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\begin{document}

\title{Assessment of Financial Relationships between
Otorhinolaryngologists and Pharmaceutical Companies in Japan between
2016 and 2019}



\author[1]{Anju Murayama}%
\author[1]{Sae Kamamoto}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 26, 2024}


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\textbf{Correspondence}

Anju Murayama

School of Medicine, Tohoku University, 2-1 Seiryo-machi, Aoba ward,
Sendai City, Miyagi, 980-0872, Japan

Telephone: 81-22-717-8006

Email address: ange21tera@gmail.com





\textbf{Abstract}

\textbf{Objective:}

To evaluate the magnitude, prevalence, and trend of the financial
relationship between Japanese otolaryngologists and pharmaceutical
companies.

\textbf{Methods}

Using payment data publicly disclosed by 92 pharmaceutical companies, we
examined magnitude, prevalence, and trend in personal payments made to
otorhinolaryngologists board certified by the Japanese Society of
Otorhinolaryngology-Head and Neck Surgery between 2016 and 2019 in
Japan. Furthermore, differences in payments were evaluated by whether
otolaryngologists were clinical practice guideline authors, society
board member, and academic journal editor or not. Trend in payments were
evaluated by generalized estimating equations.

\textbf{Results}

Of 8,190 otorhinolaryngologists, 3,667 (44.8 \%) were paid a total of
\$13,873,562, in payments for lecturing, consulting, and writing by 72
pharmaceutical companies between 2016 and 2019. Median four-year
combined payments per physician was \$1,022 (interquartile range:
\$473--\$2,526). Top 1\%, 5\%, and 10\% of otorhinolaryngologists
received 42.3\% (95\% confidence interval {[}95\% CI{]}:
37.2\%--47.4\%), 69.3\% (95\% CI: 65.9\%--72.8\%), and 80.6\% (95\% CI:
78.3\%--82.9\%) of overall payments, respectively. The median payments
per physicians were significantly higher among otorhinolaryngologists
authoring clinical practice guidelines (\$11,522), society board members
(\$22,261), and journal editors (\$35,143) than those without. The
payments and number of otorhinolaryngologists receiving payments
remained stable between 2016 and 2019.

\textbf{Conclusion}

This study demonstrates that a minority but large number of
otorhinolaryngologists received personal payments from pharmaceutical
companies for the reimbursement of lecturing, consulting, and writing in
Japan. Large amounts of these personal payments were significantly
concentrated on a small number of leading otorhinolaryngologists.

\textbf{Keywords:}

conflict of interest; Japan; industry payments; otolaryngologist;
ethics; health policy

\textbf{Introduction}

Although collaborations between industry and healthcare professionals
can bring breakthroughs in medicine, several medical scandals and
limited transparency in the financial relationships between healthcare
professionals and pharmaceutical companies led to the concern for the
undue influence of financial relationships on patient care. Since 2013,
the Japan Pharmaceutical Manufacturers Association (JPMA), the largest
pharmaceutical trade organization in Japan, has required all
pharmaceutical companies belonging to the JPMA, whose share account for
more than 80\% of total sales for pharmaceutical products in
Japan,{[}1{]} to disclose their payments made to healthcare
professionals for lecturing, consulting, and writing, based on the JPMA
voluntary transparency guidance.{[}2, 3{]} This voluntary payment
disclosure by pharmaceutical companies enabled the evaluation of the
detailed magnitude of the financial relationships between healthcare
professionals and pharmaceutical companies in several
specialties.{[}4-8{]}

As shown in previous studies in the United States, there are large and
prevalent financial transfers from pharmaceutical industries to
otorhinolaryngologists for various purposes,{[}9-13{]} as well as other
specialty physicians.{[}14-21{]} The payments from pharmaceutical
companies often disproportionately concentrate on small numbers of
physicians in leading and authoritative positions who are required to be
independent and unbiased from any industries,{[}4, 5, 22-26{]} namely
key opinion leaders.{[}27, 28{]} This trend would exist among Japanese
otorhinolaryngologists, considering previous studies showing that there
were substantial and prevalent financial relationships between leading
otorhinolaryngologists and pharmaceutical companies in other specialties
in Japan.{[}4, 7, 29, 30{]} However, there was lack of assessment
regarding the whole picture of the financial relationships between
pharmaceutical companies and otorhinolaryngologists in Japan. Thus, this
study aimed to evaluate the magnitude, prevalence, and trend in personal
payments made to otorhinolaryngologists by pharmaceutical companies for
the latest years in Japan.

\textbf{Methods}

Study design and study participants

This retrospective study examined the magnitude and trends in financial
relationships between pharmaceutical companies and all
otorhinolaryngologists board-certified by the Japanese Society of
Otorhinolaryngology-Head and Neck Surgery (JSO-HNS). As the JSO-HNS did
not disclose the name list of board-certified otorhinolaryngologists for
the previous years, we considered all board-certified
otorhinolaryngologists in 2021. The JSO-HNS, established in 1893, is the
sole and most authoritative professional medical society certifying
otorhinolaryngologists in the field of otorhinolaryngology and head and
neck surgery in Japan. The JSO-HNS has contributed to training
otorhinolaryngologists, funded clinical trials and basic research,
published many clinical practice guidelines for otorhinolaryngological
diseases, and issued the English-language academic journal (\emph{Auris
Nasus Larynx} ). This study defined leading otorhinolaryngologists as
board-certified otorhinolaryngologists authoring clinical practice
guidelines, board members of JSO-HNS, and editorial members
of\emph{Auris Nasus Larynx} .

Data collection

As the JSO-HNS did not disclose the name list of board-certified
otorhinolaryngologists for the previous years, the name, practicing
region and prefecture of all board-certified otorhinolaryngologists in
2021 were extracted from the official webpage of the JSO-HNS
(http://www.jibika.or.jp/members/nintei/senmon/senmon-kensaku.html).
Furthermore, we collected the name of all clinical practice guideline
authors issued and reviewed by the JSO-HNS between 2015 and 2020
(including one year before and after the payment period), the JSO-HNS
board members in 2018-2019 and 2020-2021, and editorial members of
the\emph{Auris Nasus Larynx} in April 2022. For data collection of
society board members, we previously collected the name list of JSO-HNS
in 2018-2019 and 2020-2021.{[}25{]} As the \emph{Auris Nasus Larynx} did
not publicly provide the name list of editorial board members in
previous years, we collected the latest editorial members of \emph{Auris
Nasus Larynx} in April 2022.

The payments concerning lecturing, consulting, and writing paid to the
board-certified otorhinolaryngologists were extracted from a total of 92
pharmaceutical companies belonging to the JPMA between 2016 and 2019.
The period of payment data collection was determined by our availability
of data collection. The companies have published and updated the payment
data each year on their company webpages. The payment data for all
companies belonging to the JPMA were collected from 2016 and as of May
2022, the payment data of 2019 were the latest analyzable data in Japan.
Payment categories were described in our previous study and the JPMA
transparency guideline.{[}3, 31{]} The detailed procedure of payment
collection was noted previously.{[}5, 7, 29{]}

Analysis

First, payment data were descriptively analyzed. Payments per physician
were also calculated only for physicians receiving payment each year, as
in other previous studies.{[}7, 12, 14, 32{]} Second, the payment
concentration was evaluated by the shares of the payment values held by
the top 1\%, 5\%, 10\%, and 25\% of the otorhinolaryngologists and the
Gini coefficient at the physician level. The Gini index ranges from 0
to1, and the greater the Gini index, the greater the disparity in the
distribution of payments.{[}4, 7, 33{]} Third, we calculated descriptive
statistics and evaluated payment differences among the leading
otorhinolaryngologists, including guideline authors, society board
members, journal editors, and other otorhinolaryngologists. The
differences in payments by each variable were evaluated by Chi-square
and fisher exact tests for the proportion of otorhinolaryngologists
receiving payments and by Mann-Whitney U test for payment values per
otorhinolaryngologist. Furthermore, the linear log-linked Poisson
regression model was used to assess the association between relative
risk of payment receipt and the otorhinolaryngologist characteristics.
To account for the skewed distribution of payment values, negative
binomial regression model was employed to evaluate the association
between relative monetary value of payments per physician and the
otorhinolaryngologist characteristics. Finally, we evaluated the trends
in payments per physician and number of physicians receiving payments
between 2016 and 2019 by the population-averaged generalized estimating
equation (GEE) with the panel data of the annual payments. As the
payment distribution was highly skewed (Supplemental Material 1), the
negative binomial GEE model for the payment values per physician and
linear log-linked GEE model with Poisson distribution for the number of
otorhinolaryngologists with payments were selected.{[}7, 34{]} The
payment values were converted from Japanese yen (\selectlanguage{ngerman}¥) to US dollars (\$)
using the 2019 average monthly exchange rates of ¥109.0 per \$1. All
analyses were conducted using Microsoft Excel, version 16.0 (Microsoft
Corp) and Stata version 15 (StataCorp).

Ethical approval

The Ethics Committee of the Medical Governance Research Institute
approved this study (approval number: MG2018-04-20200605; approval date:
June 5, 2020). As this retrospective analysis only included publicly
available information, informed consent was waived by the ethics
committee.

Patient and public involvement

No patient involved.

\textbf{Results}

Overall and per-otorhinolaryngologist payments

At the time of this study, we identified 8,190 otorhinolaryngologists
board certified by the JSO-HNS. Of the 8,190 otorhinolaryngologists,
3,667 (44.8 \%) were paid a total of \$13,873,562, entailing 22,076
contracts in payments for lecturing, consulting, and writing by 72
pharmaceutical companies between 2016 and 2019. (Table 1) Median
payments per physician were \$0 (interquartile range {[}IQR{]}: \$0 --
\$851) for overall otorhinolaryngologists. For otorhinolaryngologists
receiving payments, median payments per physician was \$1,022 (IQR:
\$473--\$2,526), while average payments were \$3,783 (standard deviation
{[}SD{]}: \$14,349). The median payment contracts and number of
companies making payments per physician were 3.0 (IQR: 1.0--6.0) and 2.0
(IQR: 1.0--4.0) over the four years, respectively. One
otorhinolaryngologist received a maximum payment of \$490,081 and 332
payment contracts.

Table 1. Summary of personal payments from pharmaceutical companies to
board-certified otorhinolaryngologists between 2016 and 2019\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Variables\strut
\end{minipage} & \begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Total\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Payment values, \$\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
13,873,562\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Instances, n\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
22,076\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Companies, n\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
72\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Average per physician (SD)\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Payment values, \$\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
3,783 (14,349)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Instances, n\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
6.0 (13.6)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Companies, n\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
3.0 (3.0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Median per physician (IQR)\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Payment values, \$\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
1,022 (473-2,526)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Instances, n\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
3.0 (1.0-6.0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Companies, n\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
2.0 (1.0-4.0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Range\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Payment values, \$\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
28-490,081\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Instances, n\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
1.0-332\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Companies, n\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
1.0-27.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Category of payments\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Lecturing\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Payment value, \$ (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
11,968,045 (84.8)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Instances, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
18,714 (84.8)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Physicians, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
3373 (41.2)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Consulting\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Payment value, \$ (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
1,075,487 (7.8)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Instances, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
2,121 (9.6)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Physicians, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
1112 (13.6)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Writing\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Payment value, \$ (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
701,495 (5.1)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Instances, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
1,075 (4.9)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Physicians, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
494 (6.0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Other\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Payment value, \$ (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
128,534 (0.9)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Instances, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
168 (0.8)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Physicians, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
113 (1.4)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Abbreviations: SD (standard deviation), IQR (interquartile range)

Payments by category and payment concentration

Payments for lecturing occupied for 86.3\% of overall monetary values
(\$11,968,045) and 84.8\% of overall payment contracts (18,714
contracts) between 2016 and 2019. Of 8,190 eligible
otorhinolaryngologists, 3,373 (41.2\%), 1,112 (13.6\%), and 494 (6.0\%)
received one or more compensation payments for lecturing, consulting,
and writing from the pharmaceutical companies over the four years,
respectively.

While majority of otorhinolaryngologists did not receive any payments
from the pharmaceutical companies over the four years, top 1\%, 5\%,
10\%, and 25\% of otorhinolaryngologists received 42.3\% (95\%
confidence interval {[}95\% CI{]}: 37.2\%--47.4\%), 69.3\% (95\% CI:
65.9\%--72.8\%), 80.6\% (95\% CI: 78.3\%--82.9\%), and 94.8\% (95\% CI:
94.1\%--95.5\%) of overall payments, respectively. (Supplemental
Material 2) The Gini coefficient for four-year combined payments per
physician was 0.889, indicating that the payments disproportionately
concentrated on small numbers of otorhinolaryngologists.

Payments to leading otorhinolaryngologists: clinical practice guideline
authors, society board members, and academic journal editors

We identified a total of 139 individual authors from eight clinical
practice guidelines accredited or authorized by the JHO-HNS between 2015
and 2020. (Table 2) Of the 139 authors, 101 (72.7\%) authors were
board-certified otorhinolaryngologists and 94 (93.1\%) received one or
more personal payments for lecturing, consulting, and writing
compensations. A total of \$2,435,239 (17.6\% {[}\$2,435,239 out of
\$13,873,562{]} of overall personal payments from the companies) were
made to 94 otorhinolaryngologists authoring clinical practice
guidelines. The aggregated payment per physician was significantly
higher among otorhinolaryngologists authoring clinical practice
guidelines than that of otorhinolaryngologists not involved in authoring
guidelines (\$11,522 {[}IQR: \$3,090--\$32,390{]} vs \$0 {[}IQR:
\$0--\$817{]}, p\textless{}0.001).

All 36 board members of the JSO-HNS during the 2018-2019 and 2020-2021
period were board-certified otorhinolaryngologists. Of 36
board-certified otorhinolaryngologists with the JSO-HNS board
membership, 34 (94.4\%) received a total of \$1,234,715 (8.9\% of
overall payments) and a median payment of \$22,261 (IQR:
\$4,537--\$50,331) per physician. (Table 2) Both the proportion of
otorhinolaryngologists receiving payments (94.4\% vs 44.6\%,
p\textless{}0.001) and the payments per physician (\$22,261 {[}IQR:
\$4,537--\$50,331{]} vs \$0 {[}IQR: \$0--\$831{]}, p\textless{}0.001)
were significantly higher for the otorhinolaryngologists positioned as
the JSO-HNS board member than those without board membership.

There were 20 Japanese editors of the \emph{Auris Nasus Larynx} and
among them, 19 editors were board-certified otorhinolaryngologists. All
19 (100\%) board-certified otorhinolaryngologists who are editors of
the\emph{Auris Nasus Larynx} received payments with \$774,171 (5.6\% of
overall payments) in total and \$35,143 (IQR: \$7,733--\$50,373) in
median per-physician payments from pharmaceutical companies. (Table 2)

The multivariable Poisson regression model showed that clinical practice
guidelines authorship, JSO-HNS board membership, and editorial
membership in the academic journal were significantly associated with
1.96 (95\% CI: 1.82--2.12) times, 1.47 (95\% CI: 1.10--1.79) times, and
1.21 (95\% CI: 1.11--1.33) times higher likelihood to accept personal
payments from pharmaceutical companies than those without authorships or
memberships. (Table 2) The multivariable negative binomial regression
model indicated that clinical practice guidelines authorship and JSO-HNS
board membership were positively associated with 13.04 times (95\% CI:
9.55--17.79) times and 8.57 (95\% CI: 3.04--24.17) times higher monetary
values in personal payments, while editorial membership in the academic
journal was negatively associated with payment values.

Table 2. Payments to the board-certified otorhinolaryngologists with
leading roles between 2016 and 2019\selectlanguage{english}
\begin{longtable}[]{@{}llllllllll@{}}
\toprule
\begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Physician with payments\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Physician with payments\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment per physician \$\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment per physician \$\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment per physician \$\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Relative payments\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Relative payments\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Relative payments\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Relative payments\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Number (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
P value\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Average (SD)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Median (IQR)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
P value\textsuperscript{b}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Relative risk for receiving payments (95\% CI)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
P value\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Relative monetary value (95\% CI)\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
P value\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Clinical practice guideline\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Non-guideline author otorhinolaryngologists\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3,573 (44.2)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1,414 (8,751)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0 (0--817)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Ref.\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Ref.\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Otorhinolaryngologists authoring guideline\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
94 (93.1)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
24,111 (33,621)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
11,522 (3,090--32,390)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1.96 (1.82--2.12)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
13.03 (9.55--17.79)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Board membership\textsuperscript{c}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Non-board members\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3633 (44.6)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1,550 (9,109)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0 (0--831)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Ref.\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Ref.\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Board membership\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
34 (94.4)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
34,298 (44,388)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
22,261 (4,537--50,331)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1.47 (1.20--1.79)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
8.57 (3.04--24.17)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Journal editorial membership\textsuperscript{c}\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Non-editor otorhinolaryngologists\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3,648 (44.7)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1,603 (9,365)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0 (0--851)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Ref.\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Ref.\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Editor otorhinolaryngologists\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
19 (100)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
40,746 (46,059)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
35,143 (7,733--50,373)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1.21 (1.11--1.33)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.54 (0.38--0.77)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Abbreviations: SD (standard deviation), IQR (interquartile range), 95\%
CI (95\% confidence interval)

\textsuperscript{a} The difference in proportion of
otorhinolaryngologists with payments was evaluated by the chi-square
test and fisher exact test.

\textsuperscript{b} The difference in payments per otorhinolaryngologist
was evaluated by the Mann--Whitney U test for two groups.

\textsuperscript{c} The interaction between continuous variable society
board membership and journal editorial membership were included in
multivariable regression models. The relative risk for the interaction
was 0.81 (95\% CI: 0.63--1.03) and relative monetary value for the
interaction was 2.29 (95\% CI: 0.63--8.38).

The JSO-HNS required clinical practice guideline authors to declare
their financial conflicts of interest (FCOIs) with the industry, and the
authors disclosed their FCOIs in the guidelines. Meanwhile, there was no
FCOI disclosure among the JSO-HNS board members and the academic journal
editors.

Trends in personal payments between 2016 and 2019

The total annual payments from the pharmaceutical companies ranged from
\$3,356,647 in 2016 to \$3,615,634 in 2017. A total of 1,988 (24.3\%)
otorhinolaryngologists in 2019 to 2,129 (26.0\%) otorhinolaryngologists
in 2018 received more than one personal payment from the companies in a
single year. (Table 3) Median annual payments per physician were \$511
(IQR: \$307-\$1,188) in 2016 to \$619 (IQR: \$473-\$1,328) in 2019,
while average annual payments per physician were \$1,663 (SD: \$5,505)
to \$1,761 (SD: \$5,518). There were no significant annual changes in
total payments, payments per physician, and the number of
otorhinolaryngologists receiving payments. A sensitivity analysis,
limiting payments from 63 companies whose payment data were available
throughout the four years, also confirmed that there were no significant
annual changes in total payments, payment per physician, and the number
of otorhinolaryngologists with payments between 2016 and 2019.

Table 3. Trend of personal payments from pharmaceutical companies to
board-certified otorhinolaryngologists between 2016 and 2019\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Variables\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Average yearly change (95\%CI), \%\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
P value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2016\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2017\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2018\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2019\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
All pharmaceutical companies\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Total payments , \$\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3,356,647\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3,615,634\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3,463,336\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3,437,945\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-0.26 (-2.06-2.59)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.84\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Average payments per physician (SD), \$\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1,663 (5,505)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1,761 (5,518)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1,627 (4,319)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1,729 (4,249)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.27 (-2.72-3.35)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.86\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Median payments per physician (IQR), \$\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
511 (307-1,188)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
511 (307-1,209)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
613 (411-1,211)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
619 (473-1,328)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Range of payments per physician, \$\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
28-164,556\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
94-151,906\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
92-91,580\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
92-82,038\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Physicians with payments, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2,019\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2,053\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2,129\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1,988\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-0.083 (-1.34-1.19)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.90\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Gini index\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.923\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.922\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.910\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.913\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Pharmaceutical companies with 4-years payment
data\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Total payments , \$\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3,315,057\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3,608,993\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3,417,689\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3,358,464\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-0.18 (-3.06-2.70)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.90\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Average payments per physician (SD), \$\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1,653 (5,491)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1,758 (5,509)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1,616 (4,290)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1,714 (4,219)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-0.18 (-3.14-2.87)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.91\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Median payments per physician (IQR), \$\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
511 (307-1,188)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
511 (307-1,209)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
613 (409-1,211)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
613 (473-1,306)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Range of payments per physician, \$\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
28-163,610\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
94-151,906\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
92-90,161\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
92-82,038\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Physicians with payments, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2,005\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2,053\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
2,115\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1,959\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-0.37 (-1.63-0.90)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.56\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Gini index\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.923\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.922\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.911\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.914\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Abbreviations: standard deviation (SD); interquartile range (IQR); and
the United States (US)

a There were 9 companies without payment data through the four years and
were excluded from the trend analysis.

Payments by company

Total payments by company were described in Figure 1. Kyorin
Pharmaceutical paid the largest personal payments to the board-certified
otorhinolaryngologists in total, accounting for 12.6\% (\$1,745,682 out
of \$13,873,561) of overall payments. Similarly, payments from Taiho
Pharmaceutical and Mitsubishi Tanabe Pharma, the second and third
largest paying companies, accounted for 12.3\% (\$1,705,181) and 12.3\%
(\$1,704,126) of overall payments, respectively. The payments from the
top ten companies occupied 73.3\% of overall personal payments between
2016 and 2019. Most companies made personal payments for the purpose of
lecturing to the board-certified otorhinolaryngologists.

\textbf{Discussion}

This study demonstrates that a minority but large number of
otorhinolaryngologists received personal payments from pharmaceutical
companies for the reimbursement of lecturing, consulting, and writing in
Japan. Large amounts of these personal payments were significantly
concentrated on a small number of otorhinolaryngologists with leading
positions such as clinical practice guideline authors, society board
members, and academic journal editors in the field of
otorhinolaryngology. We observed that the personal financial
relationships between the otorhinolaryngologists and pharmaceutical
companies had remained stable over the four years in Japan. Our findings
show significant similarities and differences compared to previous
studies assessing this issue in Japan and other developed countries.

First, this large sample-sized longitudinal observational study
elucidated that 44.8 \% of all board-certified otorhinolaryngologists
received a median personal payment of \$1,022 from the pharmaceutical
companies. Previous studies in Japan reported that there was an
increasing trend in physicians receiving payments from pharmaceutical
companies in terms of the number of physicians with payments and
payments per physician.{[}7, 8, 29, 34{]} Proportion of physicians with
payments and median four-year personal payments were from 62.0\% in
pulmonology{[}34{]} to 70.6\% in medical oncology{[}8{]} and \$2,210 in
pulmonology{[}34{]} to \$3,183 in infectious diseases,
respectively.{[}29{]} Smaller payments made to otorhinolaryngologists
observed in this study were consistent with many previous studies in the
United States.{[}9-11, 14, 35{]} Pathak et al. found that US
otorhinolaryngologists received the second lowest personal payments in
surgical specialties between 2014 and 2015.{[}11{]} Cvetanovich et
al.{[}35{]} and Rathi et al.{[}9{]} reported that the trend of lowest
payments made to the otorhinolaryngologists persisted since the launch
of the Open Payments Program in 2013. Fewer expensive and novel drugs
and the large number of otorhinolaryngologists could contribute to the
lower payment values both in Japan and the US.

Second, we observed that the personal financial relationships between
the otorhinolaryngologists and pharmaceutical companies remained stable
over the four years at both low monetary payment values and number of
otorhinolaryngologists with payments. In contrast to our findings, Morse
et al. previously observed that there was an increasing trend in
personal payments among the US otorhinolaryngologists between 2014 and
2016,{[}10{]} while the increasing trend was not observed in
2017.{[}12{]} Meanwhile, even lower personal payments to
otorhinolaryngologists significantly influence otorhinolaryngologists'
clinical practice, such as increasing brand-name prescriptions,{[}36{]}
prescribing more brand-name intranasal corticosteroids over generic
alternatives,{[}37{]} and performing more controversial treatment, sinus
balloon catheter dilation.{[}38, 39{]} Accumulating evidence strongly
suggests that personal payments made by pharmaceutical companies
significantly distort physicians' prescribing patterns which were
potentially harmful to patients,{[}36, 38, 40-46{]} increase healthcare
costs,{[}40, 47, 48{]} and lower patients' trust in
physicians,{[}49-51{]} while many physicians have denied the influence
and justified their personal financial relationships with
industries.{[}52-54{]}

In addition, our study directly demonstrated that large amounts of
personal payments significantly concentrated on only a small number of
otorhinolaryngologists positioned in authoritative and public roles,
such as clinical practice guideline authors, society board members, and
academic journal editors. High concentration of payments on leading
physicians, namely key opinion leaders, are pervading in medicine
worldwide.{[}22-24, 26, 28{]} Moynihan et al. elucidated that 72\% of
board members of ten US professional medical societies in the highest
financial burden disease areas accepted a median of \$6,026 in personal
payments from pharmaceutical and medical devices companies between 2013
and 2018.{[}23{]} Similarly, Saito et al. reported that 86.9\% of the
board member from 19 major Japanese professional medical societies
received a median per-physician payment of \$7,486 in in 2016.{[}25{]}
Also, there are prevalent and large FCOIs among clinical practice
guideline authors and journal editors in many developed countries.{[}4,
6, 55-63{]} Furthermore, many of these financial relationships between
leading physicians and pharmaceutical companies are undisclosed to the
public and underreported,{[}5, 23, 30, 61, 64, 65{]} as we found that
the JSO-HNS did not disclose FCOIs among the board members and academic
journal editors. Unlike leading physicians conducting clinical trials
and research sponsored by the industry, such leading physicians as
clinical practice guideline authors, society board members, and academic
journal editors are necessary to manage and, if possible, be free from
financial interest with the industry, as their financial interest with
industry conflict with their primary interest. Currently, FCOIs among
clinical practice guideline authors are strictly managed by many
guideline developing organizations: minority of guideline authors with
FCOIs involve in guideline development, all FCOIs for the past three
years are declared and disclosed by guideline authors, and the guideline
chairperson is required to be free from any FCOIs with
industry.{[}66-68{]} Several academic journals such as the \emph{Annals
of Emergency Medicine} , the official journal of the American College of
Emergency Physicians, and \emph{Journal of Urology} , the official
journal of the American Urological Association, disclose the editors'
FCOIs on journal webpages.{[}61{]} Transparency and rigorous managements
are necessary in financial relationships between pharmaceutical
companies and leading otorhinolaryngologists with authoritative and
public positions.

Limitations

This study included several limitations. First, there would be
underestimated payments made by non-member companies of JPMA to the
otorhinolaryngologists. However, as the member companies accounted for
80.8\% of total pharmaceutical sales in Japan in 2018,{[}1{]} such
underestimation of payments could be minimized by including data from
all member companies. Second, the pharmaceutical companies were not
required to disclose other categories of payments such as meals,
beverages, travel, and stock ownerships at an individual level,
according to the JPMA guidance.{[}3{]} This could have led to
underestimations of the extent and prevalence of overall financial
relationships between otorhinolaryngologists and industries. Third, this
study included otorhinolaryngologists as of November 2021, as the
JSO-HNS did not disclose the name list of otorhinolaryngologists for
previous years. Therefore, this study would have included
otorhinolaryngologists who were not certified during the study period.
Fourth, the payment magnitude and trend may not be applicable to other
countries.

Conclusion

Although a minority of otorhinolaryngologists board-certified by the
Japan Society of Otolaryngology-Head and Neck Surgery stably received
personal payments from pharmaceutical companies for the reimbursement of
lecturing, consulting, and writing between 2016 and 2019, large amounts
of payments significantly concentrated on a relatively small number of
otorhinolaryngologists. Leading otorhinolaryngologists such as clinical
practice guideline authors, society board members, and academic journal
editors significantly accepted far larger personal payments than those
who were not.

\textbf{Ethical approval}

The Ethics Committee of the Medical Governance Research Institute
approved this study (approval number: MG2018-04-20200605; approval date:
June 5, 2020). As this retrospective analysis only included publicly
available information, informed consent was waived by the ethics
committee.

\textbf{References}

1. Japan Pharmaceutical Manufacturers Association. Data Book 2021
Online2021 {[}updated March 11; cited 2022 March 2{]}. Available from:
https://www.jpma.or.jp/news\_room/issue/databook/2021\_en/lofurc0000004we3-att/DB2021\_en\_full.pdf.

2. Ozaki A, Saito H, Senoo Y, Sawano T, Shimada Y, Kobashi Y, et al.
Overview and transparency of non-research payments to healthcare
organizations and healthcare professionals from pharmaceutical companies
in Japan: Analysis of payment data in 2016. Health Policy.
2020;124(7):727-35. Epub 2020/05/23. doi:
10.1016/j.healthpol.2020.03.011. PubMed PMID: 32439213.

3. Japan Pharmaceutical Manufacturers Association. Regarding the
Transparency Guideline for the Relation between Corporate Activities and
Medical Institutions 2018 {[}cited 2022 March 4{]}. Available from:
https://www.jpma.or.jp/english/code/transparency\_guideline/eki4g60000003klk-att/transparency\_gl\_intro\_2018.pdf.

4. Yamamoto K, Murayama A, Ozaki A, Saito H, Sawano T, Tanimoto T.
Financial conflicts of interest between pharmaceutical companies and the
authors of urology clinical practice guidelines in Japan. Int Urogynecol
J. 2021;32(2):443-51. Epub 2020/11/06. doi: 10.1007/s00192-020-04547-3.
PubMed PMID: 33151353.

5. Murayama A, Ozaki A, Saito H, Sawano T, Shimada Y, Yamamoto K, et al.
Pharmaceutical company payments to dermatology Clinical Practice
Guideline authors in Japan. PLoS One. 2020;15(10):e0239610. Epub
2020/10/14. doi: 10.1371/journal.pone.0239610. PubMed PMID: 33048952;
PubMed Central PMCID: PMCPMC7553305 Pharmaciez. Also Dr. Saito received
personal fees from TAIHO Pharmaceutical Co., Ltd. outside the scope of
the submitted work. Drs. Ozaki and Tanimoto received personal fees from
Medical Network Systems outside the scope of the submitted work. This
donation from Ain Pharmaceiz does not alter our adherence to PLoS ONE
policies on sharing data and materials.

6. Murayama A, Kida F, Ozaki A, Saito H, Sawano T, Tanimoto T. Financial
and Intellectual Conflicts of Interest Among Japanese Clinical Practice
Guidelines Authors for Allergic Rhinitis. Otolaryngol Head Neck Surg.
2021;0(0):1945998211034724. Epub 2021/08/18. doi:
10.1177/01945998211034724. PubMed PMID: 34399654.

7. Kusumi E, Murayama A, Kamamoto S, Kawashima M, Yoshida M, Saito H, et
al. Pharmaceutical payments to Japanese certified hematologists: a
retrospective analysis of personal payments from pharmaceutical
companies between 2016 and 2019. Blood Cancer Journal. 2022;12(4):54.
doi: 10.1038/s41408-022-00656-y.

8. Ozaki A, Saito H, Onoue Y, Sawano T, Shimada Y, Somekawa Y, et al.
Pharmaceutical payments to certified oncology specialists in Japan in
2016: a retrospective observational cross-sectional analysis. BMJ Open.
2019;9(9):e028805. Epub 2019/09/09. doi: 10.1136/bmjopen-2018-028805.
PubMed PMID: 31494604; PubMed Central PMCID: PMCPMC6731803.

9. Rathi VK, Samuel AM, Mehra S. Industry ties in otolaryngology:
initial insights from the physician payment sunshine act. Otolaryngol
Head Neck Surg. 2015;152(6):993-9. Epub 2015/03/18. doi:
10.1177/0194599815573718. PubMed PMID: 25779469.

10. Morse E, Fujiwara RJT, Mehra S. Increasing Industry Involvement in
Otolaryngology: Insights from 3 Years of the Open Payments Database.
Otolaryngol Head Neck Surg. 2018;159(3):501-7. Epub 2018/05/29. doi:
10.1177/0194599818778502. PubMed PMID: 29807484.

11. Pathak N, Fujiwara RJT, Mehra S. Assessment of Nonresearch Industry
Payments to Otolaryngologists in 2014 and 2015. Otolaryngology--Head and
Neck Surgery. 2018;158(6):1028-34. doi: 10.1177/0194599818758661.

12. Morse E, Berson E, Mehra S. Industry Involvement in Otolaryngology:
Updates from the 2017 Open Payments Database. Otolaryngol Head Neck
Surg. 2019;161(2):265-70. Epub 2019/03/27. doi:
10.1177/0194599819838268. PubMed PMID: 30909808.

13. Brauer PR, Morse E, Mehra S. Industry Payments for Otolaryngology
Research: A Four-Year Analysis of the Open Payments Database.
Laryngoscope. 2020;130(2):314-20. Epub 2019/05/07. doi:
10.1002/lary.27896. PubMed PMID: 31059584.

14. Tringale KR, Marshall D, Mackey TK, Connor M, Murphy JD,
Hattangadi-Gluth JA. Types and Distribution of Payments From Industry to
Physicians in 2015. JAMA. 2017;317(17):1774-84. Epub 2017/05/04. doi:
10.1001/jama.2017.3091. PubMed PMID: 28464140; PubMed Central PMCID:
PMCPMC5470350.

15. Marshall DC, Jackson ME, Hattangadi-Gluth JA. Disclosure of Industry
Payments to Physicians: An Epidemiologic Analysis of Early Data From the
Open Payments Program. Mayo Clin Proc. 2016;91(1):84-96. Epub
2016/01/15. doi: 10.1016/j.mayocp.2015.10.016. PubMed PMID: 26763512;
PubMed Central PMCID: PMCPMC4739814.

16. Tierney NM, Saenz C, McHale M, Ward K, Plaxe S. Industry Payments to
Obstetrician--Gynecologists: An Analysis of 2014 Open Payments Data.
Obstetrics \& Gynecology. 2016;127(2).

17. Maruf M, Sidana A, Fleischman W, Brancato SJ, Purnell S, Agrawal S,
et al. Financial Relationships between Urologists and Industry: An
Analysis of Open Payments Data. Urology Practice. 2018;5(3):180-6. doi:
https://doi.org/10.1016/j.urpr.2017.03.012.

18. Gangireddy VGR, Amin R, Yu K, Kanneganti P, Talla S, Annapureddy A.
Analysis of payments to GI physicians in the United States: Open
payments data study. JGH Open. 2020;4(6):1031-6. doi:
10.1002/jgh3.12401. PubMed PMID: 33319034.

19. Heckmann ND, Mayfield CK, Chung BC, Christ AB, Lieberman JR.
Industry Payment Trends to Orthopaedic Surgeons From 2014 to 2018: An
Analysis of the First 5 Years of the Open Payments Database. J Am Acad
Orthop Surg. 2022;30(2):e191-e8. Epub 2021/12/31. doi:
10.5435/jaaos-d-21-00412. PubMed PMID: 34967798.

20. Pakanati AR, Kovvuru K, Thombre V, Kanduri SR, Nalleballe K,
Ranabothu S. Industry Payments to Nephrologists in the United States.
Cureus. 2021;13(8):e17057. Epub 2021/09/16. doi: 10.7759/cureus.17057.
PubMed PMID: 34522535; PubMed Central PMCID: PMCPMC8428165.

21. Putman MS, Goldsher JE, Crowson CS, Duarte-Garc\selectlanguage{ngerman}ía A. Industry
Payments to Practicing US Rheumatologists, 2014--2019. Arthritis \&
Rheumatology. 2021;73(11):2138-44. doi:
https://doi.org/10.1002/art.41896.

22. Clinckemaillie M, Scanff A, Naudet F, Barbaroux A. Sunshine on KOLs:
assessment of the nature, extent and evolution of financial ties between
the leaders of professional medical associations and the pharmaceutical
industry in France from 2014 to 2019: a retrospective study. BMJ Open.
2022;12(2):e051042. doi: 10.1136/bmjopen-2021-051042.

23. Moynihan R, Albarqouni L, Nangla C, Dunn AG, Lexchin J, Bero L.
Financial ties between leaders of influential US professional medical
associations and industry: cross sectional study. BMJ. 2020;369:m1505.
doi: 10.1136/bmj.m1505.

24. Karanges E, Ting N, Parker L, Fabbri A, Bero L. Pharmaceutical
industry payments to leaders of professional medical associations in
Australia: Focus on cardiovascular disease and diabetes. Australian
Journal for General Practitioners. 2020;49:151-4.

25. Saito H, Ozaki A, Kobayashi Y, Sawano T, Tanimoto T. Pharmaceutical
Company Payments to Executive Board Members of Professional Medical
Associations in Japan. JAMA Intern Med. 2019;179(4):578-80. Epub
2019/02/05. doi: 10.1001/jamainternmed.2018.7283. PubMed PMID: 30715087;
PubMed Central PMCID: PMCPMC6450293.

26. Nusrat S, Syed T, Nusrat S, Chen S, Chen WJ, Bielefeldt K.
Assessment of Pharmaceutical Company and Device Manufacturer Payments to
Gastroenterologists and Their Participation in Clinical Practice
Guideline Panels. JAMA Netw Open. 2018;1(8):e186343. Epub 2019/01/16.
doi: 10.1001/jamanetworkopen.2018.6343. PubMed PMID: 30646328; PubMed
Central PMCID: PMCPMC6324539.

27. Sismondo S. Key Opinion Leaders and the Corruption of Medical
Knowledge: What the Sunshine Act Will and Won't Cast Light on. The
Journal of Law, Medicine \& Ethics. 2013;41(3):635-43. doi:
10.1111/jlme.12073. PubMed PMID: 24088154.

28. Moynihan R. Key opinion leaders: independent experts or drug
representatives in disguise? BMJ. 2008;336(7658):1402-3. Epub
2008/06/21. doi: 10.1136/bmj.39575.675787.651. PubMed PMID: 18566074;
PubMed Central PMCID: PMCPMC2432185.

29. Murayama A, Kamamoto S, Saito H, Yamada K, Bhandari D, Shoji I, et
al. Pharmaceutical Payments to Japanese Board-Certified Infectious
Disease Specialists: A Four-Year Retrospective Analysis of Payments from
92 Pharmaceutical Companies between 2016 and 2019. International Journal
of Environmental Research and Public Health. 2022;19(12):7417. PubMed
PMID: doi:10.3390/ijerph19127417.

30. Murayama A, Yamada K, Yoshida M, Kaneda Y, Saito H, Sawano T, et al.
Evaluation of Conflicts of Interest among Participants of the Japanese
Nephrology Clinical Practice Guideline. Clinical Journal of the American
Society of Nephrology. 2022:CJN.14661121. doi: 10.2215/CJN.14661121.

31. Kusumi E, Murayama A, Kamamoto S, Kawashima M, Yoshida M, Saito H,
et al. Pharmaceutical payments to Japanese certified hematologists: a
retrospective analysis of personal payments from pharmaceutical
companies between 2016 and 2019. Blood Cancer J. 2022;12(4):54. Epub
2022/04/09. doi: 10.1038/s41408-022-00656-y. PubMed PMID: 35393417;
PubMed Central PMCID: PMCPMC8989935 Pharmaceutical Co., Ltd outside the
scope of the submitted work. HS received personal fees from Taiho
Pharmaceutical Co. Ltd outside the scope of the submitted work. AO and
TT received personal fees from Medical Network Systems outside the scope
of the submitted work. TT also received personal fees from Bionics Co.
Ltd, outside the scope of the submitted work. Regarding non-financial
competing interests among the study authors, all are engaged in ongoing
research examining financial and non-financial competing interests among
healthcare professionals and pharmaceutical companies in Japan.
Individually, AM, SK, HS, TS, TT, and AO have contributed to several
published studies assessing competing interests and quality of evidence
among clinical practice guideline authors in Japan and the United
States. Among their previous articles, the authors have self-cited
several articles in this study to gain deeper insights and explain the
context of financial competing interests among healthcare professionals
in Japan. EK was a hematology specialist board-certified by the Japanese
Society of Hematology. The other authors have no example competing
interests to disclose.

32. Feng H, Wu P, Leger M. Exploring the Industry-Dermatologist
Financial Relationship: Insight From the Open Payment Data. JAMA
Dermatol. 2016;152(12):1307-13. Epub 2016/10/06. doi:
10.1001/jamadermatol.2016.3037. PubMed PMID: 27706478.

33. Annapureddy A, Murugiah K, Minges KE, Chui PW, Desai N, Curtis JP.
Industry Payments to Cardiologists. Circulation: Cardiovascular Quality
and Outcomes. 2018;11(12):e005016. doi: 10.1161/CIRCOUTCOMES.118.005016.

34. Murayama A, Hoshi M, Saito H, Kamamoto S, Tanaka M, Kawashima M, et
al. Nature and Trends of Pharmaceutical Payments to Board Certificated
Respiratory Specialists in Japan between 2016 and 2019. medRxiv.
2022:2022.01.16.22269188. doi: 10.1101/2022.01.16.22269188.

35. Cvetanovich GL, Chalmers PN, Bach BR, Jr. Industry Financial
Relationships in Orthopaedic Surgery: Analysis of the Sunshine Act Open
Payments Database and Comparison with Other Surgical Subspecialties.
JBJS. 2015;97(15).

36. Morse E, Hanna J, Mehra S. The Association between Industry Payments
and Brand-Name Prescriptions in Otolaryngologists. Otolaryngol Head Neck
Surg. 2019;161(4):605-12. Epub 2019/09/25. doi:
10.1177/0194599819852321. PubMed PMID: 31547772.

37. Morse E, Fujiwara RJT, Mehra S. The Association of Industry Payments
to Physicians with Prescription of Brand-Name Intranasal
Corticosteroids. Otolaryngol Head Neck Surg. 2018;159(3):442-8. Epub
2018/06/06. doi: 10.1177/0194599818774739. PubMed PMID: 29865931.

38. Gadkaree SK, Rathi VK, Gottschalk E, Feng AL, Phillips KM, Scangas
GA, et al. The role of industry influence in sinus balloon dilation:
Trends over time. The Laryngoscope. 2018;128(7):1540-5. doi:
https://doi.org/10.1002/lary.27203.

39. Fujiwara RJT, Shih AF, Mehra S. Cross-sectional Analysis of the
Relationship between Paranasal Sinus Balloon Catheter Dilations and
Industry Payments among Otolaryngologists. Otolaryngol Head Neck Surg.
2017;157(5):880-6. Epub 2017/09/13. doi: 10.1177/0194599817728897.
PubMed PMID: 28895455.

40. Duarte-García A, Crowson CS, McCoy RG, Herrin J, Lam V, Putman MS,
et al. Association Between Payments by Pharmaceutical Manufacturers and
Prescribing Behavior in Rheumatology. Mayo Clin Proc. 2022;97(2):250-60.
Epub 2022/02/06. doi: 10.1016/j.mayocp.2021.08.026. PubMed PMID:
35120693; PubMed Central PMCID: PMCPMC9013005.

41. Mitchell AP, Trivedi NU, Gennarelli RL, Chimonas S, Tabatabai SM,
Goldberg J, et al. Are Financial Payments From the Pharmaceutical
Industry Associated With Physician Prescribing? : A Systematic Review.
Ann Intern Med. 2021;174(3):353-61. Epub 2020/11/24. doi:
10.7326/M20-5665. PubMed PMID: 33226858; PubMed Central PMCID:
PMCPMC8315858.

42. Inoue K, Figueroa JF, DeJong C, Tsugawa Y, Orav EJ, Shen C, et al.
Association Between Industry Marketing Payments and Prescriptions for
PCSK9 (Proprotein Convertase Subtilisin/Kexin Type 9) Inhibitors in the
United States. Circulation: Cardiovascular Quality and Outcomes.
2021;14(5):e007521. doi: 10.1161/CIRCOUTCOMES.120.007521.

43. Khan R, Nugent CM, Scaffidi MA, Gimpaya N, Grover SC. Association of
Biologic Prescribing for Inflammatory Bowel Disease With Industry
Payments to Physicians. JAMA Internal Medicine. 2019;179(10):1424-5.
doi: 10.1001/jamainternmed.2019.0999.

44. Hartung DM, Johnston K, Cohen DM, Nguyen T, Deodhar A, Bourdette DN.
Industry Payments to Physician Specialists Who Prescribe Repository
Corticotropin. JAMA Network Open. 2018;1(2):e180482-e. doi:
10.1001/jamanetworkopen.2018.0482.

45. Eloy JA, Svider PF, Bobian M, Harvey RJ, Gray ST, Baredes S, et al.
Industry relationships are associated with performing a greater number
of sinus balloon dilation procedures. International Forum of Allergy \&
Rhinology. 2017;7(9):878-83. doi: https://doi.org/10.1002/alr.21976.

46. DeJong C, Aguilar T, Tseng C-W, Lin GA, Boscardin WJ, Dudley RA.
Pharmaceutical Industry--Sponsored Meals and Physician Prescribing
Patterns for Medicare Beneficiaries. JAMA Internal Medicine.
2016;176(8):1114-22. doi: 10.1001/jamainternmed.2016.2765.

47. Modi PK, Wang Y, Kirk PS, Dupree JM, Singer EA, Chang SL. The
Receipt of Industry Payments is Associated With Prescribing Promoted
Alpha-blockers and Overactive Bladder Medications. Urology.
2018;117:50-6. Epub 2018/04/24. doi: 10.1016/j.urology.2018.04.008.
PubMed PMID: 29680480; PubMed Central PMCID: PMCPMC6005747.

48. Perlis RH, Perlis CS. Physician Payments from Industry Are
Associated with Greater Medicare Part D Prescribing Costs. PLOS ONE.
2016;11(5):e0155474. doi: 10.1371/journal.pone.0155474.

49. Jastifer J, Roberts S. Patients' Awareness of and Attitudes toward
Gifts from Pharmaceutical Companies to Physicians. International Journal
of Health Services. 2009;39(2):405-14. doi: 10.2190/HS.39.2.j.

50. Murayama A, Senoo Y, Harada K, Kotera Y, Saito H, Sawano T, et al.
Awareness and Perceptions among Members of a Japanese Cancer Patient
Advocacy Group Concerning the Financial Relationships between the
Pharmaceutical Industry and Physicians. International Journal of
Environmental Research and Public Health. 2022;19(6). doi:
10.3390/ijerph19063478.

51. Ammous A, Bou Zein Eddine S, Dani A, Dbaibou J, El-Asmar JM, Sadder
L, et al. Awareness and attitudes of the Lebanese population with regard
to physician-pharmaceutical company interaction: a survey study. BMJ
Open. 2017;7(3):e013041. Epub 2017/04/02. doi:
10.1136/bmjopen-2016-013041. PubMed PMID: 28363922; PubMed Central
PMCID: PMCPMC5387964.

52. Fadlallah R, Nas H, Naamani D, El-Jardali F, Hammoura I, Al-Khaled
L, et al. Knowledge, Beliefs and Attitudes of Patients and the General
Public towards the Interactions of Physicians with the Pharmaceutical
and the Device Industry: A Systematic Review. PLOS ONE.
2016;11(8):e0160540. doi: 10.1371/journal.pone.0160540.

53. Orlowski JP, Wateska L. The effects of pharmaceutical firm
enticements on physician prescribing patterns. There's no such thing as
a free lunch. Chest. 1992;102(1):270-3. Epub 1992/07/01. doi:
10.1378/chest.102.1.270. PubMed PMID: 1623766.

54. Spurling GK, Mansfield PR, Montgomery BD, Lexchin J, Doust J, Othman
N, et al. Information from pharmaceutical companies and the quality,
quantity, and cost of physicians' prescribing: a systematic review. PLoS
Med. 2010;7(10):e1000352. Epub 2010/10/27. doi:
10.1371/journal.pmed.1000352. PubMed PMID: 20976098; PubMed Central
PMCID: PMCPMC2957394 BM, JL, NO, and AV are members of Healthy
Skepticism Inc. Healthy Skepticism is an international nonprofit
research, education, and advocacy association with the main aim of
reducing harm from misleading health information. PRM is the director of
Healthy Skepticism Inc., and is mostly unpaid. PRM's wife and two of his
daughters are part-time employees of Healthy Skepticism Inc. JL is a
member of the management committee of Healthy Skepticism.

55. Murayama A, Ozaki A, Saito H, Sawano T, Tanimoto T. Are Clinical
Practice Guideline for Hepatitis C by the American Association for the
Study of Liver Disease and Infectious Diseases Society of America
Evidence-based? Financial Conflicts of Interest and Assessment of
Quality of Evidence and Strength of Recommendations. Hepatology.
2021;n/a(n/a). Epub 2021/12/03. doi: 10.1002/hep.32262. PubMed PMID:
34856007.

56. Chengappa M, Herrmann S, Poonacha T. Self-reported Financial
Conflict of Interest in Nephrology Clinical Practice Guidelines. Kidney
International Reports. 2021;6(3):768-74. doi:
10.1016/j.ekir.2020.12.014.

57. Wayant C, Walters C, Zaaza Z, Gilstrap C, Combs T, Crow H, et al.
Evaluation of Financial Conflicts of Interest Among Physician-Authors of
American College of Rheumatology Clinical Practice Guidelines. Arthritis
Rheumatol. 2020;72(9):1427-34. Epub 2020/02/11. doi: 10.1002/art.41224.
PubMed PMID: 32039569.

58. Elder K, Turner KA, Cosgrove L, Lexchin J, Shnier A, Moore A, et al.
Reporting of financial conflicts of interest by Canadian clinical
practice guideline producers: a descriptive study. CMAJ.
2020;192(23):E617-E25. Epub 2020/06/17. doi: 10.1503/cmaj.191737. PubMed
PMID: 32538799; PubMed Central PMCID: PMCPMC7867217 Canadian Task Force
on Preventive Health Care (CTFPHC), which was the producer of one
guideline included in the present study (cited as reference 41). Brett
Thombs, Ainsley Moore and Sharon Straus are the chair, vice-chair and
director of knowledge translation, respectively, for the CTFPHC. The
present work was not commissioned or funded by the CTFPHC, and the
authors participated in the study outside of their responsibilities with
the CTFPHC. No other competing interests were declared.

59. Desai AP, Chengappa M, Go RS, Poonacha TK. Financial conflicts of
interest among National Comprehensive Cancer Network clinical practice
guideline panelists in 2019. Cancer. 2020;126(16):3742-9. Epub
2020/06/05. doi: 10.1002/cncr.32997. PubMed PMID: 32497271.

60. Wong VSS, Avalos LN, Callaham ML. Industry payments to physician
journal editors. PLOS ONE. 2019;14(2):e0211495. doi:
10.1371/journal.pone.0211495.

61. Liu JJ, Bell CM, Matelski JJ, Detsky AS, Cram P. Payments by US
pharmaceutical and medical device manufacturers to US medical journal
editors: retrospective observational study. BMJ. 2017;359:j4619. Epub
2017/10/28. doi: 10.1136/bmj.j4619. PubMed PMID: 29074628; PubMed
Central PMCID: PMCPMC5655612 (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.

62. Moynihan R, Lai A, Jarvis H, Duggan G, Goodrick S, Beller E, et al.
Undisclosed financial ties between guideline writers and pharmaceutical
companies: a cross-sectional study across 10 disease categories. BMJ
Open. 2019;9(2):e025864. Epub 2019/03/01. doi:
10.1136/bmjopen-2018-025864. PubMed PMID: 30813119; PubMed Central
PMCID: PMCPMC6377504.

63. Taheri C, Kirubarajan A, Li X, Lam ACL, Taheri S, Olivieri NF.
Discrepancies in self-reported financial conflicts of interest
disclosures by physicians: a systematic review. BMJ Open.
2021;11(4):e045306. doi: 10.1136/bmjopen-2020-045306.

64. Bansal R, Khan R, Scaffidi MA, Gimpaya N, Genis S, Bukhari A, et al.
Undisclosed payments by pharmaceutical and medical device manufacturers
to authors of endoscopy guidelines in the United States. Gastrointest
Endosc. 2020;91(2):266-73. Epub 2019/11/19. doi:
10.1016/j.gie.2019.11.010. PubMed PMID: 31738925.

65. Saleh RR, Majeed H, Tibau A, Booth CM, Amir E. Undisclosed financial
conflicts of interest among authors of American Society of Clinical
Oncology clinical practice guidelines. Cancer. 2019;125(22):4069-75.
Epub 2019/07/30. doi: 10.1002/cncr.32408. PubMed PMID: 31355923.

66. Schunemann HJ, Al-Ansary LA, Forland F, Kersten S, Komulainen J,
Kopp IB, et al. Guidelines International Network: Principles for
Disclosure of Interests and Management of Conflicts in Guidelines. Ann
Intern Med. 2015;163(7):548-53. Epub 2015/10/06. doi: 10.7326/M14-1885.
PubMed PMID: 26436619.

67. Institute of Medicine. Clinical Practice Guidelines We Can Trust.
Graham R, Mancher M, Wolman DM, Greenfield S, Steinberg E, editors.
Washington, DC: The National Academies Press; 2011. 290 p.

68. Brems JH, Davis AE, Clayton EW. Analysis of conflict of interest
policies among organizations producing clinical practice guidelines.
PLOS ONE. 2021;16(4):e0249267. doi: 10.1371/journal.pone.0249267.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 1. Payment trends by company

Total payments made to all board-certified otorhinolaryngologists for
lecturing, consulting, and writing between 2016 and 2019 by each company

Supplemental Material 1. Distribution of payment values per physician\selectlanguage{english}
\begin{figure}[H]
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\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Supplemental Material 2. Payment concentration\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\selectlanguage{english}
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