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\begin{document}

\title{Evaluation of Research and Non-research Industry Payments to
Endocrinologists in the United States: An Analysis of the Open Payments
Database from 2014 to 2022}



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


\vspace{-1em}



  
  \date{June 18, 2024}


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Anju Murayama\textsuperscript{1,*}

\textbf{Affiliations:}

\textsuperscript{1} School of Medicine, Tohoku University, Sendai City,
Miyagi, Japan

\par\null

\textbf{*Correspondence:}

Anju Murayama

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

Telephone: +81-22-717-8006

Email address:\emph{ange21tere@gmail.com}

\par\null

Twitter summary

Using the 2014-2022 Open Payments Database, this study found 50.5\% to
68.0\% of endocrinologists in the US received general payments from the
healthcare industry each year.

\par\null

\textbf{Abstract}

Objective: This study aimed to evaluate industry payments to
endocrinologists and their institutions between 2014 and 2022.

Research Design and Methods: This serial cross-sectional study examined
general and research payments (direct to individuals or associated
research payments to institutions) made to endocrinologists registered
in the National Plan and Provider Enumeration System in the United
States, using the Open Payments Database between 2014 and 2022. Payment
data were analyzed descriptively. Trends were evaluated by generalized
estimating equations.

Results: Among 8002 active endocrinologists, 50.5\% to 68.0\% annually
received general payments excluding those for ownership interests and
royalties (GPEOR) between 2014 and 2022. The annual median GPEOR per
physician declined from \$984 in 2014 to \$438 in 2022. Only top 10\% of
endocrinologists annually received 90.0\% to 94.4\% of all GPEOR.
Despite 68.5\% of all payments being for research, only 1.6\% to 3.0\%
of endocrinologists directly received these annually, while 6.0\% to
9.3\% did through their institutions. Per-physician GPEOR decreased
between 2014 and 2019, with a relative annual change of -4.4\% (95\%
confidence interval {[}CI{]}: -5.7\% to -3.3\%). The number of
endocrinologists receiving research payments decreased by 3.5\% (95\%
CI: -4.8\% to -2.2\%) between 2014 and 2019. Both GPEOR and research
payments were significantly lower in 2020-2022 compared to 2014-2019 in
the number of endocrinologists receiving payments and/or payment
amounts.

Conclusions: Majority of endocrinologists accepted general payments from
the healthcare industry, while less than 10\% of endocrinologists
received research payments (personally or to their institution) in the
United States.

\par\null

\textbf{Highlights}

* This study examined industry payments to endocrinologists and their
institutions using the Open Payments Database from 2014 to 2022.

* Findings showed that 50.5\%-68.0\% of endocrinologists accepted
non-research payments each year between 2014 and 2022, while less than
10\% of endocrinologists received research payments annually.

* Median per-physician annual payments varied, with \$438-\$984 in
general, \$1710-\$4956 in direct research, and \$40,300-\$73,161 in
associated research.

* There was a decreasing trend in per-physician general payments between
2014 and 2019, with a relative annual change of -4.4\% (95\% confidence
interval: -5.7\% to -3.3\%, p\textless{}0.001).

\par\null

\textbf{Introduction}

Financial collaborations between physicians and the healthcare industry
can improve patient care through developing and implementing novel
medications and medical devices and fostering research to combat
diseases (1). However, these relationships might also negatively impact
patient care, as evidenced by various medical scandals involving
clinical trials and guideline recommendations (2,3). Increasing public
demand for greater transparency in physician-industry relationships led
the United States (US) to enact the 2010 Physician Payment Sunshine Act
(4), mandating that pharmaceutical and medical device companies report
all financial transfers made to physicians and teaching hospitals since
2013. The reported data is publicly disclosed under a federal
transparency database, the Open Payments Database.

Endocrinology attracts substantial attention from pharmaceutical and
medical device manufacturers due to the large and growing population of
persons with obesity and diabetes (5,6), the development of novel
medications for diabetes and endocrinological diseases, and expansion of
indications for certain of these medications over the last decade (7).

Conflicts of interest are common among the Endocrine Society guideline
authors (8). Irwig et al. reported that 74.3\% of the Society's
clinical-practice guideline authors received about \$5.5 and \$30.9
million in general and research payments, respectively, from
pharmaceutical companies. Liu et al. reported that in 2014 the editors
of Diabetes Care, an official journal of the American Diabetes
Association, received the highest median personal payments from
healthcare industries (\$19,618) of 52 US medical journals (9). While
editors must declare any financial conflicts of interest, to the
American Diabetes Association and their academic institutions, that
information may not be readily available to the public. Studies have
identified positive associations between payment amounts from
pharmaceutical companies marketing diabetes medications and increases in
physicians' prescriptions in the US and other developed countries
(10-12).

Prior studies have not investigated the overall picture of financial
relationships between the healthcare industry and endocrinologists since
the establishment of the Open Payments Database in the US. This study
aimed to shed light on the magnitude, prevalence, and trends in
physician-industry financial relationships in endocrinology in the US.

\par\null

\textbf{Research Design and Methods}

\emph{Study setting, participants, and payment collection}

This serial cross-sectional study examined the magnitude and trends in
industry payments to endocrinologists since the inception of the Open
Payments Database. Starting August 1, 2013, the Sunshine Act mandated
all pharmaceutical manufacturers, medical device manufacturers, and
group purchasing organizations to disclose financial transfers to
physicians in the Open Payments Database, which include three major
types: general, research, and ownership payments. General payments
included acquisitions (since 2021), charitable contributions, speaker
fees, consulting fees, debt forgiveness (since 2021), education,
entertainment, food and beverages, gifts, honoraria, long-term medical
supply or device loans (since 2021), royalties and licenses, and travel
and lodging. All categories of general payments were considered in this
study, as this study aimed to evaluate overall size of the
endocrinologists-industry financial relationships. As the 2013 data are
partial disclosure of payments between August and December 2013, this
study considered general and research payments provided to
endocrinologists between 2014 and 2022. The analyses did not include
data from ownership and investment payment files that are separately
disclosed from the general payment files in the Open Payments, as these
datasets contain information of status of ownership interests or stocks
of healthcare companies hold by physicians each year. Therefore, these
datasets do not indicate the transfer of payments. Meanwhile, general
payment files contain information of transfer of payments made to
physicians by healthcare industry including payments for ownership
interests. Research payments include research costs such as medication
supply and equipment used in clinical trials. Detailed definitions of
each payment category and variables used for analysis in this study are
described in Supplemental Material 1 and available on the Open Payments
Database webpage (13).

This study defined endocrinologists as physicians whose primary
specialty was ``Allopathic \& Osteopathic Physicians\textbar{}Internal
Medicine\textbar{}Endocrinology, Diabetes \& Metabolism'' (health care
provider taxonomy code: 207RE0101X) in the National Plan and Provider
Enumeration System (NPPES) and extracted National Provider Identifier
(NPI) numbers for all physicians classified as endocrinologists from the
NPPES database which was last updated on April 9, 2023. All general and
research payments data were downloaded from the Open Payments Database
between 2014 and 2022 (14) and extracted all general and research
payments they received between January 2014 and December 2022 matching
their NPI number. Payment datasets in 2014-2015 were archived as of July
2023, but were downloadable from the Open Payments Database webpage
(14). Before data analysis, the contents and nature of individual
general payments over \$100,000 were checked by the corresponding author
to exclude potential errors in these large payments. Three consulting
fees and two compensation fees were recategorized as ownership payments,
as these payments were made to an endocrinologist as registered stock
units for compensations (Supplemental Material 2). The study excluded
2013 payments from this study, as these payments only represented
August-December. Most research payments came indirectly via teaching
hospitals and other third parties. Including only direct research
payments to individual physicians leads to underestimating their
magnitude (15,16); therefore, both associated research payments and
direct research payments were included in this study (17-19). Associated
research payments include any funding for research where the physician
is a primary investigator. Direct research payments are those provided
directly to the recipient. Of 9164 active endocrinologists registered in
the NPPES, 1162 were newly activated after January 2014 and were
excluded from the study sample. Therefore, 8002 endocrinologists were
included in this study. The NPPES database only includes information for
active physicians and does not include physicians who are currently
deactivated due to death or retirement: thus, endocrinologists who were
deactivated as of April 9, 2023, were not included in this study.

\emph{Statistical analyses}

Descriptive analyses were performed on payment data. Per-physician
payments were calculated only among endocrinologists receiving payments
each year, as in previous studies (20-22). Regarding general payments,
this study performed descriptive analyses, including calculation of
per-physician payments and total amounts, for general payments excluding
ownership interests and royalties and licenses (hereby GPEOR), because
only several endocrinologists received large amounts of ownership
interests and royalties and licenses (Supplemental Material 3). For
associated research payments, per-physician payments were calculated as
total payments divided by the number of principal investigators in a
research payment, and total research payments were calculated by the
number of endocrinologists times the payment per principal investigator
because some research payments included principal investigators with
other specialties. The author evaluated the share of payments by
specific proportions of endocrinologists and the Gini index. The Gini
index ranges from 0 (complete equality) to 1 (complete inequality)
(21,23). Payment data were also analyzed by categories (20,24,25).

The study evaluated trends in GPEOR and research payments with
interrupted time series analysis, using generalized estimating equations
(GEE) of annual per-physician payment clustering individual
endocrinologists, to adjust for the COVID-19 pandemic's influence since
2020. As the payment distribution was skewed, the study employed the
negative binomial regression GEE model for changes in per-physician
payments and modified linear regression GEE model with Poisson
distribution for changes in the proportion of endocrinologists receiving
payments from 2014-2022 (22,23,25,26). Relative annual mean percentage
change was reported. The study excluded from the GEE trend analyses of
GPEOR those payments for acquisitions, debt forgiveness, and long-term
medical supply or device loans, because general payments for
acquisitions, debt forgiveness, and long-term medical supply or device
loans were only available for 2021-2021 data. Inflation was adjusted to
2022-dollar values by dividing the payment values each year by relative
consumer price index (CPI) compared to 2022 from the US Bureau of Labor
Statistics CPI Inflation Calculator (Supplemental Material 4).

\emph{Ethical clearance}

As this study only included publicly available information and
databases, informed consent from study participants was not required.

\emph{Data and resource availability}

Data extraction and analyses were performed with Python 3.9.12 (Python
Software Foundation, Beaverton, OR, USA), Microsoft Excel, version 16.0
(Microsoft Corp., Redmond, WA, USA), and Stata version 17.0 (StataCorp,
College Station, TX, USA).

\par\null

\textbf{Results}

\emph{Overview of industry payments to diabetologists and
endocrinologists}

Of the 8002 endocrinologists included in the study sample, 6901 (86.2\%)
received combined payments of \$2,063,671,856 in inflation-adjusted
values from 891 pharmaceutical, medical device, and group purchasing
companies between 2014 and 2022.

\emph{General payments}

General payments, including those payments for ownership interests and
royalties, accounted for 31.5\% of all industry payments, totaling
\$649.6 million over nearly nine years. Total amounts of GPEOR were
\$617.2 million over the study period. A total of 6882 endocrinologists
(86.0\% of all NPPES-registered endocrinologists) received one or more
GPEOR during that period.

Table 1 shows yearly breakdown of GPEOR between 2014 and 2022. The
annual number of endocrinologists accepting GPEOR peaked at 5437
(68.0\%) in 2016 and has gradually declined since then, reaching 4043
(50.5\%) in 2021. Among endocrinologists who received GPEOR each year,
annual median per-physician GPEOR decreased from \$984 (interquartile
range {[}IQR{]}: \$213--\$5,444) in 2014 to \$438 (IQR: \$96--\$1,896)
in 2022. Annual mean GPEOR ranged from \$8,423 (standard deviation
{[}SD{]}: \$28,493) to \$17,853 (SD: \$57,001). The Gini index for
per-physician annual GPEOR was 0.915-0.941, indicating only a few
endocrinologists received substantial GPEOR. Only top 1\%, 5\%, and 10\%
of all endocrinologists received 29.1\%-38.3\%, 71.6\%-85.8\%, and
90.0\%-94.4\% of all GPEOR each year.

Of payment categories of GPEOR, non-CME related speaking payments were
the largest (\$413.0 million: 67.2\%) in aggregate monetary value over
the nine-year period (Supplemental Material 3). Payments for food and
beverages were the most common, comprising 80.9\% (2.0 million) of
nine-year total number of GPEOR (Supplemental material 3). A total of
84.5\% of all endocrinologists received one or more food and beverage
payments. Of the nine-year total GPEOR paid to the top 10\% of
endocrinologists, non-CME-related speaking payments accounted for the
largest share in monetary value (\$386.9 million 71.8\%), followed by
consulting fees (\$60.9 million: 11.3\%) and travel and lodging expenses
(\$58.1 million: 10.8\%) (Figure 1A). On the other hand, food and
beverage (\$27.2 million: 35.5\%) and non-CME related speaking payments
(\$26.1 million: 34.1\%) accounted for the largest percentage of the
total GPEOR paid to the other 90\% endocrinologists over the 9-year
period (Figure 1B).

\emph{Direct and associated research payments}

Between 2014 and 2022, a total of 611 and 1220 endocrinologists,
representing 7.6\% and 15.3\% of all endocrinologists, respectively,
received one or more direct and associated research payments over the
nine years. Direct and associated research payments totaled \$35.2
million (1.7\% of all industry payments) and \$1.4 billion (66.8\% of
all industry payments) in inflation-adjusted values, respectively.
Therefore, 68.5\% of all industry payments to the endocrinologists were
provided for research purposes. More than 99.9\% (\$1,378.7 million) of
associated research payments were distributed to teaching hospitals and
other institutions. Of 1336 endocrinologists receiving direct or
associated research payments, 1317 (98.6\%) also accepted one or more
GPEOR over the nine years.

Table 2 shows the annual direct and associated research payments to the
endocrinologists. Only 1.6\% to 3.0\% of endocrinologists received
direct research payments each year. Similarly, 6.0\% to 9.3\% of
endocrinologists annually received associated research payments from the
healthcare industry between 2014 and 2022. Median annual per-physician
payments ranged from \$1,710 (IQR: \$532--\$7,160) to \$4,956 (IQR:
\$1,865--\$26,679) in direct research payments and from \$40,300 (IQR:
\$7,715--\$179,700) to \$66,163 (IQR: \$16,631--\$238,199) in associated
research payments.

\emph{Annual payment trends from 2014 to 2022}

After excluding several general-payment categories for acquisition, debt
forgiveness, and long-term medical supply or device loans from GPEOR,
the time series analyses showed that per-physician GPEOR significantly
decreased by 4.4\% (95\% CI: -5.7\% to -3.3\%, p\textless{}0.001), while
there was no significant change in the number of endocrinologists
receiving GPEOR between 2014 and 2019 (Supplemental Material 5). As
compared to 2014-2019, the number of endocrinologists accepting GPEOR
significantly decreased by more than half and per-physician GPEOR also
decreased by approximately 20\% during the COVID-19 pandemic period
(2020-2022). There were slight increasing trends in both the number of
endocrinologists receiving GPEOR and per-physician GPEOR increased
between 2020 and 2022, although the number of endocrinologists receiving
GPEOR (4358) and total amounts of GPEOR (\$37.2 million) in 2022 were
still substantially under those (5034 and \$68.9 million) in 2019.

Median per-physician associated research payments were the lowest in
2021 at \$40,300 (IQR: \$7,715--\$179,700) and there were no significant
trends in per-physician annual associated research payments before
(2014-2019) and during the COVID-19 pandemic (2020-2022) (Supplemental
Material 5). The time series analyses showed the number of
endocrinologists receiving associated research payments decreased
between 2014 and 2019 and showed more marked decreases at the beginning
of the COVID-19 pandemic (2020). The number of endocrinologists
receiving direct research payments also decreased at the beginning of
the COVID-19 pandemic: however generally there were no significant
changes in per-physician direct research payments over the study period.

\par\null

\textbf{Discussion}

This study sheds light on physician-industry financial relationships in
the field of endocrinology reported under the Sunshine Act in the US.
The study analyses show that US endocrinologists received a total of
\$2.06 billion from 891 pharmaceutical and medical device companies
during the 9 years between 2014 and 2022, and most industry payments
were made for research purposes. Although 50.5\% to 68.0\% of all
endocrinologists received at least one GPEOR each year, less than 10\%
of endocrinologists received associated research funding each year.
Per-physician annual general payments decreased by 4.4\% between 2014
and 2019. Industry general payments were disproportionately distributed
to a small number of endocrinologists. Although prior studies have
investigated the financial relationships between physicians and
healthcare industries in specialties, few have been conducted in
endocrinology.

The study found that endocrinologists received high median general
(non-research) payments in the healthcare industry, especially compared
to other specialists and primary care physicians (4,16,25,28,29). This
is consistent with a previous three-year analysis by Inoue et al. (28).
According to a previous study by Tringale et al. (4), primary care
physicians, who care for and manage most diabetes and obesity patients,
received \$179 in median per-physician general payments in 2015. The
prevalence of obesity and diabetes in the US have increased over the
past several decades (6,30). Additionally, a previous study by Inoue et
al. reporting approximately 92\% of all general payments related to
non-insulin glucose-lowering therapies such as sodium glucose
co-transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor
agonists (GLP-1RAs) in the US were paid for these same two classes of
medications (31).

The study found that large GPEOR were disproportionately concentrated
among a few endocrinologists. Only 1\% (80 endocrinologists) of
physicians received 29.1\%-38.3\% of all GPEOR in endocrinology each
year. As shown in previous studies (20,21,29), the healthcare industry
made large consulting, speaking, and research payments to physicians
with substantial clinical or research experience, often called ``key
opinion leaders'' (KOLs) (32). KOLs frequently hold influential
positions such as professional medical association leaders,
clinical-practice guideline authors, and academic journal editors
(16,33,34).

This study showed that more than 80\% of GPEOR were made for food and
beverage in the number of payments and about 10\% of GPEOR paid to the
top 10\% endocrinologists were provided for travel and lodging. However,
industry sponsorship for the sole purpose of travel, accommodation and
meals associated with attending international or national conferences is
not allowed in the US. Thus, reported travel expenses likely primarily
reflect participation in company-sponsored consulting meetings, advisory
boards, investigator meetings, rather than the provision of funds that
did not involve a formal company activity.

The author recognize that the receipt of industry-sponsored research
payments does not necessarily increase the risk of a biased outcome due
to a conflict of interest. Industry-sponsored research expenses should
be considered separately from general payments. The analysis shows that
healthcare companies invested substantial amounts in research payments
in the field of endocrinology. Although previous studies only analyzed
research payments paid directly to individual physicians (16,28), this
study included all research payments made to endocrinologists and their
institutions, including research payments for trials where the principal
investigators were endocrinologists. These estimates give a more
comprehensive evaluation of industry research investment in
endocrinology (18,19).

Research payments were distributed to only 6.0\% to 9.3\% of all
endocrinologists each year and 15.3\% over nine-years in the US, and
per-physician research payments were substantially higher than other
specialists (15,17,18,35-38). However, these payments should be viewed
with caution because they include research costs at a time when many
studies of SGLT2 inhibitors and GLP-1RAs were ongoing and nearly all of
these funds were paid directly to institutions. An important caveat is
also that the costs of trial medications sponsored by government
organizations such as the National Institutes of Health NIH would have
been included in the breakdown of research payments to principal
investigators even though the medications were donated to the government
organizations as part of a research agreement. The study was unable to
discern which these may have been from the publicly available data. The
high research payments in endocrinology indicate that companies are
focused on this area. Prior work has suggested that industry-sponsorship
can influence the outcome and interpretation of clinical trial findings
(39,40).

\emph{\textbf{Limitations}}

This study has several important limitations. First, there may be
inaccuracies in classification of endocrinologists and reporting and
attribution of the payments in the Open Payments Database and NPPES
databases. These errors may have contributed to differences in trends
since the Open Payments system was introduced in 2013. Second, there
might be financial relationships between physicians and the healthcare
industry not covered by the Open Payments Database. For example,
information on free medication samples (15,17,18,35) and some small
payments (\textless{}\$100/year) and discounts are not required to be
reported. Third, primary specialty is self-declared by each physician so
there may be misclassification. Fourth, in relation to the associated
research payments, the Open Payments Database has important limitations
in the transparency in research payment data and caution should be
exercised in interpreting the results. Associated research payments
include funding paid to affiliated institutions and are difficult to
compare to amounts paid directly to individual physicians. Further,
these research payments to teaching hospitals and other institutions
where endocrinologists served as principal investigators do not include
information about the internal allocation of research payments to
physicians, nurses, staff, and research coordinators within the
institutions. This is important as the study found that more than 99.9\%
of associated research payments were assigned to teaching hospitals and
other institutions. Finally, as mentioned, the Open Payments Database
contains indirect research costs for medications and medical supplies
which were provided by the healthcare industry and were used in research
sponsored by the public sectors such as NIH. Therefore, the study
tabulations cannot discern the amount of research supported by the
healthcare industry that was provided to the NIH as industry support for
studies in which the named endocrinologists participated.

\emph{\textbf{Conclusion}}

This study demonstrated that more than half of all endocrinologists
accepted at least one GPEOR from the healthcare industry in the US each
year, but only a few received substantial GPEOR. However, GPEOR had been
decreasing annually since the inception of the Open Payments Database.
The majority of industry payments were made to the small number of
endocrinologists for research expenses individually or mostly through
their institutions.

Acknowledgments: The author would like to thank Editage
(www.editage.com) for English language editing. Anju Murayama is the
guarantor of this work, and as such, had full access to all study data
and takes responsibility for its integrity and the accuracy of the data
analysis.

Funding:

The author did not receive any financial support for this study.

Conflicts of interest: The author declared no financial conflicts of
interest.

Author contributions: Anju Murayama: Conceptualization; methodology;
software; formal analysis; investigation; resources; data curation;
writing - original draft; writing - review \& editing; visualization;
and supervision

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15. Brauer PR, Morse E, Mehra S. Industry Payments for Otolaryngology
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17. Sharrak A, Nguyen T, Karabon P. Industry Research Payments to
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18. Murayama A, Kugo H, Saito Y, Saito H, Tanimoto T, Ozaki A. A
Nine-year Investigation of Healthcare Industry Payments to
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19. Murayama A, Kamamoto S, Kugo H, Saito H, Ozaki A. Research and
Nonresearch Industry Payments to Nephrologists in the United States
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20. Feng H, Wu P, Leger M. Exploring the Industry-Dermatologist
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21. Annapureddy A, Murugiah K, Minges KE, Chui PW, Desai N, Curtis JP.
Industry Payments to Cardiologists. Circ Cardiovasc Qual Outcomes
2018;11:e005016

22. Murayama A, Nakano K, Kamamoto S, Sato M, Saito H, Tanimoto T, Ozaki
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23. Kusumi E, Murayama A, Kamamoto S, Kawashima M, Yoshida M, Saito H,
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Japanese certified hematologists: a retrospective analysis of personal
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24. Putman MS, Goldsher JE, Crowson CS, Duarte-Garcia A. Industry
Payments to Practicing US Rheumatologists, 2014-2019. Arthritis
Rheumatol 2021;73:2138-2144

25. Murayama A, Kamamoto S, Saito H, Tanimoto T, Ozaki A. Industry
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2022;129:635-636

26. Murayama A, Kamamoto S, Higuchi K, Shigeta H, Ozaki A. Trend in
Industry Payments to Rheumatologists in the United States During the
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31. Inoue K, Duru OK, Mangione CM, Tsugawa Y. Trends in Industry
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Table 1. Summary of annual general payments to endocrinologists
excluding ownership and royalty payments between 2014 and 2022.\selectlanguage{english}
\begin{longtable}[]{@{}llllllllll@{}}
\toprule
\begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Variables\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\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
2014\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2015\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2016\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2017\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2018\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2019\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2020\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2021\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2022\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
General payments\textsuperscript{a,b}\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
Total payment amounts, \$\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
88,903,520\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
91,980,720\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
85,212,750\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
95,210,529\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
79,586,689\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
68,562,772\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
34,955,504\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
34,055,666\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
37,211,493\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Total payment contracts, n\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
309,406\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
344,276\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
346,762\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
337,222\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
306,517\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
285,485\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
161,753\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
184,880\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
198,145\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Number of physicians with payments, n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4997 (62.5)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
5290 (66.1)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
5437 (68.0)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
5333 (66.7)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
5242 (65.5)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
5034 (62.9)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4119 (51.5)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4043 (50.5)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4358 (54.5)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Payments per physician, \$\textsuperscript{b, 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
Median (IQR)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
984 (213--5,444)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
927 (182--4,158)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
822 (173--3,686)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
784 (170--3,646)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
688 (157--3,325)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
667 (149--3,271)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
452 (107--2,674)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
534 (103--2,683)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
438 (96--1,896)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Mean (SD)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
17,791 (52,859)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
17,388 (55,092)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
15,673 (49,134)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
17,853 (57,001)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
15,183 (48,742)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
13,620 (45,548)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
8,486 (27,284)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
8,423 (28,493)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
8,539 (29,651)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Range\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7--933,879\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2--991,860\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4--961,780\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.5--1,113,704\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2--913,515\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1--754,033\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.4--525,250\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1--640,947\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1--583,583\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Proportion of payments hold by top endocrinologist,
\%\textsuperscript{d}\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
Top 1\%\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
29.1\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
31.2\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
29.3\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
30.6\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
30.8\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
34.0\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
36.6\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
38.3\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
37.7\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Top 5\%\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
71.6\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
73.2\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
74.0\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
74.7\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
76.3\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
78.6\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
81.1\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
82.2\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
85.8\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Top 10\%\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
90.0\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
90.4\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
90.6\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
91.6\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
92.2\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
92.5\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
93.3\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
93.2\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
94.4\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Gini index\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.915\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.917\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.916\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.921\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.923\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.927\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.935\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.937\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.941\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

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

\textsuperscript{a} General payments for ownership interests and
royalties/licenses were excluded from the total amounts of general
payments and per-physician general payments.

\textsuperscript{b} All payment values were converted to 2022-US dollar
values.

\textsuperscript{c} Payments per physician were calculated among the
physicians accepting the payments from the healthcare companies.

\textsuperscript{d} Proportions of general payments excluding those for
ownership and royalties hold by top 1\% (top 80 endocrinologists), 5\%
(top 400 endocrinologists), and 10\% (top 800 endorinologists) of
endocrinologists include all 8002 endocrinologists who were eligible for
this study.

Table 2. Summary of annual direct research payments and associated
research payments to endocrinologists between 2014 and 2022.\selectlanguage{english}
\begin{longtable}[]{@{}llllllllll@{}}
\toprule
\begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Variables\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\strut
\end{minipage} & \begin{minipage}[b]{0.07\columnwidth}\raggedright\strut
Payment year\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
2014\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2015\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2016\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2017\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2018\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2019\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2020\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2021\strut
\end{minipage} & \begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
2022\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Direct research payments\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
Total payment amounts, \$\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3,350,746\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3,520,908\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4,195,310\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
6,290,159\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4,773,922\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3,861,696\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3,648,135\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2,557,473\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2,966,502\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Total payment contracts, no\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1168\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1181\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1681\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1647\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1476\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1186\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1681\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
776\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
809\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Number of physicians with payments, no (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
188 (2.4)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
192 (2.4)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
198 (2.5)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
240 (3.0)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
177 (2.2)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
179 (2.2)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
169 (2.1)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
125 (1.6)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
175 (2.2)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Payments per physician, \$\textsuperscript{a,b}\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
Median (IQR)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1,710 (532--7,160)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1,735 (317--7,582)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3,884 (1,392--13,493)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3,247 (658 --18,994)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4,956 (1,865--26,679)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3,386 (1,056--12,908)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4,068 (1,229--11,611)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2,675 (688--10,368)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3,577 (1,000--20,696)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Mean (SD)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
17,823 (54,394)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
18,338 (70,020)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
21,188 (52,951)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
26,209 (101,489)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
26,971 (48,973)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
21,574 (75,292)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
21,587 (64,855)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
20,460 (66,113)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
16,951 (28,899)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Range\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
20--453,778\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
18--759,773\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
11--508,101\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
14--1,190,748\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
19--339,644\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
86--767,627\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
16--526,988\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1--477,769\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
31--217,020\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Gini index\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.997\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.997\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.995\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.995\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.994\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.996\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.996\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.998\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.994\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Associated research payments\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
Total payment amounts, \$\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
152,664,185\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
177,347,747\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
172,387,576\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
170,581,666\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
149,034,668\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
168,989,253\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
132,365,689\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
135,302,217\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
120,195,828\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Total payment contracts, no\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
41,926\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
48,144\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
38,142\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
31,517\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
27,679\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
19,071\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
30,708\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
26,234\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
49,647\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Number of physicians with payments, no (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
679 (8.5)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
742 (9.3)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
727 (9.1)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
687 (8.6)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
614 (7.7)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
596 (7.5)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
523 (6.5)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
530 (6.6)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
478 (6.0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.07\columnwidth}\raggedright\strut
Payments per physician, \$\textsuperscript{a,b}\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
Median (IQR)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
63,072 (16,161--220,674)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
65,354 (11,730--211,143)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
73,161 (16,664--224,631)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
66,163 (16,631--238,199)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
52,067 (10,094--195,194)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
50,806 (11,531--213,172)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
54,350 (14,106--216,449)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
40,300 (7,715--179,700)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
49,361 (8,875--202,904)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Mean (SD)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
224,837 (506,257)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
239,013 (555,904)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
237,122 (544,337)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
248,299 (687,210)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
242,727 (793,904)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
283,539 (935,753)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
253,089 (808,702)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
255,287 (696,575)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
251,456 (633,388)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Range\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
8--7,782,492\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
18--7,350,323\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
44--9,744,507\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7--13,531,483\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2--12,793,524\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
29--13,927,018\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
28--14,722,800\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
18--8,473,246\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7--5,508,143\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Gini index\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.977\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.977\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.975\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.978\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.984\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.985\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.985\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.987\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.987\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

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

\textsuperscript{a} All payment values were converted to 2022-US dollar
values.

\textsuperscript{b} Payments per physician were calculated among the
physicians accepting the payments from the healthcare companies each
year.

\par\null\par\null\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure-R4/figure-R4}
\caption{{This is a caption
{\label{738230}}%
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\end{figure}

Figure 1. General payments excluding ownership and royalties to top 10\%
(1A) and the other 90\% (1B) of endocrinologists by categories.

Legend: Non-CME related speaking fees included ``compensation for
services other than consulting, including serving as faculty or as a
speaker at a venue other than a continuing education program.'' CME
speaking payments included ``compensation for serving as faculty or as a
speaker for an accredited or certified continuing education program''
(applicable to program years 2013-2020), ``compensation for serving as
faculty or as a speaker for an unaccredited and non-certified continuing
education program'' (applicable to program years 2013-2020), and
``compensation for serving as faculty or as a speaker for medical
education program'' (applicable beginning with program year 2021 and
subsequent program years). General payments for ownership interests and
royalties/licenses were excluded from the figure.

\par\null

Supplemental Materaial 1. Terminology of the Open Payments Database used
in this study.

~\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
Variables & Content, definition, and example\tabularnewline
Payment types & ~\tabularnewline
Associated research payment & Associated research payment is a research
payment whose recipient is recorded as either an individual
physician/nurse practitioner or a teaching hospital/institution for
research where an endocrinologist serves as a principal
investigator.\tabularnewline
Direct research payment & Direct research payment is a research payment
whose recipient is record as an individual
endocrinologist.\tabularnewline
General payments & General payment is a payment for non-research,
non-ownership purposes.\tabularnewline
Types of general payments & ~\tabularnewline
Acquisition & Acquisition payment is a buyout payment made to covered
recipients who have ownership interest in a company that has been
acquired. This payment category was introduced into the~ Open Payments
Database in 2021.\tabularnewline
Charitable contribution & Charitable contribution is a payment or
transfer of value made to an organization with tax-exempt status under
the Internal Revenue Code of 1986.\tabularnewline
Consulting fee & Consulting fee is a payment that a company makes to a
physician or nurse practitioner for advice and expertise about a medical
product or treatment. Consulting fees are typically arranged with a
written agreement between a company and physician based on the company's
particular business needs.\tabularnewline
Non-CME related speaking fee & Non-CME related speaking fees includes
``compensation for services other than consulting, including serving as
faculty or as a speaker at a venue other than a continuing education
program.'' This payment is a payment that a company makes to physicians
or nurse practitioners for speaking, training, and education engagements
that are not for continuing education.\tabularnewline
CME related speaking fee (CME speaking payment) & CME related speaking
fee includes ``compensation for serving as faculty or as a speaker for
an accredited or certified continuing education program'' (applicable to
program years 2013-2020), ``compensation for serving as faculty or as a
speaker for an unaccredited and non-certified continuing education
program'' (applicable to program years 2013-2020), and ``compensation
for serving as faculty or as a speaker for medical education program''
(applicable beginning with program year 2021 and subsequent program
years). This payment is typically a compensation for serving as faculty
or as a speaker for medical education program.\tabularnewline
Current or prospective ownership or investment interest & This payment
includes ownership or investment interest currently or potentially held
by physicians and teaching hospitals.\tabularnewline
Debt forgiveness & {This payment type includes forgiving the debt of a
covered physicians, physician owner, or the immediate family of the
physicians, such as money for drugs, medical devices, and medical
supplies. For example, in this study, there was a debt forgiveness
payment for to one endocrinologist for write-off of open accounts
receivable.}{}\tabularnewline
Education fee & Education fee is a financial transfer for educational
activities, classes, events, or materials including
textbooks.\tabularnewline
Entertainment & Entertainment fee includes a cost for attendance at
recreational, cultural, sporting or other events.\tabularnewline
Food and beverage & Food and beverage fee is a cost for lunch or dinner
meal offered at industry-sponsored educational or marketing
events.\tabularnewline
Gift & Gift is any item that does not fit into another payment category
such as clocks or stationery.\tabularnewline
Grant & Grant is a payment to support a specific purpose or activity not
related to research.\tabularnewline
Honoraria & Honoraria is a payment for a brief, one-time activity,
similar to a consulting fee, but are generally provided for services
without a set price.\tabularnewline
Long-term medical supply or device loan & This payment includes the loan
of supplies or a device for 91 days or longer.\tabularnewline
Royalty or license & Royalty or license is a payment based on sales of
medications or medical devices that use a physician's intellectual
property.\tabularnewline
Travel and lodging & Travel and lodging fee is any compensation for
costs associated with travel, such as hotel fees, airfare, mileage, and
taxi fare.\tabularnewline
\bottomrule
\end{longtable}

The definition of payment categories was based on the nature of payments
published on the Open Payments Database webpage
(\url{https://www.cms.gov/OpenPayments/Natures-of-Payment}). Definition
and content of each variable is detailly described in the Open Payments
Methodology Overview \& Data Dictionary
(https://www.cms.gov/OpenPayments/Downloads/OpenPaymentsDataDictionary.pdf).

~

Supplemental Material 2. General payments more than \$100,000 made to
endocrinologists between 2014 and 2022.

~\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
Anonymized endocrinologist name & Company name making payments & Actual
payment amounts, \$ & Inflation-adjusted amount, \$ & Payment categories
listed in the Open Payments Database & Detailed payment content
available from the Open Payments Database & Change in payment categories
in this study & Payment year\tabularnewline
Endocrinologist A & Dexcom, Inc. & 232,498 & 287,416 & Current or
prospective ownership or investment interest & Annual stock grant to
member of Dexcom Board of Director{} & No change & 2014\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 1,485,149 &
1,835,953 & Royalty or License & No information{} & No change &
2014\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 1,477,915 &
1,827,011 & Royalty or License & No information{} & No change &
2014\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 1,627,835 &
2,012,343 & Royalty or License & No information{} & No change &
2014\tabularnewline
Endocrinologist A & Dexcom, Inc. & 324,344 & 400,481 & Consulting Fee &
Compensations to member of Dexcom Board of Director{} & Changed payment
category to ``current or prospective ownership or investment
interest''\textsuperscript{a} & 2015\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 1,407,050 &
1,737,345 & Royalty or License & No information{} & No change &
2015\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 1,695,981 &
2,094,100 & Royalty or License & No information{} & No change &
2015\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 1,826,075 &
2,254,733 & Royalty or License & No information{} & No change &
2015\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 1,734,921 &
2,142,181 & Royalty or License & No information{} & No change &
2015\tabularnewline
Endocrinologist A & Dexcom, Inc. & 327,319 & 399,119 & Consulting Fee &
Compensations to member of Dexcom Board of Director{} & Changed payment
category to ``current or prospective ownership or investment
interest''\textsuperscript{a} & 2016\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 1,653,615 &
2,016,352 & Royalty or License & No information{} & No change &
2016\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 1,720,480 &
2,097,885 & Royalty or License & No information{} & No change &
2016\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 1,505,772 &
1,836,079 & Royalty or License & No information{} & No change &
2016\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 1,527,523 &
1,862,601 & Royalty or License & No information{} & No change &
2016\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 1,518,822 &
1,813,360 & Royalty or License & No information{} & No change &
2017\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 1,569,575 &
1,873,955 & Royalty or License & No information{} & No change &
2017\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 1,231,477 &
1,470,292 & Royalty or License & No information{} & No change &
2017\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 1,445,452 &
1,725,762 & Royalty or License & No information{} & No change &
2017\tabularnewline
Endocrinologist A & Dexcom, Inc. & 304,364 & 363,387 & Compensation for
services other than consulting, including serving as faculty or as a
speaker at a venue other than a continuing education program &
Resistered stock unit grant to member of Dexcom Board of Director{} &
Changed payment category to ``current or prospective ownership or
investment interest''\textsuperscript{a} & 2017\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 1,145,872 &
1,335,467 & Royalty or License & No information{} & No change &
2018\tabularnewline
Endocrinologist B & AstraZeneca Pharmaceuticals LP & 326,541 & 380,570 &
Royalty or License & No information{} & No change & 2018\tabularnewline
Endocrinologist A & Dexcom, Inc. & 332,562 & 387,587 & Consulting Fee &
Resistered stock unit grant to member of Dexcom Board of Director{} &
Changed payment category to ``current or prospective ownership or
investment interest''\textsuperscript{a} & 2018\tabularnewline
Endocrinologist D & Boehringer Ingelheim Pharmaceuticals, Inc. & 116,888
& 136,229 & Consulting Fee & No information{} & No change &
2018\tabularnewline
Endocrinologist A & Dexcom, Inc. & 331,025 & 378,930 & Compensation for
services other than consulting, including serving as faculty or as a
speaker at a venue other than a continuing education program &
Resistered stock unit grant to member of Dexcom Board of Director{} &
Changed payment category to ``current or prospective ownership or
investment interest''\textsuperscript{a} & 2019\tabularnewline
Endocrinologist C & Medtronic MiniMed, Inc. & 281,645 & 318,475 &
Royalty or License & No information{} & No change\textsuperscript{} &
2020\tabularnewline
Endocrinologist A & Dexcom, Inc. & 333,116 & 376,676 & Current or
prospective ownership or investment interest & No information{} & No
change & 2020\tabularnewline
Endocrinologist A & Dexcom, Inc. & 307,881 & 332,520 & Current or
prospective ownership or investment interest & No information{} & No
change & 2021\tabularnewline
Endocrinologist A & Dexcom, Inc. & 311,268 & 311,268 & Grant & No
information{} & No change & 2022\tabularnewline
\bottomrule
\end{longtable}

\textsuperscript{a} Five general payments of consulting fees and
compensation were paid to endocrinologists as registered stock units in
return for their membership on the board of directors of the company.
Therefore, this study classified these payments as ownership payments in
this study, as the compensations were made in the form stocks.

~

Supplemental Material 3. Industry payments by payment categories between
2014 and 2022.

~\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\textbf{Payment categories} & \textbf{Monetary amounts, \$
(\%)\textsuperscript{}} & \textbf{Payment contracts, no (\%)} &
\textbf{Number of physicians with payments, no (\%)}\tabularnewline
\textbf{General payments} & 649,638,180 (31.5) \textsuperscript{c} &
2,474,513 (88.4) \textsuperscript{c} & 6882 (86.0)\tabularnewline
Non-CME related speaking fees\textsuperscript{a\textbf{{}}} &
412,987,384 (67.2) \textsuperscript{d}{} & 212,242 (8.6)
\textsuperscript{d} & 2466 (30.8){}\tabularnewline
Consulting fees\textbf{{}} & 74,392,858 (12.1) \textsuperscript{d}{} &
25,943 (1.0) \textsuperscript{d} & 2253 (28.2){}\tabularnewline
Travel and lodging\textbf{{}} & 64,588,533 (10.5){} & 186,509 (7.5) &
2615 (32.7){}\tabularnewline
Food and beverage\textbf{{}} & 52,035,242 (8.5){} & 2,001,252 (80.9) &
6758 (84.5){}\tabularnewline
Royalty or license\textbf{{}} & 31,022,822 (not
calculated)\textsuperscript{e{}} & 48 (not calculated)
\textsuperscript{e}{} & 13 (0.2){}\tabularnewline
Honoraria\textbf{{}} & 6,027,916 (1.0){} & 2,557 (0.1) & 559
(7.0){}\tabularnewline
CME related speaking fees\textsuperscript{b}\textbf{{}} & 3,024,745
(0.5){} & 1,917 (0.1) & 335 (4.2){}\tabularnewline
Current or prospective ownership or investment interest\textbf{} &
2,935,713 (not calculated)\textsuperscript{d,e} & 13 (not calculated)
\textsuperscript{d,e}{} & 2 (0.02)\tabularnewline
Education\textbf{{}} & 1,264,534 (0.2){} & 41,465 (1.7) & 5040
(63.0){}\tabularnewline
Grant\textbf{{}} & 1,150,106 (0.2){} & 142 (0.01) & 102
(1.3){}\tabularnewline
Gift\textbf{{}} & 163,406 (0.03) & 2,363 (0.1) & 965
(12.1){}\tabularnewline
Acquisitions\textbf{{}} & 20,265 (0.003) & 3 (0.0001) & 3
(0.04){}\tabularnewline
Long-term medical supply or device loan\textbf{{}} & 12,524 (0.002){} &
6 (0.0002) & 6 (0.1){}\tabularnewline
Charitable contribution\textbf{{}} & 5,783 (0.001) & 5 (0.0002) & 5
(0.1){}\tabularnewline
Debt forgiveness\textbf{} & 5,568 (0.001) & 24 (0.001) & 24
(0.3)\tabularnewline
Entertainment\textbf{} & 781 (0.0001) & 24 (0.001) & 15
(0.2)\tabularnewline
\textbf{Research payments} & 1,414,033,684 (68.5) \textsuperscript{c} &
324,673 (11.6) \textsuperscript{c} & 1336 (16.7)\tabularnewline
Associated research payments\textbf{} & 1,378,868,832 (97.5) & 313,068
(96.4) & 1220 (15.3)\tabularnewline
Direct research payments\textbf{{}} & 35,164,852 (2.5) & 11,605 (3.6) &
611 (7.6)\tabularnewline
\bottomrule
\end{longtable}

\textsuperscript{a}Non-CME related speaking fees included ``compensation
for services other than consulting, including serving as faculty or as a
speaker at a venue other than a continuing education program.''

\textsuperscript{b}CME speaking payments included ``compensation for
serving as faculty or as a speaker for an accredited or certified
continuing education program'' (applicable to program years 2013-2020),
``compensation for serving as faculty or as a speaker for an
unaccredited and non-certified continuing education program''
(applicable to program years 2013-2020), and ``compensation for serving
as faculty or as a speaker for medical education program'' (applicable
beginning with program year 2021 and subsequent program years).

\textsuperscript{c} The proportion of geneal payments and research
payments to all industry payments to the endocrinologists.

\textsuperscript{d~}Five general payments of consulting fees and
compensation were paid to endocrinologists as registered stock units in
return for their membership on the board of directors of the company.
Therefore, this study classified these payments as ownership payments in
this study, as the compensations were made in the form stocks.~

\textsuperscript{e} General payments for ownership and
royalties/licenses were not included in the calculation of percentage
share of each payment relative to the total general payments.

~

Supplemental Material 4. Annual average consumer price index values
between 2014 and 2022 used in this study

~\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
Payment year\textbf{} & Annual average consumer price index
(CPI)\textbf{} & Relative annual average CPI
value\textbf{}\tabularnewline
2022\textbf{} & 292.655 & 1.00 (reference)\tabularnewline
2021\textbf{} & 270.97 & 0.925902513198135\tabularnewline
2020\textbf{} & 258.811 & 0.884355298901437\tabularnewline
2019\textbf{} & 255.657 & 0.873578103910748\tabularnewline
2018\textbf{} & 251.107 & 0.858030787104270\tabularnewline
2017\textbf{} & 245.12 & 0.837573251781108\tabularnewline
2016\textbf{} & 240.007 & 0.820102168081871\tabularnewline
2015\textbf{} & 237.017 & 0.809885359894757\tabularnewline
2014\textbf{} & 236.736 & 0.808925184944730\tabularnewline
\bottomrule
\end{longtable}

Data source from the Unite States Bureau of Labor Statistics (URL:
\url{https://data.bls.gov/timeseries/CUUR0000SA0})

~

Supplemental Material 5. Annual trends in number of physicians receiving
payments and payments per physician since the inception of the Open
Payments Database before and during the COVID-19 pandemic

~\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\textbf{Variables} & \textbf{Relative annual mean percentage change
(95\% confidence interval), \%}\tabularnewline
\textbf{Number of endocrinologists receiving payments}
\textsuperscript{a}\textbf{{}} & \textbf{Payments per
physician}\tabularnewline
\textbf{Overall (N = 8002)} \textsuperscript{a}\textbf{{}} &
\textbf{\$0.01--\$500 (n = 1332){}}\tabularnewline
\textbf{General payments} \textsuperscript{\textbf{b}} &
~\tabularnewline
Pre-interruption trend since the inception of the Open Payments Database
(2014-2019)\textbf{} & -0.03 (-0.3 to 0.3)\tabularnewline
Level change by the COVID-19 pandemic (2014-2019 vs 2020-2022)\textbf{}
& -24.4 (-26.1 to -22.7)***\tabularnewline
Post-interruption trend since the COVID-19 pandemic (2020-2022)\textbf{}
& 2.9 (1.8 -- 3.9)***\tabularnewline
\textbf{Direct research payments} & ~\tabularnewline
Pre interruption trend since the inception of the Open Payments Database
(2014-2019)\textbf{} & -0.7 (-3.6 to 2.3)\tabularnewline
Level change by the COVID-19 pandemic (2014-2019 vs 2020-2022)\textbf{}
& -21.8 (-34.7 to -6.2)**\tabularnewline
Post interruption trend since the COVID-19 pandemic (2020-2022)\textbf{}
& 2.7 (-5.8 to 11.9)\tabularnewline
\textbf{Associated research payments} & ~\tabularnewline
Pre interruption trend since the inception of the Open Payments Database
(2014-2019)\textbf{} & -3.5 (-4.8 to -2.2)***\tabularnewline
Level change by the COVID-19 pandemic (2014-2019 vs 2020-2022)\textbf{}
& -9.5 (-16.1 to -2.4)**\tabularnewline
Post interruption trend since the COVID-19 pandemic (2020-2022)\textbf{}
& -0.8 (-4.6 to 3.0)\tabularnewline
\bottomrule
\end{longtable}

*p\textless{}0.05. **p\textless{}0.01. p\textless{}0.001.

\textsuperscript{a} Endocrinologists who were activated before January
2014 were included in the trend analyses and this study excluded
endocrinologists who were deactivated and newly activated after 2014 to
remove new or retired endocrinologists in the trend analyses.

\textsuperscript{b~}This study excluded the payments for acquisitions,
debt forgiveness, long-term medical supply or device loans, ownership
interests, and royalties and licenses in the trend analysis of general
payments, because this study observed substantial amounts of general
payments for royalties and license in several years or these payment
categories were newly-added in 2021.

\selectlanguage{english}
\FloatBarrier
\end{document}

