Published 11/1/2009
Mary Ann Porucznik

Are orthopaedists trustworthy?

Study raises questions about self-disclosure of conflicts

It’s not easy being an orthopaedic surgeon these days. It seems as if the profession, like the rest of medicine, is under a magnifying glass.

Last month, a study in the New England Journal of Medicine prompted a reporter to ask the question that headlines this article. The study, a comparison of payments reported by implant manufacturers and presenters at the AAOS 2008 Annual Meeting, found that more than 20 percent of industry payments directly related to the topic of the presentation were not reported by physicians. In addition, half of all payments indirectly related to the topic of the presentation were not reported.

Determining disclosure
All four physician researchers are themselves members of the AAOS. They sought to “assess the accuracy of physicians’ conflict-of-interest disclosures.” Relying on the Final Program from the 2008 Annual Meeting and reports from five manufacturers of hip and knee implants, who were required to list payments to physicians under settlements the companies made with the Department of Justice, the researchers compared the program’s list of authors, presenters, faculty, board members, and committee members to the companies’ lists of physicians who received payments (as of December 2007).

Researchers also looked at the “relatedness” of the payments to the presentations. Because the companies manufactured hip and knee implants, payments were considered “directly related” to presentations that focused on implants in those joints; if the pre-

sentation involved arthroplasty but focused on something other than hip or knee implants, the payment was considered “indirectly related.” Presentations on other topics were considered “unrelated” to the payment.

The researchers then compared their lists to the disclosures printed in the final program. Any report of receiving something of value was considered disclosure of a conflict of interest. A follow-up survey among physicians who did not disclose payments was conducted to identify the reasons for the nondisclosure.

1,347 payments to 1,162 physicians

Based on information on the companies’ web sites, the five companies made a total of 1,347 payments to 1,162 physicians. More than 14 percent of the physicians received payments from more than one company.

Of these 1,347 payments, 344 were made to orthopaedists who authored presentations or served as faculty or board members at the 2008 AAOS Annual Meeting. Only 245 of these payments (71.2 percent) were disclosed, however, in the final program book. Of the 208 directly related payments, 165 (79.3 percent) were disclosed; of the 32 indirectly related payments, 16 (50 percent) were disclosed. Slightly less than half of unrelated payments (29 of 59) were disclosed. The total value of the undisclosed payments (directly and indirectly related) was more than $11.8 million.

Getting it right
In response to the study, AAOS President Joseph D. Zuckerman, MD, noted “The AAOS has and will continue to take steps to ensure that the presentation of information at our annual meetings is free from commercial bias and that our members disclose all conflicts of interest. It is in everyone’s best interests to get it right, and we will continue to simplify and perfect the disclosure process.”

According to Chief Education Officer Mark W. Wieting, the AAOS is continually improving efforts to ensure appropriate disclosure. The implementation of a disclosure database in late 2007 has improved the process significantly, and educational efforts have intensified over the past several years. “All authors must disclose all potential conflicts, whether related to the topic or not, a rule that’s somewhat more strict than the Accreditation Council for Continuing Medical Education’s ‘Standards for Commercial Support’ call for,” he said.

In addition, the Academy has taken the following steps:

  • Made the mandatory disclosure process electronic (the studied 2008 Annual Meeting was the last one to employ paper documents for disclosure)
  • Required all authors to submit their own disclosures
  • Made the online disclosure database available year-round so it can be continually updated
  • Provided several education opportunities to instruct members on the importance of full disclosure
  • Instituted education sessions for session, symposium, and course moderators on their responsibilities related to disclosure of conflicts of interest by program speakers
  • Established a template for onsite disclosure during the presentation; the first slide of every presentation must include disclosure information (Fig. 1).

“We will continue to evaluate and improve the process and our member education efforts,” Mr. Wieting concluded.

As for the trustworthiness of orthopaedists, the Academy will continue to rely on self-disclosure by its members and is confident that, as the disclosure process becomes better understood and more familiar, the number of undisclosed conflicts will rapidly be eliminated.

AAOS members who wish to submit or update conflict of interest information can do so at www.aaos.org/disclosure (member login required)

Annual Meeting Participation Guidelines

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org