Characteristics of Advanced Practice Nurses Receiving Top Industry Payments and Their Practice Settings: a Cross-sectional Study

Abstract

Background

The pharmaceutical industry promotes prescribing through the cultivation of key opinion leaders. Advanced practice nurses (APNs) are a growing and influential group of prescribers across generalist and specialty practice. Public reporting of industry payments to APNs allows for exploration of their influence within practice settings.

Objective

To understand the characteristics of APNs with top industry payments including their positions of influence and other payment recipients at the same address.

Design and Setting

Cross-sectional study of US national Open Payments reports of industry payments made between January 1, 2021, and December 31, 2021.

Participants

APNs who received > $50,000 USD in industry payments for speaking, consulting, and honoraria (“personal fees”).

Measures

Description of top APN recipients’ practice setting type, clinical specialty, presence of other payment recipients, value of payments attributed to the same address, and top manufacturers and therapeutic categories associated with payments to top APN recipients. Structured content analysis of public-facing websites for evidence of APNs’ clinical, research, and teaching leadership.

Results

A total of 99 APNs received > $50,000 USD in aggregate personal fees and a median $74,080 USD (IQR $57,303–101,702) in aggregate payments. They shared a practice setting with a median of 1 (IQR 0–5) physician and 0 (IQR 0–3) other APN payment recipients and were often the only (39%, 42/109) or the dominant (45%, 30/67) payment recipient in their practice setting. In total, 36% held clinical leadership positions, 25% led scientific research, and 18% had university appointments. Forty-two percent (37/88) owned a clinical practice, including cosmetic clinics (51%, 19/37) and mental/behavioral health clinics (24%, 9/37).

Conclusions

Top APN payment recipients attracted high-value payments in practice settings and specialities associated with high-cost drug development; however, there may be little oversight of APNs’ industry relationships. Policy development related to industry relationships must be inclusive of and responsive to the activities of interprofessional providers.

INTRODUCTION

The pharmaceutical industry has long made use of social influences on prescribing through the cultivation of “key opinion leaders.” A key opinion leader typically occupies positions of influence within their peer networks through which they are able to promote, and ultimately increase the volume of prescribing for promoted drugs.^1,]2 To reach prescribers, pharmaceutical companies typically engage two groups of key opinion leaders: clinicians, who use the product and are trusted and able to engage their peers; and researchers conducting influential scientific work at prominent institutions.^{1, 2} Clinician key opinion leaders are more prevalent and are typically engaged to provide talks to their peers through speakers’ bureaus or large-scale educational programs, whereas researcher key opinion leaders serve as consultants and engage in sponsored research.^{1, 3}

Until 2021, understanding of who among prescribers receives high-value industry payments was incomplete as advanced practice nurses (APNs), an influential and growing group of prescribers, were omitted from the US Physician Payments Sunshine Act.⁴ Analysis of Australian industry payments data suggests that some APNs receive large-value payments from industry while occupying positions of leadership within clinical settings, research, and professional and consumer advocacy organizations.⁵ The extent to which APNs as recipients of significant industry payments are characteristic of key opinion leaders in the USA is unknown.

APNs, including nurse practitioners (NPs), clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives, are key members of interprofessional teams within primary and specialty care; NPs have prescriptive privileges in all states, and those in full-time practice write an average of 21 prescriptions per day.⁶ The first published analyses of APN Open Payments data suggest industry payments to APNs are prevalent; about 36% of NPs and 25% of clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives received payments from industry during 2021⁷—largely for food and beverage, compensation for services other than consulting, and consulting fees.⁸

We aimed to identify APNs who may be influential because of their capacity to disseminate promotional messages through practice networks.^{2, 9} Most policies regulating prescriber relationships with industry exist at the practice or institutional level, such as conflict of interest policies. However, these policies may largely omit APNs and key domains of practice such as clinical teaching or preceptorship.¹⁰ To inform effective policy related to prescribers’ industry relationships, we sought to identify the settings where top APN payment recipients practice, and to what extent they practice alongside, or are isolated from, other physician and other APN payment recipients.

METHODS

Study Design

In this cross-sectional study, we analyzed Open Payments data on general (non-research, non-ownership) industry payments made to APNs during the inaugural reporting period of January 1 and December 31, 2021. In 2021, 97% of the total number of payments to NPs (and 91% of the total number of payments to physicians) were for food and beverage.⁷ As we sought to identify the most potentially influential APNs, we examined the distribution of aggregate payments paid to APNs for personal fees, defined as payments for speaking (educational and non-educational), consulting, and honoraria. Based on the right-skew and tail, we selected a threshold of $50,000 in aggregate payments for personal fees to meaningfully operationalize “top payment recipient.”

Using network analysis techniques, we identified recipients’ practice settings using the business addresses associated with their payments, and all other APNs and physicians reporting payments at the same practice addresses. Using web-based content analysis, we described the characteristics of these practice settings and the broader professional roles of top APN payment recipients.

Data Sources and Linkage

On July 1, 2022, we downloaded the 2021 payment dataset from the Open Payments website. The dataset included general payments (including compensation for consulting, speaking, or non-consulting services, honoraria, education, entertainment, food and beverage, gifts, travel and lodging, and debt forgiveness) and details including the reporting entity (i.e., manufacturer), recipient’s name, unique Open Payments identifier, National Provider Identifier (NPI), primary provider type, primary business address, the type, value, and associated therapeutic area of the payment.¹¹

We aggregated payment records at the individual provider level using the Open Payments unique identifier. Noting inconsistencies in provider type across payment records for the same Open Payments identifier, we determined each recipient’s primary provider type by linking the Open Payments data to the National Plan and Provider Enumeration System (NPPES) data (June 2022) using recipients’ NPI. We assigned primary provider type by selecting the first listed Healthcare Provider Taxonomy Code (NPPES) or, if missing, the Covered Recipient Specialty in Open Payments. We included all allopathic and osteopathic physicians (hereafter “physicians”), NPs, clinical nurse specialists, certified nurse midwives, and certified registered nurse anesthetists (hereafter “APNs”).

Characterizing Practice Settings of Top APN Payment Recipients

We standardized the primary business addresses for all recipients in the 2021 Open Payments data using 5-digit ZIP codes, geographic data provided by https://download.geonames.org/, and the postmastr library (0.1.0.9)¹² in R (4.2.2)¹³, developing author extensions to the postmaster library to add functionality to enable standardization of primary business addresses at the level of department, suite, or unit.

For the top APN payment recipients, we further aggregated variations in primary business addresses across payment records manually. Using Google Maps and structured internet searches, we verified that a relationship plausibly existed between the APN and the reported address (e.g., current or past employment, affiliation, professional activity) within the past 10 years. We grouped related addresses into a single practice setting (e.g., multiple clinic addresses for the same practice) and identified key characteristics including clinical specialty and practice type. For each practice setting, we aggregated the number and value of the top APN recipients’ payments of any type (i.e., including personal fees, food and beverage, travel and lodging, etc.) across records. We further characterized these practice settings in terms of geographic region, CMS provider type (using the CMS Provider Look-Up tool), teaching hospital affiliation, and federally qualified health center status.

For each top APN practice setting, we identified all payment recipients within the 2021 Open Payment dataset (physician and APN) with an exact matching business address (at the level of department, suite, unit, or standalone clinic, etc.), excluding those which matched only at the level of the street address where this difference was deemed material (e.g., the address for a medical office tower but missing details related to suite). We identified the number of payment recipients and recorded the aggregate value of general payments of any type associated with the practice setting and calculated the share attributed to the top APN recipient.

Characterizing the Capacity for Influence Within Professional Networks

To assess potential reasons why these APNs are top recipients among all APNs receiving payments, we adapted criteria previously used to identify key opinion leaders⁵ (Appendix). We conducted structured internet searches using their provided names, NPIs, and practice addresses as keywords to identify the correct individual and catalogued the URLs of web pages containing professional biographical information (e.g., LinkedIn pages, practice bios, published work), examining up to three pages of search results, or until saturation was reached.¹⁴ We searched the WayBack Machine (a non-profit digital archive of the World Wide Web)¹⁵ to determine any historical association between the provider and practice setting. Each top-paid APN was searched in Google Scholar to identify peer-reviewed authored publications in the past 10 years. We then conducted targeted searches to identify evidence of any leadership using the search terms ““[APN name]” “nurse” editor OR director OR professor OR instructor OR president OR partner OR founder,” examining up to three pages of research results. Using a coding manual adapted from previous work⁵ (Appendix), we coded all sampled web content in duplicate.

Data Analysis

Descriptive statistics were calculated including frequencies, medians, and interquartile ranges.

RESULTS

In the 2021 Open Payments data, there were 572,641 recipients with a clear provider type, including 413,483 physicians and 159,158 APNs. We excluded 48,958 individuals with ambiguous provider types from further analysis. In total, 4205 APNs (2.6%, 4205/159,158) and 44,753 physicians (10.8%, 44,753/413,483) received personal fees (payments for speaking, consulting, or honoraria), representing 36.5% of the total value of payments made to APNs ($28,710,832/$78,659,554) and 43.0% of the total value of payments made to physicians ($804,626,418/$1,870,719,929). APNs who were paid personal fees received a median $1287 (IQR 438–5600) in aggregate value and a range of 1–218 unique payments per person; physicians received a median $4800 (IQR 1415–17,979) in aggregate personal fees and 1–1327 unique payments per person.

There were 99 APNs who received > $50,000 in aggregate personal fees during the reporting period, comprising 2.4% (99/4,205) of APNs receiving personal fees, and 0.6% of all APN payment recipients. In comparison, physicians receiving > $50,000 in aggregate personal fees represented 8.7% (3921/44,753) of physicians receiving personal fees and 0.9% (3921/413,483) of physicians receiving any payment. Virtually all of the APNs were nurse practitioners (96/99, 97.0%). These 99 APNs received a median 51 (IQR 38–68.5) number of payments for personal fees, valued at a median $74,080 (IQR $57,303–101,702) in aggregate payments during 2021.

Practice Settings of Top APN Payment Recipients

After automated standardization, there were 220 unique variations of primary business addresses for the top 99 APN payment recipients, with a median 2 addresses per APN (IQR 1–3). For 11 of the top APNs, we were unable to identify a connection with the primary business address associated with their payments. Thus, we judged these payments as misattributed to the address and excluded these individuals from the analysis describing practice settings. We identified 24 addresses as residential buildings and excluded these addresses from our descriptive analysis of practice settings, unless it was the only address provided for a recipient.

This process resulted in identification of 109 distinct practice settings for 88 top APN payment recipients. The largest proportion of practice settings were located in the South (37.6%, 41/109), followed by the West (25.7%, 28/109), the Midwest (19.3%, 21/109), and the Northeast (18.3%, 20/109).

Practice settings associated with payments to top APN recipients were rarely affiliated with teaching hospitals (5/109, 4.6%) or federally qualified health centers (4/109, 3.7%), and 29.3% (32/109) were not identifiable within the CMS Provider Look-Up database.

Top APN payment recipients shared a practice setting (payment records with a primary business address that was an exact match at the level of clinic or department) with a median of 1 (IQR 0–5) physician and 0 (IQR 0–3) other APN payment recipients (Table 1). Practice settings identified in the CMS Provider Look-Up database (60%, 65/109) had a median 32 providers (IQR 7–199.5), ranging from 1 to 2797 (e.g., medical group associated with large teaching hospital). For 39% (42/109) of the practice settings, the top APN payment recipient was the only recipient with payments attributed to that address. For practice settings with other providers receiving payments, the top APN payment recipient received more than 90% of the total value of reported payments at 45% (30/67) of practice settings.

Table 1.

Characteristics of Practice Settings (n = 109) Associated with APNs Reporting > $50,000 USD in Industry Payments (n = 88)

Practice setting type	N (%)	Median number of individual recipients in practice setting (IQR)		Median total value (USD) of payments reported at practice setting (IQR)				Median share (%) of total value
	Practice settings of APNs reporting > $50 k*	Other APNs	Physicians	APNs reporting > $50 k	Other APNs	Physicians	Total	APNs reporting > $50 k
CMS providers†
Group practice	65 (59.6%)	2 (0–5)	1 (0–8)	69,628.76 (57,241.71–100,501.08)	348.69 (0–3390.83)	1072.36 (0–10,283.74)	88,064.96 (64,654.91–126,926.90	94.3 (74.7–99.9)
Anesthesiology	3 (2.8%)	0 (0–5)	0 (0–4.5)	139,241.49 (120,253.55–152,203.35)	0 (0–295.79)	0 (0–285.61)	139,241.49 (120,830.94–152,203.35)	100 (99.4–100)
Endocrinology	9 (8.3%)	2 (0–3)	2 (0–10)	82,839.83 (60,807.18–107,674.38)	1098.25 (0–4807.46)	5694.47 (0–55,968.64)	126,216.90 (109,066.80–139,813.20)	74.7 (30.8–94.3)
Family medicine	6 (5.5%)	2 (1.25–2.75)	2 (1.25–4.25)	62,028.12 (57,666.13–88,992.59)	208 (40.75–430.16)	494.93 (308.87–5616.90)	66,258.36 (58,937.04–93,461.86)	94.9 (90.1–98.0)
Gastroenterology	1 (0.9%)	0 (0–0)	0 (0–0)	283,342.01 (283,342.01–283,342.01)	0 (0–0)	0 (0–0)	283,342.01 (283,342.01–283,342.01)	100 (100–100)
Hematology/ oncology	10 (9.2%)	3 (0.25–7.25)	4.5 (1.75–15)	75,223.42 (42,221.32–108,855.84	1698.69 (9.85–6153.28)	9271.71 (708.51–21,793.09)	110,744.88 (58,075.26–186,025.70)	88.2 (67.0–98.7)
Mental health	14 (12.8%)	2 (0–5)	1 (0–2.5)	73,027.92 (57,817.60–97,489.05)	243.44 (0–4968.25)	227.95 (0–1232.71)	76,360.68 (63,635.79–98,913.84	98.2 (92.7–99.9)
Neurology	18 (16.5%)	1 (0–3)	2 (1–9.5)	61,432.74 (55,531.16–67,727.00)	237.79 (0–3300.14)	8328.89 (95.62–34,252.18)	76,638.39 (59,188.42–100,858.80)	86.4 (47.9–99.1)
Orthopedics	2 (1.8%)	1 (0.5–1.5)	4 (2–6)	95,846.81 (78,025.81–113,667.83)	152.02 (76.01–228.02)	2073.04 (1036.52–3109.55)	98,071.86 (81,363.38–114,780.33)	96.6 (94.8–98.3)
Reproductive health	2 (1.8%)	10 (7–13)	1.5 (1.25–1.75)	76,114.37 (75,581.35–76,647.38)	1727.28 (1534.52–1920.05)	1592.66 (1006.23–2179.10)	79,434.31 (78,122.09–80,746.53)	95.9 (95.0–96.8)
Hospital	11 (10.1%)	1 (0–3)	3 (0–14)	94,948.86 (62,144.55–169,628.41)	165.82 (0–3,195.58)	392.96 (0–123,779.30)	94,948.86 (62,144.56–350,693.40)	77.4 (33.9–99.9)
Teaching hospital	5 (4.6%)	3 (0–14)	14 (1–30)	156,530.31 (113,161.36–182,726.51)	2878.18 (0–7285.06)	230,485.70 (392.96–520,816)	394,301.07 (183,119.47–636,855.57)	39.7 (17.8–99.8)
Non-teaching hospital	6 (5.5%)	0.5 (0–1.75)	1.5 (0–3.75)	63,472.29 (15,870.84–88,520.7)	82.91 (0–2432.08)	82.94 (0–1324.65)	73,602.53 (19,556.77–93,585.82)	88.7 (60.9–99.9)
Nursing home (for-profit)	1 (0.9%)	0 (0–0)	1 (1–1)	20.68 (20.68–20.68)	0 (0–0)	22.95 (22.95–22.95)	43.63 (43.63–43.63)	47.4 (47.4–47.4)
Non-CMS providers†
Behavioral health clinic	15 (13.8%)	0 (0–1)	0 (0–0.5)	65,865.18 (1168.79–96,675.02)	0 (0–178.2)	0 (0–9.89)	65,865.18 (1168.79–96,675.02)	100 (99.4–100)
Cosmetic clinic	13 (11.9%)	0 (0–0)	0 (0–0)	90,873.04 (74,354.2–123,002.90)	0 (0–0)	0 (0–0)	90,873.04 (74,354.2–123,002.88)	100 (100–100)
Other‡	4 (3.7%)	0 (0–0)	0 (0–0)	99,119.58 (88,745.71–130,266.11)	0 (0–0)	0 (0–0)	99,119.575 (88,745.71–130,266.11)	100 (100–100)

*The payments for the 88 APNs reporting > $50,000 in personal fees were associated with 109 practice settings; there was only one top APN payment recipient per practice setting identified

^†The APNs reporting > $50,000 in personal fees and their practice addresses reported in Open Payments were also identified within the CMS Provider Look Up tool; those returning no results with the CMS provider Look Up tool are labeled Non-CMS providers

^‡Other included a healthcare company and 2 residential addresses, which were the only addresses reported for the top APN payment recipient

Within hematology/oncology, neurology, and endocrinology practices and hospitals, there were a larger median number of other payment recipients, particularly physicians, at these practice addresses. Further, the top APN payment recipients accounted for a smaller share of the total value of all payments reported to these practice settings. For example, top APN recipients received a median share of 39.7% (IQR 17.8–99.8%) of payments reported to departments within teaching hospitals in contrast to primary care settings where top APN recipients received median shares over 95%.

The manufacturers (n = 73 companies) and therapeutic areas associated with payments to top APN recipients were largely related to hematology/oncology, neurology, psychiatry, and diabetes care, with the exception of manufacturers and products used in facial aesthetics, which dominated spending (Fig. 1).

Figure 1.

Manufacturers (n=73) reporting payments for personal fees to top APN payment recipients and associated therapeutic categories

Roles and Activities of Top APN Payment Recipients

Table 2 describes the top APN payment recipients’ clinical, research, education, and advocacy roles and activities within any practice setting, including those addresses reported and not reported within Open Payments. Eleven individuals had insufficient information available online, and were excluded from the analysis in Table 2.

Table 2.

Characteristics of Clinical, Research, and Educational Leadership and Expertise Among Top Advanced Practice Nurse Payment Recipients (n = 88)

Characteristics	N	(%)
Clinical leadership and expertise
Clinical ownershipa	37	42
At practice setting reported in Open Payments	16	18
At practice setting not reported in Open Payments	21	24
Clinical leadershipb	32	36
Professional organization membership	49	56
Leadership positionc	15	17
Consumer/patient advocacy organization involvementd	18	20
Research and scientific expertise
Research involvemente	22	25
Doctorally preparedf	19	22
Teaching and educational expertise
Post-secondary professor or instructor	16	18
Clinical instructor or teaching	17	19
Content creatorg	12	14
Entrepreneurshiph	13	15

^aClinical ownership indicates owner, partner, founder of practice or company

^bClinical leadership indicates supervising or lead NP, clinical or program director

^cLeadership position in a professional organization indicates committee leadership, board membership, or an executive position (president, chair, vice president, secretary, or treasurer)

^dInvolvement in a consumer or patient advocacy organization indicates committee leadership, board membership, an executive position, consultant, or advisory role

^eResearch involvement indicates authorship of peer-reviewed publications detailing empirical or primary research, director or principal investigator of a research group, clinical trial coordinator, or journal editor

^fDoctoral level preparation including Doctor of Philosophy (PhD), Doctor of Nursing (DN), Doctor of Nursing Practice (DNP), or Doctor of Nursing Science (DNS)

^gCreator or author of content including authorship of books (popular or lay press), social media channels (e.g., YouTube channel), podcasts, etc.

^hEngaged in non-clinical entrepreneurial activities such as consulting or business ownership

A minority of top-paid APNs had evidence of formal research or educational leadership: 25% were involved in or leading scientific research; 18% had university appointments. A larger proportion of APNs (42%, 37/88) had evidence of clinical ownership or clinical leadership (36%, 32/88). The practice settings owned by top APN payment recipients were mostly not those reported in Open Payments (57%, 21/37). Half of APNs with clinical ownership were owners of cosmetic clinics (51%, 19/37) followed by mental or behavioral health clinics (24%, 9/37). Additionally, 15% (13/88) had evidence of non-clinical entrepreneurship such as coaching, consulting, or wellness-related businesses.

Separately from those with formal research and educational activities, several top APN payment recipients had publication records or educational roles that were solely a product of their industry relationships. For example, the publication records for 8 top APN recipients exclusively comprised posters or conference abstracts, narrative reviews, and case reports where a pharmaceutical company was credited with manuscript funding, development, medical writing, and editorial assistance. Another 17 (19%) top APN payment recipients self-identified as “injection trainers,” referring to their company-sponsored educational roles in the cosmetic field. We also found that 16 of these 88 top APN payment recipients (18%) were connected with one another through industry sponsored activities.

DISCUSSION

APNs who were paid > $50,000 during 2021 for consulting, speaking, and advisory board roles can be characterized as key opinion leaders for pharmaceutical and medical device companies. Consistent with studies of physician key opinion leaders,^{1, 2} most top APN payment recipients are characteristic of industry “clinician” key opinion leaders, engaged in speaking, education, and leadership within clinical practice networks, while a minority are characteristic of researcher key opinion leaders, with formal research, education, or leadership roles at academic institutions.

Top APN payment recipients were largely NPs working in private group practice settings. They also engaged in clinical practice, consulting, or entrepreneurial activities outside of their principal clinical NP role and across multiple settings. Thus, policy development around the disclosure and management of APNs’ relationships with industry needs to account for APNs’ multiple practice settings and professional roles.

Top APN recipients were often the only or the dominant payment recipient at their practice address. Further, the number of other payment recipients at these practice settings was generally small. The lack of “clustering” of large-value payment recipients within a practice may reflect previous evidence suggesting that the density of network ties is negatively associated with receipt of industry payments.¹⁶

There was variability across practice setting types and specialties. For example, teaching hospitals and group practices in endocrinology, hematology/oncology, and neurology had a higher number of physician payment recipients sharing a practice address with top APN recipients but accounted for a lower median share of total payments reported to these addresses. These findings are consistent with previous work identifying such specialties as attracting a high prevalence and value of industry payments,¹⁷ and network analyses finding that individuals may be more likely to accept industry payments when it is the norm within their practice environment.¹⁶

Most personal fees paid to top APN recipients were associated with manufacturers of highly priced, newly approved drugs with among the highest spend.¹⁸ One manufacturer, which markets products for facial aesthetics, dominated payments to top APN recipients. These findings are significant given that key opinion leaders are engaged as speakers to increase the volume of prescriptions for the product not only among their peers, but also in their own prescribing.¹ Understanding the prescribing habits of top payment recipients is an important area for future research.

Several of the practice settings associated with top APN payment recipients did not serve people on Medicare and may have minimal regulatory oversight in general (i.e., private cosmetic medicine or behavioral health clinics). Because industry payments to prescribers are associated with increased physician prescribing of promoted and brand name drugs and increased prescribing costs,^19–21 it is important to address prescribers’ relationships with industry in tackling the promotion, use, and pricing of high-cost drugs. However, nurses’ relationships with industry have remained relatively invisible at the practice and policy level.^{10, 22} Thus, institutional policies on industry relations need to be inclusive of APN practice, and novel policy mechanisms may be required to safeguard the outcomes for people receiving care in settings without institutional oversight, such as action on part of state licensing boards or credentialing bodies.

Limitations

In identifying top APN payment recipients, we included those who received > $50,000 in personal fees. There may be somewhat different patterns in the practice settings, roles, and activities of top APN recipients in general (i.e., including food and beverage, travel-related). Since Open Payments exempts reporting ownership payments to APNs and very few had research payments reported during 2021, payments for personal fees generally reflected the highest value payments to APNs (sampled APNs comprised 93 of the top 99 in terms of those receiving > $50,000 of any payment type).

For a portion of our sample, the primary business addresses reported in Open Payments were out of date or no association between the individual and the address was evident. Through extensive automated and manual cleaning, we standardized and harmonized primary business addresses for top APN payment recipients; however, due to the sample size, we only used automated methods to standardize the primary business addresses for physician and other APN recipients. Therefore, the findings related to the presence of other payment recipients and the number and value of payments reported at a practice setting are likely an underestimate as we excluded payments reported to addresses that were not exact match.

Our search of APN characteristics depended on publicly available data, on the premise that “key opinion leaders” would possess an active online presence. The absence of information available for several top APN payment recipients indicates that the reasons for which industry engages with clinician key opinion leaders need further investigation.

CONCLUSION

Top APN payment recipients attracted high-value payments in practice settings that may have little oversight of their industry relationships. Top APN payment recipients’ capacity for influence extended beyond and across clinical practice settings, including through industry-sponsored practice networks. Exemplifying the diversity of APN practice in terms of domains and settings, these findings should prompt a re-thinking of conflict of interest policy that is inclusive of and responsive to the activities of interprofessional providers.

Funding

This work was supported by the Greenwall Foundation Making a Difference Grant.

Data Availability

All data pertaining to payment records are publicly available for download from the Center for Medicare and Medicaid Services Open Payments website at: https://openpaymentsdata.cms.gov and NPPES https://download.cms.gov/nppes/NPI_Files.html

Declarations

Ethics Approval

The University of Toronto Research Ethics Board approved the study (#42961); however, the data reported in this paper was publicly available and did not involve the recruitment or participation of human subjects.

Conflict of Interest

QG, FH, DH, CB, EL, and LB declare no conflicts of interest. EGC has served as a paid expert witness for the Arizona Attorney General’s Office on a legal case related to conflicts of interest in medicine.

Disclaimer

The Greenwall Foundation had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.