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\begin{document}

\title{Financial relationships between board-certified neurologists and
pharmaceutical industry in Japan~~~~}



\author[1]{Anju Murayama}%
\author[1]{Kenichi Higuchi}%
\author[1]{Yuki Senoo}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{June 18, 2024}


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\textbf{Financial relationships between board-certified neurologists and
pharmaceutical industry in Japan}

Anju Murayama\textsuperscript{1,2*}; Kenichi Higuchi\textsuperscript{1};
Yuki Senoo, MD, MUDr\textsuperscript{3}

\textbf{Affiliations:}

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

\textsuperscript{2} Department of Population Health Science and Policy,
Icahn School of Medicine at Mount Sinai, New York City, NY, USA

\textsuperscript{3} Department of Internal Medicine, Higashitotsuka
Memorial Hospital, Yokohama, Kanagawa, Japan

*Corresponding author

\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:\emph{anju.murayama.s8@dc.tohoku.ac.jp}

\par\null



\textbf{Background}

Neurologist-industry financial interactions could lead to conflicts of
interest.

\textbf{Objectives:}

To evaluate extent and trends in personal payments to neurologists from
pharmaceutical companies in Japan.

\textbf{Methods:}

Using publicly available payment data collected from pharmaceutical
companies, this study examined the extent and trends of personal
payments to board-certified neurologists between 2016-2020. Trends in
payments to neurologists were analyzed using generalized estimating
equation models.

\textbf{Results}

Of 6107 board-certified neurologists, 3,615 (59.2) received personal
payments totaling \$45.7 million over the five years. Of neurologists
receiving payments, the median payments per neurologist was \$2,423
(IQR: \$765--\$9,076), with a mean of \$12,649 (SD: \$35,012). Only top
1\% and 10\% of these neurologists received 30.3\% and 78.8\% of all
payments, respectively. The payments to neurologists significantly
increased by 3.2\% each year between 2016-2019, but decreased by 21.1\%
in 2020.

\textbf{Conclusion}

The majority of neurologists received personal payments. Payments
increased annually until 2020.

\textbf{Keywords:}

Conflicts of interest, ethics, health policy, medical ethics, Japan,
Japanese Society of Neurology, industry payments

\textbf{List of abbreviations}

95\% CI: 95\% confidence interval; GEE: generalized estimating equation;
IQR: interquartile range; JPMA: Japanese Pharmaceutical Manufacturers
Association

\textbf{Main body of the manuscript}

\textbf{Introduction}

Financial interactions between physicians and pharmaceutical companies
could foster healthcare innovation and improve patient care though
research collaboration. However, these interaction introduce financial
conflicts of interest (COIs) among physicians{[}1-3{]}, potentially
biasing physicians' decision-making such as clinical practice{[}4-6{]},
guideline recommendations{[}7-10{]}, health policy{[}11{]}, and
integrity of scientific research{[}12,13{]}. Pharmaceutical companies
made more than \$236.0 million per year to physicians and healthcare
organizations for consulting and speaking compensations in
Japan{[}14{]}. The majority of these payments were directly made to
individual physicians. Previous studies reported that the majority of
all physicians received these personal payments for speaking and
consulting services other than food and travel payments in
Japan{[}7,8,15-32{]}, surpassing those in other developed countries such
as the United States{[}3,33-44{]}, Australia{[}45,46{]}, and
France{[}47{]}.

Among several disease areas, there is increasing attention to
neurological disorders from pharmaceutical industry. The number and
prevalence of patients with dementia is critically increasing in Japan.
There were 4.62 million patients with dementia as of 2012{[}48{]}, and
it is predicted that more than 20\% of all people aged 65 years and
older will have dementia by 2030{[}49{]}. The healthcare spending
related to Alzheimer's disease drug were US\$1.0 billion (JPY 1,073
billion) in Japan in 2018{[}48{]}. The sales of antidementia drugs
including memantine (Memary from Daiichi Sankyo), donepezil (Aricept
from Eisai), and galantamine (Reminyl from Takeda Pharmaceutical) was
\$437, \$220, and \$160 million in 2017, respectively. Previous research
found that there were substantial financial relationships between
dementia clinical guideline authors and the antidementia drug
manufacturers. However, the whole picture of the financial relationships
between pharmaceutical companies and all neurologists has never been
investigated. Using a publicly accessible transparency database, we
investigated the extents and trends of personal payments from
pharmaceutical companies to all neurologists in Japan.

\textbf{Methods}

Study design setting, and participants

This study is a retrospective analysis of payment data publicly
disclosed by major pharmaceutical companies in Japan. The analysis
included all neurologists certified by the Japanese Society of Neurology
(JSN) as of February 2022. The JSN, established in 1960, is the
preeminent professional medical society for neurologists and is the sole
credentialing body for neurologists in Japan since 1967. As of the
specified date, 6107 neurologists were recognized as board-certified by
the JSN{[}50{]}.

Payment data reported by pharmaceutical companies

To improve transparency in financial relationships between
pharmaceutical companies and healthcare professionals, the Japanese
Pharmaceutical Manufacturers Association (JPMA), representing of more
than 70 leading pharmaceutical companies, demands its member companies
to disclose payments for lecturing, consulting, and manuscript drafting
made to physicians, including the recipients' names and affiliations on
their websites, as previously explained{[}22,23{]}. However, according
to the JPMA guidance, payment categories, such as meals, travel and
accommodations, and other gifts, are disclosed in aggregated amounts and
could not be analyzed at individual physician level{[}23,51{]}. Thus, we
focused on lecturing, consulting, and drafting payments to neurologists
in this study.

We retrieved the names and affiliated hospitals of all board-certified
neurologists from the JSN website. Then, we collected the personal
payments made for lecturing, consulting, and drafting services to these
neurologists by JPMA-affiliated companies from a publicly accessible
payment database from 2016 to 2020{[}52{]}, as conducted in prior
studies{[}15-17,20{]}.

Statistical analyses

We calculated mean and median payments per neurologist and proportion of
neurologists receiving payments. We assessed the concentration of
payments among neurologists using the Gini index, a measure
traditionally applied to analyze income inequality in economics{[}53{]}.
The index ranges from 0 (indicating uniform payment distribution) to 1
(where a single neurologist receives all payments), with higher values
signaling greater disparity. We also analyzed payment data by category
and the pharmaceutical companies making these payments. Trends in the
number of neurologists receiving payments and the payment amounts from
2016 to 2020 were evaluated using generalized estimating equation (GEE)
models. Due to the non-normal distribution of payments, the analyses
were conducted using a log-linked GEE model with a Poisson distribution
and a negative binomial GEE model{[}20-23{]}. The study period was
divided into two intervals (2016-2019 and 2020) to evaluate impact of
COVID-19 pandemic on the payment patterns, as indicated in previous
studies in the United States{[}33,35-37,39{]}. For trend analysis, we
adjusted for inflation, converting all payment values to 2020-Japanese
yen value with consumer price index. Statistical significance was set at
a p-value of less than 0.05.

\par\null

Ethical clearance

As all data used in this study were publicly available and met the
definition of non-human subjects research, no institutional review board
approval was required.

\textbf{Results}

Of the 6,107 board-certified neurologists, 3,615 (59.2\%) received
personal payments from the pharmaceutical companies over the five years
between 2016 and 2020 (Table 1). The total amounts of personal payments
were in \$45,726,920 entailing 37,337 payments. For neurologists who
received at least one payment, the median amount per neurologist was
\$2,423 (interquartile range {[}IQR{]}: \$765--\$9,076), in contrast to
a mean of \$12,649 (standard deviation {[}SD{]}: \$35,012) over the
five-year span. The Gini index, used to measure payment distribution
among neurologists, was 0.871, suggesting that a small proportion of
neurologists received the majority of personal payments over the five
years. Specifically, the top 1\% (61 neurologists), 5\% (305
neurologists), and 10\% (611 neurologists) of these neurologists
received 30.3\%, 52.8\%, and 78.8\% of all personal payments,
respectively. Of the three payment categories, lecturing payments
occupied 84.4\% of overall payments to the neurologists (\$38,612,931).
Additionally, 58.1\% of all neurologists received at least one lecturing
payments from the pharmaceutical companies between 2016 and 2020. Mean
value per payment was \$1,243 for lecturing payments, \$1,236 for
consulting payments, and \$915 for writing payments.

Of 78 pharmaceutical companies making payments to the neurologists,
Daichi Sankyo made the largest amounts of personal payments totaling
\$6.3 million, followed by Eisai (\$5.0 million), Takeda Pharmaceutical
(\$4.5 million), Otsuka Pharmaceutical (\$3.8 million), and Kyowa Kirin
(\$3.2 million). The top 5 and 10 companies with the largest payment
amounts were responsible for 50.2\% (\$22.9 million) and 74.5\% (\$34.1
million) of all payments over the five years.

The total annual amounts of personal payments to neurologists showed an
increasing trend from \$8.8 million in 2016 to \$10.0 million in 2019
(Table 2), but decreased to \$8.1 million in 2020. There was a similar
trend in the number of payments over the five years. Of all
neurologists, 33.0\% to 36.8\% received at least one personal payment
each year. The number of neurologists receiving payments significantly
increased by 1.5\% (95\% confidence interval {[}95\% CI{]}:
0.4\%--2.6\%, p\textless{}0.001) each year from 2179 in 2016 to 2292 in
2019. Among neurologists receiving payments, median annual payments per
neurologist were from \$1,077 to \$1,356 in monetary value and 2.0 in
the number of payments. Payments per neurologist annually increased by
3.2\% (95\% CI: 0.9\%--5.5\%, p=0.006) in monetary value and by 3.5\%
(95\% CI: 2.4\%--4.7\%, p\textless{}0.001) in the number of payments
between 2016 and 2019. Contrarily, there was significant decreases of
14.3\% (95\% CI: -16.4\% to -10.1\%, p\textless{}0.001) in the number of
neurologists receiving payments and 21.1\% (95\% CI: -25.3\% to -16.7\%,
p\textless{}0.001) in payments per neurologist in 2020 when compared to
those in the previous years.

\textbf{Discussion}

This study investigated the financial relationships between the
pharmaceutical companies and all board-certified neurologists in Japan.
We found that 59.2\% of all board-certified neurologists received
personal payments for lecturing, consulting and writing services from
the pharmaceutical companies in Japan between 2016 and 2020. The total
amounts of personal payments were more than \$45.8 million over the five
years. Only the small number of neurologists received the substantial
amounts of personal payments from the pharmaceutical companies.
Furthermore, there were significant increasing trends in the payment
amounts and number of neurologists receiving personal payments over the
study period. To the best of our knowledge, this is the first analysis
examining the whole picture of financial relationships between the
pharmaceutical companies and neurologists in Japan.

Comparing with previous research, there were several important insights
from the study findings. First, Ahlawat et al. reported that 51\% of all
neurologists received non-research payments including meal and travel
payments from the healthcare industry in the United States (US) in
2015{[}3{]}. The median annual payments per neurologist was \$81 and
only 14.5\% of neurologists received more than \$500 in the US. Compared
to this previous study, our elucidated that both the proportion of
neurologists receiving payments and payment amounts per neurologists
were much higher in Japan than those in the US. Furthermore, the total
non-research payments made to all US neurologists in 2015 were \$6.2
million including meal, travel, entertainment, consulting, honoraria,
royalties \& licenses, and lecturing payments, while we found that at
least \$8.1 million to \$10.0 million per year were made for just the
three personal payment types including lecturing, consulting, and
writing fees. These findings indicate stronger and more widespread
financial ties between neurologists and pharmaceutical companies in
Japan.

However, the substantial and widespread financial relationships between
physicians and pharmaceutical companies was not only among neurologists
but also among other specialists in Japan. Previous studies in Japan
showed that the proportion of specialists receiving personal payments
were 45.3\% for dermatologists{[}22{]}, 52.8\% for
gastroenterologists{[}23{]}, 62.0\% for pulmonologists{[}17{]}, 64.7\%
for hematologists{[}18{]}, 65.4\% for infectious disease
specialists{[}16{]}, 70.7\% for rheumatologists {[}21{]}, and 70.7\% for
urologists{[}20{]}. Additionally, the payment amounts to the
neurologists were also within the ranges reported in previous
studies{[}15,17,18,20-23,26{]}.

Furthermore, we demonstrated that there were significant increasing
trends in personal payments to the neurologists between 2016 and 2019.
The significant decrease in payments to neurologists in 2020 would be
due to the COVID-19 pandemic and behavioral restrictions of physicians
and pharmaceutical company representatives to prevent SARS-CoV-2
infection, as highlighted in previous studies{[}54{]}. Considering that
these personal payments to physicians are associated with physicians'
clinical practice such as increased likelihood of prescribing brand-name
drugs rather than generic alternatives and increased healthcare
costs{[}4-6,55{]}, the increasing trend in payments to neurologists is
an alarming finding. Future research should evaluate the associations
between payments to neurologists and their prescribing patterns in
Japan.

\par\null

This study has several limitations including possibilities of errors in
payment data reported by the companies and in the database.
Additionally, because of unavailability of several payment types such as
meal, travel, royalty, and gift payments in Japan, the financial
relationships between the neurologists and the pharmaceutical companies
would be underestimated in this study. Also, as this study only included
payments from JPMA-affiliated pharmaceutical companies, there would be
unmeasured financial relationship between the neurologists and non-JPMA
affiliated companies.

Despite these limitations, this study demonstrated that nearly 60\% of
neurologists certified by the Japanese Society of Neurology received
personal payments related to lecturing, consulting, and writing from the
pharmaceutical companies between 2016 and 2020. Notably, these personal
payments concentrated on the small number of neurologists and
significantly increased before the COVID-19 pandemic period.

\textbf{Declarations}

\textbf{Data availability statement}

All data used in this study is available from Yen For Docs database run
by Medical Governance Research Institute (\emph{https://yenfordocs.jp/})
and each pharmaceutical companies belonging to the Japan Pharmaceutical
Manufacturers Association. The datasets generated during and/or analyzed
during the current study are available from the corresponding author on
reasonable request.

\textbf{Conflicts of interest:}

The authors have no conflicts of interest for this study.

\textbf{Funding statement:}

The authors declare that there were no funding sources for this study.

\textbf{Ethics approval statement:}

As this study was a retrospective analysis of publicly available data
and met the definition of non-human subjects research, no institutional
board review and approval were required. This study followed the
Strengthening the Reporting of Observational Studies in Epidemiology
(STROBE) guideline.

\textbf{Patient consent statement}

Not applicable

\textbf{Permission to reproduce material from other sources}

Not applicable

\textbf{Clinical trial registration}

Not applicable

\textbf{Declaration of generative AI in scientific writing}

During the preparation of this work, the authors used ChatGPT version
4.0 to check and correct grammatical and spelling errors. After using
this tool, the authors carefully reviewed and edited the content as
needed and takes full responsibility for the content of the publication.

\textbf{Author contribution:}

A.M.: conceptualization; methodology; resource; software; formal
analysis; investigation; writing - original draft; writing - review \&
editing; visualization; study administration

K.H.: conceptualization; methodology; resource; software; formal
analysis; investigation; writing - review \& editing

Y.S.: conceptualization; methodology; resource; formal analysis;
investigation; writing - original draft; writing - review \& editing

\textbf{Acknowledgments}

We would like to thank Ms. Megumi Aizawa for her dedicated support of
our research project. For proofreading parts of the presented text, we
used the freely available pre-trained ChatGPT (version 4.0) model
developed by OpenAI in order to check and proofread the manuscript for
language, spelling and grammatical errors. We checked and edited the
text for unintended plagiarism and verified all facts and values that I
used from the ChatGPT outputs before the manuscript submission. The
version of ChatGPT accessed was the latest as of April 2023.

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44. Murayama A, Hirota S. Industry payments to pathologists in the USA
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45. Karanges EA, Ting N, Parker L, Fabbri A, Bero L. Pharmaceutical
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46. Pokorny AMJ, Bero LA, Moynihan R, Mintzes BJ. Industry payments to
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47. Clinckemaillie M, Scanff A, Naudet F, Barbaroux A. Sunshine on KOLs:
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48. Ikeda S, Mimura M, Ikeda M, Wada-Isoe K, Azuma M, Inoue S, Tomita K.
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49. Nakahori N, Sekine M, Yamada M, Tatsuse T, Kido H, Suzuki M. Future
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54. Inoue K, Figueroa JF, Kondo N, Tsugawa Y. Changes in industry
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Table 1. Summary of personal payments to board-certified neurologists\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
Value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Total amounts of payments\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
45,726,920\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Number of payments, No.\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
37,337\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Payments per neurologist\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Mean (standard deviation) \textsuperscript{a}\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
12,649 (35,012)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Number of payments, No.\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
10.3 (14.5)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Median (interquartile range) \textsuperscript{a}\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
2,423 (765 -- 9,076)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Number of payments, No.\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
4.0 (2.0 -- 13.0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Maximum\textsuperscript{a}\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
616,257\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Number of payments, No.\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
147.0\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Gini index\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
0.871\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Neurologists with specific amounts of payments (N=6107), n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
No payment\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
2,492 (40.8)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Any payments\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
3,615 (59.2)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
\$1-\$1,000\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
1,083 (17.7)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
\$1,001-\$10,000\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
1,703 (27.9)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
\$10,001-\$50,000\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
636 (10.4)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
\$50,001-\$100,000\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
98 (1.6)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
\$100,001-\$200,000\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
64 (1.1)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
\$200,001 or more\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
31 (0.5)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Payment categories\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Lecturing payments\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Monetary value\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
38,612,931\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Number of payments\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
31,073\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Number of neurologists receiving payments\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
3,548 (58.1)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Consulting payments\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Monetary value\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
5,325,411\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Number of payments\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
4,310\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Number of neurologists receiving payments\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
1,297 (21.2)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Writing payments\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Monetary value\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
1,788,578\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Number of payments\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
1,954\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Number of neurologists receiving payments\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
818 (13.4)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Legends: \textsuperscript{a} Payments per neurologist were calculated
among neurologists who received one or more payments, as 40.8\% of
neurologists did not receive any payments over the five years.

Table 2. Trend in personal payments from pharmaceutical companies to
board-certified neurologists between 2016 and 2020.\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
\begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
Variables\strut
\end{minipage} & \begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
2016\strut
\end{minipage} & \begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
2017\strut
\end{minipage} & \begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
2018\strut
\end{minipage} & \begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
2019\strut
\end{minipage} & \begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
2020\strut
\end{minipage} & \begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
Average relative yearly change between 2016 and 2019 (95\% CI), \%\strut
\end{minipage} & \begin{minipage}[b]{0.10\columnwidth}\raggedright\strut
Relative change rate between 2016-2019 and 2020 (95\% CI), \%\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Total payments\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Monetary value, \$\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
8,810,976\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
9,403,513\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
9,410,890\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
10,003,094\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
8,098,447\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
Number of payments, No.\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
7,251\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
7,534\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
7,802\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
8,041\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6,709\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]{0.10\columnwidth}\raggedright\strut
Payments per neurologist\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Monetary value, \$\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Mean (standard deviation)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,044 (9,633)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,194 (9,875)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,192 (9,328)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,364 (9,453)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4,015 (8,613)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3.2 (0.9 -- 5.5)*\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
-21.1 (-25.3 to -16.7)**\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Median (interquartile range)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1,077 (521--3,388)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1,251 (521--3,337)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1,356 (521--3,650)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1,359 (531--3,852)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1,290 (532--3,529)\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
Maximum\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
112,859\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
137,685\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
141,689\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
147,166\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
107,707\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
Gini index\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0.898\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0.894\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0.890\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0.887\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0.896\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]{0.10\columnwidth}\raggedright\strut
Number of payments, No.\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Mean (standard deviation)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3.3 (3.5)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3.4 (3.4)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3.5 (3.5)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3.5 (3.5)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3.3 (3.3)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3.5 (2.4 -- 4.7)**\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
-19.6 (-22.4 to -16.7)**\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Median (interquartile range)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2.0 (1.0 -- 4.0)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2.0 (1.0 -- 4.0)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2.0 (1.0 -- 4.0)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2.0 (1.0 -- 5.0)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2.0 (1.0 -- 4.0)\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
Maximum\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
27.0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
29.0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
31.0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
34.0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
32.0\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
Gini index\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0.811\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0.805\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0.805\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0.799\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0.820\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]{0.10\columnwidth}\raggedright\strut
Physicians with payments (\%) (N=6107), n\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2,179 (35.7)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2,242 (36.7)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2,245 (36.8)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2,292 (37.5)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2,017 (33.0)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1.5 (0.4 -- 2.6)**\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
-14.3 (-16.4 to -10.1)*\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Abbreviation: 95\% confidence interval (95\% CI). *p\textless{}0.01.
**p\textless{}0.001.

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