Yale Daily News

In a study published in the Journal of the American Medical Association at the beginning of November, Yale researchers report an association between industry payments received by cardiologists and the medical devices they select to implant into their patients. According to their findings, physicians’ decisions might be influenced by which manufacturers are giving them the most money.

Jeptha Curtis, medical director of performance improvement at Yale’s Heart and Vascular Center, and Amarnath Annapureddy, a clinical fellow at Yale, led the study. In their research, they found that patients are more likely to receive an implantable cardioverter defibrillator (ICD) or a cardiac resynchronization therapy-defibrillator (CRT-D) device –– both of which produce a minor electrical shock, to keep cardiac rhythms regular, in the heart of patients at risk for sudden cardiac arrest –– made by a manufacturer that pays the doctors well.

“Superficially, it looks like a medical discussion, but the way the payments work is there is a psychological bias,” Annapureddy told the News. “If I buy you lunch, I am not asking you to pay me back, but next time you feel obligated to [give me] something in return.” 

Annapureddy pointed out that although payments from manufacturers to physicians have been common prior to 2010, it was not until then, when the Affordable Care Act was passed, that they were first documented. Only in 2013 were the first payment records published online through the Open Payment Program, according to Annapureddy. 

Annapureddy explained that before this study, there had been no investigation of the data with regards to a potential relationship between industry payments and ICD and CRT-D devices. Instead, most past research in this area focused on the drugs that physicians chose to administer.

In their study, Curtis, Annapureddy and their co-authors examined the records of 145,900 patients who received an ICD or CRT-D from Jan. 1, 2016 to Dec. 31, 2018.  After reviewing the payments made to physicians by different manufacturers, as well as which device was ultimately chosen, they found that patients were substantially more likely to receive devices manufactured by companies who had given physicians higher payments for them. As a matter of fact, 38.5 to 54.7 percent of patients got an ICD or CRT-D made by the company that paid their physicians the most.

In an email to the News, Perry Wilson, associate professor at the School of Medicine and director of Yale’s Clinical and Translational Research Accelerator, explained that regardless of whether payments to physicians affect their choice of device, many patients are often unaware that their doctors are being paid at all.

“The open payments system is public, transparent and easy-to-use, but is not widely publicized (as neither physicians nor industry have much incentive to do so!),” he wrote. “But patients should absolutely put their doctor’s names into this database, see what is there and ask them questions about it.”

While the ethics of whether physicians should accept these payments are still hotly debated, this system allows for patients to verify whether their doctor has any financial relationships with the industry that manufactures products that may be used in their patient care, Wilson said.

Curtis pointed out that while he finds such an association concerning, at least when it comes to these two types of devices, it did not translate into adverse patient outcomes.

“All available ICDs and CRT-D devices are highly effective,” he wrote in an email to the News. “In my opinion, physicians should choose the device that they feel best serves their patients, and payments from manufacturers should not be a factor.”

Curtis mentioned that even though there are some differences in battery life and the performance of the wire that connects these devices to the heart across devices, they are relatively modest.

Annapureddy also noted that while there is a relationship between physician payments and device selection, this does not mean that a physician’s selection of devices hinges solely on payments they have received. 

“At the end of the day I do not think these financial entanglements have a direct impact on clinical outcomes,” Curtis wrote. “However, I do think they undermine the public’s trust in the medical profession which is already pretty shaky.”

According to Stat, physicians received approximately $9.3 billion dollars in industry payments between 2014 and 2018.

Maria Fernanda Pacheco | maria.pacheco@yale.edu

Nicole Rodriguez | nicole.rodriguez.nr444@yale.edu