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Design: Cross-sectional survey with 2-week reproducibility assessment.

Whether or not express, finder''s fees are now commonplace, and are but one indication of the increasingly competitive environment in which Contract Research Organizations (CROs), academic research institutes, and pharmaceutical companies compete for access to research subjects. (10) The increased demand and competition for subjects is a reflection of the spectacular increase in research activity over the last two decades, an increase in large part driven by growing commercial interest in research. The forces generated by increasing commercial investment in research are particularly apparent in the context of clinical trials focusing on drag development.

Based on the conceptualization illustrated in Figure 1, this study focused on how having a regular doctor differs from having a regular site in affecting the use of five preventive services: mammograms, pap smears, blood pressure checkups, cholesterol level checkups, and flu shots. The probabilities of having a usual doctor, a regular site, and no usual source of care were analyzed first in the selection stage. It was followed by the examination of the impact of having a regular doctor and having a regular site on the utilization of each above-mentioned preventive service, while incorporating individuals'' unobservable preferences in the selection stage.

Over the past 5 years, a series of articles in leading American newspapers has revealed the extent to which the conduct of clinical trials may be affected by inducements offered by corporate research sponsors and accepted by some unscrupulous physicians. (1) The cases described were disturbing. They involved physicians engaged in excessive "enrollment activities" in exchange for money. Some of these physicians perpetrated fraud, falsifying their recruitment records in order to increase their profits. Others ignored exclusion criteria designed to ensure the safety of subjects and the validity of research results, referring their patients to research investigating treatments for conditions from which they did not suffer. (2) One of the articles reports that physicians focusing exclusively on commercial research regularly divulge annual incomes upwards of $1,000,000 with profits in excess of $300,000. Two physicians accumulated well over $10,000,000 through clinical trials activities in less than a decade. (3) Another article reported the role of finder''s fees and payments to parents in increasing the enrollment of children in medical research in the United States from 16,000 in 1997 to 45,000 in 2001. (4) It also highlighted the fact that subjects may be exposed to serious harm through referrals by zealous and inexperienced physicians, drawn to recruitment activity by offers of up to $5,000 per patient referred. Finally, several other "disturbing recruitment practices" were reported by the U.S. Department of Health and Human Services'' Office of Inspector General in its report on subject recruitment practices. These include many cases of patients being harassed for participation; a nursing home resident being told to participate in research or leave the home; and a subject who died and was later found not to have met the inclusion criteria for the study. (5)

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