Cardiac Cath and EP Labs: Study Shines Light on Directors’ Financial Ties to Industry

Directors of cardiac catheterization labs at top hospitals in the United States tend to have more financial connections to industry than their peers who aren’t in these roles, according to an analysis of data from 2017. The same pattern can also be seen for electrophysiology laboratories, raising the possibility that conflicts of interest (CoI) could be influencing practice patterns.

“We have known for a while that cardiologists receive larger and more frequent payments from industry compared with other medical specialties,” senior author Jeptha P. Curtis, MD (Yale School of Medicine, New Haven, CT), noted to TCTMD in an email. “Our paper demonstrates that these payments are even larger among cath lab and EP lab directors. It is not surprising in the sense that lab directors are often highly successful physicians who are leaders in their field.”

As leaders, these clinicians have the potential to influence their peers, impact purchasing decisions, and drive the use of certain devices, Curtis pointed out.

“There is nothing inherently wrong about payments from industry to cath and EP lab directors. Collaborations between industry and clinicians are what moves our field forward, and these often require financial entanglements,” Curtis observed. “However, there is the potential for CoI that needs to be closely monitored. Hospital administrators and lab directors need to pay close attention and enforce policies designed to mitigate CoI. Finally, clinicians should be prepared to justify their interactions with industry to patients and peers.”

James Blankenship, MD (Geisinger Medical Center, Danville, PA), though, pointed out one limitation of the analysis that undermines its message: it is comparing physicians who have many years of practice that enabled them to rise to the role of director with others who are not at the same stage of their careers. “The average interventionalist or average EP doctor is going to be a lot less experienced. They’re going to have a lot less industry contacts. There’s going to be a lot less status, a lot less authority,” he said.

Matching physicians with those who have similar academic appointments, age, and background would likely lessen the differences in financial ties. That said, earlier research has shown that even something as small as free meals appear to affect doctors’ behavior. “There’s no clear [cutoff], but my personal feeling is it’s wise to minimize these kinds of relationships. Having said that, some of these connections are very valuable,” in terms of spreading knowledge about newer techniques and procedures, Blankenship commented to TCTMD.

Open Payments Data

Curtis and colleagues, led by Amarnath Annapureddy, MD (Yale School of Medicine), derived 2017 Open Payments Program data on a variety of categories: compensation for services, consulting fees, food and beverage, travel and lodging, speaking at accredited and nonaccredited continuing medical education events, honoraria, grants, education, ownership or investment interest, charitable contribution, entertainment, royalty, and gifts. Their results were recently published online as a research letter in JAMA Internal Medicine.

Cath lab and EP lab directors for the top 100 US cardiovascular hospitals, as defined by the 2017 US News & World Report rankings, received payments from industry totaling $1,416,232 and $2,307,504, respectively, in 2017. In all, there were 195 individuals included, of whom 11 received no payments. Nearly one-third of cardiac cath lab directors received payments of at least $10,000, while nearly half of EP lab directors met this threshold. Most commonly, the payments were consulting fees or compensation for services such as speaking at dinners. Device manufacturers in particular were the source of 74% of payments to electrophysiologists and 61% of those to interventional cardiologists.

Notably, the payments did not correlate with US News & World Report’s estimation of hospital quality and only poorly matched up with physicians’ research productivity.

Median payments to cardiac cath lab directors were higher than those given to other interventional cardiologists practicing in the same zip codes ($3,203 vs $1,064), as were those to EP lab directors in comparison to their peers ($10,521 vs $2,900).

How Much Sway Do Directors Have?

Rita F. Redberg, MD (University of California, San Francisco School of Medicine), editor of JAMA Internal Medicine, makes her case in an editorial for why it’s important to unearth industry ties, particularly with device manufacturers.

“The United States spends many billions of dollars on medical devices annually; cardiac devices are a significant component of these expenditure,” she explains. “Device pricing is quite hidden because patients are rarely billed separately for devices; rather, devices are part of a package. Many hospitals have committees that determine which type and brand of devices to use and may negotiate pricing as well. Again, these prices and negotiations are secret. Commonly, physicians are key participants in those decisions.”

Curtis said his group is now researching whether industry payments do, in fact, influence device selection.

Most hospitals already have policies on conflicts of interest, he added, but it’s important to make sure that the policies are followed and enforced. Hospitals might also take steps to make CoI information public, to spur conversation.

For her part, Redberg asserts that these relationships with industry may mean that decisions are not being made “wholly in the best interests of patients.” She, too, stresses the need for action. “In addition to individual ethical standards, professional society guidelines should prohibit doctors with relationships with industry from participating in decisions about what devices their hospital chooses to purchase. Finally, patients should be made aware if their doctor has a relationship with the company that makes the device they have been recommended,” Redberg concludes.

But Blankenship told TCTMD that he thinks both the researchers and Redberg overestimate the role that directors have in device selection. “As a cath lab director for 20 years and now as a director of cardiology at my institution, I [still] have very little input into which particular device we select. In our case—and I think increasingly across the industry—these decisions are made by clinical use committees, which include administrators, physicians, and supply chain personnel,” he said, adding that decisions get made through complicated processes that consider both prices and operator preferences.