Potential Financial Conflicts Of Interest Research Articles

Financial Conflicts of Interest and Industry Funding are Associated With Conclusions Favorable to New Technologies: A Review of Published Economic Analyses in Hip and Knee Arthroplasty

BackgroundNew technologies in hip and knee arthroplasty are commonly evaluated using cost-effectiveness analyses and similar economic assessments. There is a wide variation in the methodology of these studies, introducing the potential for bias. The purpose of this study was to evaluate associations between potential financial conflicts of interest (COI) and the outcomes of economic analyses. We hypothesized that authors’ COI and industry funding would be associated with conclusions favorable to a new technology. MethodsEconomic analyses making cost-effectiveness or economic implementation claims on patient-specific instrumentation, robotics, and implants used in hip and knee arthroplasty published from 2010 to 2022 were identified. Papers were evaluated to determine if conclusions were favorable to the new technology being studied. Fisher’s exact test was utilized to determine the relationship between the presence of COI and an article’s conclusions. ResultsOf 43 eligible articles, 76.7% were cost-effectiveness analyses, 23.2% were cost analyses, and 67.4% of articles had conclusions favorable to a technology. Of the 29 articles with favorable conclusions, 26 had an author with a financial COI (89.7%), and 14 had industry funding (48.3%). Of the 33 articles with a financial COI, 26 (78.8%) had favorable conclusions, and of the 16 articles with industry funding, 14 (87.5%) had favorable conclusions. Fisher’s exact test revealed a statistically significant association between an article having favorable conclusions and the presence of an author’s COI or industry funding (odds ratio, 13.5; 95% CI [confidence interval], 2.3 to 79.9; P = .003). ConclusionsFinancial COIs were present in 79.1% of lower extremity arthroplasty economic analyses on technologies and were associated with an article having conclusions favorable to the new technology. Surgeons and decision-makers should be aware of the variability and assumptions in these studies and the potential bias of the conclusions.

Patient's reporting of adverse drug reactions: Which added value in 2023?

Several studies were focused on the qualitative and quantitative analysis of serious adverse drug reactions (ADRs) leading to hospitalisation or death. These figures do not take into account ADRs in ambulatory patients affecting their quality of life. Patient reporting has the advantages of bringing novel information about ADRs. It provides a more detailed description of ADRs, and reports about different drugs and system organ classes when compared with health care professional (HCP) reporting. A certain amount of information is crucial in order to determine the drug-reaction relationship. European regulation and patient support programs have contributed widely to increased patient reporting but the quality of ADR reports is still unequal from one country to another. Patient reports of ADRs have contributed enormously to pharmacovigilance signal detection in a number of ways. Over the last decades, countries have developed dedicated websites for direct patient reporting. The increasing involvement of patients in ADR reporting activities facilitated by a web portal was confirmed by some studies. Patients are now recognised as having a legitimate part to play in the decision-making process. The contribution of patient reports to drug safety was acknowledged and consolidated by European Union (EU) PV legislation in 2012 aiming to involve patients more actively, nowadays called "patient centricity in pharmacovigilance". Patient organisations are involved in regulatory issues and collaborate with health institutions on the development of guidelines. However, some studies suggested that a substantial number of patient organisations have potential financial conflicts of interest but limited disclosure practices. Pharmaceutical companies integrate into patient associations, particularly for chronic diseases by different strategies: educational therapeutic or observance support programs. The question of conflict of interest of patient associations is important requiring better transparency.

Ambulatory surgery centers: A 2012 to 2018 analysis on growth in number of centers, utilization, Medicare services, and Medicare reimbursements

BackgroundGiven declining reimbursements and potential financial conflicts of interest in ownership, it is important to continually assess ambulatory surgery center role and growth. The objective of this study is to evaluate scope of practice, number of patients served, number of procedures performed, and revenue of ambulatory surgery centers within a Medicare fee-for-service population. MethodsThis retrospective study includes data from Medicare Part B: Provider Utilization and Payment Datafiles (2012–2018). In addition to total number and geographic distribution, sums and medians were gathered for Medicare reimbursements, services performed, number of patients, and unique current procedural terminology codes used. ResultsThe number of Medicare fee-for-service-serving ambulatory surgery centers grew 7.0% from 4,886 to 5,227 between 2012 and 2018. A total of 8,169,288 Medicare fee-for-service services were performed on 3,910,434 patients in 2018, an increase of 10.8% and 6.5% since 2012, respectively. At the median, each ambulatory surgery center performed 1,050 services in 2018, which was slightly less than in 2012 (median: 1,094). Ambulatory surgery centers collected $5.1 billion in payments in 2018, compared to $3.6 billion in 2012 (29.1% inflation-adjusted growth). ConclusionTotal inflation-adjusted allowed Medicare fee-for-service payments have increased 29.1% between 2012 and 2018, despite just 7% growth in number of ambulatory surgery centers and 10.8% increase in total number of services. The 16.5% increase in inflation-adjusted revenue generated per service may indicate that the increased use of complex procedures with higher reimbursement, previously only performed in an inpatient setting, are now offered more readily in ambulatory surgery centers.

Clinical Outcomes of a Novel Cranial Movement Therapy (CMT) in Post-Traumatic Brain Injury: A Case Report

<h3>Research Objectives</h3> To describe potential effects of a novel Cranial Movement Therapy (CMT) on long-lasting post-Traumatic Brain Injury (TBI) symptoms. <h3>Design</h3> Case report. <h3>Setting</h3> Specialized private practice on concussion and TBI. <h3>Participants</h3> A 57-year-old female with sustaining post-TBI symptoms for 2 years, with a new incident 2 weeks prior to initial visit. <h3>Interventions</h3> A novel technique of CMT was originally developed to improve post-TBI symptoms by potential restoration of the cranial bones' position and optimization of CSF and blood flow. This approach consists of a detailed history of the mechanism of injury, systematic evaluation including palpation, assessment, and manipulation of the cranial bones, cervical spine and surrounding musculature. Each session, symmetry, mobility, and tonicity of cranial structures and soft tissues were assessed. Treatment protocol consisted of 5 consecutive sets of proposed CMT technique on the palate and other osseous cranial structures found with deficits, of 1 session every 20 minutes, over the course of 4 days with added home-based cognitive training program. Follow-up was repeated for 2 months post-initial treatment. <h3>Main Outcome Measures</h3> Primary outcomes were severity of headache and cognitive dysfunction on a 0-10 scale and frequency of occurrence. <h3>Results</h3> Following receiving CMT, the participant reported 80% decrease in headache severity (5/10 to 1/10) and complete resolution (100% decrease) of cognitive dysfunction (6/10 to 0/10) at the conclusion of treatment on day 4 with no recurrence after 2 months of follow up. <h3>Conclusions</h3> This case report successfully documented a significant reduction in severity and frequency of headaches, complete elimination of cognitive difficulties following application of this novel CMT technique in a patient experiencing long-lasting post-TBI symptoms. Findings warrant future randomized controlled investigation of this approach in the treatment of patients with post-TBI symptoms. <h3>Author(s) Disclosures</h3> Primary authors (CS) who has originally developed this novel technique foresees potential financial conflict of interest since he is the CEO/owner of the facility this case is treated. All other authors declare that they have no relevant financial or non-financial competing interests to report.

Death, taxes and uncertainty: Economic motivations in end-of-life decision making

Economic motivations are key drivers of human behavior. Unfortunately, they are largely overlooked in literature related to medical decisionmaking, particularly with regard to end-of-life care. It is widely understood that the directions of a proxy acting in bad faith can be overridden. But what of cases in which the proxy or surrogate appears to be acting in good faith to effectuate the patient’s values, yet doing so directly serves the decision-maker’s financial interests? Such situations are not uncommon. Many patients care as deeply about economic wellbeing of their families as they do for their own lives and health. This brief work examines three scenarios that raise ethical issues regarding the role of pecuniary motives in making critical medical decisions. Each scenario presents a potential financial conflict of interest between an incapacitated patient and a third-party decision-maker and offers a framework for integrating ethical and legal concerns into clinical care. It is our hope that this work prepares physicians for unexpected ethical conflicts of interest and enables them to further the interests of his or her patients.

Non-financial conflict of interest in social intervention trials and systematic reviews: An analysis of the issues with case studies and proposals for management

Research suggests that effect sizes are larger when program developers conduct studies compared to independent researchers. This is sometimes attributed to biases linked to conflicts of interest (CoI). While potential financial CoI is often acknowledged, non-financial CoI is more subtle, rarely reported and just as likely to lead to biased results. This paper highlights key arguments about non-financial CoI in the field of social and behavioral intervention research. It presents three cases studies of widely-disseminated child and family interventions which have been the subject of critical appraisals and debates related to potential non-financial CoI as a source of bias. The case studies illustrate how evidence appraisal can differ depending on the independence of the appraisers and how this may affect decisions around what is considered ‘good’ evidence. The case studies highlight the complex issues involved in trying to substantiate non-financial CoI, the unsatisfactory and fragmented ways that it is currently addressed, and the need for improved guidance to prevent and redress it.

The Relationship between Industry Payments on Research Productivity and Career Success of Academic Radiation Oncologists

Radiation oncology is a specialty that treats 60% of all cancer patients but receives only 1.6% of total National Institutes of Health funding for cancer research. Industry support to academic radiation oncologists may represent an opportunity to undertake research and enable them to progress their careers, though it also represents potential financial conflict of interest. The Physician Payments Sunshine Act in 2010 required industry funding of physicians to be reported, now enabling assessment of the effects of industry funding on physician productivity in radiation oncology. The goal of this paper is to investigate whether there is a correlation between industry payments and physician productivity and success, as defined by total publications, h-index, or academic rank, for academic radiation oncologists. This study examined the relationship between industry payments, research productivity, and academic title in academic radiation oncologists. Academic radiation oncologists were identified from institutions with residency programs. Industry payments data was obtained from the Center for Medicare and Medicaid Services Open Payment database, and bibliometric data was obtained from Scopus. Sixty-Six percent of academic radiation oncologists received industry payments. The annual mean general payments to Professors, Associate Professors, Assistant Professors, and Instructors were $3,626, $1,293, $622, and $217 respectively. The annual mean research payments were $15,813, $7,022, $1,616, and $293 respectively. Our analysis revealed a significant direct correlation between industry funding and H-index for associate professors, assistant professors, and clinicians/other, but this relationship was not significant for professors and instructors. While univariate analysis revealed both general and research payments were significantly associated with H-index, this association was insignificant for general payments when controlling for academic rank, region, degrees, research payments, and gender. The multivariate model showed that an increase in $10,000 annually in research payments was associated with a 1.19-times increase in odds to be in the top quartile of publications and a 1.10-times increase in odds to be in the top quartile of h-index. Most academic radiation oncologists receive industry funding. Increased research productivity is significantly associated with increased academic rank and research-specific industry payments, but not general industry payments. No conclusions can be made regarding the causal relationship between industry payments and research productivity.

Pharmaceutical company payments to dermatology Clinical Practice Guideline authors in Japan.

Clinical Practice Guidelines (CPGs) play significant roles in most medical fields. However, little is known about the extent of financial Conflicts of Interest (FCOIs) related to pharmaceutical companies (Pharma) selling dermatology prescription products and dermatology CPG authors in Japan. The aims of this study were to elucidate the characteristics and distribution of payments from Pharma to dermatology CPG authors in Japan, and to evaluate the extent of transparency and accuracy in their FCOI disclosures. We analyzed the records of 296 authors from 32 dermatology CPGs published by the Japanese Dermatological Association from the beginning of 2015 to the end of 2018. Using the payment data reported by 79 Pharma between 2016-2017 in Japan, we investigated the characteristics of the CPG authors and the payments from the Pharma to them. Furthermore, we evaluated the transparency and accuracy of the FCOI disclosures of the individual CPG authors. Of the 296 CPGs authors, 269 authors (90.6%) received at least one payment from the Pharma. The total monetary value of payments for the 2-year period was $7,128,762. The median and mean monetary value of payments from the Pharma reporting were $10,281 (interquartile range $2,796 -$34,962) and $26,600 (standard deviation $40,950) for the two years combined. Of the 26 CPG authors who disclosed FCOIs due to the monies received from Pharma, only the atopic dermatitis CPG authors and the acne vulgaris CPG authors published their potential FCOIs. In Japan, most dermatology CPG authors received financial payments from Pharma. The transparency of the CPGs, as reported by the CPG authors, was inadequate, and a more rigorous framework of reporting and monitoring FCOI disclosure is required to improve the accuracy and transparency with relation to possible Conflicts of Interest.

Industry Payments by Allergan, Inc to Plastic Surgery and Related Specialties in 2018.

In 2014, payments to medical providers from drug/device manufacturers were made public through the Open Payments Database. Although previous studies have used the Open Payments Database to describe relationships between specialties and industry, few have evaluated specific companies and the effect of their contributions. As a large contributor to industry payments in plastic surgery, Allergan, Inc represents a significant source of potential financial conflicts of interest in the field. In this study, we aimed to describe the quantity, type, and specific products associated with Allergan's payments to both plastic surgeons and physicians of other specialties. In 2018, Allergan paid a total of $48,484,163 in 397,225 payments to 90,386 physicians. Psychiatry and neurology received $11,867,861 in payments, the largest of any specialty, whereas internal medicine received the largest number of individual payments. Plastic surgeons made the most per physician ($3025). Most payments made to plastic surgeons were categorized as "gifts." Payments made in relation to Botox were predominantly made to neurologists, whereas most payments attributed to Natrelle breast implants were made to plastic surgeons (74.4%). Surprisingly, 18.2% of Natrelle payments were made to family medicine physicians. Further study is needed to fully understand the implications of the financial contributions revealed in this study.

CD26 as a Prognostic Marker in Allogeneic Hematopoietic Stem Cell Transplantation

Background: The success of hematopoietic stem cell transplantation (HSCT) depends upon donor stem cell harvest. Conventionally CD34 has been considered as marker of hematopoietic stem cells; however, the association of CD34+ cells with post-transplant outcomes has not been consistent. Current efforts are focused on identification of new markers that serve as potential predictors of post-transplant clinical outcome. Methods: This study includes donor harvests collected from twenty-three allogeneic donors during period 2008-2009 and respective transplant recipients followed for clinical outcomes till March 2019. Percent CD26+ and CD34+ cells in PBSC harvest were analyzed using flow cytometry. Infused dose of CD26+ and CD34+ cells was evaluated for its association with various clinical outcomes. Findings: Median donor and patient age was 28 and 24 years, respectively; 13 and 17 were males, respectively. Median CD34br CD45lo HSC expression was 0·57% (IQR 0·24-1·03) while median CD26 expression was 19·64% (IQR 8·96-33·56) of all nucleated cells. Lower CD26 expression correlated with lower risk of developing aGvHD (p=0·056). Higher infused CD26+ cell dose was associated with early WBC engraftment (p=0·004), higher risk of CMV reactivation (p=0·020) and a tendency to lower overall survival (p=0·066). There was no correlation between infused CD26+ and CD34+ cell dose. Interpretation: This forms the first study suggesting CD26 expression on donor harvest and CD26+ cell dose may serve as potential markers for transplant outcomes. If validated further in larger studies, it may be helpful in management of GvHD prophylaxis and improving survival with risk-based tailored therapeutics. Funding Statement: This study was funded by Indian Co-operative Oncology Network- Academic Research Organization, Mumbai, India. Declaration of Interests: Authors declare no potential financial conflicts of interest. Ethics Approval Statement: The study was approved by the institutional ethics committee. All patients and donors provided consent for study participation.

Analysis of Potential Conflicts of Interest among Otolaryngologic Patient Advocacy Organizations in 2016

Patient advocacy organizations (PAOs) are nonprofits dedicated to benefiting patients and their families through activities such as education/counseling and research funding. Although medical drug/device companies may serve as important partners, industry donations may bias the efforts of PAOs. We conducted a retrospective cross-sectional analysis of the Kaiser Health News nonprofit database to identify and characterize otolaryngologic PAOs (n = 32) active in 2016. Among these PAOs, half (n = 16, 50.0%) focused on otologic diseases, and mean total annual revenue was $3.1 million. Among the 15 PAOs (46.9%) with publicly available donor lists, 10 (66.7%) received donations from industry. Few PAOs publicly reported the total amount donated by industry (n = 3, 9.4%) or published policies for mitigating potential financial conflicts of interest with donors (n = 3, 9.4%). Requiring drug and device companies to publicly report donations to PAOs may help patients, providers, and policy makers to better understand advocacy by these influential stakeholders.

Do doctors in dispensing practices with a financial conflict of interest prescribe more expensive drugs? A cross-sectional analysis of English primary care prescribing data

ObjectivesApproximately one in eight practices in primary care in England are ‘dispensing practices’ with an in-house dispensary providing medication directly to patients. These practices can generate additional income by negotiating...

Prevalence and Disclosure of Potential Conflicts of Interest in Dermatology Patient Advocacy Organizations

Patient advocacy organizations are nonprofit organizations that represent patients with medical conditions. Although these organizations may increase disease awareness and influence health care policy, reports have suggested financial relationships between organizations and drug, device, and biotechnology companies, which may lead to potential conflicts of interest. The extent of these conflicts has not been explored among patient advocacy organizations in dermatology. To examine potential financial conflicts of interest and characterize disclosure practices among dermatology patient advocacy organizations. This cross-sectional study of the largest dermatology patient advocacy organizations using the Kaiser Health News database acquired data on total revenue from each organization's Form 990 for the year 2015. Tax forms and annual reports from 2017 were used for 2 organizations that were missing donor information for 2015. Annual reports, websites, and LinkedIn profiles were manually examined to ascertain donations and determine disclosure practices pertaining to financial support and board membership. The amount and minimum proportion of donations attributable to industry sponsorship among organizations as well as the proportion of organizations disclosing (1) industry-sponsored financial support, (2) the amount of industry-derived donations, and (3) current and past relationships between governing board members and industry sponsors. This study identified 24 dermatology patient advocacy organizations with annual revenues that exceeded $500 000. Of these, 5 (21%) had total donations that exceeded $5 million and 4 (17%) reported industry donations that exceeded $500 000. Two organizations (8%) reported having at least 40% of total donations from industry sponsorship. Overall, 17 organizations (71%) reported receiving donations from industry on the annual report or the website and 12 (50%) reported the amount of donations in ranges. None of the organizations reported the exact amount or use of donations. On the basis of annual reports and websites, 3 organizations (13%) reported having a current or former industry executive on the organization's governing board. When this search was replicated using LinkedIn, this figure was at least 54%. These findings suggest inconsistent disclosure of industry-derived financial support and board membership that may represent conflicts of interest. Policies that support the transparency and consistency of disclosure practices between industry and patient advocacy organizations appear to be needed to fully characterize the extent of conflicts of interest among patient advocacy organizations in dermatology and maintain trust in these important institutions.

Conflicts of Interest, Baselga, and Clinical Trialists.

A working relationship between academia and industry is often required for progress, and the proper reporting of potential financial conflicts of interest in consideration of such relationships is essential. In light of the recent resignation of Dr. José Baselga, this editorial reflects on the current system for reporting disclosures and calls for greater transparency.

577 Dermatology journal editorial board member potential financial conflicts of interest

577 Dermatology journal editorial board member potential financial conflicts of interest

Undisclosed conflicts of interest among biomedical textbook authors

ABSTRACTBackground: Textbooks are a formative resource for health care providers during their education and are also an enduring reference for pathophysiology and treatment. Unlike the primary literature and clinical guidelines, biomedical textbook authors do not typically disclose potential financial conflicts of interest (pCoIs). The objective of this study was to evaluate whether the authors of textbooks used in the training of physicians, pharmacists, and dentists had appreciable undisclosed pCoIs in the form of patents or compensation received from pharmaceutical or biotechnology companies. Methods: The most recent editions of six medical textbooks, Harrison's Principles of Internal Medicine (HarPIM), Katzung and Trevor's Basic and Clinical Pharmacology (KatBCP), the American Osteopathic Association's Foundations of Osteopathic Medicine (AOAFOM), Remington: The Science and Practice of Pharmacy (RemSPP), Koda-Kimble and Young's Applied Therapeutics (KKYAT), and Yagiela's Pharmacology and Therapeutics for Dentistry (YagPTD), were selected after consulting biomedical educators for evaluation. Author names (N = 1,152, 29.2% female) were submitted to databases to examine patents (Google Scholar) and compensation (ProPublica's Dollars for Docs [PDD]). Results: Authors were listed as inventors on 677 patents (maximum/author = 23), with three-quarters (74.9%) to HarPIM authors. Females were significantly underrepresented among patent holders. The PDD 2009–2013 database revealed receipt of US$13.2 million, the majority to (83.9%) to HarPIM. The maximum compensation per author was $869,413. The PDD 2014 database identified receipt of $6.8 million, with 50.4% of eligible authors receiving compensation. The maximum compensation received by a single author was $560,021. Cardiovascular authors were most likely to have a PDD entry and neurologic disorders authors were least likely. Conclusion: An appreciable subset of biomedical authors have patents and have received remuneration from medical product companies and this information is not disclosed to readers. These findings indicate that full transparency of financial pCoI should become a standard practice among the authors of biomedical educational materials.

Editorial boards of dermatology journals and their potential financial conflict of interest

Financial relationships between editorial board members of peer-reviewed journals and pharmaceutical and medical device manufacturing companies can potentially lead to biases and loss of objectivity of the medical literature. The purpose of this study was to evaluate the potential financial conflicts of interest that exist among editorial board members of dermatology journals. Editorial board members for 36 dermatology journals were identified and searched using the Open Payments database on the Center for Medicare and Medicaid Services website. The total amount of general payments made to these physician editors were collected and stratified using a tier system: 1) nothing reported, 2) >$0 and <$10,000, 3) >$10,000 and <$100,000, and 4) >$100,000. We identified 551 editors from 36 dermatology journals for use in our analysis. Some form of general payment was made to 87% of these physicians (480 of 551). Four journals had >25% of their editorial staff receiving >$100,000. Financial relationships exist between editorial board members of dermatology journals and pharmaceutical/medical device manufacturing companies, which could lead to financial conflicts of interest. Publications coming from journals with highly paid physician editors have more potential to be biased.

Conflicted hope: social egg freezing and clinical conflicts of interest

ABSTRACTOver the past decade ‘social egg freezing’ has emerged as a technology of hope that purports to empower women by enabling them to continue their careers or find the right partner without the fear of jeopardising their fertility. This technology has been promoted and celebrated by fertility companies, bioethicists, clinicians, and multi-national corporations such as Apple and Facebook. While critical questions have been raised, they tend to focus on ethical and legal issues, such as informed consent and patient autonomy. This paper uses Foucault’s notion of dispositif as analytic lens to examine the entanglement of the commercial arrangements of fertility companies, the discursive use of hope in promoting these services, and effects on professional medical care. Drawing on socio-political analyses of hope, this paper examines the potential financial conflicts of interest facing clinicians and the way discourses of hope might mask problematic financial relations and lack of evidence of effectiveness.

Potential Financial Conflict of Interest Among Physician Editorial Board Members of Orthopaedic Surgery Journals.

The practice of medicine is based on evidence from peer-reviewed literature. As can occur with author-related funding, the integrity of the process by which manuscripts are reviewed, edited, and approved for publication may be at risk due to financial conflict of interest. The purpose of our study was to assess potential financial conflict of interest among physician editorial board members of orthopaedic surgery journals. We identified the physician editorial board members of 15 orthopaedic surgery journals and searched the 2014 payments that were archived in the Centers for Medicare & Medicaid Services Open Payments system (mandated by the Physician Payments Sunshine Act). Total dollar values were calculated and tabulated in a multilevel fashion: nothing reported, >$0 and ≤$10,000, >$10,000, >$250,000, and >$950,000. We identified 908 physician editors of 15 orthopaedic surgery journals. Something of financial value was received by 78% (712 of 908) of these individuals. Rates of editorial board potential financial conflict of interest for individual journals ranged from 4% to 73% in the >$10,000 category. At the >$250,000 mark, rates ranged from 0% (2 journals) to 31%. When applying the >$950,000 criterion, physician potential conflict of interest ranged from 0% (5 journals) to 13%. Editor-related potential financial conflicts of interest exist in the orthopaedic surgery journals that we analyzed. These potential financial conflicts could possibly impact reviews.

Treatment Patterns and Overall Survival Associated with First-Line Systemic Therapy for Patients with Advanced Non-Small Cell Lung Cancer.

A variety of regimens are used as first-line treatment in patients with advanced non-small cell lung cancer (NSCLC), which may include combination regimens and single agents, depending on histology, molecular profile, and performance status. To describe the types of first-line therapies and compare overall survival between therapies used for patients with advanced NSCLC in an integrated health care system. This retrospective cohort study included patients aged 18 years or older from Kaiser Permanente California with a diagnosis of stage IIIB/IV NSCLC. First systemic treatment date occurred from January 1, 2008, through September 30, 2013. Overall survival was measured as the number of months from initial treatment until death, end of enrollment, or September 30, 2014. Treatment regimens were categorized into 6 mutually exclusive groups: platinum doublets; pemetrexed-based, bevacizumab-based, and pemetrexed + bevacizumab-based combinations; singlets; and tyrosine-kinase inhibitors (TKIs). Survival was compared using Kaplan-Meier curves and adjusted Cox proportional hazard models. Subgroup analyses were performed by age group and by nonsquamous histology. Of 2,081 patients, approximately half (52.3%) received platinum doublets, followed by TKIs (19.0%), pemetrexed-based regimens (13.4%), bevacizumab-regimens (8.0%), singlets (5.5%), and pemetrexed + bevacizumab-based combinations (1.8%). Median survival was longest for pemetrexed + bevacizumab-based combinations (18.5 months), followed by bevacizumab-based regimens (14.5), TKIs (12.7), pemetrexed-based regimens (10.4), doublets (9.2), and singlets (5.3). There was a significantly reduced risk of mortality for pemetrexed + bevacizumab-based combinations (HR = 0.64; 95% CI = 0.42-0.94) and TKIs (HR = 0.83; 95% CI = 0.73-0.94) compared with doublets. Singlets were associated with an increased risk of mortality (HR = 1.50; 95% CI = 1.22-1.84). Subgroup analysis among patients aged 65 years and over found no significant differences among treatment groups, with the exception of singlets, which were associated with an increased risk of mortality compared with doublets (HR = 1.51; 95% CI = 1.20-1.90). Among patients under aged 65 years, pemetrexed + bevacizumab-based combinations (HR = 0.36; 95% CI = 0.21-0.64) and TKIs (HR = 0.76; 95% CI = 0.59-0.97) were associated with a reduced risk of mortality, and singlets were associated with an increased risk (HR = 1.85; 95% CI = 1.17-2.92). In this cohort of patients with advanced NSCLC, patients received a platinum agent with or without bevacizumab or pemetrexed, a TKI, or a single agent. Younger patients (aged < 65 years) receiving bevacizumab + pemetrexed-based combinations had a survival advantage over those receiving platinum doublets, and this finding merits further investigation. Younger patients receiving TKIs also had longer survival. Compared with platinum doublets, we found no survival advantage for older patients receiving bevacizumab or pemetrexed, which suggests that combination therapy of a platinum agent and taxane, such as carboplatin and paclitaxel, could be a reasonable option for older patients who are not candidates for targeted therapy. No outside funding supported this study. Rashid has received past funding from Bristol-Myers Squibb, Astellas, Novartis, and Pfizer. No other authors report any potential financial conflicts of interest. Study concept and design were primarily contributed by Spence and Hui, with input from the other authors. Hui, Spence, and Rashid took the lead in data collection, and data interpretation was performed by Schottinger, Millares, and Spence, assisted by the other authors. The manuscript was written primarily by Spence, along with Chang, and revised by Spence, with input from the other authors.