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More than half of peer reviewers for four top medical journals received payments from drug and medical device manufacturers, totaling $1.06 billion, from 2020 to 2022, according to an analysis of the Open Payments database.

Among nearly 2,000 physician peer reviewers at JAMA, the New England Journal of Medicine, The BMJ, and The Lancet, 58.9% received at least one industry payment during that period, including 54% who accepted general payments and 31.8% who accepted research payments, reported Christopher Wallis, MD, PhD, of the University of Toronto, and colleagues in a research letter in .

The $1.06 billion in industry payments included $1 billion (94%) to physicians or their institutions and $64.18 million (6%) in general payments. Consulting fees and speaking compensation unrelated to continuing medical education programs accounted for $34.31 million and $11.80 million, respectively.

The median general payment was $7,614 (interquartile range [IQR] $495-$43,069) and the median research payment was $153,173 (IQR $29,307-$835,637) over the 3 years.

"Peer reviewers act as critical arbiters of both the validity and relevance of peer-reviewed studies," Wallis told MedPage Today. "Therefore, understanding the potential intellectual and financial relationships that may affect their decision making is key to understanding how these influences affect the peer-reviewed literature."

Adriane Fugh-Berman, MD, director of PharmedOut, a project at Georgetown University Medical Center in Washington, D.C. that educates medical professionals about industry marketing practices, told MedPage Today that the prominence of those with conflicts of interest in many steps of medical publishing is "not good."

Nearly half of physician editors at journals, , also have widespread conflicts of interest. Wallis noted that "financial relationships between physicians/reviewers and pharmaceutical companies are not inherently bad or negative," but not everyone agrees.

"Just because something's common, it shouldn't be normalized, and in this case, this really should be vilified rather than normalized," Fugh-Berman said. "It's really important for peer reviewers to be objective. It's really important for medical journal editors to be objective. And they can't be when they have conflicts of interest with industry."

Though journals typically have policies for authors and editors to disclose conflicts of interest, few do the same for peer reviewers, the authors wrote. Journals may consider conflicts in the peer review process, but public disclosure is rare, and industry ties in academic research are common.

Because pharmaceutical companies are the largest purchasers of article reprints, and advertise heavily in medical journals, "it affects what gets published," Fugh-Berman noted. "Obviously, pharma-critical articles are going to be published less often in journals that are supported by pharmaceutical companies, whose medical editors are supported by pharmaceutical companies, and whose peer reviewers are supported by pharmaceutical companies."

Fugh-Berman recalled an incident in which a paper she submitted to a journal received a review she described as "so obviously written by someone from industry" that she wrote to the editor, rebutting it. The journal ended up getting another peer reviewer, and publishing the piece. However, she said, many writers may not attempt to rebut a review, or recognize that a reviewer could have industry ties.

It's unclear whether or not the reviewer in this case was heavily funded by industry, or an employee of a drug or device company, but Fugh-Berman said she suspects neither would be excluded from the peer review process. "You can work for industry and author articles, right?" she said.

For this analysis, Wallis and colleagues selected four journals with a high impact factor and a "reputation as leading publications of original general medical research." They identified peer reviewers from each journal's 2022 reviewer list, and obtained reviewer affiliations, sex, and specialty through Scopus and the National Plan and Provider Enumeration System. Limiting the group to U.S.-based physicians, they pulled general and research payments from the Centers for Medicare & Medicaid Services Open Payments database from 2020 to 2022.

Drug and medical device manufacturer research payments included those to individual physicians and institutional payments for research in which physicians served as a principal investigator. General payments included non-research payments -- for example, gifts, travel, food and beverage, and honoraria.

After accounting for non-U.S. reviewers, non-physicians, and those who were not searchable in Scopus, 1,962 reviewers were included. The majority were men (71.2%), and 38.1% were in a medical specialty.

Male reviewers had significantly higher median total payments than female reviewers ($38,959 vs $19,586), as well as general payments ($8,663 vs $4,183).

Wallis and team acknowledged that it was not known if existing relationships were relevant to the reviewed articles. They also did not capture non-U.S.-based physicians, or payments from insurance and technology companies, which may have underestimated payments to peer reviewers. The findings were also limited to the four journals, and may not be generalizable to others.

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