American Association of Neurological Surgeons- Annual-Scientific-Meeting 2019

Conflicts of interest

Conflicts of interest

Definition

The Institute of Medicine (IOM) defines conflict of interest as “circumstances that create a risk that professional judgments or actions regarding a primary interest will be unduly influenced by a secondary interest” 1).


Developmental incentives are fundamental to surgical progress, yet financial and professional incentives inherently create conflicts of interest(COI). Understanding how to manage COI held by neurosurgeons, industryhospitals, and journal editors, without thwarting progress and innovation is critical.

A review of the literature was performed to assess conflicts of interest that affect neurosurgical innovation, and review ways to manage COI of various parties while adhering to ethical standards.

COI are inherent to collaboration and innovation, and are therefore an unavoidable component of neurosurgery. The lack of a clear distinction between clinical practice and innovation, ability to use devices off-label, and unstandardized disclosure requirements create inconsistencies in the way that conflicts of interest are handled. Additionally, lack of requirements to compare innovation to the standard of care and inherent bias that affects study design and interpretation can have profound effects on the medical literature. Conflicts of interest can have both direct and downstream effects on neurosurgical practice, and it is possible to manage them while improving the quality of research and innovation.

Conflicts of interest are inherent to surgical innovation, and can be handled in an ethically sound manner. Neurosurgeons, device companieshospitals, and medical journals can take steps to proactively confront bias and ensure patient autonomy and safety. These steps can preserve public trust and ultimately improve evidence-based neurosurgical practice 2).

Relationships

Financial and nonfinancial relationships between pharmaceutical or medical device industry, physicians, investigators, and academic institutions are common and generally considered essential for development of new technology and advancement in medicine 3) 4).

However, these ties may at the same time create conflicts of interest: a set of circumstances that creates a risk that professional judgments or actions regarding a primary interest will be unduly influenced by a secondary interest 5).

Industry’s interests

The health care industry-manufacturers of drugs, devices, and medical equipment and its associated political and lobbying power, heavily influence strategic directions in clinical research. They may intervene, through experts with disclosed or silenced financial industry ties, in clinical guideline formation and dissemination, and may ultimately affect daily clinical practice.

The industry’s interests are not necessarily aligned with the interests of patients and society and may lead to study participant injury or harm and also reduce the public’s trust and confidence in clinical research.

It is obvious that the growing number of clinical trials conducted in vulnerable countries requires commitment from all stakeholders to ensure adherence to a core of internationally accepted ethical principles that reflect one of the basic ethical premises of the Declaration of Helsinki; that is, that the interests of science and society are not an excuse to conduct clinical trials in vulnerable countries.

Transnational clinical research should be controlled by internationally accredited ethical review boards, and research protocols rejected in one country should not be given permission to proceed elsewhere.

In addition, international human research monitoring agencies should have “…the power to sanction corporations and research groups that fail to respect universal standards”.

While these mechanisms are implemented, the role of major journals publishing the results of RCTs is crucial. This is because, as Smith emphasizes, when results are published in a major journal, the study receives “…the journal’s stamp of approval”, the published results carry a kind of professional approbation, and the paper becomes more attractive to both the readers and media, who may amplify the real value of the results.


A study aimed to determine the prevalence and financial magnitude of potential conflict of interest among editorial board members of five leading spine journals. The editorial boards of: The Spine Journal; Spine; European Spine Journal; Journal of Neurosurgery: Spine; and Journal of Spinal Disorders & Techniques were extracted on January 2013 from the journals’ websites. Disclosure statements were retrieved from the 2013 disclosure index of the North American Spine Society; the program of the 20th International Meeting on Advanced Spine Techniques; the program of the 48th Annual Meeting of the Scoliosis Research Society; the program of the AOSpine global spine congress; the presentations of the 2013 Annual Eurospine meeting; and the disclosure index of the American Academy of Orthopaedic Surgeons. Names of the editorial board members were compared with the individuals who completed a disclosure for one of these indexes. Disclosures were extracted when full names matched. Two hundred and ten (29%) of the 716 identified editorial board members reported a potential conflict of interest and 154 (22%) reported nothing to disclose. The remaining 352 (49%) editorial board members had no disclosure statement listed for one of the indexes. Eighty-nine (42%) of the 210 editorial board members with a potential conflict of interest reported a financial relationship of more than $10,000 during the prior year. This finding confirms that potential conflicts of interest exist in editorial boards which might influence the peer review process and can result in bias. Academia and medical journals in particular should be aware of this and strive to improve transparency of the review process. Janssen et al. emphasize recommendations that contribute to achieving this goal 6).


Traditional peer-review processes used by journal editors to aid in deciding which papers are worth publishing is not capable of filtering some of the more sophisticated techniques of covered marketing and conflicts of interest. The incorporation of ethicists in the peer review process would likely help to raise red flags and to properly consider the routine statement that the study was accepted by the “human review board” of some prestigious university. By rejecting suspicious ethical studies, editors may not be able to help make the world a fairer place, but they will help in building a healthier scientific community and sending a clear message, to both scientists and the industry, that it is unacceptable to exploit and potentially harm a few people for the sake of many 7).

Surgeon-industry

Surgeon-industry conflict of interest (COI) has become a source of considerable interest. Professional medical societiesindustry, and policy makers have attempted to regulate potential COI without consideration for public opinion.

The objective of a study was to report on the opinions of individuals representing the general public regarding surgeon-industry consulting relationships.

Survey was administered using a “spine Web site,” and opinions are collected on surgeon-industry consulting and regulation. Associations among responses to similar questions were assessed to ensure validity and subgroup analysis performed for respondent age, sex, education, insurance, employment, and patient status.

Six hundred ten of 642 surveys had complete data. The sample population comprised more females and was older and more educated than the American population. About 80% of respondents felt it was ethical and either beneficial or of no influence to the quality of health care if surgeons were consultants for surgical device companies. Most felt disclosure of an industry relationship was important and paying surgeons royalties for devices, other than those they directly implant, would not affect quality of care. Respondents support multidisciplinary surgeon-industry COI regulation and trust doctors and their professional societies to head this effort.

Despite the known potential negative impact of surgeon-industry COI on patient care, this study revealed that this does not seem to be reflected in the opinion of the general public. The respondents felt that disclosure is deemed one of the most important means of self-regulation and COI management, which is in agreement with current trends of most spine societies and journals that are increasing the stringency of disclosure policies 8).

Editorial board members of medical journals

Conflicts of interest arising from ties between pharmaceutical industry and physicians are common and may bias research. The extent to which these ties exist among editorial board members of medical journals is not known.

A study aims to determine the prevalence and financial magnitude of potential conflicts of interest among editorial board members of five leading spine journals. The editorial boards of: The Spine Journal; Spine; European Spine Journal; Journal of Neurosurgery: Spine; and Journal of Spinal Disorders & Techniques were extracted on January 2013 from the journals’ websites. Disclosure statements were retrieved from the 2013 disclosure index of the North American Spine Society; the program of the 20th International Meeting on Advanced Spine Techniques; the program of the 48th Annual Meeting of the Scoliosis Research Society; the program of the AOSpine global spine congress; the presentations of the 2013 Annual Eurospine meeting; and the disclosure index of the American Academy of Orthopaedic Surgeons. Names of the editorial board members were compared with the individuals who completed a disclosure for one of these indexes. Disclosures were extracted when full names matched. Two hundred and ten (29%) of the 716 identified editorial board members reported a potential conflict of interest and 154 (22%) reported nothing to disclose. The remaining 352 (49%) editorial board members had no disclosure statement listed for one of the indexes. Eighty-nine (42%) of the 210 editorial board members with a potential conflict of interest reported a financial relationship of more than $10,000 during the prior year. This finding confirms that potential conflicts of interest exist in editorial boards which might influence the peer review process and can result in bias. Academia and medical journals in particular should be aware of this and strive to improve transparency of the review process. Janssen et al. emphasize recommendations that contribute to achieving this goal 9).

Physician fully employed by industry

We would not allow a physician fully employed by industry to make a scientific presentation or publish an article for a peer-reviewed journal related to his or her company’s device or drug, yet we know from previously released orthopedic surgeon related data that many physician lecturers and writers are receiving yearly “consulting fees” and “royalty arrangements” that greatly exceed what is paid to physicians employed by device manufacturers—many above $1 million/year 10) 11) 12).

If publicly reporting these numbers places some in an uncomfortable position, so be it. This information is critical in the analysis of the clarity, sanctity, and scientific integrity of information and data presented. Collaboration has been valuable, but full transparency is critical to open, unbiased scientific dialogue and exchange.

References

1)

IOM (Institute of Medicine) Conflict of interest in medical research, education, and practice. Washington, DC: National Academies Press; 2009.
2)

DiRisio AC, Muskens IS, Cote DJ, Babu M, Gormley WB, Smith TR, Moojen WA, Broekman ML. Oversight and Ethical Regulation of Conflicts of Interest in Neurosurgery in the United States. Neurosurgery. 2019 Feb 1;84(2):305-312. doi: 10.1093/neuros/nyy227. PubMed PMID: 29850841.
3)

Bekelman JE, Li Y, Gross CP. Scope and impact of financial conflicts of interest in biomedical research: a systematic review. JAMA. 2003; 289: 454–465.
4)

Garfin SR. Spine surgeons: spine industry. Eur Spine J. 2008; 17: 785–790.
5)

Steering Committee on Science and Creationism: National Academy of Sciences (1999) Science and Creationism: A View from the National Academy of Sciences, Second Edition The National Academies Press;
6) , 9)

Janssen SJ, Bredenoord AL, Dhert W, de Kleuver M, Oner FC, Verlaan JJ. Potential Conflicts of Interest of Editorial Board Members from Five Leading Spine Journals. PLoS One. 2015 Jun 4;10(6):e0127362. doi: 10.1371/journal.pone.0127362. eCollection 2015. PubMed PMID: 26042410.
7)

Sahuquillo J, Biestro A. Is intracranial pressure monitoring still required in the management of severe traumatic brain injury? Ethical and methodological considerations on conducting clinical research in poor and low-income countries. Surg Neurol Int. 2014 Jun 5;5:86. doi: 10.4103/2152-7806.133993. eCollection 2014. PubMed PMID: 25024886; PubMed Central PMCID: PMC4093744.
8)

DiPaola CP, Dea N, Noonan VK, Bailey CS, Dvorak MF, Fisher CG. Surgeon-industry conflict of interest: survey of North Americans’ opinions regarding surgeons consulting with industry. Spine J. 2014 Apr;14(4):584-91. doi: 10.1016/j.spinee.2013.06.028. Epub 2013 Aug 22. PubMed PMID: 23973098.
10)

Feder BJ. New focus of inquiry into bribes: doctors. New York Times. 2008 Mar 22; Available at: http://www.nytimes.com/2008/03/22/business/22device.html. Accessed December 30, 2010.
11)

Burns G. Partnerships between surgeons, implant makers raise ethical concerns. Chicago Tribune. 2008 Oct 26;
12)

Carryerou J, McGinty T. Top spine surgeons reap royalties, Medicare bounty. Wall Street Journal. 2010 Dec 20;:A1. Available at: http://online.wsj.com/article/SB10001424-052748703395204576024023361023138.html. Accessed December 30, 2010.

Social media

Social media

see also WhatsApp

Social media are interactive computer-mediated technologies that facilitate the creation and sharing of information, ideas, career interests and other forms of expression via virtual communities and networks.

The variety of stand-alone and built-in social media services currently available introduces challenges of definition.

Social media, web based applications, and internet has revolutionized communication process. Similarly, learning and teaching process in the field of medicine had transformed slowly and progressively to suit the changes according to the geographical and economic constraints.


Electronic media has irrupted physician’s clinical practice. Patients increasingly use Internet and social media to obtain enormous amounts of unsupervised data about cancer. Blogs, social networking sites, online support groups and forums are useful channels for medical education and experience sharing but also perfect environments for misinformation, quackery, violation of privacy and lack of professionalism. The widespread availability of such electronic resources allows some followers of the alternative oncology to spread useless irrational and controversial remedies for cancer, like false medicaments, miraculous diets, electronic devices, and even psychic therapies, as did charlatans in the past, providing false expectations about cancer treatments. Moreover, so-called predatory journals have introduced confusion and malpractice within the academic biomedical publishing system. This is a rising editorial phenomenon affecting all fields of biomedicine, including oncology that jeopardizes the quality of scientific contribution and damages the image of open access publication 1).


Brainbook is a multi-platform, social media-based resource that was created specifically to enhance public engagement in neurosurgery.

Results from one of its case discussions was reported in collaboration with the NIHR Global Health Research Group on Neurotrauma and presented over 3 days (23-25 February 2018). YouTube videos were created depicting the management of an acute subdural hematoma using patient interviews, medical illustration, consultant-led discussion and operative footage. Content was shared across all Brainbook social media platforms and analytics were gathered through social media applications.

Over a 72-hour time period, and across multiple social media accounts, 101,418 impressions were achieved (defined as penetrance onto individual media feeds and total views of the content), with active discussion on social media.

Neurosurgical content published across multiple social media outlets represents an encouraging and exciting potential for global engagement across multiple audiences. Social media can be an effective method of not only disseminating neurosurgical knowledge, but activating and engaging the public, allied healthcare professionals, medical students and neurosurgeons 2).


The purpose of a study was to assess the impact of certain demographics, social media usage, and physician review website variables for spine surgeons across Healthgrades.com (Healthgrades), Vitals.com (Vitals), and Google.com (Google).

Through a directory of registered North American Spine Society (NASS) physicians, they identified spine surgeons practicing in Texas (107 neurosurgery trained, 192 orthopedic trained). Three physician rating websites (Healthgrades, Vitals, Google) were accessed to obtain surgeon demographics, training history, practice setting, number of ratings/reviews, and overall score (January 2, 2018-January 16, 2018). Using only the first 10 search results from Google.com, we then identified whether the surgeon had a website presence or an accessible social media account on Facebook, Twitter, and/or Instagram.

Physicians with either a personal or institutional website had a higher overall rating on Healthgrades compared to those who did not have a website (p < 0.01). Nearly all spine surgeons had a personal or institutional website (90.3%), and at least 1 accessible social media account was recorded for 43.5% of the spine surgeons in our study cohort (39.5% Facebook, 10.4% Twitter, 2.7% Instagram). Social media presence was not significantly associated with overall ratings across all 3 sites, but it did significantly correlate with more comments on Healthgrades. In multivariable analysis, increasing surgeon age was significantly associated with a lower overall rating across all 3 review sites (p < 0.05). Neurosurgeons had higher overall ratings on Vitals (p = 0.04). Longer wait times were significantly associated with a lower overall rating on Healthgrades (p < 0.0001). Overall ratings from all 3 websites correlated significantly with each other, indicating agreement between physician ratings across different platforms.CONCLUSIONSLonger wait times, increasing physician age, and the absence of a website are indicative of lower online review scores for spine surgeons. Neurosurgery training correlated with a higher overall review score on Vitals. Having an accessible social media account does not appear to influence scores, but it is correlated with increased patient feedback on Healthgrades. Identification of ways to optimize patients’ perception of care are important in the future of performance-based medicine 3).


Mata-Gómez et al. made an observational transversal study between February and March 2017, with a systematic search of the Facebook, Twitter and Youtube accounts from public and private neurosurgical units, scientific societies, peer-reviewed publications and patients groups in relation with Neurosurgical pathologies. We rank them according their popularity.

Only 5 public neurosurgical services have social media accounts, being their popularity inferior to the private units accounts. In relation with the scientific societies and neurosurgical publications their presence in social media is marginal, even more in comparison to the accounts of other medical specialities. The popularity of associations of patients and supporting groups is high, especially among patients, finding there more information about their disease.

The use in Spain of Social Media about Neurosurgery is low in comparison to other medical specialities. There is a huge field to improve the popularity of the accounts, making in them promotion of health and extend the diffusion of the scientific society and the peer-reviewed publication Neurocirugía 4).

Metrics

When you click on the Page you want to analyze, you will be taken to that Page’s insights. Here, you will find an overview of your most important metrics, followed by detailed sections on your Likes, reach, visits, posts, and people. The overview starts with your Page’s main metrics, including the following.

Page Likes: Total Pages Likes is number of unique people who like your Page. New Page Likes shows the number of new Likes your Page received during the last seven days, compared with the previous seven-day period.

Post Reach: Total Reach is the number of unique people who have seen any content associated with your Page, including ads, during the last seven days. Post Reach shows the number of unique people who have seen your Page posts.

Engagement: People Engaged is the number of unique people who have clicked, Liked, commented on or shared your posts during the last seven days. Likes, Comments, Shares and Post Clicks show the totals for these actions during the last week.

A study shows different uses of social media platforms and numbers of users of the online neurosurgical community. Content optimization, advanced metrics of user engagement, and their subsequent effects on academic impact remain unanswered queries and require further prospective study 5).


A survey has shown that caregivers of children with shunt-treated hydrocephalus frequently use social media networks for support and information gathering.

The objective of a study is to describe and assess social media utilization among users interested in hydrocephalus.

Publicly accessible accounts and videos dedicated to the topic of hydrocephalus were comprehensively searched across 3 social media platforms (Facebook, Twitter, and YouTube) throughout March 2016. Summary statistics were calculated on standard metrics of social media popularity. A categorization framework to describe the purpose of pages, groups, accounts, channels, and videos was developed following the screening of 100 titles. Categorized data were analyzed using nonparametric tests for statistical significance. RESULTS The authors’ search identified 30 Facebook pages, 213 Facebook groups, 17 Twitter accounts, and 253 YouTube videos. These platforms were run by patients, caregivers, nonprofit foundations, and patient support groups. Most accounts were from the United States (n = 196), followed by the United Kingdom (n = 31), Canada (n = 17), India (n = 15), and Germany (n = 12). The earliest accounts were created in 2007, and a peak of 65 new accounts were created in 2011. The total number of users in Facebook pages exceeded those in Facebook groups (p < 0.001). The majority of users in Facebook groups were in private groups, in contrast to public groups (p < 0.001). The YouTube videos with the highest median number of views were for surgical products and treatment procedures. CONCLUSIONS This study presents novel observations into the characteristics of social media use in the topic of hydrocephalus. Users interested in hydrocephalus seek privacy for support communications and are attracted to treatment procedure and surgical products videos. These findings provide insight into potential avenues of hydrocephalus outreach, support, or advocacy in social media 6).


In 2017 three social media platforms (Facebook, Twitter, and YouTube) were assessed for public content pertaining to brain aneurysms in March 2016. We conducted a mixed-method analysis that includes a descriptive examination of cross-sectional data and a qualitative evaluation of online communications for thematic analysis. We assessed categorized data using nonparametric tests for statistical significance.

The analyses showed that Facebook was the most highly used social media platform, with 11 relevant pages and 83 groups. Facebook accounts were all nonprofit foundations or patient support groups. Most users in Facebook groups were joining private support groups as opposed to public (P < 0.05). The most frequently viewed category of YouTube videos was on treatment procedures (P < 0.001). Six prominent themes emerged from the coded data of posts and comments: inspiration and motivation (27.7%), providing and sharing information (26.3%), requesting information (14.4%), seeking emotional support (12.1%), admiration (8.3%), and loss and grief (8.3%).

This study was the first to provide insight into characteristics and patterns of social media communications regarding brain aneurysms. These findings should serve to inform the treating physicians of the needs and expectations of individuals affected by brain aneurysms 7).

References

1)

Delgado-López PD, Corrales-García EM. Influence of Internet and Social Media in the Promotion of Alternative Oncology, Cancer Quackery, and the Predatory Publishing Phenomenon. Cureus. 2018 May 13;10(5):e2617. doi: 10.7759/cureus.2617. Review. PubMed PMID: 30027009; PubMed Central PMCID: PMC6044480.
2)

Alamri A, Rogers P, Kearns C, Doke T, Al-Habib A, Servadei F, Hutchinson PJ, Kolias AG, Uff C. Social media for dissemination and public engagement in neurosurgery-the example of Brainbook. Acta Neurochir (Wien). 2019 Jan;161(1):5-9. doi: 10.1007/s00701-018-3757-8. Epub 2018 Dec 10. PubMed PMID: 30535760.
3)

Donnally CJ, McCormick JR, Li DJ, Maguire JA, Barker GP, Rush AJ, Wang MY. How do physician demographics, training, social media usage, online presence, and wait times influence online physician review scores for spine surgeons? J Neurosurg Spine. 2018 Nov 1:1-10. doi: 10.3171/2018.8.SPINE18553. [Epub ahead of print] PubMed PMID: 30497169.
4)

Mata-Gómez J, Gilete-Tejero IJ, Rico-Cotelo M, Royano-Sánchez M, Ortega-Martínez M. Current use of Social Media in Neurosurgery in Spain. Neurocirugia (Astur). 2018 May – Jun;29(3):109-115. doi: 10.1016/j.neucir.2018.01.001. Epub 2018 Feb 24. English, Spanish. PubMed PMID: 29486985.
5)

Alotaibi NM, Badhiwala JH, Nassiri F, Guha D, Ibrahim GM, Shamji MF, Lozano AM. The Current Use of Social Media in Neurosurgery. World Neurosurg. 2015 Nov 14. pii: S1878-8750(15)01528-4. doi: 10.1016/j.wneu.2015.11.011. [Epub ahead of print] PubMed PMID: 26585734.
6)

Elkarim GA, Alotaibi NM, Samuel N, Wang S, Ibrahim GM, Fallah A, Weil AG, Kulkarni AV. Social media networking in pediatric hydrocephalus: a point-prevalence analysis of utilization. J Neurosurg Pediatr. 2017 May 26:1-6. doi: 10.3171/2017.3.PEDS16552. [Epub ahead of print] PubMed PMID: 28548615.
7)

Alotaibi NM, Samuel N, Wang J, Ahuja CS, Guha D, Ibrahim GM, Schweizer TA, Saposnik G, Macdonald RL. The Use of Social Media Communications in Brain Aneurysms and Subarachnoid Hemorrhage: A Mixed-Method Analysis. World Neurosurg. 2017 Feb;98:456-462. doi: 10.1016/j.wneu.2016.11.085. Epub 2016 Nov 24. PubMed PMID: 27890750.
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