Received: 9 March 2021 Revised: 18 May 2021
DOI: 10.1111/andr.13064
ORIGINAL ARTICLE
Association between author conflicts of interest
and industry-sponsorship with the favorability of
outcomes of systematic reviews focusing on treatments
of erectile dysfunction
Adam Corcoran1 Cody Hillman1
Michael Weaver2 Bradley S. Johnson1
1
Office of Medical Student Research,
Oklahoma State University Center for Health
Sciences, Tulsa, Oklahoma, USA
2
Kansas City University of Medicine and
Biosciences, College of Osteopathic Medicine,
Joplin, Missouri, USA
3
Department of Psychiatry and Behavioral
Sciences, Oklahoma State University Center
for Health Sciences, Tulsa, Oklahoma, USA
Correspondence
Adam Corcoran, Oklahoma State University
Center for Health Sciences, 1111 W 17th St.,
Tulsa, OK, 74107, USA.
Email: Adam.Corcoran@okstate.edu
Funding information
The Oklahoma State University Center for
Health Sciences Presidential Mentor-Mentee
Research Fellowship Grant
© 2021 American Society of Andrology and European Academy of Andrology
Andrology. 2021;9:1819–1827.
Accepted: 3 June 2021
Tanner Cole1 Michael Anderson1
Micah Hartwell1,3 Matt Vassar1,3
Abstract
Background: Authors’ conflicts of interest and industry sponsorship have been shown
to influence study outcomes.
Objective: We aimed to determine whether author conflicts of interest and industry
sponsorship influenced the nature of results and conclusions of systematic reviews
focusing on treatment interventions for erectile dysfunction.
Materials and methods: We searched PubMed and Embase for systematic reviews
and meta-analyses focusing on erectile dysfunction treatments published between
September 1, 2016, and June 2, 2020. Authors’ conflicts of interest were collected from
the systematic reviews’ disclosure statements. These disclosures were verified using
the information provided by the Open Payments, Dollars for Profs, Google Patents, and
US Patent and Trademark Office databases and from previously published disclosure
statements.
Results: Our study included 24 systematic reviews authored by 138 authors. Nine-
teen authors (13.8%) were found to have conflicts of interest (disclosed, undisclosed,
or both). No authors completely disclosed all conflicts. Nine reviews (37.5%) contained
at least one author with conflicts of interest; of which eight reported narrative results
favoring the treatment group, and seven reported conclusions favoring the treatment
group. Of the 15 (62.5%) reviews without a conflicted author, 11 reported results
favoring the treatment group, and 12 reported conclusions favoring the treatment
group.
Discussion: The results and conclusions of systematic reviews for erectile dysfunction
treatments did not appear to be influenced by authors who reported conflicts of inter-
est. However, our search algorithm relied on the US-based Open Payments database
and a large percentage of reviews in our study were produced by authors with inter-
national affiliations. Our study results underscore the difficulties in conducting such
analyses.
wileyonlinelibrary.com/journal/andr 1819
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1820 CORCORAN ET AL .

Conclusion: Although we found that undisclosed conflicts of interest (COI) were prob-
lematic among systematic reviews of erectile dysfunction treatment, only 14% of
authors in our sample possessed them and these COI did not appear to influence the
favorability of systematic review outcomes.

KEYWORDS
conflicts of interest, erectile dysfunction, industry bias, industry sponsorship, systematic review

1 INTRODUCTION tice, we investigated potential financial biases in SRs of ED treat-

Systematic reviews (SRs) employ comprehensive and systematic
methodologies to locate and summarize all evidence for a particular
topic, such as treatments for erectile dysfunction (ED). These reviews
are critical for understanding the totality of evidence and can provide
experts with comprehensive summaries that may be used to guide clin-
ical decision making. For example, the American Urological Associa-
tion’s 2018 clinical practice guideline on ED1 cites an SR as supporting
evidence for the referral of patients to mental health professionals.2
SRs also provide a fuller context than a single study’s results regard-
ing the totality of evidence. For example, a 2015 clinical trial inves-
ments. Specifically, we sought to investigate whether industry-funded
SRs were more likely to report favorable findings and conclusions and
whether SRs with conflicted authors were more likely to report favor-
able results and conclusions.
2 METHODS
2.1 Transparency, reproducibility, and reporting
Because this cross-sectional analysis did not involve human research

tigating the use of 3D conformal radiotherapy for the treatment of subjects, it was not subjected to institutional review board over-

prostate cancer found it to be safe and effective.3 In contrast, a 2016 sight. We have provided study materials and our a priori proto-

SR reported that radiotherapy had an overall increased risk of prostate col on the Open Science Framework to increase transparency and

cancer-related mortality and suggested surgical prostatectomy as a reproducibility.13 When drafting this paper, we consulted the preferred

preferred treatment for prostate cancer.4 If urologists had read the reporting items for systematic reviews and meta-analyses (PRISMA)14

2015 study only, they may have continued using radiotherapy, putting guidelines and the reporting guidelines by Murad and Wang for meta-

their patients at an increased risk of harm. epidemiological studies.15

Owing to the critical nature of SRs in clinical practice and health

policy, they should be conducted objectively with particular attention
2.2 Search strategy
to limiting bias. One form of bias that may affect the integrity of an
SR, including its outcomes and conclusions, is industry sponsorship
A systematic review librarian searched MEDLINE and Embase (using
bias.5 For example, a 2019 study investigating the effectiveness of
the Ovid search interface) for all SRs with or without meta-analyses
photoselective vaporization of the prostate for non-neurogenic lower
published prior to the date which these searches were performed,
urinary tract symptoms found that industry-sponsored trials were
June 2, 2020. The search strategy used to perform these searches is
more likely to report favorable outcomes than trials without industry
provided in Table S1. Results from these searches were uploaded to
sponsorship.6 Furthermore, a meta-analysis investigating testosterone
Rayyan (https://rayyan.qcri.org/), an SR platform, to screen titles and
supplementation as a treatment for decreased male sexual function
abstracts.
reported that only pharmaceutical company-sponsored randomized
controlled trials showed a positive association between testosterone
supplementation and improved sexual function.7 Outcomes from these 2.3 Screening
studies and many others outside of urology8–10 highlight the potential
effect of study sponsorship on conclusions drawn within the urology C.H. and A.C. screened records from the database searches by title and
literature. abstract in a masked, duplicate manner based on the criteria outlined
A second and related form of bias within SRs is a conflict of inter- in Section 2.4. Discrepancies were discussed, and third-party adjudica-
est (COI) among one or more study authors. A 2019 study reported tion was available if necessary.
that SRs authored by individuals who have COI related to drug and
device companies more frequently report favorable conclusions than
do SRs whose authors have no such conflicts. Also, reviews conducted 2.4 Eligibility criteria
by one or more authors with a COI were associated with lower over-
all methodological quality, compared with studies without a conflicted To be included, SRs must have (1) met the PRISMA-P definition of an
author.11 Because SRs have important implications in clinical prac- SR or meta-analysis16 ; (2) included a head-to-head comparison of one
 20472927, 2021, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/andr.13064 by Nat Prov Indonesia, Wiley Online Library on [29/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
CORCORAN ET AL . 1821

TA B L E 1 Categories of COIs as defined by ICMJE

Grants or contracts from any entity (not included in funding

statement)
Royalties or licenses, consulting fees
Payment or honoraria for lectures, presentations, speakers bureaus,
manuscript writing or educational events
Payment for expert testimony
Support for attending meetings and/or travel, patents planned, issued
or pending
Participation on a data safety monitoring board or advisory board
Leadership or fiduciary role in other board, society, committee or
advocacy group, paid or unpaid
Stock or stock options
Receipt of equipment, materials, drugs, medical writing, gifts or other
services
Other financial or non-financial interests

FIGURE 1 Stepwise search for undisclosed conflicts of interest

treatment to another treatment (or combination), placebo, or standard
of care; (3) investigated a treatment for ED; (4) been a full-text arti-
cle published between September 1, 2016, and June 2, 2020 (includ-
ing SRs published on or after September 2016), allowed 36 months
from the time the Open Payments database went online and thus
allowed searches for undisclosed COI in accordance with the Interna-
tional Committee of Medical Journal Editors’ disclosure timeframe17
(Table 1); (5) been published in the English language; and (6) included
data from human participants.
(COIs)
reported for at least one study population, and mixed/inconclusive if
both positive and negative findings were reported in the results. For the
conclusions, favorable was designated if the authors favored the target
intervention (either directly stated or implied by the nature of the pre-
sentation), unfavorable if the conclusion favored the control group, and
mixed/inconclusive if the conclusion did not meet the criteria for favor-
able or unfavorable (e.g., a negative population outcome but a positive
subgroup analysis).

2.5 Training
All investigators completed training modules that consisted of an
overview of the study methodology and objectives; study materials;
and data extraction from one example SR. This training session was
recorded and is available online for reference.13
2.8 Identification of undisclosed conflicts
of interest
The search for undisclosed COI was undertaken using a stepwise
search, illustrated in Figure 1. For this process, we consulted the
methodology by Mandrioli et al.,18 slightly modified to include three

2.6 Data extraction additional databases (Open Payments, Dollars for Profs, and the US
Patent and Trademark Office), each of which is described in Figure 1.

Two investigators (C.H. and A.C.) performed data extraction indepen- When performing searches for undisclosed COI, we searched all SR

dently in a masked, duplicate fashion using a pilot-tested Google form.
We extracted data from the full-text of each SR or meta-analysis. The
list of data collected is available within Open Science Framework.13 For
the purpose of this study, we used the term “conclusion” to describe a
review’s discussion and conclusion sections.
2.7 Favorability of narrative results
and conclusions
We designated the results and conclusions of each SR as either “favor-
able,” “unfavorable,” or “mixed/inconclusive.” For the results section,
favorable was designated when only positive results were reported
for all study populations, unfavorable when negative results were
authors. To ensure accuracy between investigators, a custom program
was created by M.W. using the Python programming language (Python
Software Foundation, https://www.python.org/) to generate search
strings for the PubMed, US Patent and Trademark Office, and Google
Patents databases. Searches for patents were limited to 10 years prior
to the publication of the original SR because of the longevity of patents.
Patent searches were considered inconclusive if the patent was unable
to be attributed to an author. For PubMed searches, studies published
by authors within 36 months prior to the publication of the included
SR were included. For the PubMed searches that returned more than
10 publications, 10 were randomly selected for data extraction. C.H.
and A.C. each generated their own random samples to broaden the
search. As in Mandrioli et al.,18 we performed this search process until
an undisclosed COI was discovered, at which time we terminated the
 20472927, 2021, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/andr.13064 by Nat Prov Indonesia, Wiley Online Library on [29/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1822 CORCORAN ET AL .

search, and that author was considered to have an undisclosed COI

(Figure 1).

2.9 Risk of bias evaluations

To evaluate the risk of funding bias in the SRs, we applied the Cochrane
Collaboration’s criteria for assessment, which include the following
four items from Mandrioli et al.18 : (1) whether explicit and well-defined
criteria that could be replicated by others were used to include and
exclude studies; (2) whether an adequate study inclusion method (i.e.,
two or more assessors selecting studies) was used; (3) whether com-
prehensive search strategies were used; and (4) whether methodolog-
ical differences that may introduce bias were controlled for. Each item
was designated as “yes,” “no,” or “unclear.” We considered the overall
risk of bias to be low if at least three of the criteria were sufficiently
met. Otherwise, the risk of bias was considered high.

2.10 Statistical analysis
Results are reported as frequencies and percentages. Relationships
between review characteristics and outcomes were evaluated using
Fisher’s exact test, when possible. Stata 16.1 (StataCorp, LLC, College
Station, TX) was used for all analyses.
F I G U R E 2 Preferred reporting items for systematic reviews and
meta-analyses (PRISMA) flowchart for included and excluded
systematic reviews
COIs in the SR’s disclosure statement. Three authors (3/19; 15.8%)
reported a COI; however, these authors were found to have COI that
were omitted from the COI disclosure. The remaining 16 authors

3 RESULTS (16/19; 84.2%) stated they had no COI to disclose but were found to
have at least one COI upon further review. Table 2 summarizes the

Our database search returned 2224 records. After screening records results.

by title and abstract, 152 potential studies were included for further
analysis. The full-text screening excluded another 128 studies, leaving
24 SRs with or without meta-analyses that met the final inclusion crite- 3.3 Relationship between conflict of interest
ria (Figure 2). and favorability of results and conclusions

3.1 Systematic review characteristics
Our sample of 24 SRs and meta-analyses included 138 authors and
18 unique journals. The most common journal represented in our sam-
ple was the American Journal of Men’s Health (3/24; 12.5%). Reviews
most commonly investigated were pharmaceutical (11/24; 45.8%) and
medical device (8/24; 33.3%) interventions. Twenty SRs (20/24; 83.3%)
included COI disclosure statements indicating the authors had no com-
peting interests, two (2/24; 8.3%) reported at least one author had a
COI, and two (2/24; 8.3%) did not include a COI disclosure statement.
Table 2 provides additional characteristics.
Of the nine SRs conducted by at least one author with a COI, eight
(88.9%) reported narrative results favoring the treatment group, and
seven (77.8%) reported conclusions favoring the treatment group. Of
the SRs without a conflicted author, 11 of 15 (73.3%) reported results
favoring the treatment group, and 12 of 15 (80.0%) reported con-
clusions favoring the treatment group. There were no statistically
significant associations between author COI, whether it was among
all authors, or first and last authors, and SR results and conclusions
(Table 3).
3.4 Relationship between sponsorship and
favorability of results and conclusions

3.2 Completeness of author conflict of interest
disclosure
Of the 138 authors, 19 (13.8%) were found to have a COI (disclosed,
undisclosed, or both). Of these authors, none completely disclosed all
Eight SRs (8/24; 33.3%) received external funding support. Of these,
only one (12.5%) was industry sponsored. Both results and conclusions
from this industry-sponsored SR demonstrated favorability toward the
treatment group. The remaining seven of eight (87.5%) received non-
industry support. Six reviews (6/7; 85.7%) reported results favoring the
 20472927, 2021, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/andr.13064 by Nat Prov Indonesia, Wiley Online Library on [29/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
CORCORAN ET AL . 1823

TA B L E 2 Characteristics of included systematic reviews and TA B L E 2 (Continued)

meta-analyses
Characteristic No. (%)
Characteristic No. (%) Avicenna Journal of Phytomedicine 1 (4.17)
Accuracy of author COI disclosure statementa Drugs 1 (4.17)
No COI found 119 (86.23) European Urology 1 (4.17)
All COI disclosed in a systematic review 0 (0.0) Indian Journal of Sexually Transmitted Diseases and 1 (4.17)
No COI disclosed in systematic review, but has 16 (11.68) AIDS
one or more undisclosed COI International Brazilian Journal of Urology 1 (4.17)
Disclosed one or more COI in systematic review, 3 (2.19) International Journal of Impotence Research 1 (4.17)
but has undisclosed COI
International Urology and Nephrology 1 (4.17)
Intervention typeb
Nephron 1 (4.17)
Pharmaceutical 11 (45.8)
Sexual Medicine 1 (4.17)
Electrical shockwave therapy 8 (33.3)
Sexual medicine reviews 1 (4.17)
Nutritional supplements 4 (16.7)
The Cochrane Database of Systematic Reviews 1 (4.17)
Surgical technique/intervention 1 (4.2)
Therapeutic Advances in Urology 1 (4.17)
Affiliation of first authorb
Abbreviation: COI, conflict of interest.
Public academic institution 22 (91.7)
a
There were 138 authorships among the systematic reviews.
Private academic institution 2 (8.3) b
Our sample consisted of 24 systematic reviews or meta-analysis.
Government 0 (0.0)
Non-profit 0 (0.0)
treatment group, and five of seven (71.4%) reported conclusions favor-
private/industry 0 (0.0)
ing the treatment group (Table 4). Because of an insufficient number
Affiliation of last authorb of industry-sponsored SRs, we were unable to assess whether industry
Public academic institution 20 (83.3) funding influenced the favorability of results and conclusions.
private academic institution 2 (8.3)
Government 1 (4.2)
Private/industry non-profit 1 (4.2) 0 (0.0) 3.5 Relationship between risk of bias and
Source of funding b industry sponsorship and conflicts of interest
Public 6 (25.0)
All 24 SRs were found to have a low risk of bias. Thus, we were unable
Private/industry 1 (4.2)
to determine whether an association exists between the risk of bias and
University 1 (4.2)
the nature of results and conclusions of SRs investigating interventions
Stated as having received no funding 8 (33.3) for ED.
No funding statement listed 8 (33.3)
COI statementb
One or more authors report a COI 2 (8.3) 4 DISCUSSION
All authors report no COI 20 (83.3)
In this investigation, the results and conclusions of systematic reviews
No COI statement present 2 (8.3)
for ED treatments did not appear to be influenced by authors who
Self-citation of primary studiesb
reported conflicts of interest. However, the complexities of our data
Yes, included one or more self-cited primary 3 (12.5)
may indicate that more nuanced analyses are warranted. First, a large
studies
percentage of SRs in our study were produced by authors with interna-
No, did not include self-cited primary studies 21 (87.5)
tional affiliations, most of which did not report industry affiliations or
Journalb
other conflicts. These data align with previous studies on COI reporting
American Journal of Men’s Health 3 (12.5) among international researchers.19,20 A sensitivity analysis in which
Andrology 2 (8.3) SRs are compared according to the affiliated country for each SR’s
The journal of Sexual Medicine 2 (8.3) primary author is a possibility, but our present sample is too small
Urologia Internationalis 2 (8.3) to make meaningful conclusions in this way. Because our search for
Urology 2 (8.3) undisclosed COI involved databases which provide information regard-
ing US-based authors (e.g., Open Payments Database, USPTO), inter-
Actas Urologicas Espanolas 1 (4.17)
national authors’ COI disclosure statements were not subject to the
(Continues)
same degree of scrutiny as authors from the United States, which might
 20472927, 2021, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/andr.13064 by Nat Prov Indonesia, Wiley Online Library on [29/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1824 CORCORAN ET AL .

TA B L E 3 Relationship between COI and favorability of systematic review results, conclusions, and risk of bias

COI among systematic review authors

Review outcomes No COI (n = 15) COI (n = 9) Fisher’s exact
Favorability of results
Results favor treatment group 11 (73.3) 8 (88.9) p = 0.62
Results are mixed/inconclusive 4 (26.7) 1 (11.1)
Results favor placebo/control group 0 (0.0) 0 (0.0)
Favorability of discussion/conclusions
Discussion favors treatment group 12 (80.0) 7 (77.8) p = 1.00
Discussion is mixed/inconclusive 3 (20.0) 2 (22.2)
Discussion favors placebo or control group 0 (0.0) 0 (0.0)
Risk of bias
Low risk of bias 15 (100.0) 9 (100.0) p = 1.00
High risk of bias 0 (0.0) 0 (0.0)

TA B L E 4 Relationship between review sponsorship and favorability of results and conclusions and risk of bias

Funding sponsor
Industry Non-industry No funding received No statement listed
Review outcomes (n = 1) (n = 7) (n = 8) (n = 8)
Favorability of results
Results favor treatment group 1 (100.0) 6 (85.7) 6 (75.0) 6 (75.0)
Results are mixed/inconclusive 0 (0.0) 1 (14.3) 2 (25.0) 2 (25.0)
Results favor placebo or control group 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Favorability of discussion/conclusions
Discussion favors treatment group 1 (100.0) 5 (71.4) 7 (87.5) 6 (75.0)
Discussion is mixed/inconclusive 0 (0.0) 2 (28.6) 1 (12.5) 2 (25.0)
Discussion favors placebo or control group 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Risk of bias
Low risk of bias 1 (100.0) 7 (100.0) 8 (100.0) 8 (100.0)
High risk of bias 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)

suggest our results represent the lower bound estimate of the preva-
lence (and degree of influence) of author COI on outcomes of SRs
regarding interventions for ED.
A second complicating factor in our study was the process used
to identify undisclosed conflicts. Using the available online resources,
we found undisclosed conflicts, most often for authors in the United
States. We attribute this finding to our search algorithm, which relied
on the US-based Open Payments database. Other countries do not
have such robust mechanisms for COI reporting. After completing this
investigation, we concluded that the currently available resources do
not provide sufficient information to fully investigate nondisclosure by
countries. Also, in our study, the algorithm continued until an undis-
closed conflict was found and then stopped. Thus, it is possible that
we missed some conflicts, resulting in an underrepresentation of the
true nature of COI disclosure. In studies of disclosure accuracy, Wayant
et al. reported that approximately one-third of the authors of pivotal
cancer trials published in high-impact journals failed to accurately dis-
close financial relationships.21 Moreover, Boscolo-Berto et al. found
that the strongest indicator for a study supporting the use of phos-
phodiesterase inhibitors for the treatment of ED was the number of
authors with financial COI.22
Nearly one-half of the SRs included in our sample were co-authored
by at least one individual with a potential competing interest. Most
of the authors with undisclosed COI reported no conflicts at the time
their studies were published. These findings are concerning as the
ICMJE requires transparent disclosure of all industry relationships and
views purposefully failing to report such relationships as misconduct.23
Our results add to existing literature suggesting that inadequate COI
disclosure is pervasive throughout medical literature.24–26 Given the
inconsistent disclosure of COI among authors within our sample, fur-
ther accountability is necessary to improve disclosure rates and out-
come reporting.

CORCORAN ET AL .
Our second primary objective was to investigate whether industry-
sponsored SRs were more likely to report results and conclusions
favoring the intervention. Our sample included only one industry-
sponsored SR, thus preventing this analysis. However, upon fur-
ther investigation of this SR, we conclude that additional studies
on industry-sponsored SRs are needed. The study was funded by
Medispec Ltd., a manufacturer of shockwave therapy devices, and it
included seven randomized controlled trials. The SR concluded that
low-intensity extracorporeal shockwave therapy is an effective treat-
ment for ED. However, an audit of the primary studies revealed that
Medispec Ltd. also funded nearly half of the trials in the SR’s meta-
analysis (3/7, 42.9%). All of these industry-funded studies reported
results and discussions that were favorable toward the treatment,
whereas those without industry funding were more likely to report
mixed or inconclusive results, thus skewing the analysis of the SR. For
example, a Cochrane review analyzing pharmacologic efficacy found
that studies sponsored by industry or with conflicted authors were
more likely to present favorable outcomes than studies with no such
conflicts.11 Our results suggest a unique source of industry bias that
may be introduced into SRs without the need for direct funding. There-
fore, we contend that authors should report the funding sources of all
primary studies included within their SR. This level of transparency is
necessary for readers to adequately assess the influence industry fund-
ing may have on the results.
It is important to note that the existence of either a COI should
not be taken as grievances toward an author. The American Urological
Association (AUA) acknowledges this within their COI disclosure form
stating, “the existence of an actual or apparent COI does not imply fault
or wrongdoing on the part of an individual.”27 Industry funding is an
important part of academia and researchers rely on its financial sup-
port to carry out studies.28,29 While these funding sources are often
given without stipulation, some experts contend their existence may
lead authors to form biases in favor of their benefactor.30,31 By fully
disclosing COIs, authors allow readers to critically evaluate their work
for any subconscious biases their COIs may add.
Although full disclosure of COI is the best practice, readers must
consider these influences when they evaluate a study. For instance,
Tijdink et al. created a fictitious randomized controlled trial for an
antipsychotic drug and asked psychiatrists to interpret the study out-
comes. They found that psychiatrists did not consider the disclosure
of industry funding when interpreting a study.32 Thus, it is necessary
for physicians and others interpreting medical research to consider not
only the completeness of author COI disclosures but also the influence
that these conflicts may have on the nature of study outcomes. Other-
wise, there is no significant method to mitigate biased industry report-
ing from potentially affecting clinical practice.
Our study results underscore the difficulties in conducting such
analyses, the unreliability of author COI disclosures, the influence
of financial COI and industry sponsorship bias on outcomes and
conclusions of SRs, and the need for greater transparency. First, we
recommend accountability of authors in adhering to COI policies and
of journals in enforcing them. A study analyzing 130 highly influential
journals found that 99% require authors to disclose COI.33 However,
20472927, 2021, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/andr.13064 by Nat Prov Indonesia, Wiley Online Library on [29/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1825
a considerable body of research has found serious problems with
disclosure accuracy. We and others thus recommend that journals use
the Open Payments database, brought about by the Physician Payment
Sunshine Act, to validate disclosure statements.34 This database has
greatly increased transparency of financial relationships between
physicians and the pharmaceutical industry within the United States,
allowing public access to details of specific physicians’ relationships
with the industry.35–37 Despite some initial concerns,38,39 the accuracy
of database continues to improve.39 Finally, we share the International
Committee of Medical Journal Editors’ recommendation40 that the
topic of COI and its influence on research be included in both medical
education and continuing medical education curricula.
4.1 Strengths and limitations
A strength of our study is that the protocol and other study mate-
rials are posted on the Open Science Framework to ensure repro-
ducibility and transparency. Further, this protocol was developed a pri-
ori, and deviations were recorded as amendments. Data extraction
was performed independently by two investigators in a masked, dupli-
cate fashion, which is the gold standard of meta-research according to
the Cochrane Handbook.41 With regard to limitations, we have already
noted in this section some limitations of our methodology. Another is
that our analysis was limited to studies published between September
2016 and June 2020, thus reducing the generalizability of our results to
other time periods. Because of this study’s cross-sectional design, our
sample size was limited and may not be attributable to all SRs regarding
ED treatment.
5 CONCLUSIONS
Although we found that undisclosed COI were problematic among SRs
of ED treatment, only a small percentage of authors in our sample pos-
sessed them and these COI did not appear to influence the favorability
of SR outcomes. The American Urological Association acknowledges
that “the existence of an actual or apparent COI does not imply fault
or wrongdoing on the part of an individual.”27 Nevertheless, as the link
between medicine and industry will likely continue, disclosure state-
ments represent an important mechanism through which clinicians can
gauge industry bias when they study reporting outcomes.
ACKNOWLEDGEMENTS
This study funded by the Oklahoma State University Center for Health
Sciences Presidential Mentor-Mentee Research Fellowship Grant.
CONFLICTS OF INTEREST
Vassar reports grant funding from the National Institutes of Health,
the US Office of Research Integrity, and Oklahoma Center for the
Advancement of Science and Technology, all outside the present work.
All other authors have nothing to report.

1826
AUTHOR CONTRIBUTIONS
J.M.A, M.W, M.H, and M.V. designed the study. Training was conducted
by J.M.A, M.W, M.H, and M.V. The study was supervised by M.H and M.V.
Data was collected by A.C. and C.H. with J.M.A and M.W available as
mediators. A.C, M.H analyzed the data. M.H performed statistical anal-
ysis of the data. All authors co-wrote the first-draft with A.C, J.M.A,
M.H, and M.V writing the final draft.
ORCID
Adam Corcoran https://orcid.org/0000-0002-4067-5008
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