Financial Relationships between Industry and 2023 AUA Annual Meeting Speakers

1. INTRODUCTION

In the landscape of academic medicine, the interplay between industry and physicians has garnered significant attention, particularly in urology [1]. In 2014, urology was the 8th most compensated specialty in non-research payments from industry for practicing urologists within the United States [2]. While pivotal for advancing medical research and patient care, this relationship has comp-lexities. The essence of these interactions often lies in the delicate balance between fostering innovation and maintaining the integrity of clinical and academic decision-making. The American Urological Association (AUA) plenary sessions, featuring some of the most esteemed and influential urologists and specialists in the United States, represent a focal point where the impact of these industry-physician relationships is both pronounced and consequential.

The concept of Conflict of Interest (COI) and the necessity for disclosures in the medical field are well-established. These disclosures are intended to provide transparency when a physician's financial ties might unduly influence their clinical or research decisions, potentially impacting patient care or scientific integrity [3, 4]. However, conventional COI disclosures often fall short of capturing the depth and breadth of these financial relationships, leading to a gap in understanding the true extent of potential industry influence. In a study of presentations at ASTRO meetings over three years, nearly a third of presenters displayed their COI slides in a manner that was not understandable to the average audience [5].

The Physician Payments Sunshine Act, a component of the Affordable Care Act, mandates the disclosure of financial transactions between healthcare providers and the pharmaceutical and medical device industries [6, 7]. This legislation, administered by the Centers for Medicare & Medicaid Services (CMS), aims to bring transparency to these financial relationships. In urology, the Sunshine Act is a critical tool for scrutinizing the financial interactions between industry and healthcare professionals, particularly those in influential positions, such as AUA plenary speakers.

Despite the availability of comprehensive financial data, there is still a notable gap in research specifically focused on quantifying and characterizing the relationships between industry and AUA plenary speakers. This gap is particularly significant considering recent findings from a research letter that revealed extensive industry payments to American editorial board members of major urology journals [1]. Given the stature and influence of AUA plenary speakers in shaping the field of urology, comprehending the extent and nature of their industry relationships is crucial. It is imperative to determine whether the financial ties of these key opinion leaders have the potential to influence clinical practices, research directions, or educational content within the urological community, like the concerns raised about editorial decision-making in academic journals.

Therefore, the primary objective of our study was to characterize and quantify the financial relationships between industry and AUA 2023 plenary speakers. By leveraging the data available through the Sunshine Act, this research study aimed to provide a comprehensive overview of these interactions, offering insights into the nature and magnitude of industry payments and perhaps informing the development of a more comprehensive and transparent COI disclosure process.

2. MATERIALS AND METHODS

3. RESULTS

Our study analyzed data from 171 U.S.-based plenary speakers for the AUA 2023 Annual Meeting. Two speakers were not listed in the Open Payments database and were subsequently excluded from the analysis. The analysis results revealed a statistical difference in total payments received in 2022 among subspecialties (p <0.01). The medical oncology subspecialty received the highest compensation with a median of $14,815 and an IQR of $4,255 to $32,434. When assessing payments based on AUA sections, the New York section emerged as the highest compensated, with a median payment of $2,984 and an IQR of $211 to $12,804. However, the payment difference across sections was not statistically significant (p = 0.61). A comparative analysis of payments based on gender revealed that male speakers received higher total payments than their female counterparts. The median payment for male speakers in 2022 was $17,748 (IQR: $2,704–$95,794), whereas for female speakers, it was $14,690 (IQR: $2,410–$81,346). This difference approached, but did not reach, statistical significance (p = 0.07) (Table 1). Although the H-index was calculated for each speaker, no significant correlation was found between the H-index and the extent of industry payments received. The data showed a modest positive correlation (Spearman coefficient = 0.34, p < 0.01), suggesting that more academically productive individuals tend to receive higher payments.

Notably, of the AUA 2023 plenary speakers, 24% received over $100,000 in total payments in the seven years (2015 – 2022). In 2022, 7% of the speakers received over $50,000, and 28% received over $10,000 in the same year (Fig. 1).

Fig. (2) provides a detailed visualization of the distribution of payments to plenary speakers who also served on AUA and NCCN guideline panels. Of the members serving on AUA or NCCN guideline panels, 48% received payments exceeding $50,000 over the seven years. In 2022, approximately 34% of the guideline panel members received payments exceeding $10,000.

For the entire cohort of plenary speakers, most payments were categorized as consulting services, accounting for 50% of all payments (Fig. 3). This was followed by 31% categorized as “other payments”, which did not include research funds, encompassing various forms of compensation not explicitly defined as consulting or honoraria. Only a small fraction, i.e., 5%, constituted honoraria. Among the AUA guideline panel members who were also plenary speakers, consulting fees again constituted the majority, representing 43% of payments. However, the proportion of payments classified as 'other' was slightly higher at 40%, followed by 8% in honoraria. The NCCN guideline panel members showed that 66% of their payments were for consulting, with other compensation accounting for 24%.

4. DISCUSSION

Our study focused on quantifying and characterizing the financial compensations received by AUA 2023 plenary speakers from the industry, and the results reflected the industry's significant relationships with urologists. With industry contributions to urologists reaching $32.7 million in 2022, our research shed light on the underlying financial dynamics at influential medical conferences [8]. This analysis sought to provide a detailed overview of financial relationships.

Our study examined the financial ties between AUA plenary speakers and the healthcare industry. Previous analyses have shed light on the financial interactions within the realm of urology, revealing that nearly 50% of guideline authors have received more than $10,000 in a single year from the industry, with 37% of the guideline author disclosure statements being inaccurate [9]. Additionally, the median payments to editorial board members in urology have been reported to exceed those typically received by the broader urologist community [10]. Our study aligned with these findings, indicating that in 2022, 7% of AUA plenary speakers earned over $50,000, and among those AUA plenary speakers serving on guideline panels, 12% received payments exceeding this amount.

We also examined geographic distribution trends by analyzing AUA geographic sections. Previous research indicated that in 2018, the Southeastern, North Central, and Western sections had the largest median annual payments, with reported median payments per urologist of $562, $317, and $209, respectively [11]. Our findings showed a similar geographic distribution, with New York, Southeastern, Western, and Mid-Atlantic sections receiving the highest annual payments. However, the median payments for AUA speakers in 2022 were substantially higher than those for the average urologist, with the Southeastern, North Central, and Western sections receiving median payments of $2,250, $756, and $2,001, respectively. Given previous evidence that male urologists receive more total funding and higher median payments than their female counterparts, we assessed the AUA plenary speakers for similar disparities [11]. Our

analysis confirmed that male speakers received more funding in total and annually compared to their female counterparts. This observed disparity aligned with trends documented in other surgical specialties, including ortho-pedics and cardiology, where gender-based differences in industry compensation have been well established [12-14]. These findings underscore the need for further exploration of systemic factors that contribute to these disparities.

Previous analyses of payments to urologists across various specialties revealed distinct trends in compen-sation. Over a five-year study period, oncologic urologists collectively received the largest total payments, while reconstructive urologists possessed the highest median total payment, exceeding $4,000 per provider. Urologists specializing in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) and andrology reported median payments of over $3,000 [11]. Our findings aligned with these trends, identifying laparoscopy/robotics, FPMRS, oncology, and endourology as the subspecialties with the highest payments from the industry. Notably, median payments for urologic oncology among AUA plenary speakers were significantly higher than in previous studies, with FPMRS and endourology showing similar patterns. The most substantial payments were observed in medical oncology, aligning with studies focused on novel pharmaceuticals. While most payments to medical oncologists were modest, a subset, representing 1% of all medical oncologists, received over $100,000 annually, accounting for 37% of all industry payments in this specialty. Interestingly, nearly a quarter of these high-earning medical oncologists were found to serve on journal editorial boards, and 10% have authored clinical practice guidelines [15]. This highlights the significant financial involvement of key opinion leaders in medical oncology with the industry, underscoring the importance of transparency.

Our analysis revealed that consulting fees made up a significant portion of the payments to AUA plenary speakers, reflecting the industry's reliance on these experts for advisory roles, educational initiatives, and input on product development. This finding aligned with previous reports where consulting and speaker's fees constituted the largest percentage of reported financial relationships in the field [16]. While earlier studies have indicated that food and beverage expenses account for most of the industry spending for all urologists, our focused analysis of AUA plenary speakers, recognized as thought leaders, showed a different trend. In this group, most payments were consulting and speaking fees, typically being much higher than other types of compensation [11]. This shift under-scores the elevated status and influence of AUA plenary speakers in the industry, reflecting their significant roles in shaping clinical practice and guidelines.

Our final analysis included a detailed examination of the financial compensation provided to members of AUA and NCCN guideline panels who were also AUA plenary speakers. The data indicated that these individuals, who are recognized for their expertise and leadership within the field, tend to receive higher levels of compensation from the industry compared to the general cohort of urologists and even among the plenary speakers themselves. This finding was found to be in accordance with other specialties, such as medical oncology and ophthalmology [15, 17]. One study found that 25% of oncologic clinical guidelines authors had received non-research payments of more than $10,000 in a single year [18].

In the realm of academic urology, especially among AUA plenary speakers recognized as thought leaders, a symbiotic relationship with the industry is indispensable for conducting clinical trials and fostering innovation. While the financial contributions from these industry relationships constitute a minor fraction of an academic urologist's overall income, evidence suggests that even minimal interactions, such as a single industry-sponsored meal, can influence prescribing behaviors [19, 20]. It is complex to precisely delineate the impact of industry on medical decisions yet asserting that industry payments play no role would be misleading, as demonstrated by studies linking industry payments to favorable positions on the use of devices for treating lower urinary tract symptoms [21]. However, the positive aspects of such collaborations merit acknowledgment. Clinical and academic leaders signifi-cantly influence the strategic direction of pharmaceutical and medical device companies, using their expertise to steer product development in ways that ultimately benefit patient care. This complexity underscores the critical need for robust conflict-of-interest policies and transparent disclosures, ensuring that the valuable contributions of academic urologists to medical innovation and patient care are balanced with ethical standards and the preservation of trust in the medical profession. Given the pervasiveness of industry payments, professional societies must implement robust COI management strategies. Although disclosure policies exist, these alone may be insufficient to mitigate bias or undue influence. Professional organizations, such as the AUA, must strengthen their leadership in developing more comprehensive policies, possibly requiring active management and enforcement of COI standards beyond mere disclosure. Implementing standardized processes, including independent panels for guideline development and clear limits on financial engagement, can help address the potential for conflicts while maintaining industry collaboration.

The strength of our study was the utilization of official government data from the Sunshine Act, ensuring the reliability of financial information. However, the study was not without limitations. These included not accounting for the number of years in practice for each physician, reliance on reported data that may not capture all financial transactions, and the focus on U.S.-based speakers only. While this analysis has deliberately omitted research-related payments, there is a chance that some payments classified as general might pertain to research endeavors. While such misclassification could inflate the perceived income physicians receive from industry, it is improbable that this would significantly alter the findings of our study.

CONCLUSION

In conclusion, our analysis has meticulously documented the financial interactions between AUA 2023 plenary speakers and the healthcare industry, emphasizing the criticality of transparency and diligent conflict-of-interest management to preserve integrity and trust in the urological community. These interactions, while essential for the progression of urology, necessitate refined disclosure processes to guarantee transparency and objectivity in clinical guidance and research. The study advocates for the development of comprehensive and accessible COI disclosure protocols during professional gatherings, ensuring that the contributions of these relationships to urology are recognized without compromising ethical standards. However, addressing COI issues may require more than improved disclosure processes. Professional organizations must implement more proactive measures, including setting limits on financial engagements, establishing independent panels for guideline development, and mandating periodic training on COI management. Strengthening oversight and enforcement of these policies is essential to ensure that collaborations with industry are managed transparently and without compromising the integrity of clinical decisions. Further research is encouraged to understand the broader effects of these financial relationships on clinical decision-making and guideline development within the field.

REFERENCES