Evaluation of Conflict of Interest in Consulting Fee Payments in Plastic Surgery and Related Specialties.

BACKGROUND: The Physician Payments Sunshine Act was enacted to increase transparency regarding physician and industry financial interests. Consulting fee payments constitute a large proportion of these financial relationships. The authors hypothesized that there are discrepancies among industry-derived consulting payments to medical and surgical specialties. The purpose of this study was to evaluate the distribution of consulting fee payments to plastic surgery and related specialties. METHODS: This cross-sectional study used the publicly available Centers for Medicare & Medicaid Services Open Payments Program database for 2018. Consulting fee payments to physicians practicing in dermatology, internal medicine, neurosurgery, orthopedic surgery, otolaryngology, and plastic surgery were isolated and analyzed to identify discrepancies in consulting payments among these specialties and within plastic surgery. RESULTS: A total of $250,518,240 was paid in consulting fees to specialties analyzed, with the largest average payment made to orthopedic surgeons and neurosurgeons. Nearly half of physicians were paid at least $5000 for consulting fees in 2018. Most payments were not associated with contextual information. Among U.S. plastic surgeons, 4.2% held financial relationships with corporations and were likely to be paid more when consulting for small companies. CONCLUSIONS: Consulting payments make up a large proportion of payments included in the Open Payments Database. Although sex, state, company type, and sole proprietorship did not correlate with higher pay, plastic surgeons who consulted for small companies were paid more per payment than those working for large companies. Future studies are warranted to determine whether these industry financial relationships impact physician behavior.

A Guide to Industry Payments and an Algorithm for Their Management.

BACKGROUND: The Open Payments database was created to increase transparency of industry payment relationships within medicine. The current literature often examines only 1 year of the database. In this study, the authors use 5 years of data to show trends among industry payments to plastic surgeons from 2014 to 2018. In addition, the authors lay out the basics of conflict-of-interest reporting for the new plastic surgeon. Finally, the authors suggest an algorithm for the responsible management of industry relationships. METHODS: This study analyzed nonresearch payments made to plastic surgeons from January 1, 2014, to December 31, 2018. Descriptive statistics were calculated using R Statistical Software and visualized using Tableau. RESULTS: A total of 304,663 payments totaling $140,889,747 were made to 8148 plastic surgeons; 41 percent ($58.28 million) was paid to 50 plastic surgeons in the form of royalty or license payments. With royalties excluded, average and median payments were $276 and $25. The average yearly total per physician was $2028. Of the 14 payment categories, 95 percent of the total amount paid was attributable payments in one of six categories. Seven hundred thirty companies reported payments to plastic surgeons from 2014 to 2018; 15 companies (2 percent) were responsible for 80 percent ($66.34 million) of the total sum paid. Allergan was responsible for $24.45 million (29.6 percent) of this amount. CONCLUSIONS: Although discussions on the proper management of industry relationships continue to evolve, the data in this study illustrate the importance of managing industry relationships. The simple guidelines suggested create a basis for managing industry relationships in the career of the everyday plastic surgeon.

Industry Payments by Allergan, Inc to Plastic Surgery and Related Specialties in 2018.

In 2014, payments to medical providers from drug/device manufacturers were made public through the Open Payments Database. Although previous studies have used the Open Payments Database to describe relationships between specialties and industry, few have evaluated specific companies and the effect of their contributions. As a large contributor to industry payments in plastic surgery, Allergan, Inc represents a significant source of potential financial conflicts of interest in the field. In this study, we aimed to describe the quantity, type, and specific products associated with Allergan's payments to both plastic surgeons and physicians of other specialties. In 2018, Allergan paid a total of $48,484,163 in 397,225 payments to 90,386 physicians. Psychiatry and neurology received $11,867,861 in payments, the largest of any specialty, whereas internal medicine received the largest number of individual payments. Plastic surgeons made the most per physician ($3025). Most payments made to plastic surgeons were categorized as "gifts." Payments made in relation to Botox were predominantly made to neurologists, whereas most payments attributed to Natrelle breast implants were made to plastic surgeons (74.4%). Surprisingly, 18.2% of Natrelle payments were made to family medicine physicians. Further study is needed to fully understand the implications of the financial contributions revealed in this study.

Utilization of surgical treatment for sleep apnea: A study of health disparities.

OBJECTIVE: Barriers to surgical treatment for sleep apnea remain understudied. In this study, we sought to evaluate whether specific demographic and socioeconomic characteristics are associated with whether or not patients receive surgery for sleep apnea management. METHODS: The National Inpatient Sample (NIS) database was analyzed for 2007-2014. Patients aged 18 or older with primary or secondary diagnoses of sleep apnea were selected. Patients were sub-categorized by whether they received related soft-tissue removal or skeletal modifying procedures. Age, race, gender, region, insurance, comorbidities, procedure type, and procedure setting were analyzed between surgical and nonsurgical groups. RESULTS: A total of 449,705 patients with a primary or secondary diagnosis of sleep apnea were identified, with 27,841 (5.8%) receiving surgical intervention. Compared with the non-surgical group, patients in the surgical cohort were more likely to be younger, male (74.4% vs. 59.0%), Hispanic (10.2% vs. 6.2%), Asian (3.6% vs. 1.0%) (p < 0.001), and have less clinical comorbidities. Those receiving surgery were more likely to be in the highest income bracket (36.1% versus 25.1%) and utilize private insurance (76.3% vs. 50.8%). Soft-tissue surgeries comprised 88.5% of total procedures while skeletal modifying procedures constituted 11.5% (p < 0.001). CONCLUSIONS: This study identified multiple demographic, socioeconomic, and clinical discrepancies in the utilization of surgical versus nonsurgical management of sleep apnea in the United States. Future studies should examine the causes for these health disparities in the ultimate effort to provide more equitable healthcare in the United States.

National Trends in Hospitalization Charges for Autologous Free Flap Breast Reconstruction.

BACKGROUND: There is significant cost variation among patients undergoing autologous free flap breast reconstruction. Previous studies hypothesize that factors like length of stay and hospital volume are key drivers of cost; however, how these factors have affected cost have not been well studied. Our study analyzes the factors influencing hospital charges relating to these procedures and their trends over a multiyear time frame. METHODS: The Healthcare Cost and Utilization Project's National Inpatient Sample database was analyzed from January 2009 to December 2014. All female patients who were diagnosed with breast cancer or at a high risk for breast cancer who underwent autologous free flap breast reconstruction were included. Variables of interest included demographic data, hospital characteristics, hospitalization data, and total hospital charges. Univariate and generalized linear models were used to examine associations between selected variables and the hospitalization charges, as well as trends in these factors over the years included. RESULTS: There were 659,220 female patients diagnosed with breast cancer or had a high risk of breast cancer between 2009 and 2014. Of these patients, 20,050 (3.0%) received autologous free flap breast reconstruction and were included. The mean total hospital charge was US $98,839.33 (SD = US $61,532.04). Regression analysis showed that the proportion of procedures to the total population of potential patients significantly increased over the selected time frame (P = 0.02). The average total charges also increased significantly (P < 0.01), despite a decrease in length of stay (P = 0.05). Procedures performed in the west were associated with significantly higher charges when compared with other regions (US $147,855.42, P < 0.001). Higher hospital charges were also associated with urban hospitals, regardless of teaching status. CONCLUSIONS: The overall demand for the autologous free flap breast reconstruction is increasing within the patient population, in conjunction with increasing associated hospital charges. This increase in cost is seen despite an overall decrease in length of stay, originally thought to be the main contributor to regional cost variation. Further studies should be done to develop strategies to better target increased hospitalization charges, because the overall health care burden of this procedure is expected to rise if current trends continue.

Processing and integration of functionally oriented prespacers in the Escherichia coli CRISPR system depends on bacterial host exonucleases.

CRISPR-Cas systems provide bacteria with adaptive immunity against viruses. During spacer adaptation, the Cas1-Cas2 complex selects fragments of foreign DNA, called prespacers, and integrates them into CRISPR arrays in an orientation that provides functional immunity. Cas4 is involved in both the trimming of prespacers and the cleavage of protospacer adjacent motif (PAM) in several type I CRISPR-Cas systems, but how the prespacers are processed in systems lacking Cas4, such as the type I-E and I-F systems, is not understood. In Escherichia coli, which has a type I-E system, Cas1-Cas2 preferentially selects prespacers with 3' overhangs via specific recognition of a PAM, but how these prespacers are integrated in a functional orientation in the absence of Cas4 is not known. Using a biochemical approach with purified proteins, as well as integration, prespacer protection, sequencing, and quantitative PCR assays, we show here that the bacterial 3'-5' exonucleases DnaQ and ExoT can trim long 3' overhangs of prespacers and promote integration in the correct orientation. We found that trimming by these exonucleases results in an asymmetric intermediate, because Cas1-Cas2 protects the PAM sequence, which helps to define spacer orientation. Our findings implicate the E. coli host 3'-5' exonucleases DnaQ and ExoT in spacer adaptation and reveal a mechanism by which spacer orientation is defined in E. coli.