New risks inadequately managed: the case of smart implants and medical device regulation

Many emerging technologies are associated with 'risk'. While the concept of risk is protean, it is usually conceived of as the potential of something damaging or harmful happening. Thus, risks are a primary target of many regulatory regimes. In this article, after articulating an understanding of risk, we assess the European medical devices regulatory regime from a risk perspective, focusing on its handling of 'smart' implantable medical devices. In doing so, we discuss the empirical evidence obtained from expert participants in the Implantable Smart Technologies Project, which evidence is framed around three risk typologies: materiality, geography and modality. We conclude that none of these risks are sufficiently addressed within the existing regime, which falls down not just from a standards perspective, but also from the perspective of transparency and balance.

Obtaining reimbursement in France and Italy for new diabetes products

Manufacturers launching next-generation or innovative medical devices in Europe face a very heterogeneous reimbursement landscape, with each country having its own pathways, timing, requirements and success factors. We selected 2 markets for a deeper look into the reimbursement landscape: France, representing a country with central decision making with defined processes, and Italy, which delegates reimbursement decisions to the regional level, resulting in a less transparent approach to reimbursement. Based on our experience in working on various new product launches and analyzing recent reimbursement decisions, we found that payers in both countries do not reward improved next-generation products with incremental reimbursement. Looking at innovations, we observe that manufacturers face a challenging and lengthy process to obtain reimbursement. In addition, requirements and key success factors differ by country: In France, comparative clinical evidence and budget impact very much drive reimbursement decisions in terms of pricing and restrictions, whereas in Italy, regional key opinion leader (KOL) support and additional local observational data are key.

Early health economic evaluation of the future potential of next generation artificial vision systems for treating blindness in Germany

The next generation of artificial vision devices (AVDs), which is currently developed in pre-clinical settings, has the potential to improve the vision of blind patients with retinitis pigmentosa (RP) in a manner that they will be categorized as visual impaired but no more as blind. This unprecedented vision improvement will result in a mentionable quality of life gain which poses the question at which costs the next generation AVDs are to be regarded as cost-effective, from a German healthcare payer perspective. In order to answer this research question a Markov model was developed to simulate and to compare the costs and effects of next generation AVDs versus best supportive care (BSC). Applying the base case settings resulted in incremental costs of 107,925, in 2.03 incremental quality-adjusted life years (QALYs) and in a cost-effectiveness ratio of 53,165 per QALY gained. Probabilistic and deterministic sensitivity analyses as well as scenario analyses for the effect size and the AVD costs were performed in order to investigate the robustness of results. In these scenario analyses a strong variation of the cost-effectiveness results was obtained ranging from 23,512 (best case) to 176,958 (worst case) per QALY gained by AVD therapy. This early health economic evaluation has to handle with three main uncertainty factors: the effect size of next generation AVDs, the costs of next generation AVDs and the WTP threshold that might be applied in RP patients, which reflect the main limitations of the presented assessment. In conclusion the presented early cost-effectiveness evaluation has obtained that next generation AVDs have the potential to be a cost-effective therapy option in patients with RP in Germany. The innovative nature, the high unmet medical need and the expected unprecedented efficacy of next generation AVDs will highly likely lead to the case that even relatively high incremental cost-effectiveness ratios, that have been obtained when simulating various effect and pricing scenarios, will be regarded as acceptable from a German healthcare payer perspective.

Association of industry sponsorship and positive outcome in randomised controlled trials in general and abdominal surgery: protocol for a systematic review and empirical study

BACKGROUND

Industry sponsorship has been identified as a factor correlating with positive research findings in several fields of medical science. To date, the influence of industry sponsorship in general and abdominal surgery has not been fully studied. This protocol describes the rationale and planned conduct of a systematic review to determine the association between industry sponsorship and positive outcome in randomised controlled trials in general and abdominal surgery.

METHODS/DESIGN

A literature search in the Cochrane Library, MEDLINE and EMBASE and additional hand searches in relevant citations will be conducted. In order to cover all relevant areas of general and abdominal surgery, a new literature search strategy called multi-PICO search strategy (MPSS) has been developed. No language restriction will be applied. The search will be limited to publications between January 1985 and July 2014. Information on funding source, outcome, study characteristics and methodological quality will be extracted.The association between industry sponsorship and positive outcome will be tested by a chi-squared test. A multivariate logistic regression analysis will be performed to control for possible confounders, such as number of study centres, multinational trials, methodological quality, journal impact factor and sample size.

DISCUSSION

This study was designed to clarify whether industry-sponsored trials report more positive outcomes than non-industry trials. It will be the first study to evaluate this topic in general and abdominal surgery. The findings of this study will enable surgical societies, in particular, to give advice about cooperation with the industry and disclosure of funding source based on empirical evidence.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014010802.

Molecular determinants of staphylococcal biofilm dispersal and structuring

Staphylococci are frequently implicated in human infections, and continue to pose a therapeutic dilemma due to their ability to form deeply seated microbial communities, known as biofilms, on the surfaces of implanted medical devices and host tissues. Biofilm development has been proposed to occur in three stages: (1) attachment, (2) proliferation/structuring, and (3) detachment/dispersal. Although research within the last several decades has implicated multiple molecules in the roles as effectors of staphylococcal biofilm proliferation/structuring and detachment/dispersal, to date, only phenol soluble modulins (PSMs) have been consistently demonstrated to serve in this role under both in vitro and in vivo settings. PSMs are regulated directly through a density-dependent manner by the accessory gene regulator (Agr) system. They disrupt the non-covalent forces holding the biofilm extracellular matrix together, which is necessary for the formation of channels, a process essential for the delivery of nutrients to deeper biofilm layers, and for dispersal/dissemination of clusters of biofilm to distal organs in acute infection. Given their relevance in both acute and chronic biofilm-associated infections, the Agr system and the psm genes hold promise as potential therapeutic targets.

Medical devices and the Middle East: market, regulation, and reimbursement in Gulf Cooperation Council states

With some of the richest economies in the world, the Gulf Cooperation Council (GCC) is undergoing rapid growth not only in its population but also in health care expenditure. Despite the GCC's abundance of hydrocarbon-based wealth, the drivers of the medical device industry in the GCC are still in flux, with gains yet to be made in areas of infrastructure, regulation, and reimbursement. However, the regional disease burden, expanding health insurance penetration, increasing privatization, and a desire to attract skilled expatriate health care providers have led to favorable conditions for the medical device market in the GCC. The purpose of this article is to investigate the current state of the GCC medical device industry, with respect to market, regulation, and reimbursement, paying special attention to the three largest medical device markets: Saudi Arabia, the United Arab Emirates, and Qatar. The GCC would seem to represent fertile ground for the development of medical technologies, especially those in line with the regional health priorities of the respective member states.

Contrasting clinical evidence for market authorisation of cardio-vascular devices in Europe and the USA: a systematic analysis of 10 devices based on Austrian pre-reimbursement assessments

BACKGROUND

European medical device regulation is under scrutiny and will be re-regulated with stricter rules concerning requirements for clinical evidence for high-risk medical devices. It is the aim of this study to analyse the differences between Europe and USA in dealing with risks and benefits of new cardio-vascular devices.

METHODS

Since no information is available on clinical data used by the Notified Body for CE-marking, data from Austrian pre-reimbursement assessments close to European market approval were used as proxy and compared with clinical data available at time of market approval by FDA in the USA.

RESULTS

10 cardio-vascular interventions with 27 newly CE approved medical devices were analysed. The time lag between market authorisation in Europe and in the USA is 3 to 7 years. Only 7 CE-marked devices also hold a FDA market approval, 7 further devices are in FDA approved ongoing efficacy trials. For 4 of the CE-marked devices the FDA market application or the approval-trial was either suspended due to efficacy or safety concerns or the approval was denied. Evidence available at time of CE-marking are most often case-series or small feasibility RCTs, while large RCTs and only in rare cases prospective cohort studies are the basis of FDA approvals. Additionally, the FDA often requires post-approval studies for high-risk devices.

CONCLUSIONS

Market authorisation based on mature clinical data deriving from larger RCTs and longer follow-ups do not only change the perspective on the risk-benefit ratio, but also secures real patient benefit and safety and assures payers of investing only in truly innovative devices.

Medical device procurement in low- and middle-income settings: protocol for a systematic review

BACKGROUND

Medical device procurement processes for low- and middle-income countries (LMICs) are a poorly understood and researched topic. To support LMIC policy formulation in this area, international public health organizations and research institutions issue a large body of predominantly grey literature including guidelines, manuals and recommendations. We propose to undertake a systematic review to identify and explore the medical device procurement methodologies suggested within this and further literature. Procurement facilitators and barriers will be identified, and methodologies for medical device prioritization under resource constraints will be discussed.

METHODS/DESIGN

Searches of both bibliographic and grey literature will be conducted to identify documents relating to the procurement of medical devices in LMICs. Data will be extracted according to protocol on a number of pre-specified issues and variables. First, data relating to the specific settings described within the literature will be noted. Second, information relating to medical device procurement methodologies will be extracted, including prioritization of procurement under resource constraints, the use of evidence (e.g. cost-effectiveness evaluations, burden of disease data) as well as stakeholders participating in procurement processes. Information relating to prioritization methodologies will be extracted in the form of quotes or keywords, and analysis will include qualitative meta-summary. Narrative synthesis will be employed to analyse data otherwise extracted. The PRISMA guidelines for reporting will be followed.

DISCUSSION

The current review will identify recommended medical device procurement methodologies for LMICs. Prioritization methods for medical device acquisition will be explored. Relevant stakeholders, facilitators and barriers will be discussed. The review is aimed at both LMIC decision makers and the international research community and hopes to offer a first holistic conceptualization of this topic.

Selective serotonin reuptake inhibitors and the risk of osseointegrated implant failure: a cohort study

Selective serotonin reuptake inhibitors (SSRIs), the most widely used drugs for the treatment of depression, have been reported to reduce bone formation and increase the risk of bone fracture. Since osseointegration is influenced by bone metabolism, this study aimed to investigate the association between SSRIs and the risk of failures in osseointegrated implants. This retrospective cohort study was conducted on patients treated with dental implants from January 2007 to January 2013. A total of 916 dental implants in 490 patients (94 implants on 51 patients using SSRIs) were used to estimate the risk of failure associated with the use of SSRIs. Data analysis involved Cox proportional hazards, generalized estimating equation models, multilevel mixed effects parametric survival analysis, and Kaplan-Meier analysis. After 3 to 67 mo of follow-up, 38 dental implants failed and 784 succeeded in the nonusers group, while 10 failed and 84 succeeded in the SSRI-users group. The main limitation of this retrospective study was that drug compliance dose and treatment period could not be acquired from the files of the patients. The primary outcome was that compared with nonusers of SSRIs, SSRI usage was associated with an increased risk of dental implants failure (hazard ratio, 6.28; 95% confidence interval, 1.25-31.61; p = .03). The failure rates were 4.6% for SSRI nonusers and 10.6% for SSRI users. The secondary outcomes were that small implant diameters (≤4 mm; p = .02) and smoking habits (p = .01) also seemed to be associated with higher risk of implant failure. Our findings indicate that treatment with SSRIs is associated with an increased failure risk of osseointegrated implants, which might suggest a careful surgical treatment planning for SSRI users.

Regulation of cognitive enhancement devices: commentary

Maslen et al. (2013) have provided us with a comprehensive overview of the current legislation regulating non-clinical cognitive enhancement devices (CEDs) in the European Union and have proposed a specific model whereby CEDs would be regulated in the same way as medical devices. An alternative model would be to require manufacturers to quantify risks only. Irrespective of the purported 'benefits' of a product, this would allow the consumer freedom of choice to use the product at their will and allow the periodic review of worthwhile indications and unexpected adverse events. Although this departs from the standard Cochrane-type assessment, it takes into account the facts that (i) the evaluation of clinically used cognitive enhancement techniques may not be as rigorous as one might expect, (ii) variations and case-by-case use might be widespread, and (iii) independent variables of significance and useful endpoints may not be obvious ab initio. We consider cerebrospinal fluid diversion techniques which are widely used clinically to enhance cognition in patients with normal pressure hydrocephalus despite any large-scale clinical studies demonstrating substantial benefit, and the real risks of paralysis and death from these invasive procedures. The risks of CEDs which have been available for some time need to be kept in perspective: are the risks really more than using conventional cognitive enhancement techniques such as imbibing too caffeinated drinks? Furthermore, the loss of Europe as a market for CEDs which do not comply with the proposed regulatory model implies a potential gain in the market for other parts of the world. This could impact on the ability of companies in Europe being able to compete in an evolving market demand for CEDs. Legislation to regulate CEDs should be guided by the principle of 'do no harm' and allow for innovation and competition.

Development and Validation of Endovascular Chemotherapy Filter Device for Removing High-Dose Doxorubicin: Preclinical Study

To develop a novel endovascular chemotherapy filter (CF) able to remove excess drug from the blood during intra-arterial chemotherapy delivery (IAC), thus preventing systemic toxicities and thereby enabling higher dose IAC. A flow circuit containing 2.5 mL of ion-exchange resin was constructed. Phosphate-buffered saline (PBS) containing 50 mg doxorubicin (Dox) was placed in the flow model with the hypothesis that doxorubicin would bind rapidly to resin. To simulate IAC, 50 mg of doxorubicin was infused over 10 min into the flow model containing resin. Similar testing was repeated with porcine serum. Doxorubicin concentrations were measured over 60 min and compared to controls (without resin). Single-pass experiments were also performed. Based on these experiments, an 18F CF was constructed with resin in its tip. In a pilot porcine study, the device was deployed under fluoroscopy. A control hepatic doxorubicin IAC model (no CF placed) was developed in another animal. A second CF device was created with a resin membrane and tested in the infrarenal inferior vena cava (IVC) of a swine. In the PBS model, resin bound 76% of doxorubicin in 10 min, and 92% in 30 min (P < 0.001). During IAC simulation, 64% of doxorubicin bound in 10 min and 96% in 60 min (P < 0.001). On average, 51% of doxorubicin concentration was reduced during each pass in single pass studies. In porcine serum, 52% of doxorubicin bound in 10 min, and 80% in 30 min (P < 0.05). CF device placement and administration of IAC were successful in three animals. No clot was present on the resin within the CF following the in vivo study. The infrarenal IVC swine study demonstrated promising results with up to 85% reduction in peak concentration by the CF device. An endovascular CF device was developed and shown feasible in vitro. An in vivo model was established with promising results supporting high-capacity rapid doxorubicin filtration from the blood that can be further evaluated in future studies.

How many testers are needed to assure the usability of medical devices?

Before releasing a product, manufacturers have to follow a regulatory framework and meet standards, producing reliable evidence that the device presents low levels of risk in use. There is, though, a gap between the needs of the manufacturers to conduct usability testing while managing their costs, and the requirements of authorities for representative evaluation data. A key issue here is the number of users that should complete this evaluation to provide confidence in a product's safety. This paper reviews the US FDA's indication that a sample composed of 15 participants per major group (or a minimum of 25 users) should be enough to identify 90-97% of the usability problems and argues that a more nuanced approach to determining sample size (which would also fit well with the FDA's own concerns) would be beneficial. The paper will show that there is no a priori cohort size that can guarantee a reliable assessment, a point stressed by the FDA in the appendices to its guidance, but that manufacturers can terminate the assessment when appropriate by using a specific approach - illustrated in this paper through a case study - called the 'Grounded Procedure'.

Human centred design considerations for connected health devices for the older adult

Connected health devices are generally designed for unsupervised use, by non-healthcare professionals, facilitating independent control of the individuals own healthcare. Older adults are major users of such devices and are a population significantly increasing in size. This group presents challenges due to the wide spectrum of capabilities and attitudes towards technology. The fit between capabilities of the user and demands of the device can be optimised in a process called Human Centred Design. Here we review examples of some connected health devices chosen by random selection, assess older adult known capabilities and attitudes and finally make analytical recommendations for design approaches and design specifications.

Improving medical device regulation: the United States and Europe in perspective

CONTEXT

Recent debates and events have brought into question the effectiveness of existing regulatory frameworks for medical devices in the United States and Europe to ensure their performance, safety, and quality. This article provides a comparative analysis of medical device regulation in the two jurisdictions, explores current reforms to improve the existing systems, and discusses additional actions that should be considered to fully meet this aim. Medical device regulation must be improved to safeguard public health and ensure that high-quality and effective technologies reach patients.

METHODS

We explored and analyzed medical device regulatory systems in the United States and Europe in accordance with the available gray and peer-reviewed literature and legislative documents.

FINDINGS

The two regulatory systems differ in their mandate and orientation, organization, pre- and postmarket evidence requirements, and transparency of process. Despite these differences, both jurisdictions face similar challenges for ensuring that only safe and effective devices reach the market, monitoring real-world use, and exchanging pertinent information on devices with key users such as clinicians and patients. To address these issues, reforms have recently been introduced or debated in the United States and Europe that are principally focused on strengthening regulatory processes, enhancing postmarket regulation through more robust surveillance systems, and improving the traceability and monitoring of devices. Some changes in premarket requirements for devices are being considered.

CONCLUSIONS

Although the current reforms address some of the outstanding challenges in device regulation, additional steps are needed to improve existing policy. We examine a number of actions to be considered, such as requiring high-quality evidence of benefit for medium- and high-risk devices; moving toward greater centralization and coordination of regulatory approval in Europe; creating links between device identifier systems and existing data collection tools, such as electronic health records; and fostering increased and more effective use of registries to ensure safe postmarket use of new and existing devices.

Ventilator associated pneumonia: evolving definitions and preventive strategies

Ventilator-associated pneumonia (VAP) is one of the most frequent hospital-acquired infections occurring in intubated patients. Because VAP is associated with higher mortality, morbidity, and costs, there is a need to solicit further research for effective preventive measures. VAP has been proposed as an indicator of quality of care. Clinical diagnosis has been criticized to have poor accuracy and reliability. Thus, the Centers for Disease Control and Prevention has introduced a new definition based upon objective and recordable data. Institutions are nowadays reporting a VAP zero rate in surveillance programs, which is in discrepancy with clinical data. This reduction has been highlighted in epidemiological studies, but it can only be attributed to a difference in patient selection, since no additional intervention has been taken to modify pathogenic mechanisms in these studies. The principal determinant of VAP development is the presence of the endotracheal tube (ETT). Contaminated oropharyngeal secretions pool over the ETT cuff and subsequently leak down to the lungs through a hydrostatic gradient. Impairment of mucociliary motility and cough reflex cannot counterbalance with a proper clearance of secretions. Lastly, biofilm develops on the inner ETT surface and acts as a reservoir for microorganism inoculum to the lungs. New preventive strategies are focused on the improvement of secretions drainage and prevention of bacterial colonization. The influence of gravity on mucus flow and body positioning can facilitate the clearance of distal airways, with decreased colonization of the respiratory tract. A different approach proposes ETT modifications to limit the leakage of oropharyngeal secretions: subglottic secretion drainage and cuffs innovations have been addressed to reduce VAP incidence. Moreover, coated-ETTs have been shown to prevent biofilm formation, although there is evidence that ETT clearance devices (Mucus Shaver) are required to preserve the antimicrobial properties over time. Here, after reviewing the most noteworthy issues in VAP definition and pathophysiology, we will present the more interesting proposals for VAP prevention.

Biologics: the role of delivery systems in improved therapy

The beginning of the 21st century saw numerous protein and peptide therapeuticals both on the market and entering the final stages of clinical studies. They represent a new category of biologically originated drugs termed biologics or biologicals. Their main advantages over conventional drugs can be summarized by their high selectivity and potent therapeutic efficacy coupled with limited side effects. In addition, they exhibit more predictable behavior under in vivo conditions. However, up to now most of the formulations of biologics are designed and destined for the parenteral route of administration. As a consequence, many suffer from short plasma half-lives, resulting in their frequent administration and ultimately poor patient compliance. This review represents an attempt to address some of the challenges and promises in the product development of biologics both for parenteral and noninvasive administration. Some of the products currently in the pipeline of pharmaceutical development and corresponding perspectives are discussed in more detail.

Antifouling polyurethanes to fight device-related staphylococcal infections: synthesis, characterization, and antibiofilm efficacy

In hospital settings, biofilm-based medical device-related infections are considered a threat to patients, the sessile growing bacteria playing a key role in the spreading of healthcare-associated infections. In recent decades, the design of antifouling coatings for medical devices able to prevent microbial adhesiveness has emerged as one of the most promising strategies to face this important issue. In order to obtain suitable antifouling materials, segmented polyurethanes characterized by a hard/soft domain structure, having the same hard domain but a variable soft domain, have been synthesized. The soft domain was constituted by one of the following macrodiols: polypropylenoxide (PPO), polycaprolactide (PCL), and poly-l-lactide (PLA). The effects of the polymer hydrophilicity and the degree of hard/soft domain separation on antifouling properties of the synthesized polyurethanes were investigated. Microbial adherence assays evidenced as the polymers containing PCL or PLA were able to significantly reduce the adhesion of Staphylococcus epidermidis with respect to the PPO-containing polymer.

Regulation of medicines and medical devices: contrasts and similarities

In recent times, there has been an unprecedented level of public interest and active debate regarding the regulation of medical devices. This is in light of the topical, rather dissimilar, incidents involving poly-implant-prothèse (PIP) breast and metal-on-metal hip implants. Although medicines and devices are regulated under European Union (EU) law, the regulatory regimes are very different and some have argued that features of the pharmaceutical regime should be applied to medical devices in the current review of the medical devices directives. Both medicines and certain devices need to have an assessment of their risks and benefits before being used in patients, and undergo subsequent monitoring for adverse events. However, there are significant differences between these two groups in terms of the number of products, the pattern of innovation and development, and the types of adverse events that arise from their use. This review will summarise the key issues through a comparison of how both are regulated and monitored.

Preparation and characterization of an advanced medical device for bone regeneration

Tridimensional scaffolds can promote bone regeneration as a framework supporting the migration of cells from the surrounding tissue into the damaged tissue and as delivery systems for the controlled or prolonged release of cells, genes, and growth factors. The goal of the work was to obtain an advanced medical device for bone regeneration through coating a decellularized and deproteinized bone matrix of bovine origin with a biodegradable, biocompatible polymer, to improve the cell engraftment on the bone graft. The coating protocol was studied and set up to obtain a continuous and homogeneous polylactide-co-glycolide (PLGA) coating on the deproteinized bone matrix Orthoss® block without occluding pores and decreasing the scaffold porosity. The PLGA-coated scaffolds were characterized for their morphology and porosity. The effects of PLGA polymer coating on cell viability were assessed with the 3-(4,5-dimethyl-2-thiazolyl)-2,5 diphenyl-2H-tetrazolium assay. The polymer solution concentration and the number of polymeric layers were the main variables affecting coating efficiency and porosity of the original decellularized bone matrix. The designed polymer coating protocol did not affect the trabecular structure of the original decellularized bone matrix. The PLGA-coated decellularized bone matrix maintained the structural features, and it improved the ability in stimulating fibroblasts attachment and proliferation.

The Crowd, the Cloud and Improving the Future of Medical Device Innovation

Barriers and delays to medical device innovation are often solely attributable to the regulatory environment instead of both the current state of innovation practices and product development processes in the industry. Increasing the pace of innovation while reducing costs requires the creation of a new approach that fits both established medical device corporations as well as entrepreneurial start-ups. In this commentary we advance the concept of innovation platforms to facilitate ideation in the medical device space. Such platforms could also allow the full health benefits from individual medical devices to be reaped, by overcoming interoperability concerns through simulation and credentialing. Given the dramatic benefits of medical device success, such non-traditional business models for development may be potential solutions for industry, users and regulators.

Approval of high-risk medical devices in the US: implications for clinical cardiology

Since 1976, the US Food and Drug Administration (FDA) has used the premarket approval (PMA) process to approve high-risk medical devices, including implantable cardioverter defibrillators (ICDs), coronary stents, and artificial heart valves. The PMA process is widely viewed as a rigorous evaluation of device safety and effectiveness, though recent recalls-most notably related to underperforming ICD leads-have raised concerns about whether physicians and patients should sometimes be more wary about devices approved via this pathway. The FDA must utilize a "least burdensome" approach to approve new medical devices, and many widely used device models have been approved as supplements to existing PMA-approved devices with limited clinical testing. A recent Supreme Court ruling has made it difficult for patients harmed by unsafe PMA-approved devices to seek damages in court. Cardiologists who utilize high-risk medical devices should be aware that FDA approval of new devices relies on variable levels of evidence and does not necessarily indicate improved effectiveness over existing models. Clinician and patient engagement in postmarket surveillance and comparative effectiveness research remains imperative.