Industry Payments to Vascular Neurologists Jump in the Thrombectomy Era

LOS ANGELES, CA—The emergence of device-based treatment for acute ischemic stroke, among other developments, has been accompanied by a substantial increase in payments from industry to vascular neurologists, a new study shows.

From August 2013 to December 2018, data from the Open Payments program show that the yearly amount paid to vascular neurologists rose from $99,749 to $1,032,302, Aliza Brown, PhD (University of Arkansas for Medical Sciences, Little Rock), reported at the International Stroke Conference here last week.

The focus of the payments shifted from activities related to pharmaceuticals to those tied to devices.

By the end of the study period, the top 1% of vascular neurologists (45 physicians) were receiving nearly 80% of the total payments. Of this group, about three-quarters were considered to be key leaders in the field, defined as division chiefs, professors, or directors of a stroke fellowship program.

As for the potential impact this large increase in industry payments to physicians could be having on clinician behavior and patient care, “we don’t know yet,” Brown told TCTMD. “Regarding payments from different industry and private sponsors, I think that needs to be looked at more critically [to know] how that influences what we do in the field for patients.”

Commenting for TCTMD, Ralph Sacco, MD (University of Miami, FL), incoming editor-in-chief of Stroke and a spokesperson for the American Stroke Association (ASA), added a note of caution to the discussion by pointing out that the Open Payments database used for this study can be inaccurate, a limitation noted by the researchers as well.

Sacco cited a personal experience in which industry money sent to his institution because of his service on a data and safety monitoring board was listed as going into his pocket. “So you have to be careful that the money attributed in these databases is actually going to the individual. That’s always the issue,” he stressed.

Even so, Sacco said, it’s clear industry payments to vascular neurologists have gone up. “But . . . think about how much work is happening in the field,” he said, alluding to the emergence of endovascular approaches to treating acute stroke and other developments. “Many more therapies, many more devices, and a lot more activity. So over time the numbers have gone up, which one would expect, given that a lot of the breakthroughs in our field have come from pharmaceutical- and device-sponsored trials.”

He stressed that the American Heart Association(AHA)/ASA have strict policies governing relationships with industry among its guideline writers. For most documents, at least 51% of the writing committee members have to be free of industry relationships. For the prevention guidelines, all of the authors have to be free of such ties prior to and during the writing, as well as a for year after publication.

“The organization understands the importance of minimizing conflicts of interest and stands behind the high quality guidelines that they provide to healthcare providers,” Sacco said.

Open Payments

For the study, published simultaneously online in Stroke, with lead authors Krishna Nalleballe, MD, and Sen Sheng, MD, PhD (both University of Arkansas for Medical Sciences), the investigators tapped into publicly available data from the Open Payments program overseen by the Centers for Medicare & Medicaid Services, which mandates the public reporting of financial relationships between physicians and industry. They focused on the field of vascular neurology, in which there has been rapid adoption of endovascular treatment of acute stroke following an avalanche of positive clinical trial results that started coming out at the end of 2014 with MR CLEAN.

Between August 2013 and December 2018, the number of board-certified vascular neurologists increased from 1,169 to 1,746, according to data from the American Board of Psychiatry and Neurology. Over that time period, 16% to 17% received payments from industry, which totaled nearly $3.8 million overall after excluding those related to research and partnerships.

I don’t think we would have moved quite so fast in the last decade as we have if we were just expecting public funding without any potential entanglements. Jeremy Payne

In addition to the tenfold increase in annual payments from industry to vascular neurologists over the study period, there was an increase in mean payments per physician from $627 to $3,396. The highest individual payment, made in 2017, was $190,551. The types of payments accounting for the biggest slices of the pie were “consulting fees” (31.1%) and “compensation for services other than consulting” (30.7%). The most frequent types of payments were for “food and beverage,” although these only accounted for 12.4% of the total amount.

Overall, the 10 biomedical companies that paid the most accounted for 74% to 79% of the total amount from industry. In the last year of the study, the drug or device had the largest proportion of payments was the Trevo stent retriever (Stryker), at 18.04%. That was followed by alteplase (Activase; Genentech) at 5.92% and Penumbra catheters (Penumbra) at 5.80%.

The proportion of payments that went to the top 1% of vascular neurologists increased over time from 64% to 79%. In this group, 42% of physicians specialized in neurointervention, 40% in vascular neurology, and 18% in general neurology. Only 11% contributed to AHA/ASA guidelines, but most were considered key leaders in the field.

‘Absolutely Inevitable’

According to Jeremy Payne, MD, PhD (Banner - University Medicine Neuroscience Institute, Phoenix, AZ), the trends described in the study are “absolutely inevitable, and it’s just the way things work these days.”

Over time, public funding for research has become harder and harder to obtain, and industry has taken the lead on funding and developing new therapies, Payne told TCTMD. When it comes to treating stroke in particular, the evolution of the field in recent years has been so rapid that it can be hard to keep track of new developments, underscoring the need for healthcare professionals to be continually educated, he said.

“As that stuff evolves, [and] it’s exactly like what happens in the cardiology space, there’s such rapid progression and evolution of the tools and technologies, it’s always going to be funded by private industry,” Payne said.

That will unavoidably lead to more ties between industry and physicians, he said, “because there’s no other way to drive this bus as fast as we’ve been driving it down the road. It’s helpful to be aware of those things. None of us wants to think that we are so entangled that we lose our perspective. . . . We can’t be just writing prescriptions for drug X because we get payments for drug X and not think that we don’t have any bias. But at the same time, that’s how it works, and I don’t think we would have moved quite so fast in the last decade as we have if we were just expecting public funding without any potential entanglements.”

The only real way to reduce ties between industry and physicians is to increase federal funding for this type of research, Payne suggested. “We need to recognize that that’s not something we’ve done a good enough job in the last couple of decades advocating for.”

In the absence of a major influx of federal funding, though, industry relationships are likely to remain. “We have to manage them and be careful that we are staying on the right side of that bright line, but we can’t just not have those relationships either,” Payne said. “That would be foolish.”

For Sacco, “the article calls attention to a rapidly growing field, and I think as readers we need to always look at what the conflicts of interest may or may not be and put them into balance when we listen to or read something from someone who could have more relationships with industry than others.”