A Framework for Incorporating Patient Preferences Regarding Benefits and Risks into Regulatory Assessment of Medical Technologies

BACKGROUND

In response to 2012 guidance in which the US Food and Drug Administration's (FDA) Center for Devices and Radiological Health (CDRH) stated the importance of patient-centric measures in regulatory benefit-risk assessments, the Medical Device Innovation Consortium (MDIC) initiated a project. The project was used to develop a framework to help the Food and Drug Administration (FDA) and industry sponsors understand how patient preferences regarding benefit and risk might be integrated into the review of innovative medical devices.

METHODS

A public-private partnership of experts from medical device industry, government, academia and non-profits collaborated on development of the MDIC patient centered benefit-risk framework.

RESULTS

The MDIC Framework examines what patient preference information is and the potential use and value of patient preference information in the regulatory process and across the product development life cycle. The MDIC Framework also includes a catalog of patient preference assessment methods and an agenda for future research to advance the field.

CONCLUSIONS

This article discusses key concepts in patient preference assessment of particular importance for regulators and researchers that are addressed in the MDIC Framework for patient centered benefit-risk assessment as well as the unique public-private collaboration that led its development.

Regionalization as an approach to regulatory systems strengthening: a case study in CARICOM member states

Improving basic capacities for regulation of medicines and health technologies through regulatory systems strengthening is particularly challenging in resource-constrained settings. "Regionalization"-an approach in which countries with common histories, cultural values, languages, and economic conditions work together to establish more efficient systems-may be one answer. This report describes the Caribbean Regulatory System (CRS), a regionalization initiative being implemented in the mostly small countries of the Caribbean Community and Common Market (CARICOM). This initiative is an innovative effort to strengthen regulatory systems in the Caribbean, where capacity is limited compared to other subregions of the Americas. The initiative's concept and design includes a number of features and steps intended to enhance sustainability in resource-constrained contexts. The latter include 1) leveraging existing platforms for centralized cooperation, governance, and infrastructure; 2) strengthening regulatory capacities with the largest potential public health impact; 3) incorporating policies that promote reliance on reference authorities; 4) changing the system to encourage industry to market their products in CARICOM (e.g., using a centralized portal of entry to reduce regulatory burdens); and 5) building human resource capacity. If implemented properly, the CRS will be self-sustaining through user fees. The experience and lessons learned thus far in implementing this initiative, described in this report, can serve as a case study for the development of similar regulatory strengthening initiatives in resource-constrained environments.

[Use of data: legal and ethical aspects]

Health care professionals and organizations, in carrying out their activities, consistently handle information related to identified or identifiable (even indirectly) natural persons, therefore "personal data". The application of Legislative Decree 30 June 2003 n. 196--the Code concerning the protection of personal data--as integrated by the pronunciations of the authority tasked with the application of such a complex legislation, the Authority for the Protection of Personal Data, consequently follows. The aforementioned legislation is seldom fully applied even 12 years after its publication, and even so not properly or with the adequate level of care. As a consequence, the data processed is often not adequately safeguarded, and compliance is hindered at an organisational level: this is particularly true with reference to the state of the art in medical technology, which is characterized by the utilization of ICT technologies such as the ones used with clinical registries and the Electronic Health Record. This chapter shows that, even when processing personal data that is of a sensitive nature, and at the same time of great importance, it is possible to reconcile the need to access and manage information with the protection of the individuals to whom such information refers to. This possibility is however closely linked to the awareness of the issues involved, awareness that in turn comes from an indispensable knowledge of the different aspects of that complex legislation.

[Health agencies and biomedicine: a new technocratic legitimity and a strategy to share power]

The role of health agencies in the field of biomedicine does not appear today anymore as a question of systemic approach but much more as a question of implementing the bioethical principles acknowledged in the legislation and by the different stake-holders of the biomedical techniques.

Career imperative. Is it legal? Is it ethical?

This paper gives sample ethical case vignettes and discussions that will be presented at the 36th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC'14) special session of the Ethics and Professional Responsibility Committee. The session includes additional cases with audience participation and panel discussions.

Employment rights of people with diabetes: changing technology and changing law

Though the treatment of diabetes has advanced remarkably, the law and many employers have not always kept pace. New insulins, delivery systems, and monitoring systems give people with diabetes exceptional control over their blood sugar and virtually eliminate serious complications such as hypoglycemia and hyperglycemia. Changes in the law, particularly the Americans with Disabilities Act and its 2008 amendments, give people with diabetes greater rights and employment opportunities than ever before. Despite these advances, many employers continue to use blanket bans or ill-considered standards to bar people with diabetes. Efforts to break down these remaining barriers are ongoing through employee litigation and through the American Diabetes Association's collaboration with entities that set occupational standards.

Considerations for an institution for evaluation of diabetes technology devices to improve their quality in the European Union

All medical devices used for self-monitoring of blood glucose (BG), insulin injection, continuous subcutaneous insulin infusion, and continuous glucose monitoring in the European Union (EU) must have a Communauté Européenne (CE) mark. However, the approval process for obtaining this mark is different from that used by the European Medicines Agency in the EU for drugs or by the Food and Drug Administration in the United States for such medical and in vitro diagnostic devices. The notified bodies involved in the CE mark process perform this evaluation in cooperation with the manufacturers. They have only limited diabetes know-how; they have to handle all kinds of medical devices. There are devices for therapy on the market in the EU (i.e., they have market approval) that do not fulfill quality requirements, as indicated, for example, in the international norm ISO 15197 for BG test systems. Evaluation of the performance of such systems is usually provided by the manufacturers. What is missing in the EU is an independent institution that performs regular and critical evaluation of the quality of devices used for diabetes therapy before and also after their market approval. The work of such an institution would focus on BG test systems (these represent two-thirds of the market of medical devices for diabetes treatment) but would also evaluate the performance of other devices. It has to be clarified what legal framework is required for such an institution and how it can be financed; probably this can be done in a shared manner by the manufacturers of such devices and the health insurance companies. Positive evaluation results should be a prerequisite prior to any reimbursement for such devices.

Development of a personal health monitoring system--the IT-systems industry view

The Development and Implementation of PHM systems require a different approach than typical application development processes. Based on a practical example it is described how ethical and legal aspects will be considered during the development process. The result is a cohesion and adoption of different methods with defined interaction points to reiterate the solution design by legal and ethical aspects.

Legal aspects of personal health monitoring

Personal health monitoring (PHM) can be defined as comprising all technical systems, processing, collecting, and storing of data linked to a person. PHM involves several legal issues that are described in this paper. This article analyses firstly the short term actions that are needed at the European level to allow personal health monitoring in respect of the interests and rights of patients such as the need to have more harmonised medical liability rules at the EU level. Introducing PHM implies also legal action at the EU level on the long run. These long-term actions are related to e.g. the way in which hospitals are organised in their relation with healthcare professionals and with other hospitals or healthcare actors. The paper analyses finally also how health monitoring projects may change the traditional (non-)relationship between patients and pharmaceutical/medical device industry. Today, the producers and distributors of medicinal products have no specific contact with patients. This situation may change when applying telemonitoring projects and may require new legal rules.

The right to enjoy the benefits of scientific progress: in search of state obligations in relation to health

After having received little attention over the past decades, one of the least known human rights--the right to enjoy the benefits of scientific progress and its applications--has had its dust blown off. Although included in the Universal Declaration of Human Rights (UDHR) and in the International Covenant on Economic, Social and Cultural Rights (ICESCR)--be it at the very end of both instruments -this right hardly received any attention from States, UN bodies and programmes and academics. The role of science in societies and its benefits and potential danger were discussed in various international fora, but hardly ever in a human rights context. Nowadays, within a world that is increasingly turning to science and technology for solutions to persistent socio-economic and development problems, the human dimension of science also receives increased attention, including the human right to enjoy the benefits of scientific progress and its applications. This contribution analyses the possible legal obligations of States in relation to the right to enjoy the benefits of scientific progress and its applications, in particular as regards health.

The secret to health information technology's success within the diabetes patient population: a comprehensive privacy and security framework

Congress made an unprecedented investment in health information technology (IT) when it passed the American Recovery and Reinvestment Act in February 2009. Health IT provides enormous opportunities to improve health care quality, reduce costs, and engage patients in their own care. But the potential payoff for use of health IT for diabetes care is magnified given the prevalence, cost, and complexity of the disease. However, without proper privacy and security protections in place, diabetes patient data are at risk of misuse, and patient trust in the system is undermined. We need a comprehensive privacy and security framework that articulates clear parameters for access, use, and disclosure of diabetes patient data for all entities storing and exchanging electronic data.