For healthcare professionals only

CCBYNC Open access
Research

# Payments by US pharmaceutical and medical device manufacturers to US medical journal editors: retrospective observational study

BMJ 2017; 359 (Published 26 October 2017) Cite this as: BMJ 2017;359:j4619
1. Jessica J Liu, internist and assistant professor1 2,
2. Chaim M Bell, internist and professor1 2 3 4,
3. John J Matelski, biostatistician2,
4. Allan S Detsky, internist and professor1 2 3,
5. Peter Cram, internist and professor1 2 3 4
1. 1Department of Medicine, University of Toronto, Toronto, Ontario, Canada
2. 2Department of Medicine, Division of General Internal Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
3. 3Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
4. 4Institute for Clinical and Evaluative Sciences, Toronto, Ontario, Canada
1. Correspondence to: J J Liu Department of Medicine, Division of General Internal Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada jessica.liu{at}uhn.ca
• Accepted 18 September 2017

## Abstract

Objective To estimate financial payments from industry to US journal editors.

Design Retrospective observational study.

Setting 52 influential (high impact factor for their specialty) US medical journals from 26 specialties and US Open Payments database, 2014.

Participants 713 editors at the associate level and above identified from each journal’s online masthead.

Main outcome measures All general payments (eg, personal income) and research related payments from pharmaceutical and medical device manufacturers to eligible physicians in 2014. Percentages of editors receiving payments and the magnitude of such payments were compared across journals and by specialty. Journal websites were also reviewed to determine if conflict of interest policies for editors were readily accessible.

### Patient involvement

No patients were involved in setting the research question or the outcome measures, nor were they involved in developing plans for design or implementation of the study. No patients were asked to advise on interpretation or writing up of results. There are no plans to disseminate the results of the research to study participants or the relevant patient community.

## Results

Approximately 72.1% of editors (713/988) at our 52 journals were eligible for inclusion in Open Payments (table 1). Of eligible editors, 50.6% (361/713) received general payments in 2014 and 19.5% (139/713) received research payments. For the 713 editors, the median general payment was $11 (interquartile range$0-2923) and the median payment for research was $0 ($0-0).

Table 1 shows that the highest median general payments received by journal editors were from endocrinology ($7207, interquartile range$0-85 816), cardiology ($2664,$0-12 912), gastroenterology ($696,$0-20 002), rheumatology ($515,$0-14 280), and urology ($480,$90-669). For high impact general medical journals, median payments were $0 ($0-14). The five largest individual physician general payments to editors came from four specialty journals: cardiology ($10 981 153), orthopaedics ($1 264 234 and $325 860), endocrinology ($554 162), and rheumatology ($355 923). We also examined the percentage of editors, by specialty, who received general payments in excess of certain specified thresholds (≥$0, $10 000,$25 000, $50 000, and$100 000) (see supplementary appendix figures 5-9). Even beyond these thresholds, there were notable outliers—for example, two editors received general payments of greater than $1m in 2014 ($1 263 234 and $10 981 153) (table 2). Table 2 General payments* to journal editors in 2014, by journal specialty View this table: The response rate to our editors in chief survey was 15/52 (28.8%). Figure 1 summarises the results of the survey. Fig 1 Results of survey emailed to editors in chief of 52 journals In our review of journal websites, we found conflicts of interest policies for 32.7% (17/52) of journals. For an additional 5.8% of journals (3/52) the existence of a conflicts of interest policy was strongly inferred by website information but we could not find the actual policy. Agreement between reviewers was excellent (κ=0.74). Posted policies varied substantially for detail of information provided. Of the 20 journals with posted or inferred policies, the implication was that all personal and industry related editorial conflicts of interest were self disclosed. Formal recusal processes were mentioned by 15 of the 20 journals with policies. The websites of several journals (Journal of the American Academy of Dermatology, American Journal of Sports Medicine, Annals of Emergency Medicine, Journal of Urology) stated that editors must disclose conflicts of interest with no specific mention of how such conflicts of interest are handled. Annals of Emergency Medicine published very detailed information about editor relations with industry, and the Journal of Urology provided an email address to request further information. We noted that one journal (Anesthesiology) handled transparency of editor conflicts of interest particularly well, with an accessible policy as well as detailed information on specific editor relations with industry. ## Discussion We used information from the CMS Open Payments database to examine financial payments from industry to US editors of 52 prestigious medical journals drawn from 26 specialties in 2014. We found that 50.9% of editors received at least some general payments from industry, and these payments were often large. It is important to consider our findings of payments to editors in the context of the existing literature on industry payments to physicians. Previous studies of industry payments have typically focused on general populations of physicians, have not used Open Payments, and have not specifically focused on editors.36373839 Nevertheless, review of the existing literature is informative. Two separate analyses of Open Payments data reported overall median payments between$100 and $201 for all physicians, which is higher than our finding of median general payments to editors of$11.3637 In addition, one of the analyses reported overall mean general payments of $1407 to all physicians, compared with our finding that editors received mean general payments of$27 941.37 Several studies focusing on orthopaedics found median general payments ranging from $38-$420 compared with our finding of payments to editors of $121.4041 Similarly, other studies reported median general payments ranging from$175-$1851 for physicians specialising in cardiovascular diseases, compared with our findings of$2664.363742

It is also important to compare our findings with information directly available from Open Payments, which reports all mean and median payments of a given specialty annually.35 Generally speaking, median general payments to editors of a specific specialty were higher than median general payments of all physicians in the specialty as reported by Open Payments. For example, we found median payments to cardiology journal editors of $2664 compared with Open Payments-reported median payments of$582 to all cardiologists. Similarly, median payments to gastroenterology editors were $696 versus$475 reported by Open Payments for all gastroenterologists, and median payments to endocrinology editors were $7207 versus$758 reported by Open Payments for all endocrinologists.

We found differences in payment to editors between specialties that might have been expected. Payments were higher for specialties that rely on costly devices (cardiology, orthopaedics) and specialties where there has been recent innovation in development of drugs used to treat chronic diseases over long periods (endocrinology).4344 Surprisingly, payments were not high for other specialties (eg, oncology) with major innovation and where previous research has found physician-industry relations common.45

Our finding that editors of high impact journals (in specialties such as cardiology, gastroenterology, and endocrinology) receive larger payments than the typical practicing physician of the same specialty should raise questions. It is well recognised that pharmaceutical and medical device makers target physician “thought leaders” for lucrative consulting and advisory roles.3839464748495051 The rationale for such a strategy is that these leaders can influence both their physician peers and trainees to boost sales of products. Our finding suggests that, not surprisingly, editors at influential journals are attractive to industry; indeed, the same traits that make an individual attractive to an influential journal as a candidate for an editorial role would likely make that individual attractive to industry. At the same time, it is important to acknowledge that we do not know if editorial relations influence publication decisions. In the best case, the answer would be a categorical “no.” That said, even the appearance of conflicts of interest can severely damage the fragile public trust in the medical research enterprise.52 Editors have an important influence and responsibility for ensuring the integrity of medical research.45 Editorships at high impact journals are sought after positions, and editors set the tone for the rest of the academic profession.

Despite the recommendation from professional associations such as the ICMJE, WAME, and COPE regarding editorial conflicts of interest policies, our finding that only one third of journals have readily accessible editorial conflicts of interest policies is consistent with previous studies.121526272853 We found that even when journals posted editorial conflicts of interest policies on their websites, the degree of detail differed considerably, consistent with previous studies in this area.6712 We would contend that policies, although necessary, are not sufficient, and there seems to be important shortcomings in the implementation and enforcement of these policies at many journals.

The organisation of the 52 journals included in our study varied tremendously. The number of editors at included journals ranged from 1 to 85, and job titles were highly variable. There was also variability in the time commitment required by editors, and in compensation. At some journals, editors are reimbursed well for their time whereas at others work is basically performed on a volunteer basis. Similarly, we found noticeable variation in the rigor with which editorial conflicts of interest policies were implemented. Given the variability in journal organisation and oversight it is not surprising that payments varied markedly, even between journals within the same specialty. It is also worthwhile wondering whether the 52 journals included in our study are representative of all journals with respect to editor-industry payments. We would posit that our highly influential journals are well resourced and prestigious and may well represent the “best case.” Further study is needed to expand our work to a larger sample of journals.

To address potential editor conflicts of interest, journals typically have recusal processes that exclude editors from review of manuscripts where the editor has a conflict; we found that three quarters of journals reported having a recusal process on their website. However, for all journals, potential editorial conflicts of interest are only identified by editor self report, and previous studies have shown self report of conflicts of interest to have considerable shortcomings.5354555657 While editors may not believe that financial payments from industry influence their judgments, there is evidence to suggest that all individuals are subject to subconscious bias from many kinds of influences that are much more subtle than money, the impact of which may be even more difficult to ascertain and self report.1315

Finally, it is important to consider the case of physician entrepreneurship as a reason for exceptional payments. An internet search of one editor who received general payments of \$10 981 153 in 2014 revealed that this individual founded a private company that was subsequently sold to an international medical device corporation in 2012. Many of the key publications for this device were published in the same journal where the company physician founder served as an editor. While we would never question the value of physician entrepreneurship or whether physician inventors should be compensated well for their inventions, there are important concerns about potential conflicts of interest, and we wonder whether such entrepreneurs should be allowed to serve as editors.58

### Strengths and limitations of this study

Open Payments, made available by the Affordable Care Act, has provided a valuable source of data to improve research into clinician-industry relations.29303132333435 Previous studies of financial relations have relied on either physician self report or smaller databases made available by specific companies or states.53839 Open payments is unique because of its reach—all payments from pharmaceutical and medical device manufacturers to all US clinicians.30 Because Open Payments collects data directly from companies, the database circumvents well recognised problems inherent in obtaining data from physician self reports, including faulty memory and selective recall.55152535455 Studies have shown that journals are more likely to publish reports from members of their own editorial membership,9 although others have shown the opposite.13 Thus, our study expands substantially on previous research by providing far more accurate data on the percentage of editors receiving payments and the quantity of those payments.

We acknowledge several limitations. Firstly, there is considerable heterogeneity in how editorial decisions were made across journals. Our intent was to focus on those with an active role in the editorial process; we intentionally omitted individuals such as editorial board members who do not have ultimate control of publication decisions. We also gave all editors in chief a chance to review our editorial lists and received few modifications. Secondly, while we selected journals in a rigorous and transparent manner, we acknowledge that there is likely no method to select journals for inclusion that would satisfy everyone. In addition, while two of our journals (American Family Physician and Current Opinion in Rheumatology) do not publish original research, they meet our other inclusion criteria. Moreover, journals focusing on clinical audiences can be influential, and editorial conflicts at such journals are relevant. Thirdly, we obtained our list of editors in 2016 but examined payments in 2014; we would contend that the mismatch in timing is both unavoidable and largely immaterial. Even if relations were terminated within the interceding timeframe, the potential impact of payments (ie, favourable disposition towards a particular drug or device) is likely to linger. The standardised ICJME disclosure form recommends reporting financial relations within the previous 36 months; therefore, we thought it reasonable to extract 2014 payment data using 2016 editorial mastheads, as any purported influence from industry would fall within this period. Fourthly, Open Payments is currently limited to payments to pharmaceutical and medical device industry; editors who have relations with, for example, electronic health record vendors are not captured. Finally, data are limited to payments to independently licensed clinicians as defined by Open Payments; nurse practitioners, pharmacists, and those with PhD degrees are not captured.

### Conclusions

We found that industry payments to journal editors are common and can be substantial. Moreover, many journals lack clear and transparent editorial conflicts of interest policies and disclosures. Given our findings, we would suggest that journals take several steps. Firstly, we would strongly argue that all journals should develop and implement a transparent, publicly accessible editorial conflicts of interest policy. Secondly, editors in chief should consider excluding those with considerable industry relations from editorial positions. While such a stance could be considered drastic, editors play a crucial role in research integrity; even an appearance of conflict can serve to undermine the clinical research enterprise.

In summary, we found that a substantial percentage of journal editors received personal payments from industry and these payments were often large. Journal editors should reconsider their conflict of interest policies and the impact that editor relations with industry may have on public trust in the research enterprise.

#### What is already known on this topic

• Academic journals have made major efforts to ensure that authors disclose potential conflicts of interest

• However, less attention has been paid to potential conflicts of interest by journal editors, who play a crucial role in deciding which manuscripts are published

#### What this study adds

• Industry payments to journal editors are not rare, can be of substantial monetary value, and vary substantially between journals and by specialty

• This study used publicly available US government data (Open Payments) rather than physician self report, which provides more accurate data on industry payments to journal editors

• Journal editors should reconsider their conflict of interest policies and the impact that editor relations with industry may have on public trust in the research enterprise

## Footnotes

• Contributors: All the authors made substantial contributions to the conception or design of the work, or the acquisition, analysis, or interpretation of the work; drafting the work or revising it critically for important intellectual content; gave final approval of the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. JJL and PC are the guarantors.

• Funding: PC is supported by a K24 award from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (AR062133).

• Competing interests: All authors have completed the ICMJE uniform disclosure form (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

• Ethical approval: This study was approved by the Sinai Health System research ethics board.

• Data sharing: No additional data available.

• Transparency: The lead author (JJL) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

View Abstract