarding awareness of the physician-industry relation ship are summarized in Table II. In total, 77% of patients were aware that private companies manufacture implants and 71% have seen advertisements for total joint or spine implants. The majority of patients believe that their physician should disclose any financial relationship they have with industry. Data regarding the perception of these relationships are summarized in Table III. Overall, the majority of patients believe that the physician-industry relationship is beneficial to patient care and appropriate. The majority (84%) of patients trusts their doctor to choose the right implant for them and
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Patient Perceptions of Surgeon-Industry Relations in a Military Setting TABLE II.
Patient Awareness of Physician-Industry Relationship Statement
Response No. (%)
Are you aware that private companies manufacture implants for total joint and spine surgery? Have you seen television, Internet, or print advertisements for joint or spine implants?
Yes-227 (77) No-67 (23) Yes-212 (72) No-83 (28)
Totals may vary because of missing data or patient refusal. Percentages may not total 100 because of rounding.
do not seem to think that there is undue financial pressure to choose one specific implant over the other. Data regarding implant selection are summarized in Table IV. Regarding who should have the choice of surgical implant, only 33% of patients disagree with the statement that “The govemment/military should have the sole choice of implant,” whereas only 45% agree that surgeons should have the sole choice of implant, compared to 39% who feel that the patient should have the sole choice of implant. P a tie n t V iew s A b o u t P h y s ic ia n T ru s t a n d E x p e rtis e
Data regarding patient views on physician trust and experi ence are summarized in Table V. The majority of patient feel that their doctor cares about them and is considerate of their needs, however, only 53% of the respondents agree with the statement “If my physician tells me something, it must be true” and 27% of respondents agree with the statement that “they sometimes distrust their surgeon’s opinions and want a second one.”
TABLE III.
P a tie n t V iew s A b o u t P a y m e n ts to P h y s ic ia n s
Data regarding patient views about payments to physicians are summarized in both Table III and Table VI. Most patients (74%) believe that doctors should receive payment for design ing surgical implants, but that they should not be paid indi vidually for implants used during surgery that they helped design (66% disagree). The vast majority (86%) felt that thenphysician should be paid “market rate” for their involvement in designing implants, but this rate was not defined. DISCUSSION Although the impact of physician-industry relationships have been a significant topic in both literature and the public sphere, perceptions of patients in the setting of a military treatment facility have yet to be investigated to date. Pub lished civilian patient data demonstrates an overwhelmingly positive perception of their physicians, and view physician relationships with industry as both a necessary and positive force in providing good care and advancing technology related to orthopedic implants. This sentiment seems to be reflected in our study population. Compared to the general population, our study population is younger than the average joint replacement or spine sur gery patient, but at least for joint replacement surgery, the average age is steadily decreasing. This may be reflective of the increased physical demands over the lifetime of active duty service members, resulting in earlier onset of musculo skeletal pathology requiring surgical intervention. Addition ally, our population was nearly 60% male, which may be because of a combination of the increased proportion of males in the military compared to the general population and
Patient Perception of Physician-Industry Relationship
Statement It is beneficial for you if your doctor advises the medical device manufacturers to improve/design medical implants Your doctor should receive financial reimbursement from private companies for this advisory role The doctor industry relationship is appropriate and beneficial for your care Your doctor should receive additional payment from private industry for each spinal implant or prosthesis that he/she uses during your surgery Your doctor should tell you about any financial or advisory relationships with private industry before surgery The outcome of your surgery is affected by your doctor’s choice of spinal implant or joint replacement design You trust your doctor to choose the spinal implant or joint replacement that is best for you Your doctor is influenced to choose the spinal implant or joint replacement because of financial reimbursement by industry relation Your doctor should promote the implants that he/she helped to design Private companies should advertise implants directly to consumers (i.e., TV, radio, magazine ads) Private companies should advertise implants directly to physicians
Strongly/Somewhat Agree (%)
Neutral (%)
Strongly/Somewhat Disagree (%)
81
15
4
29
33
38
65 15
28 29
7 66
63
23
14
73
16
11
84
9
7
25
41
34
33 41
39 36
28 23
61
30
9
Totals may vary because of missing data or patient refusal. Percentages may not total 100 because of rounding.
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Patient Perceptions o f Surgeon-Industry Relations in a Military Setting TABLE IV.
Patient Views About Implant Selection
Statement
Strongly/Somewhat Agree (%)
Neutral (%)
Strongly/Somewhat Disagree (%)
The government/military should have the sole choice of surgical implant Patients should have sole choice of surgical implant Hospitals or insurers should have sole choice of surgical implant Doctors should have sole choice of surgical implant
41 39 17 45
26 31 22 31
33 30 61 24
Totals may vary because of missing data or patient refusal. Percentages may not total 100 because of rounding.
TABLE V.
Patient Views About Physician Trust and Expertise
Statement My doctor really cares about me as a person My doctor is usually considerate of my needs and puts them first If my doctor tells me something is so, then it must be true I sometimes distrust my doctor’s opinions and would like a second one I feel my doctor does NOT do everything he/she should do about my medical care I trust my doctor to put my medical needs above all other considerations when treating my medical problems My doctor is an expert in managing musculoskeletal problems like mine
Strongly/Somewhat Agree (%)
Neutral (%)
Strongly/Somewhat Disagree (%)
74 77 53 27 14 73
18 16 32 29 23 16
8 7 15 44 63 11
67
27
6
Totals may vary because of missing data or patient refusal. Percentages may not total 100 because of rounding.
the higher proportion of males among spine surgery patients. Population data from the Spine Patient Outcomes Research Trial shows a higher preponderance of males in the operative treatment group . 10 In our cohort, subgroup analysis to distin guish between patients receiving spine surgery versus total joint arthroplasty was not investigated. Most patients agree that physicians should be paid for their contributions to designing implants, but not receive royalties for individual implants placed. Additionally, patients think that their surgeon should disclose relevant financial relationships with industry, which is consistent with the views
TABLE VI.
Perception About Payment to Physicians for Implants Statement
Do you feel your doctor has chosen your spinal implant or joint replacement prosthesis based on: Personal Financial Gain Familiarity and Personal Preference Medical Research Other Do you feel your doctor should receive payment for designing surgical implants for private companies? Yes No If yes, how much should your doctor receive? An Hourly rate Market Rate A Percentage of Implant Cost
Response (%)
0 50 32 18
74 26 11 86 3
Totals may vary because of missing data or patient refusal. Percentages may not total 100 because of rounding.
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on the AAOS, and NASS official positions on physician conflict of interest. In the Military Treatment Facility setting, it is far less likely surgeons will have a direct financial stake in a medical device company. However, this study was per formed in a tertiary care referral center within the military system and is an academic institution where the potential exists for industry-sponsored funding for research. Such rela tionships may nonetheless interfere with conflict of interest and such funding has been reported in up to one-third of academic medical centers. 12 Patients were also asked about who they feel should ulti mately choose their implant, which we thought was relevant to an institution that is funded exclusively with government funds, in order to get patients perceptions of who is in control of these decisions. Interestingly, patients were nearly split on whether patients, doctors, or the government/military should choose the implant, but most agreed that “the hospital” should not be the one to choose. The distinction that our cohort made between “the government/military” and “the hospital” was not clear, and follow-up studies may be needed to eluci date this difference. However, this supports our hypothesis that patients in our system may overestimate the influence of the government in how we choose surgical implants. There are several limitations to this study. Although we included both preoperative and postoperative patients, which had not been done in previous studies, we did not perform subgroup analysis on spine surgery and total joint patients, which may have slightly different demographics. We grouped these patients together because these are groups where there is instrumentation involved, they are elective procedures, and there is significant industry influence from manufacturers to use particular technologies. Additionally, because the
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questions were not all identical to previously published stud ies, it is difficult to elucidate statistical difference from responses in the civilian literature. Last, for the purposes of simplicity and to increase the likelihood of patient participa tion, the survey was kept short enough so that patients would be able to complete it in the time that they spend waiting to be seen in the clinic. We subsequently did not explore details about patients’ depth of understanding of the nature of the physician-industry relationship or dollar amounts of financial relationships. This may require further study to investigate. In conclusion, we feel that the views expressed by our patients reinforce the overall sense of trust in both the ortho pedic surgery profession and our relationship with our partners in industry in a military treatment facility setting, which had not been previously investigated.
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ACKNOWLEDGMENTS We thank Dr. Scott McGovern, Dr. Brad Currier, and the Mayo Clinic for granting permission to use and modify their survey to suit the needs of our patient population. We also thank Dr. Jay Aden for his work in the statistical analysis of our data set.
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http://www5.aaos.org/industryrelationships/pdfs/standards.pdf; accessed March 25, 2014. North American Spine Society: Position statement on physician and industry relations. 2011. Available at https://www.spine.org/Documents/ Advocacy/PositionStatementPhysicianlndustryRelations.pdf; accessed March 23, 2014. Office of the Inspector General: Hearing before US senate special com mittee on aging. Examining the relationship between the medical device industry and physicians. 2008. Available at http://oig.hhs.gov/testimony/ docs/2008/demske_testimony022708.pdf; accessed March 25, 2014. Khan MH, Lee JY, Rihn JA, et al: The surgeon as a consultant for medical device manufacturers: what do our patients think? Spine (Phila Pa 1976). 2007; 32(23): 2616-8; discussion 2619. Camp MW MD, Gross AE, Mattingly DA, et al: Patients' views on surgeons’ financial conflicts of interest. J Bone Joint Surg Am. 2013; 95-A(2): e9 (l-8 ). McGovern SC TR, Currier BL: Patient perceptions of surgeon-industry relationships. Paper presented at American Academy of Orthopaedic Surgeons Annual Meeting; 2010; New Orleans, LA. Available at http:// www.aaos.org/news/aaosnow/mayl0/clinical9.asp; accessed April 1, 2014. Crowninshield RD RA, Sporer SM Rosenberg AG: Changing demo graphics of patients with total joint replacement. Clin Orthop Relat Res 2006; 443: 266-72. Weinstein JN TT, Tosteson TD. Lurie JD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 2008; 358(8): 794-810. Educational Attainment by Selected Characteristics 2010: US Census Bureau. Statistical abstract of the United States. U.S. Department of Education, 2012. Available at http://www.census.gov/compendia/statab/ 2012/tables/l 2s0231.pdf; accessed April 1, 2014. Jacobs JJ GJ, Galante JO, Mirza SK, Zdeblick T: Relationships with industry: critical for new technology or an unnecessary evil? J Bone Joint Surg Am 2006; 88-A(7): 1650-63.
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