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Hossaini S, Hoffmann C, Cousins S, Blencowe N, McNair AGK, Blazeby JM, Avery KNL, Potter S, Macefield R. Development of a conceptual framework for reporting modifications in surgical innovation: scoping review. BJS Open 2023; 7:7145934. [PMID: 37104755 PMCID: PMC10139440 DOI: 10.1093/bjsopen/zrad020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 01/20/2023] [Accepted: 01/28/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Innovative surgical procedures and devices are often modified throughout their development and introduction into clinical practice. A systematic approach to reporting modifications may support shared learning and foster safe and transparent innovation. Definitions of 'modifications', and how they are conceptualized and classified so they can be reported and shared effectively, however, are lacking. This study aimed to explore and summarize existing definitions, perceptions, classifications and views on modification reporting to develop a conceptual framework for understanding and reporting modifications. METHODS A scoping review was conducted in accordance with PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. Targeted searches and two database searches were performed to identify relevant opinion pieces and review articles. Included were articles relating to modifications to surgical procedures/devices. Data regarding definitions, perceptions and classifications of modifications, and views on modification reporting were extracted verbatim. Thematic analysis was undertaken to identify themes, which informed development of the conceptual framework. RESULTS Forty-nine articles were included. Eight articles included systems for classifying modifications, but no articles reported an explicit definition of modifications. Some 13 themes relating to perception of modifications were identified. The derived conceptual framework comprises three overarching components: baseline data about modifications, details about modifications and impact/consequences of modifications. CONCLUSION A conceptual framework for understanding and reporting modifications that occur during surgical innovation has been developed. This is a first necessary step to support consistent and transparent reporting of modifications, to facilitate shared learning and incremental innovation of surgical procedures/devices. Testing and operationalization is now needed to realize the value of this framework.
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Affiliation(s)
- Sina Hossaini
- Department of Population Health Sciences, National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Christin Hoffmann
- Department of Population Health Sciences, National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Cousins
- Department of Population Health Sciences, National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Natalie Blencowe
- Department of Population Health Sciences, National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Gastrointestinal Surgery, North Bristol NHS Trust, Bristol, UK
| | - Angus G K McNair
- Department of Population Health Sciences, National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Gastrointestinal Surgery, North Bristol NHS Trust, Bristol, UK
| | - Jane M Blazeby
- Department of Population Health Sciences, National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- Division of Surgery, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Kerry N L Avery
- Department of Population Health Sciences, National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shelley Potter
- Department of Population Health Sciences, National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Breast Care Centre, North Bristol NHS Trust, Bristol, UK
| | - Rhiannon Macefield
- Department of Population Health Sciences, National Institute for Health and Care Research Bristol Biomedical Research Centre, Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
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DeRuyter MT, Mansy LN, Krumme JW, Cheng AL, Dubin JR, Cil A. Risk of Recall for Total Joint Arthroplasty Devices Over 10 Years. J Arthroplasty 2023:S0883-5403(23)00088-8. [PMID: 36773660 DOI: 10.1016/j.arth.2023.01.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/29/2023] [Accepted: 01/31/2023] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND Orthopaedic devices comprise nearly 20% of devices on the market and 12% to 20% of these devices undergo a recall within 10 years. More than 95% of these devices are approved without supporting clinical data through the Food and Drug Administration's 510(k) pathway. The risk of recall of orthopaedic arthroplasty devices approved through the 510(k) pathway has not been previously studied. METHODS The FDA 510(k) database was queried for orthopaedic devices approved between January 01, 2008 and December 31, 2018 and subsequently codified to hip and knee arthroplasty devices using product codes. The database included 904 arthroplasty devices during the study period, with hip and knee making up 53.7% (485) and 46.3% (419) of devices, respectively. Information regarding numbers, dates, and reasons for recall were recorded. Cumulative incidence function was conducted to compare the risk of recall between hip and knee arthroplasty. RESULTS In total, 94 (19.4%) hip and 85 (20.3%) knee devices were recalled. The hazard of recall by 10 years for hip and knee arthroplasty devices was approximately 24%, with no statistical differences between each region. The most common causes of recall were process control and device design, accounting for 29.6% and 26.3% of recalls, respectively, with no significant difference between study groups. CONCLUSION The risk of recall for arthroplasty devices is more than that previously understood. Improved postmarket surveillance strategies along with increased physician participation in detecting and reporting device safety issues are necessary to strengthen patient safety.
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Affiliation(s)
| | | | | | | | | | - Akin Cil
- University of Missouri, Kansas City, Missouri
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The FDA and Ensuring Safety and Effectiveness of Devices, Biologics, and Technology. J Am Acad Orthop Surg 2022; 30:658-667. [PMID: 35797679 DOI: 10.5435/jaaos-d-22-00179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/06/2022] [Indexed: 02/01/2023] Open
Abstract
Orthopaedic devices account for nearly 20% of all devices on the market, with more than 600 novel orthopaedic devices cleared or approved by the FDA for marketing in the United States annually. Advances in technology and biologic therapies offer tremendous potential for patients with musculoskeletal ailments; however, it is important that the safety and effectiveness of these products be assessed to safeguard the public health. The FDA uses multiple different premarket pathways for devices, biologics, and combination products based on perceived risk of the novel product. More than 97% of orthopaedic devices go through the FDA's 510(k) pathway, which does not require clinical trials. The remaining high-risk devices must receive premarket approval and submit clinical trial data demonstrating safety and effectiveness. Similarly, high-risk biologics must obtain a biologics license application by submitting clinical trial data. Postmarketing surveillance strategies, including extended clinical trials or real-world evidence from registries, are increasingly being relied on by the FDA to expedite approval while also improving its capacity to identify problematic products.
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Páez A, Rovers M, Hutchison K, Rogers W, Vasey B, McCulloch P. Beyond the RCT: When are Randomized Trials Unnecessary for New Therapeutic Devices, and What Should We Do Instead? Ann Surg 2022; 275:324-331. [PMID: 34238815 PMCID: PMC8746919 DOI: 10.1097/sla.0000000000005053] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to develop an evidence-based framework for evaluation of therapeutic devices, based on ethical principles and clinical evidence considerations. SUMMARY BACKGROUND DATA Nearly all medical products which do not work solely through chemical action are regulated as medical devices. Their huge range of purposes, mechanisms of action and risks pose challenges for regulation. High-profile implantable device failures have fuelled concerns about the level of clinical evidence needed for market approval. Calls for more rigorous evaluation lack clarity about what kind of evaluation is appropriate, and are commonly interpreted as meaning more randomized controlled trials (RCTs). These are valuable where devices are genuinely new and claim to offer measurable therapeutic benefits. Where this is not the case, RCTs may be inappropriate and wasteful. METHODS Starting with a set of ethical principles and basic precepts of clinical epidemiology, we developed a sequential decision-making algorithm for identifying when an RCT should be performed to evaluate new therapeutic devices, and when other methods, such as observational study designs and registry-based approaches, are acceptable. RESULTS The algorithm clearly defines a group of devices where an RCT is deemed necessary, and the associated framework indicates that an IDEAL 2b study should be the default clinical evaluation method where it is not. CONCLUSIONS The algorithm and recommendations are based on the principles of the IDEAL-D framework for medical device evaluation and appear eminently practicable. Their use would create a safer system for monitoring innovation, and facilitate more rapid detection of potential hazards to patients and the public.
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Affiliation(s)
- Arsenio Páez
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Northeastern University, Bouvé College of Health Sciences, Boston, MA
- IDEAL Collaboration, Nuffield Department of Surgical Sciences, University of Oxford, UK
| | - Maroeska Rovers
- IDEAL Collaboration, Nuffield Department of Surgical Sciences, University of Oxford, UK
- Departments of Operating Rooms and Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Katrina Hutchison
- IDEAL Collaboration, Nuffield Department of Surgical Sciences, University of Oxford, UK
- Department of Philosophy, Macquarie University, Sydney, Australia
| | - Wendy Rogers
- IDEAL Collaboration, Nuffield Department of Surgical Sciences, University of Oxford, UK
- Department of Philosophy, Macquarie University, Sydney, Australia
- Department of Clinical Medicine, Macquarie University, Sydney, Australia
| | - Baptiste Vasey
- IDEAL Collaboration, Nuffield Department of Surgical Sciences, University of Oxford, UK
- Oxford University Hospitals, IDEAL Collaboration, Nuffield Department of Surgery, John Radcliffe Hospital, Oxford, UK
| | - Peter McCulloch
- IDEAL Collaboration, Nuffield Department of Surgical Sciences, University of Oxford, UK
- Oxford University Hospitals, IDEAL Collaboration, Nuffield Department of Surgery, John Radcliffe Hospital, Oxford, UK
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Abstract
IMPORTANCE US law generally requires testing of high-risk medical devices prior to approval, as well as premarket evaluation of moderate-risk medical devices, with the goal of ensuring that the benefits of these products exceed their risks. The US Food and Drug Administration (FDA) attempts to balance the need for evidence generation with an approval process that facilitates access and encourages innovation. OBJECTIVE To review the development of laws and standards affecting the evaluation and oversight of medical devices by the US regulatory system and the outcomes of this system from 1976 to 2020. EVIDENCE REVIEW Laws enacted by US Congress and regulations promulgated by the FDA through 2020; databases maintained by the FDA of device authorizations from 1976 to 2020; and annual reports of user fees paid to the FDA by industry. FINDINGS Since Congress and the FDA initiated premarket review of medical devices in 1976, some fundamental innovations in the device regulation system have included special pathways to accelerate availability of investigational devices, more flexible evidence and review requirements, and increased funding to the FDA through industry-paid user fees. From 1987 to 2020, the annual number of novel devices granted premarket approval (which excludes supplements) ranged from 8 to 56 (median, 32), and the number of clearances for 510(k) devices (those that are "substantially equivalent" to marketed devices) ranged from 2804 to 5762 (median, 3404). User fee funding for devices was established in 2002 and annual fees collected increased from $30 million in 2003 (in 2019 dollars) to more than $208 million in 2019; this represented 43% of FDA funding related to the review of medical devices. Although many new devices have led to considerable patient benefit, such as hypodermic needles and magnetic resonance imaging machines, important adverse events caused by some devices, such as an implanted device for birth control and a surgical mesh implant for pelvic organ prolapse, have led to calls to reexamine the regulatory system for such products. CONCLUSIONS AND RELEVANCE Over the last 45 years, medical device regulation has become more complex, with more regulatory pathways and greater variations in the evidence and controls required for authorization. Increased FDA support from industry and concern about flexible authorization requirements reflect the tension between efficient access and the need for assurances that products will safely benefit patients.
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Affiliation(s)
- Jonathan J Darrow
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jerry Avorn
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Persons AK, Ball JE, Freeman C, Macias DM, Simpson CL, Smith BK, Burch V. RF. Fatigue Testing of Wearable Sensing Technologies: Issues and Opportunities. MATERIALS (BASEL, SWITZERLAND) 2021; 14:4070. [PMID: 34361264 PMCID: PMC8347841 DOI: 10.3390/ma14154070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/09/2021] [Accepted: 07/16/2021] [Indexed: 12/23/2022]
Abstract
Standards for the fatigue testing of wearable sensing technologies are lacking. The majority of published fatigue tests for wearable sensors are performed on proof-of-concept stretch sensors fabricated from a variety of materials. Due to their flexibility and stretchability, polymers are often used in the fabrication of wearable sensors. Other materials, including textiles, carbon nanotubes, graphene, and conductive metals or inks, may be used in conjunction with polymers to fabricate wearable sensors. Depending on the combination of the materials used, the fatigue behaviors of wearable sensors can vary. Additionally, fatigue testing methodologies for the sensors also vary, with most tests focusing only on the low-cycle fatigue (LCF) regime, and few sensors are cycled until failure or runout are achieved. Fatigue life predictions of wearable sensors are also lacking. These issues make direct comparisons of wearable sensors difficult. To facilitate direct comparisons of wearable sensors and to move proof-of-concept sensors from "bench to bedside", fatigue testing standards should be established. Further, both high-cycle fatigue (HCF) and failure data are needed to determine the appropriateness in the use, modification, development, and validation of fatigue life prediction models and to further the understanding of how cracks initiate and propagate in wearable sensing technologies.
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Affiliation(s)
- Andrea Karen Persons
- Department of Agricultural and Biological Engineering, Mississippi State University, 130 Creelman Street, Starkville, MS 39762, USA; (A.K.P.); (C.L.S.)
- Human Factors and Athlete Engineering, Center for Advanced Vehicular Systems, Mississippi State University, 200 Research Boulevard, Starkville, MS 39759, USA;
| | - John E. Ball
- Human Factors and Athlete Engineering, Center for Advanced Vehicular Systems, Mississippi State University, 200 Research Boulevard, Starkville, MS 39759, USA;
- Department of Electrical and Computer Engineering, Mississippi State University, 406 Hardy Road, Starkville, MS 39762, USA
| | - Charles Freeman
- School of Human Sciences, Mississippi State University, 255 Tracy Drive, Starkville, MS 39762, USA;
| | - David M. Macias
- Department of Kinesiology, Mississippi State University, P.O. Box 6186, Starkville, MS 39762, USA;
- Columbus Orthopaedic Clinic, 670 Leigh Drive, Columbus, MS 39705, USA
| | - Chartrisa LaShan Simpson
- Department of Agricultural and Biological Engineering, Mississippi State University, 130 Creelman Street, Starkville, MS 39762, USA; (A.K.P.); (C.L.S.)
| | - Brian K. Smith
- Department of Industrial and Systems Engineering, Mississippi State University, 479-2 Hardy Road, Starkville, MS 39762, USA;
| | - Reuben F. Burch V.
- Human Factors and Athlete Engineering, Center for Advanced Vehicular Systems, Mississippi State University, 200 Research Boulevard, Starkville, MS 39759, USA;
- Department of Industrial and Systems Engineering, Mississippi State University, 479-2 Hardy Road, Starkville, MS 39762, USA;
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Dubin JR, Simon SD, Norrell K, Perera J, Gowen J, Cil A. Risk of Recall Among Medical Devices Undergoing US Food and Drug Administration 510(k) Clearance and Premarket Approval, 2008-2017. JAMA Netw Open 2021; 4:e217274. [PMID: 33956132 PMCID: PMC8103223 DOI: 10.1001/jamanetworkopen.2021.7274] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE The US Food and Drug Administration (FDA) uses 510(k) clearance and premarket approval (PMA) pathways to ensure device safety before marketing. Premarket approval evaluates high-risk medical devices and requires clinical trials, whereas 510(k) clearance evaluates moderate-risk devices and relies on benchtop (nonclinical and biomechanical) and descriptive data. Existing literature suggests that the clinical trials required by PMA are associated with reduced risk of recall compared with devices granted 510(k) clearance. Several investigators have found weaknesses in pivotal PMA trials, raising safety concerns. Furthermore, methodological factors may have led to a previous underestimation of recall risk for devices with PMA. OBJECTIVES To compare risk of recall and high-risk recall between devices that received 510(k) clearance and those that received PMA and to compare the risk of recall between devices for medical specialties. DESIGN, SETTING, AND PARTICIPANTS This cohort study compared devices with 510(k) clearance vs those with PMA that reached the market between January 1, 2008, and December 31, 2017. Two- to 12-year follow-up was obtained from the FDA's 510(k) and PMA medical device database. Orthopedic surgery was chosen arbitrarily as the reference category for analysis between specialties because no baseline exists. Statistical analysis was performed from February 1 to November 1, 2020. MAIN OUTCOMES AND MEASURES The FDA issues recalls for safety concerns. These recalls are stratified into class I, II, and III, with class I representing high-risk issues for serious harm or death. The main outcome was the hazard ratio of any recall and class I recall between devices with PMA and those with 510(k) clearance. The secondary outcome was the recall hazard ratio between specialties with respect to the reference category. A single Cox proportional hazards regression model evaluating the association of medical specialty and FDA approval pathway with the risk of recall was performed. RESULTS During the study period, 28 246 devices received 510(k) clearance and 310 devices (10.7%) received PMA; 3012 devices (10.7%) with 510(k) clearance and 84 devices (27.1%) with PMA were recalled. A total of 216 devices (0.8%) with 510(k) clearance and 16 devices (5.2%) with PMA had class I recalls. Devices with PMA compared with those with 510(k) clearance had a hazard ratio for recall of 2.74 (95% CI, 2.19-3.44; P < .001) and a hazard ratio for high-risk recall of 7.30 (95% CI, 4.39-12.13; P < .001). Only radiologic devices were associated with an increased risk of recall (hazard ratio, 1.57; 95% CI, 1.32-1.87; P < .001), whereas 6 specialties were assocated with a decreased risk compared with the orthopedic reference category: general and plastic surgery, otolaryngology, obstetrics and gynecology, physical medicine, hematology, and general hospital. CONCLUSIONS AND RELEVANCE This study suggests that high-risk medical devices approved via PMA are associated with a greater risk of recall than previously reported. Most recalls are for devices with 510(k) clearance, also raising safety concerns. Strengthening postmarketing surveillance strategies and pivotal trials may improve device safety.
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Affiliation(s)
- Jonathan R. Dubin
- Department of Orthopedic Surgery, University of Missouri–Kansas City, Kansas City
- Department of Orthopedic Surgery, Truman Medical Center, Kansas City, Missouri
| | - Stephen D. Simon
- Department of Medical and Health Informatics, University of Missouri–Kansas City, Kansas City
| | - Kirsten Norrell
- Department of Orthopedic Surgery, University of Missouri–Kansas City, Kansas City
- Department of Orthopedic Surgery, Truman Medical Center, Kansas City, Missouri
| | - Jacob Perera
- Department of Orthopedic Surgery, University of Missouri–Kansas City, Kansas City
| | - Jacob Gowen
- Department of Orthopedic Surgery, University of Missouri–Kansas City, Kansas City
| | - Akin Cil
- Department of Orthopedic Surgery, University of Missouri–Kansas City, Kansas City
- Department of Orthopedic Surgery, Truman Medical Center, Kansas City, Missouri
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Saleem N, Ismail MK, Tombazzi CR, Soin S, Dhruva SS. Endoscopic transmission of carbapenem-resistant Enterobacteriaceae: implications for U.S. Food and Drug Administration approval and postmarket surveillance of endoscopic devices. Gastrointest Endosc 2021; 93:231-238. [PMID: 32750323 DOI: 10.1016/j.gie.2020.07.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022]
Abstract
Since the first widely reported case cluster of duodenoscope-associated transmission of carbapenem-resistant Enterobacteriaceae (CRE) in 2013 that affected 38 patients, similar outbreaks have occurred throughout the world. The U.S. Food and Drug Administration (FDA), Centers for Disease Control and Prevention, professional gastroenterology societies, and endoscope manufacturers have taken multiple steps to address this issue. Unlike prior outbreaks attributed to lapses in cleaning and reprocessing, transmission and outbreaks have continued to occur despite compliance with current reprocessing guidelines. A definitive method of duodenoscope reprocessing remains elusive, and the FDA recently recommended transition to new designs with disposable components that do not require reprocessing. The first fully disposable duodenoscope received FDA clearance as a "breakthrough" device in December 2019. Although the human, microbiologic, and endoscopic design factors responsible for infectious transmissions and disinfecting techniques to avoid them have been examined, discussion has not included the critical role of FDA regulation of duodenoscopes through the 510(k) clearance pathway and the mechanisms of postmarket surveillance, including adverse event reporting. We present an overview of the FDA approval of duodenoscopes by analyzing the FDA's 510(k) premarket notification database for data supporting clearance of duodenoscope models implicated in CRE-related outbreaks as well as subsequently required postmarket studies. We address the policy implications of CRE outbreaks on postmarketing surveillance and the need for increased gastroenterologist involvement in the life cycle of duodenoscopes and other medical devices. This includes reporting thorough adverse event data to the FDA and device manufacturers, supporting active surveillance studies to ensure safety and effectiveness, and evaluating implementation of recommendations to reduce adverse events.
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Affiliation(s)
- Nasir Saleem
- Division of Gastroenterology, Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
| | - Mohammad K Ismail
- Division of Gastroenterology, Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Claudio R Tombazzi
- Division of Gastroenterology, Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sarthak Soin
- Department of Internal Medicine, Saint Joseph Hospital, Chicago, Illinois, USA
| | - Sanket S Dhruva
- Department of Medicine, UCSF School of Medicine, San Francisco, and Veterans Affairs Health Care System, San Francisco, California, USA
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Postmarket Modifications of High-risk Plastic Surgery Devices. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2621. [PMID: 32309074 PMCID: PMC7159931 DOI: 10.1097/gox.0000000000002621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/19/2019] [Indexed: 12/04/2022]
Abstract
Background: In the United States, high-risk medical devices must be cleared through the premarket approval (PMA) pathway, which requires clinical evidence ensuring safety and efficacy. Approved devices can be modified and reintroduced to market without additional study through the PMA supplemental review track. This study characterizes the changes of high-risk plastic surgery devices once they undergo initial clearance. Methods: A retrospective, cross-sectional analysis of the Food and Drug Administration (FDA) PMA database. The following data were extracted from the PMA database (January 1, 1980 to December 31, 2018): initial clearance date, device type, the number and type of supplement, supplement reason, and product withdrawal date. Data from the FDA medical device recall database were also extracted and reported. The median number of device modifications and median lifetime of device-years were calculated. Results: There have been 39 original plastic surgery devices approved by the FDA. There was no significant change with respect to initial clearance dates for original devices over time (r = 0.28; P = 0.084). PMA supplement usage has significantly increased with time (rs = 0.9174, P = 0.000). Overall, approved plastic surgery devices have undergone a median of 11 changes (IQR, 3–35). Breast implant devices collectively underwent the most modifications with a median of 28 modifications per device (IQR, 20.25–33.25). Conclusions: Over the past 2 decades, plastic surgery device manufacturers have significantly increased the use of supplement track review. High-risk plastic surgery devices may undergo frequent minor changes without clinical evidence to support the safety and efficacy of modified versions.
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Abstract
OBJECTIVES To more clearly define the landscape of digital medical devices subject to US Food and Drug Administration (FDA) oversight, this analysis leverages publicly available regulatory documents to characterise the prevalence and trends of software and cybersecurity features in regulated medical devices. DESIGN We analysed data from publicly available FDA product summaries to understand the frequency and recent time trends of inclusion of software and cybersecurity content in publicly available product information. SETTING The full set of regulated medical devices, approved over the years 2002-2016 included in the FDA's 510(k) and premarket approval databases. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the share of devices containing software that included cybersecurity content in their product summaries. Secondary outcomes were differences in these shares (a) over time and (b) across regulatory areas. RESULTS Among regulated devices, 13.79% were identified as including software. Among these products, only 2.13% had product summaries that included cybersecurity content over the period studied. The overall share of devices including cybersecurity content was higher in recent years, growing from an average of 1.4% in the first decade of our sample to 5.5% in 2015 and 2016, the most recent years included. The share of devices including cybersecurity content also varied across regulatory areas from a low of 0% to a high of 22.2%. CONCLUSIONS To ensure the safest possible healthcare delivery environment for patients and hospitals, regulators and manufacturers should work together to make the software and cybersecurity content of new medical devices more easily accessible.
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Affiliation(s)
- Ariel Dora Stern
- Harvard Business School Technology and Operations Management, Boston, Massachusetts, USA
- Harvard-MIT Center for Regulatory Science, Boston, Massachusetts, USA
| | - William J Gordon
- Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Adam B Landman
- Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Daniel B Kramer
- Harvard Medical School, Boston, Massachusetts, USA
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Rajan PV, Holtzman JN, Kesselheim AS, Yeh RW, Kramer DB. Landscape of Cardiovascular Device Registries in the United States. J Am Heart Assoc 2019; 8:e012756. [PMID: 31433706 PMCID: PMC6585371 DOI: 10.1161/jaha.119.012756] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 04/24/2019] [Indexed: 12/03/2022]
Abstract
Background Regulators increasingly rely on registries for decision making related to high-risk medical devices in the United States. However, the limited uniform standards for registries may create substantial variability in registry implementation and utility to regulators. We surveyed the current landscape of US cardiovascular device registries and chart the extent of inconsistency in goals, administration, enrollment procedures, and approach to data access. Methods and Results A systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines identified studies (1995-2017) referencing cardiovascular device registries with a US-based institution. Registries were then evaluated by reviewing associated articles and websites. Extracted data included device type, primary scientific aim(s), funding, stewardship (eg, administration of registry procedures), enrollment procedures, informed consent process, and mechanisms to access data for research. The 138 cardiovascular device registries in the cohort covered devices addressing interventional cardiology (65.9%), arrhythmias (15.2%), heart failure (10.1%), and valvular disease (10.1%). While the majority (55.8%) were industry-funded, stewardship was predominantly overseen by academic centers (74.0%). Most registry participation was voluntary (77.5%), but a substantial minority (19.7%) were required as a condition of device implantation. Informed consent requirements varied widely, with written consent required in only 55.1% of registries. Registry data were primarily accessible only to stewards (84.1%), with 13.8% providing pathways for external applications. Conclusions The majority of cardiovascular device registries were funded privately under the auspices of academic institutions, which set the rules for data access. The substantial variation between cardiovascular device registries suggests a role for regulators to further strengthen guidelines to improve quality, consistency, and ethical standards.
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Affiliation(s)
- Prashant V. Rajan
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyBeth Israel Deaconess Medical CenterBostonMA
- Harvard Medical SchoolBostonMA
| | - Jessica N. Holtzman
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyBeth Israel Deaconess Medical CenterBostonMA
- Harvard Medical SchoolBostonMA
| | - Aaron S. Kesselheim
- Harvard Medical SchoolBostonMA
- Program on Regulation, Therapeutics, and Law (PORTAL)Department of Pharmacoepidemiology and PharmacoeconomicsBrigham and Women's HospitalBostonMA
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyBeth Israel Deaconess Medical CenterBostonMA
- Harvard Medical SchoolBostonMA
| | - Daniel B. Kramer
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyBeth Israel Deaconess Medical CenterBostonMA
- Harvard Medical SchoolBostonMA
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Mayer M, Baeumner AJ. A Megatrend Challenging Analytical Chemistry: Biosensor and Chemosensor Concepts Ready for the Internet of Things. Chem Rev 2019; 119:7996-8027. [DOI: 10.1021/acs.chemrev.8b00719] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Michael Mayer
- Institute of Analytical Chemistry, Chemo- and Biosensors, University of Regensburg, 93040 Regensburg, Germany
| | - Antje J. Baeumner
- Institute of Analytical Chemistry, Chemo- and Biosensors, University of Regensburg, 93040 Regensburg, Germany
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13
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Sweat-Based in Vitro Diagnostics (IVD): From Sample Collection to Point-of-Care Testing (POCT). JOURNAL OF ANALYSIS AND TESTING 2019. [DOI: 10.1007/s41664-019-00097-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Sauerland S, Fujita-Rohwerder N, Zens Y, Molnar S. Premarket evaluation of medical devices: a cross-sectional analysis of clinical studies submitted to a German ethics committee. BMJ Open 2019; 9:e027041. [PMID: 30798319 PMCID: PMC6398724 DOI: 10.1136/bmjopen-2018-027041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE To assess the methodological quality of pre-market clinical studies performed on medical devices (MDs), including in-vitro diagnostic (IVD) MDs, in Europe. DESIGN Observational cross-sectional study. SETTING A large German ethics committee. MATERIALS From the consecutive sample of study applications between March 2010 and December 2013, we selected MD study applications requiring approval by an ethics committee and the competent federal authority. These included pre-market studies on devices that had not yet received a CE (Conformité Européenne) mark or had previously been CE marked for a different indication. Also included were post-CE studies requiring federal authority approval because the study entailed additional invasive or otherwise burdensome components. PRIMARY AND SECONDARY OUTCOME MEASURES Besides the design of the studies, we assessed the planned sample size, study duration and other aspects. RESULTS 122 study applications were analysed: 98 (80%) concerned therapeutic rather than diagnostic devices and 84 (69%) were pre-market studies. The proportion of studies on class I, IIa, IIb and III devices was 10%, 15%, 28% and 39%, respectively. 10 studies (8%) investigated IVD MDs. A randomised controlled trial (RCT) was planned in 70 (57%) of the 122 applications; studies with non-randomised control groups (n=23; 19%) or without controls (n=29; 24%) were less common. In the sub-group of pre-market studies on therapeutic devices, the proportion of RCTs was 66% (43/65). The median sample size was 120 participants or samples (IQR 53-229). The median study duration was 24 (14-38) months. 87 studies (71%) considered at least one patient-relevant outcome. 12 (17%) and 37 (53%) of the 70 RCTs applied a fully or partially blinded design, respectively. CONCLUSION A large proportion of MD studies in Germany apply a randomised controlled design, thus contradicting the industry argument that RCTs on MDs are commonly infeasible.
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Affiliation(s)
- Stefan Sauerland
- Department of Non-Drug Interventions, Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany
| | - Naomi Fujita-Rohwerder
- Department of Non-Drug Interventions, Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany
| | - Yvonne Zens
- Department of Non-Drug Interventions, Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany
| | - Sandra Molnar
- Department of Non-Drug Interventions, Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany
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15
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Janetos TM, Xu RS, Walter JR, Xu S. Reducing FDA regulations for medical devices: cutting red tape or putting patients' lives at risk? Expert Rev Med Devices 2018; 15:859-861. [PMID: 30345824 DOI: 10.1080/17434440.2018.1539666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Timothy M Janetos
- a Department of Ophthalmology , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Rebecca S Xu
- b Feinberg School of Medicine , Northwestern University , Chicago , IL , USA
| | - Jessica R Walter
- c Department of Obstetrics and Gynecology , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Shuai Xu
- d Department of Dermatology , Northwestern University Feinberg School of Medicine , Chicago , IL , USA.,e Center for Bio-Integrated Electronics , Northwestern University , Chicago , IL , USA
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16
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Abstract
Medical devices are essential in the diagnosis and treatment of otolaryngologic disease. The US Food and Drug Administration (FDA) is tasked with assuring the safety and effectiveness of these devices. Otolaryngologists, in turn, are often responsible for helping patients understand risks, benefits, and alternatives when deciding whether to rely on devices in their care. To best counsel patients, otolaryngologists should be aware of the strengths and limitations of device regulation by the FDA. This article reviews the FDA regulatory framework for medical devices, premarket evidentiary standards for marketing devices, and postmarket methods of safety surveillance.
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Affiliation(s)
- Vinay K Rathi
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.
| | - Stacey T Gray
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA
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17
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Fraser AG, Butchart EG, Szymański P, Caiani EG, Crosby S, Kearney P, Van de Werf F. The need for transparency of clinical evidence for medical devices in Europe. Lancet 2018; 392:521-530. [PMID: 30017550 DOI: 10.1016/s0140-6736(18)31270-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/21/2018] [Accepted: 05/29/2018] [Indexed: 12/27/2022]
Abstract
To use medical devices rationally, health-care professionals must base their choices of which devices to recommend for individual patients on an objective appraisal of their safety and clinical efficacy. The evidence submitted by manufacturers when seeking approval of their high-risk devices must be publicly available, including technical performance and premarket clinical studies. Giving physicians access to this information supplements the peer-reviewed scientific literature and might be essential for comparing alternative devices within any class. Interested patients should be encouraged to review the evidence for any device that has been recommended for them. The new EU law on medical devices states that the manufacturer is to prepare a summary of the evidence for any implantable or high-risk device. Defining its content, however, has been delegated to implementing legislation, which is now being considered. From a clinical perspective, it is imperative that all evidence reviewed by notified bodies and regulatory authorities is disclosed-with the exception, if justified, only of technical specifications that are considered confidential or manufacturing details that are protected as intellectual property-and public access to this evidence must be guaranteed by EU law. From ethical and other perspectives, there are no grounds for less clinical evidence being available to health-care professionals about the medical devices that they use than is already available for new pharmaceutical products. Full transparency is needed; without it, informed decisions relating to the use of new medical devices will remain impossible.
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Affiliation(s)
- Alan G Fraser
- School of Medicine, Cardiff University, University Hospital of Wales, Cardiff, UK; Department of Cardiovascular Sciences, Katholieke University Leuven, Leuven, Belgium.
| | - Eric G Butchart
- Retired Consultant Cardiothoracic Surgeon, University Hospital of Wales, Cardiff, UK
| | | | - Enrico G Caiani
- Department of Biomedical Engineering and e-Health, Politecnico di Milano, Milan, Italy
| | | | - Peter Kearney
- Department of Cardiology, Cork University Hospital, Wilton, Cork, Ireland
| | - Frans Van de Werf
- Department of Cardiovascular Sciences, Katholieke University Leuven, Leuven, Belgium
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18
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Szymanski P, Leggeri I, Kautzner J, Fraser AG. The new European regulatory framework for medical devices: opportunities for engagement by electrophysiologists. Europace 2018; 20:902-905. [PMID: 29244116 DOI: 10.1093/europace/eux344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Piotr Szymanski
- Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland.,ESC EU Regulatory Affairs Committee on Medical Devices, The European Heart House, 2035 Route des Colles, Les Templiers, 06903 Sophia Antipolis, France
| | - Ilaria Leggeri
- Advocacy and Representation Division, European Society of Cardiology, The European Heart House, 2035 Route des Colles, Les Templiers, 06903 Sophia Antipolis, France
| | - Josef Kautzner
- ESC EU Regulatory Affairs Committee on Medical Devices, The European Heart House, 2035 Route des Colles, Les Templiers, 06903 Sophia Antipolis, France.,Institute for Clinical and Experimental Medicine, Charles University Medical School I, Videnska 1958/9, CZ-140 21 Prague, Czech Republic
| | - Alan G Fraser
- ESC EU Regulatory Affairs Committee on Medical Devices, The European Heart House, 2035 Route des Colles, Les Templiers, 06903 Sophia Antipolis, France.,Cardiff University, Cardiff, UK.,Wales Heart Research Institute, University Hospital of Wales, Heath Park, CF14 4XN Cardiff, Wales, UK
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19
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Ezaldein HH, Scott JF, Yin ES, Ventura A, DeRuyter NP, Leffell DJ. Transparency and Dermatologic Device Approval by the US Food and Drug Administration. JAMA Dermatol 2018; 154:273-280. [PMID: 29365020 DOI: 10.1001/jamadermatol.2017.5757] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The US Food and Drug Administration approves Class III medical devices via the premarket approval pathway, often requiring clinical data on safety and efficacy. Manufacturers can submit incremental device changes via supplemental applications, which are not subjected to such vetting measures and can cause understudied changes that lead to drift from a device's original design. Objectives To characterize the postapproval changes to Class III dermatologic devices and to evaluate inconsistencies in the use of the premarket approval pathway. Design, Setting, and Participants This study was a cross-sectional retrospective cohort analysis of a public US Food and Drug Administration database for premarket approval of devices. Included were dermatologic devices approved by the US Food and Drug Administration between January 1, 1980, and November 1, 2016, through the premarket pathway for device approval. Main Outcomes and Measures Original devices were identified, and their supplements were characterized chronologically, by review track, and by modification category. Results The 27 dermatologic devices studied consisted of 14 injectables, 11 photodynamic therapies, a dermal replacement matrix, and a diagnostic imaging instrument. Supplemental applications are increasingly used: the data-requiring panel-track pathway was the least common approach (2.8% [16 of 562 supplements]), while the 30-day track, which does not require clinical data, was most frequently used (42.5% [239 of 562 supplements]). Four devices (14.8%) underwent low-risk recalls (Class II or Class III), and 10 devices (37.0%) were voluntarily withdrawn. Conclusions and Relevance As manufacturers make increasing use of supplemental applications, minor device changes may occur without supporting clinical data, which could pose a safety risk to patients.
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Affiliation(s)
- Harib H Ezaldein
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.,Department of Surgery, University of Washington, Seattle.,Department of Dermatology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jeffrey F Scott
- Department of Dermatology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Emily S Yin
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Alessandra Ventura
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut.,Dermatology Department, University of Rome Tor Vergata, Rome, Italy
| | | | - David J Leffell
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
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20
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Muskens IS, Gupta S, Hulsbergen A, Moojen WA, Broekman ML. Introduction of Novel Medical Devices in Surgery: Ethical Challenges of Current Oversight and Regulation. J Am Coll Surg 2017; 225:558-565. [DOI: 10.1016/j.jamcollsurg.2017.07.1068] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/19/2017] [Accepted: 07/19/2017] [Indexed: 10/19/2022]
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21
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Talati RK, Gupta AS, Xu S, Ghobadi CW. Major FDA medical device recalls in ophthalmology from 2003 to 2015. Can J Ophthalmol 2017; 53:98-103. [PMID: 29631834 DOI: 10.1016/j.jcjo.2017.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 07/05/2017] [Accepted: 08/08/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess recent high-risk ophthalmic medical device recalls. METHODS The publicly available Food and Drug Administration Center for Devices and Radiological Health database was mined for Class I (high-risk) ophthalmic device recalls from January 1, 2003 to December 31, 2015. The number of Class I ophthalmic device recalls was quantified. Additionally, recall characteristics and market entry data were determined for each device. RESULTS Twelve Class I ophthalmic device recall events were identified, collectively affecting over 68 million units in distribution. A median of 147,491 units (range 20 to 57,252,581) were recalled per event. 9 out of 12 recalls (75%) had at least one documented occurrence of an adverse event to a patient. Pre-market related issues accounted for one device recall (8%), post-market related issues accounted for nine device recalls (75%), and two device recalls (17%) were indeterminate. 510(k) clearance was the most common pathway to market, accounting for 50% of Class I recalls. Three devices were approved through pre-market approval (PMA) pathway, two devices were exempt from review, and one device failed to register with the FDA. CONCLUSION Class I recalls surrounding ophthalmology are relatively infrequent compared to other medical specialties. However, given the impact of Class I recalls in the field, ophthalmologists have an impetus to advocate for stronger device regulation particularly in the context of post-marketing surveillance.
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Affiliation(s)
- Rushi K Talati
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ankur S Gupta
- NorthShore Hospital in affiliation with the University of Chicago, Chicago, IL
| | - Shuai Xu
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL
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22
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Lohman ME, Ghobadi CW, Xu S. Device Safety Implications of the Clinical Data Leading to US Food and Drug Administration Approval of Soft-Tissue Fillers. JAMA FACIAL PLAST SU 2017; 19:421-429. [DOI: 10.1001/jamafacial.2017.0082] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mary E. Lohman
- Department of Medicine, McGaw Medical Center, Northwestern University, Chicago, Illinois
| | - Comeron W. Ghobadi
- Department of Radiology, University of Chicago Medical Center, Chicago, Illinois
| | - Shuai Xu
- Department of Dermatology, McGaw Medical Center, Northwestern University, Chicago, Illinois
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23
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Zheng SY, Dhruva SS, Redberg RF. Characteristics of Clinical Studies Used for US Food and Drug Administration Approval of High-Risk Medical Device Supplements. JAMA 2017; 318:619-625. [PMID: 28810022 PMCID: PMC5817595 DOI: 10.1001/jama.2017.9414] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE High-risk medical devices often undergo modifications, which are approved by the US Food and Drug Administration (FDA) through various kinds of premarket approval (PMA) supplements. There have been multiple high-profile recalls of devices approved as PMA supplements. OBJECTIVE To characterize the quality of the clinical studies and data (strength of evidence) used to support FDA approval of panel-track supplements (a type of PMA supplement pathway that is used for significant changes in a device or indication for use and always requires clinical data). DESIGN AND SETTING Descriptive study of clinical studies supporting panel-track supplements approved by the FDA between April 19, 2006, and October 9, 2015. EXPOSURE Panel-track supplement approval. MAIN OUTCOMES AND MEASURES Methodological quality of studies including randomization, blinding, type of controls, clinical vs surrogate primary end points, use of post hoc analyses, and reporting of age and sex. RESULTS Eighty-three clinical studies supported the approval of 78 panel-track supplements, with 71 panel-track supplements (91%) supported by a single study. Of the 83 studies, 37 (45%) were randomized clinical trials and 25 (30%) were blinded. The median number of patients per study was 185 (interquartile range, 75-305), and the median follow-up duration was 180 days (interquartile range, 84-270 days). There were a total of 150 primary end points (mean [SD], 1.8 [1.2] per study), and 57 primary end points (38%) were compared with controls. Of primary end points with controls, 6 (11%) were retrospective controls and 51 (89%) were active controls. One hundred twenty-one primary end points (81%) were surrogate end points. Thirty-three studies (40%) did not report age and 25 (30%) did not report sex for all enrolled patients. The FDA required postapproval studies for 29 of 78 (37%) panel-track supplements. CONCLUSIONS AND RELEVANCE Among clinical studies used to support FDA approval of high-risk medical device modifications, fewer than half were randomized, blinded, or controlled, and most primary outcomes were based on surrogate end points. These findings suggest that the quality of studies and data evaluated to support approval by the FDA of modifications of high-risk devices should be improved.
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Affiliation(s)
- Sarah Y. Zheng
- Department of Psychiatry, University of California, San Francisco
| | - Sanket S. Dhruva
- Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine, New Haven, Connecticut
- Veterans Affairs Connecticut Healthcare System, West Haven
| | - Rita F. Redberg
- Division of Cardiology, University of California, San Francisco
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24
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Abstract
PURPOSE OF REVIEW The Food and Drug Administration (FDA) is responsible for assuring the safety, effectiveness, and quality of medical devices in the USA. Extensive review times coupled with the demand for necessary treatments have prompted the policymakers to implement measures to speed medical devices to market.The purpose of this review is to summarize the evolution of the regulatory pathways through which medical devices utilized in diabetes care gain market access. RECENT FINDINGS Regulatory pathways, ranging from premarket notification to premarket approval, require distinct, yet necessary ("least burdensome") evidence demonstrating a device's safety and effectiveness. Collaboration between manufacturers, regulators, and patients has resulted in the development and approval of novel diabetes care devices, including the first hybrid closed-loop artificial pancreas. Policy provisions, ranging from the least burdensome approach to the "breakthrough device" expedited pathway, aim to balance innovation, access, and safety. Clinicians must be aware of the evolving regulatory landscape and play an active role in enhancing patient safety.
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Affiliation(s)
- Shelley A Jazowski
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, McGravan-Greenberg Hall, CB #7411, Chapel Hill, NC, 27599-7411, USA
| | - Aaron N Winn
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, McGravan-Greenberg Hall, CB #7411, Chapel Hill, NC, 27599-7411, USA.
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Incremental Revisions across the Life Span of Ophthalmic Devices after Initial Food and Drug Administration Premarket Approval, 1979-2015. Ophthalmology 2017; 124:1237-1246. [PMID: 28501378 DOI: 10.1016/j.ophtha.2017.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/17/2017] [Accepted: 03/20/2017] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To characterize the frequency, nature, and regulatory mechanisms by which ophthalmic devices are iteratively modified after initial Food and Drug Administration (FDA) Premarket Approval (PMA). DESIGN Retrospective cross-sectional analysis using publicly available FDA data. PARTICIPANTS Ophthalmic devices initially approved via the FDA's PMA pathway between January 1, 1979 and December 31, 2015. METHODS We used the FDA's PMA Database to identify and characterize initial approvals and subsequent postmarket modifications to Class III ophthalmic devices. The FDA Recalls Database was used to identify associated safety events. MAIN OUTCOME MEASURES Median iterated life span (timespan across which modifications occurred after initial PMA) and median number of supplements approved per device, by device type, and overall, stratified by regulatory pathway and modification type. RESULTS Between 1979 and 2015, the FDA approved 168 original ophthalmic devices via the PMA pathway and 2813 subsequent modifications. More than one third (n = 64; 38%) of original approvals were intraocular lenses. Overall, devices underwent a median of 11 postmarket modifications (interquartile range [IQR], 3-24.8) across a median 10.0-year iterated life span (IQR, 4.1-16.7). The majority of devices (n = 144; 86%) underwent more than 1 postapproval modification, including more than 1 design modification (n = 84; 50%). The median number of changes altering device design or labeling was 3.5 (IQR, 1-9). Although manufacturing alterations (n = 834 of 2813; 30%) were the most frequent type of revision, changes involving device design (n = 667; 24%) and labeling (n = 417; 15%) were common. Recalled devices underwent more frequent postapproval modifications per year (median, 1.4; IQR, 0.7-2.3; mean, 1.5; 95% confidence interval, 1.1-1.9) in the period preceding recall than did nonrecalled devices (median, 0.5; IQR, 0.2-1.1; mean, 0.8; 95% confidence interval, 0.7-1.0) across their market approval period (P < 0.001). CONCLUSIONS Most ophthalmic devices approved via the FDA's PMA pathway have undergone extensive revisions, including serial design and labeling changes, since their initial approvals, often without supporting clinical data. Ophthalmologists should take into consideration that cumulative revisions may render the clinical evidence that supported an original FDA approval less relevant to newer device models.
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Medical Device Approvals Through the Premarket Approval Pathway in Obstetrics and Gynecology From 2000 to 2015: Process and Problems. Obstet Gynecol 2017; 127:1110-1117. [PMID: 27159747 DOI: 10.1097/aog.0000000000001430] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recent controversies surrounding obstetrics and gynecology devices, including a permanent sterilization device, pelvic meshes, and laparoscopic morcellators, highlight the need for deeper understanding of obstetrics and gynecology medical device regulation. The U.S. Food and Drug Administration premarket approval database was queried for approvals assigned to the obstetrics and gynecology advisory committee from January 2000 to December 2015. Eighteen device approvals occurred in the time period studied. The most common clinical indications included endometrial ablation (33%), contraception (28%), and fetal monitoring (17%). The median approval time was 290 days (range 178-1,399 days). Regarding the pivotal trials leading to approval, there were 11 randomized controlled trials, one randomized crossover study, five nonrandomized prospective studies, and two human factor studies. Fourteen devices (78%) met their primary clinical efficacy endpoint. Only 12 of 18 devices were required to conduct postmarket surveillance. A significant proportion of devices (42%) were approved on the basis of nonrandomized controlled trials. Three devices have been withdrawn after approval, all of which were either not referred or not recommended for approval by the obstetrics and gynecology advisory committee. Of the three devices withdrawn from the market, two failed to demonstrate clinical benefit in their pivotal trials. One device was not required to undergo postmarketing surveillance and was subsequently withdrawn as a result of patient safety concerns. Our results reveal significant weaknesses in the preapproval and postapproval regulation of high-risk obstetrics and gynecology devices. Greater specialty group involvement is necessary to ensure the development of safe and clinically effective devices.
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Hutchison K, Sparrow R. Ethics and the cardiac pacemaker: more than just end-of-life issues. Europace 2017; 20:739-746. [DOI: 10.1093/europace/eux019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 03/30/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Katrina Hutchison
- Philosophy Program, ARC Centre of Excellence for Electromaterials Science, Monash University, Wellington Road, Melbourne, VIC 3800, Australia
| | - Robert Sparrow
- Philosophy Program, Centre for Human Bioethics, ARC Centre of Excellence for Electromaterials Science, Monash University, Wellington Road, Melbourne, VIC 3800, Australia
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29
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Radiological Medical Device Innovation: Approvals via the Premarket Approval Pathway From 2000 to 2015. J Am Coll Radiol 2017; 14:24-33. [DOI: 10.1016/j.jacr.2016.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 08/07/2016] [Accepted: 08/16/2016] [Indexed: 11/20/2022]
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30
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Drummond M, Tarricone R, Torbica A. Incentivizing research into the effectiveness of medical devices. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2016; 17:1055-1058. [PMID: 27492637 DOI: 10.1007/s10198-016-0820-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Michael Drummond
- Centre for Health Economics, University of York, Alcuin A Block, Heslington, York, YO10 5DD, UK.
- Centre for Research on Health and Social Care Management (Cergas), Università Bocconi, Milan, Italy.
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (Cergas), Università Bocconi, Milan, Italy
| | - Aleksandra Torbica
- Centre for Research on Health and Social Care Management (Cergas), Università Bocconi, Milan, Italy
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31
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Graber MA, Bailey O. The wizard behind the curtain: programmers as providers. Philos Ethics Humanit Med 2016; 11:4. [PMID: 27491390 PMCID: PMC4974808 DOI: 10.1186/s13010-016-0038-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 07/22/2016] [Indexed: 06/06/2023] Open
Abstract
It is almost universally accepted that traditional provider-patient relationships should be governed, at least in part, by the ethical principles set forth by Beauchamp and Childress (Beauchamp and Childress, Principles of biomedical ethics, 1979). These principles include autonomy, beneficence, non-maleficence and justice (Beauchamp and Childress, Principles of biomedical ethics, 1979). Recently, however, the nature of medial practice has changed. The pervasive presence of computer technology in medicine raises interesting ethical questions. In this paper we argue that some software designers should be considered health care providers and thus be subject the ethical principles incumbent upon "traditional" providers. We argue that these ethical responsibilities should be applied explicitly rather than as a passive, implicit, set of guidelines.
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Affiliation(s)
- Mark A Graber
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 1008 JCP, Iowa City, IA, 52242, USA.
- Department of Family Medicine, University of Iowa Carver College of Medicine, Iowa City, USA.
| | - Olivia Bailey
- Department of Family Medicine, University of Iowa Carver College of Medicine, Iowa City, USA
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Saleem N, Xu S. Overview of High-Risk Medical Device Innovation in Gastroenterology from 2000 to 2014: Enhancing the Pipeline. Dig Dis Sci 2016; 61:2165-2174. [PMID: 27003144 DOI: 10.1007/s10620-016-4117-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 03/04/2016] [Indexed: 12/21/2022]
Abstract
Medical devices are a critical component in the diagnosis and treatment of diseases of the alimentary tract. The United States Food and Drug Administration database was mined for high-risk medical device development via the pre-market approval (PMA) pathway from 2000 to 2014. In total, there were only nine GI (gastrointestinal) devices approved during this period. Furthermore, only one GI device was granted expedited review. The clinical studies leading to approval were mostly limited to non-blinded, non-randomized studies. Only a minority of pivotal studies defined and met their primary endpoints (27 %). Eight out of nine devices were required to undergo post-marketing studies. Ultimately, cardiology led with 157 total approvals in the time period studied. GI ranked 12 out of 18 across various medical and surgical specialties and accounted for <2 % of total PMA approvals. Future efforts should focus on spurring more high-risk device innovation in the field.
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Affiliation(s)
- Nasir Saleem
- Department of Internal Medicine, Presence Saint Joseph Hospital in Affiliation with University of Illinois College of Medicine, 2900 N. Lake Shore Dr., Chicago, IL, 60657, USA.
| | - Shuai Xu
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Willis AR, Ippolito JA, Patterson FR, Benevenia J, Beebe KS. Customizable orthopaedic oncology implants: one institution's experience with meeting current IRB and FDA requirements. SPRINGERPLUS 2016; 5:967. [PMID: 27429877 PMCID: PMC4932010 DOI: 10.1186/s40064-016-2696-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 06/27/2016] [Indexed: 11/17/2022]
Abstract
Background Customizable orthopaedic implants are often needed for patients with primary malignant bone tumors due to unique anatomy or complex mechanical problems. Currently, obtaining customizable orthopaedic implants for orthopaedic oncology patients can be an arduous task involving submitting approval requests to the Institutional Review Board (IRB) and the Food and Drug Administration (FDA). There is great potential for the delay of a patient’s surgery and unnecessary paperwork if the submission pathways are misunderstood or a streamlined protocol is not in place. Purpose The objective of this study was to review the existing FDA custom implant approval pathways and to determine whether this process was improved with an institutional protocol. Methods An institutional protocol for obtaining IRB and FDA approval for customizable orthopaedic implants was established with the IRB at our institution in 2013. This protocol was approved by the IRB, such that new patients only require submission of a modification to the existing protocol with individualized patient information. During the two-year period of 2013–2014, eight patients were retrospectively identified as having required customizable implants for various orthopaedic oncology surgeries. The dates of request for IRB approval, request for FDA approval, and total time to surgery were recorded, along with the specific pathway utilized for FDA approval. Results The average patient age was 12 years old (7–21 years old). The average time to IRB approval of a modification to the pre-approved protocol was 14 days (7–21 days). Average time to FDA approval after submission of the IRB approval to the manufacturer was 12.5 days (7–19 days). FDA approval was obtained for all implants as compassionate use requests in accordance with Section 561 of the Federal Food Drug and Cosmetic Act’s expanded access provisions. Conclusions Establishment of an institutional protocol with pre-approval by the IRB can expedite the otherwise time-consuming and complicated process of obtaining customizable orthopaedic implants for orthopaedic oncology patients. Level of evidence Retrospective case series, Level IV. See the Guidelines for authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Joseph A Ippolito
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, ACC Building, Suite D-1610, Newark, NJ 07103 USA
| | - Francis R Patterson
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, ACC Building, Suite D-1610, Newark, NJ 07103 USA
| | - Joseph Benevenia
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, ACC Building, Suite D-1610, Newark, NJ 07103 USA
| | - Kathleen S Beebe
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, ACC Building, Suite D-1610, Newark, NJ 07103 USA
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Hwang TJ, Sokolov E, Franklin JM, Kesselheim AS. Comparison of rates of safety issues and reporting of trial outcomes for medical devices approved in the European Union and United States: cohort study. BMJ 2016; 353:i3323. [PMID: 27352914 PMCID: PMC4925918 DOI: 10.1136/bmj.i3323] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate safety alerts and recalls, publication of key trial outcomes, and subsequent US approval of high profile medical devices introduced in the European Union. DESIGN Cohort study. SETTING Novel cardiovascular, orthopedic, and neurologic devices approved in the EU through Conformité Européenne marking between 2005 and 2010. DATA SOURCES Public and commercial databases searched up to January 2016 for press releases and announcements of approvals; public Food and Drug Administration and European regulatory authority databases for US approvals and safety alerts and recalls; and Medline, Embase, and Web of Science for peer reviewed publications. MAIN OUTCOME MEASURES We categorized the novelty of the devices in the study sample as a "major innovation" or an "other change," and extracted descriptive data about the devices and information on any safety alerts and withdrawals. Linear regression models examined factors associated with differential EU and US approvals. Cox proportional hazards regression models were used to evaluate factors associated with safety alerts and recalls and the publication of trial outcomes for devices categorized as major innovations. Models controlled for time, therapeutic category, regulatory pathway, size of sponsoring company, and indicator variables for devices approved first in the EU and devices approved only in the EU. RESULTS 67% (206/309) of devices identified were approved in both the US and the EU, of which 63% (129/206) were approved first in the EU. The unadjusted rate of safety alerts and recalls for devices approved first in the EU was 27% (62/232) compared with 14% (11/77) for devices approved first in the US. The adjusted hazard ratio for safety alerts and recalls was 2.9 (95% confidence interval 1.4 to 6.2) for devices approved first in the EU. The results of pivotal trials were published for 49% (37/75) of devices categorized as major innovations, with an overall publication rate of 37% five years after approval. CONCLUSIONS Devices approved first in the EU are associated with an increased risk of post-marketing safety alerts and recalls. Poor trial publication rates mean that patients and clinicians need greater regulatory transparency to make informed decisions about treatment.
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Affiliation(s)
- Thomas J Hwang
- Faculty of Arts and Sciences, Harvard University, Cambridge, MA, USA Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Elisaveta Sokolov
- Department of Neurology and Neurophysiology, King's College London, London, UK
| | - Jessica M Franklin
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Samuel AM, Rathi VK, Grauer JN, Ross JS. How do Orthopaedic Devices Change After Their Initial FDA Premarket Approval? Clin Orthop Relat Res 2016; 474:1053-68. [PMID: 26584802 PMCID: PMC4773325 DOI: 10.1007/s11999-015-4634-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 11/06/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND The FDA approves novel, high-risk medical devices through the premarket approval (PMA) process based on clinical evidence supporting device safety and effectiveness. Devices subsequently may undergo postmarket modifications that are approved via one of several PMA supplement review tracks, usually without additional supporting clinical data. While orthopaedic devices cleared via the less rigorous 510(k) pathway have been studied previously, devices cleared through the PMA pathway and those receiving postmarket PMA supplements warrant further investigation. QUESTIONS/PURPOSES We asked: What are (1) the types of original orthopaedic devices receiving FDA PMA approval, (2) the number and rate of postmarket device changes approved per device, (3) the types of PMA supplement review tracks used, (4) the types of device changes approved via the various review tracks, and (5) the number of device recalls and market withdrawals that have occurred for these devices? METHODS All original PMA-approved orthopaedic devices between January 1982 and December 2014 were identified in the publically available FDA PMA database. The number of postmarket device changes approved, the PMA supplement review track used, the types of postmarket changes, and any FDA recalls for each device were assessed. RESULTS Seventy original orthopaedic devices were approved via the FDA PMA pathway between 1982 and 2014. These devices included 34 peripheral joint implants or prostheses, 18 spinal implants or prostheses, and 18 other devices or materials. These devices underwent a median 6.5 postmarket changes during their lifespan or 1.0 changes per device-year (interquartile range, 0.4-1.9). The rate of new postmarket device changes approved per active device, increased from less than 0.5 device changes per year in 1983 to just fewer than three device changes per year in 2014, or an increase of 0.05 device changes per device per year in linear regression analysis (95% CI, 0.04-0.07). Among the 765 total postmarket changes, 172 (22%) altered device design or components. The majority of the design changes were reviewed via either the real-time review track (n = 98; 57%), intended for minor design changes, or the 180-day review track (n = 71; 41%), intended for major design changes. Finally, a total of 12 devices had FDA recalls at some point during their lifespan, two being for hip prostheses with high revision rates. CONCLUSIONS Relatively few orthopaedic devices undergo the FDA PMA process before reaching the market. Orthopaedic surgeons should be aware that high-risk medical devices cleared via the FDA's PMA pathway do undergo considerable postmarket device modification after reaching the market, with potential for design "drift," ie, shifting away from the initially tested and approved device designs. CLINICAL RELEVANCE As the ultimate end-users of these devices, orthopaedic surgeons should be aware that even among high-risk medical devices approved via the FDA's PMA pathway, considerable postmarket device modification occurs. Continued postmarket device monitoring will be essential to limit patient safety risks.
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Affiliation(s)
- Andre M. Samuel
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT 06510 USA ,Yale School of Medicine, New Haven, CT USA
| | | | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT 06510 USA
| | - Joseph S. Ross
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT USA ,Department of Health Policy and Management, Yale School of Public Health, New Haven, CT USA
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Day CS, Park DJ, Rozenshteyn FS, Owusu-Sarpong N, Gonzalez A. Analysis of FDA-Approved Orthopaedic Devices and Their Recalls. J Bone Joint Surg Am 2016; 98:517-24. [PMID: 26984921 DOI: 10.2106/jbjs.15.00286] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The U.S. Food and Drug Administration (FDA) evaluates medical devices by two main pathways. The more stringent Premarket Approval (PMA) review requires clinical trials, and the Premarket Notification 510(k) process generally exempts devices from clinical trials if they prove to be substantially equivalent to existing devices. We hypothesized that orthopaedic devices are more likely to be cleared through the 510(k) process and thus are more susceptible to being recalled. METHODS Using the FDA's public database, we searched for the following: PMA and 510(k) clearances for orthopaedics and non-orthopaedic specialties, including General & Plastic Surgery, Gastroenterology/Urology, Obstetrics/Gynecology, and Ear Nose & Throat, from 1992 to 2012. Additionally, we searched for all device recall events from 2002 to 2012. For the top-twenty recall companies, we calculated the odds ratio that compares the likelihood of recall for 510(k)-approved devices with that for PMA-approved devices. RESULTS From 1992 to 2012, the proportion of non-orthopaedic devices cleared via the 510(k) process decreased from 91% to 53%. However, that of orthopaedic devices decreased only from 94% to 88%. Furthermore, we found that from 2002 to 2012, the percentage of recalled devices was 17.8% for 510(k)-cleared devices and 1.6% for PMA-approved devices. When stratified on the basis of recall class, the odds ratios were 3.5 for class-I devices, 13.2 for class-II devices, and 8.5 for class-III devices. CONCLUSIONS Given that 510(k)-cleared devices were 11.5 times more likely to be recalled than PMA-approved devices, it is concerning that most orthopaedic devices are cleared through the 510(k) process with limited clinical trials data. CLINICAL RELEVANCE When orthopaedic surgeons are considering using a new device clinically in their patients, it is important for them to consider how the new device was approved by the FDA. If the device was approved by the 510(k) pathway, then it may have been approved without additional clinical studies confirming efficacy or safety.
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Affiliation(s)
- Charles S Day
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts Harvard Medical School, Boston, Massachusetts
| | - David J Park
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts Tufts University School of Medicine, Boston, Massachusetts
| | - Frederick S Rozenshteyn
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts Tufts University School of Medicine, Boston, Massachusetts
| | - Nana Owusu-Sarpong
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts Tufts University School of Medicine, Boston, Massachusetts
| | - Aldebarani Gonzalez
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Gupta N, Kiley ML, Anthony F, Young C, Brar S, Kwaku K. Multi-Center, Community-Based Cardiac Implantable Electronic Devices Registry: Population, Device Utilization, and Outcomes. J Am Heart Assoc 2016; 5:e002798. [PMID: 26961369 PMCID: PMC4943256 DOI: 10.1161/jaha.115.002798] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The purpose of this study is to describe key elements, clinical outcomes, and potential uses of the Kaiser Permanente–Cardiac Device Registry. Methods and Results This is a cohort study of implantable cardioverter defibrillators (ICD), pacemakers (PM), and cardiac resynchronization therapy (CRT) devices implanted between January 1, 2007 and December 31, 2013 by ≈400 physicians in 6 US geographical regions. Registry data variables, including patient characteristics, comorbidities, indication for procedures, complications, and revisions, were captured using the healthcare system's electronic medical record. Outcomes were identified using electronic screening algorithms and adjudicated via chart review. There were 11 924 ICDs, 33 519 PMs, 4472 CRTs, and 66 067 leads registered. A higher proportion of devices were implanted in males: 75.1% (ICD), 55.0% (PM), and 66.7% (CRT), with mean patient age 63.2 years (ICD), 75.2 (PM), and 67.2 (CRT). The 30‐day postoperative incidence of tamponade, hematoma, and pneumothorax were ≤0.3% (ICD), ≤0.6% (PM), and ≤0.4% (CRT). Device failures requiring revision occurred at a rate of 2.17% for ICDs, 0.85% for PMs, and 4.93% for CRTs, per 100 patient observation years. Superficial infection rates were <0.03% for all devices; deep infection rates were 0.6% (ICD), 0.5% (PM), and 1.0% (CRT). Results were used to monitor vendor‐specific variations and were systematically shared with individual regions to address potential variations in outcomes, utilization, and to assist with the management of device recalls. Conclusions The Kaiser Permanente–Cardiac Device Registry is a robust tool to monitor postprocedural patient outcomes and postmarket surveillance of implants and potentially change practice patterns.
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Affiliation(s)
- Nigel Gupta
- Department of Electrophysiology, Southern CA Permanente Medical Group, Los Angeles, CA
| | - Mary Lou Kiley
- Surgical Outcomes & Analysis Department, Kaiser Permanente, San Diego, CA
| | - Faith Anthony
- Surgical Outcomes & Analysis Department, Kaiser Permanente, San Diego, CA
| | - Charlie Young
- Department of Electrophysiology, The Permanente Medical Group, Santa Clara, CA
| | - Somjot Brar
- Department of Electrophysiology, Southern CA Permanente Medical Group, Los Angeles, CA
| | - Kevin Kwaku
- Department of Cardiology, Hawaii Permanente Medical Group, Honolulu, HI
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Affiliation(s)
- Joseph S Ross
- From Section of General Internal Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine; Department of Health Policy and Management, Yale University School of Public Health; and Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S.R.); and Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (A.S.K.).
| | - Aaron S Kesselheim
- From Section of General Internal Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine; Department of Health Policy and Management, Yale University School of Public Health; and Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S.R.); and Program On Regulation, Therapeutics, And Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (A.S.K.)
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Zeitler EP, Al-Khatib SM, Slotwiner D, Kumar UN, Varosy P, Van Wagoner DR, Marcus GM, Kusumoto FM, Blum L. Proceedings from Heart Rhythm Society's emerging technologies forum, Boston, MA, May 12, 2015. Heart Rhythm 2016; 13:e39-49. [PMID: 26801401 PMCID: PMC4724379 DOI: 10.1016/j.hrthm.2015.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Indexed: 11/15/2022]
Abstract
Physicians are in an excellent position to significantly contribute to medical device innovation, but the process of bringing an idea to the bedside is complex. To begin to address these perceived barriers, the Heart Rhythm Society convened a forum of stakeholders in medical device innovation in conjunction with the 2015 Heart Rhythm Society Annual Scientific Sessions. The forum facilitated open discussion on medical device innovation, including obstacles to physician involvement and possible solutions. This report is based on the themes that emerged. First, physician innovators must take an organized approach to identifying unmet clinical needs and potential solutions. Second, extensive funds, usually secured through solicitation for investment, are often required to achieve meaningful progress, developing an idea into a device. Third, planning for regulatory requirements of the US Food and Drug Administration and Centers for Medicare & Medicaid Services is essential. In addition to these issues, intellectual property and overall trends in health care, including international markets, are critically relevant considerations for the physician innovator. Importantly, there are a number of ways in which professional societies can assist physician innovators to navigate the complex medical device innovation landscape, bring clinically meaningful devices to market more quickly, and ultimately improve patient care. These efforts include facilitating interaction between potential collaborators through scientific meetings and other gatherings; collecting, evaluating, and disseminating state-of-the-art scientific information; and representing the interests of members in interactions with regulators and policymakers.
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Affiliation(s)
- Emily P Zeitler
- Duke Clinical Research Institute; Duke University Hospital, Durham, North Carolina.
| | - Sana M Al-Khatib
- Duke Clinical Research Institute; Duke University Hospital, Durham, North Carolina
| | | | - Uday N Kumar
- Biodesign Program, Stanford University, Stanford, California
| | - Paul Varosy
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - David R Van Wagoner
- Cleveland Clinic Lerner College of Medicine, Case Western Research University, Cleveland, Ohio
| | - Gregory M Marcus
- University of California, San Francisco, San Francisco, California
| | | | - Laura Blum
- Heart Rhythm Society, Washington, District of Columbia
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Sarpatwari A, Kesselheim AS. The 21st century cures act: Opportunities and challenges. Clin Pharmacol Ther 2015; 98:575-7. [DOI: 10.1002/cpt.208] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- A Sarpatwari
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine; Brigham and Women's Hospital and Harvard Medical School; Boston Massachusetts USA
| | - AS Kesselheim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine; Brigham and Women's Hospital and Harvard Medical School; Boston Massachusetts USA
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Rathi VK, Ross JS, Samuel AM, Mehra S. Postmarket Modifications of High-Risk Therapeutic Devices in Otolaryngology Cleared by the US Food and Drug Administration. Otolaryngol Head Neck Surg 2015; 153:400-8. [DOI: 10.1177/0194599815587508] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 04/28/2015] [Indexed: 11/16/2022]
Abstract
Objective: The US Food and Drug Administration (FDA) grants initial marketing clearance for novel high-risk medical devices via the premarket approval (PMA) pathway, which requires clinical data demonstrating safety and effectiveness. Manufacturers may subsequently file supplemental PMA applications (supplements) to implement incremental device changes, usually without additional clinical data. Given the potentially significant clinical implications of using new device models, this study characterized the frequency and nature of changes to high-risk therapeutic otolaryngic devices cleared via the PMA pathway. Study Design: Retrospective cohort study. Setting: FDA PMA database. Methods: Original high-risk therapeutic otolaryngic devices and supplements were identified. Supplements were characterized by clearance date, change type, and review track, including real-time (design-minor) and 180-day (design-major) tracks. Median device lineage life span (postmarket period over which changes occurred) and median number of changes per original device were calculated. Results: Through 2014, the FDA cleared 14 original high-risk therapeutic otolaryngic devices via the PMA pathway and 528 incremental changes via supplements. Devices were modified over a median 10.5-year life span (interquartile range, 4.4-15.8; range, 0.7-24.1), and they underwent a median 22 changes (interquartile range, 10-70; range, 2-108). Over half (272 of 528; 52%) altered device design, most of which were reviewed via the 180-day track (199 of 272; 73%) intended for major design changes. Few real-time design changes (11 of 73; 15%) were designated by the FDA as “minor.” Conclusion: A substantial number of incremental changes have been made to high-risk therapeutic otolaryngic devices over time, including many major design changes without supporting clinical data.
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Affiliation(s)
- Vinay K. Rathi
- Yale University School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Saral Mehra
- Department of Surgery (Otolaryngology), Yale University School of Medicine, New Haven, Connecticut, New Haven, Connecticut
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Kramer DB, Hatfield LA, McGriff D, Ellis CR, Gura MT, Samuel M, Retel LK, Hauser RG. Transvenous implantable cardioverter-defibrillator lead reliability: implications for postmarket surveillance. J Am Heart Assoc 2015; 4:e001672. [PMID: 26025935 PMCID: PMC4599526 DOI: 10.1161/jaha.114.001672] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background As implantable cardioverter-defibrillator technology evolves, clinicians and patients need reliable performance data on current transvenous implantable cardioverter-defibrillator systems. In addition, real-world reliability data could inform postmarket surveillance strategies directed by regulators and manufacturers. Methods and Results We evaluated Medtronic Sprint Quattro, Boston Scientific Endotak, and St Jude Medical Durata and Riata ST Optim leads implanted by participating center physicians between January 1, 2006 and September 1, 2012. Our analytic sample of 2653 patients (median age 65, male 73%) included 445 St Jude, 1819 Medtronic, and 389 Boston Scientific leads. After a median of 3.2 years, lead failure was 0.28% per year (95% CI, 0.19 to 0.43), with no statistically significant difference among manufacturers. Simulations based on these results suggest that detecting performance differences among generally safe leads would require nearly 10 000 patients or very long follow-up. Conclusions Currently marketed implantable cardioverter-defibrillator leads rarely fail, which may be reassuring to clinicians advising patients about risks and benefits of transvenous implantable cardioverter-defibrillator systems. Regulators should consider the sample size implications when designing comparative effectiveness studies and evaluating new technology for preventing sudden cardiac death.
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Affiliation(s)
- Daniel B Kramer
- Beth Israel Deaconess Medical Center, Boston, MA (D.B.K., M.S.) Hebrew SeniorLife Institute for Aging Research, Boston, MA (D.B.K.) Harvard Medical School, Boston, MA (D.B.K., L.A.H.)
| | | | - Deepa McGriff
- Minneapolis Heart Institute Foundation, Minneapolis, MN (D.M.G., L.K.R., R.G.H.)
| | | | - Melanie T Gura
- Northeast Ohio Cardiovascular Specialists, Akron, OH (M.T.G.)
| | - Michelle Samuel
- Beth Israel Deaconess Medical Center, Boston, MA (D.B.K., M.S.)
| | - Linda Kallinen Retel
- Minneapolis Heart Institute Foundation, Minneapolis, MN (D.M.G., L.K.R., R.G.H.)
| | - Robert G Hauser
- Minneapolis Heart Institute Foundation, Minneapolis, MN (D.M.G., L.K.R., R.G.H.)
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Ghafar-Zadeh E. Wireless integrated biosensors for point-of-care diagnostic applications. SENSORS 2015; 15:3236-61. [PMID: 25648709 PMCID: PMC4367357 DOI: 10.3390/s150203236] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 12/03/2014] [Indexed: 11/16/2022]
Abstract
Recent advances in integrated biosensors, wireless communication and power harvesting techniques are enticing researchers into spawning a new breed of point-of-care (POC) diagnostic devices that have attracted significant interest from industry. Among these, it is the ones equipped with wireless capabilities that drew our attention in this review paper. Indeed, wireless POC devices offer a great advantage, that of the possibility of exerting continuous monitoring of biologically relevant parameters, metabolites and other bio-molecules, relevant to the management of various morbid diseases such as diabetes, brain cancer, ischemia, and Alzheimer's. In this review paper, we examine three major categories of miniaturized integrated devices, namely; the implantable Wireless Bio-Sensors (WBSs), the wearable WBSs and the handheld WBSs. In practice, despite the aforesaid progress made in developing wireless platforms, early detection of health imbalances remains a grand challenge from both the technological and the medical points of view. This paper addresses such challenges and reports the state-of-the-art in this interdisciplinary field.
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Affiliation(s)
- Ebrahim Ghafar-Zadeh
- Department of Electrical Engineering and Computer Sciences, Lassonde School of Engineering, York University, Toronto, ON M3J1P3, Canada.
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Sedrakyan A. Precarious innovation of anti-infective coated devices. Lancet 2014; 384:111-3. [PMID: 24718271 DOI: 10.1016/s0140-6736(14)60577-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Art Sedrakyan
- Patient-Centered Comparative Effectiveness Program, Departments of Health Policy and Research and Cardiac Surgery, Weill Cornell Medical College of Cornell University, New York, NY 10065, USA.
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Zannad F, Stough WG, Piña IL, Mehran R, Abraham WT, Anker SD, De Ferrari GM, Farb A, Geller NL, Kieval RS, Linde C, Redberg RF, Stein K, Vincent A, Woehrle H, Pocock SJ. Current challenges for clinical trials of cardiovascular medical devices. Int J Cardiol 2014; 175:30-7. [PMID: 24861254 DOI: 10.1016/j.ijcard.2014.05.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 05/08/2014] [Accepted: 05/11/2014] [Indexed: 01/01/2023]
Abstract
Several features of cardiovascular devices raise considerations for clinical trial conduct. Prospective, randomized, controlled trials remain the highest quality evidence for safety and effectiveness assessments, but, for instance, blinding may be challenging. In order to avoid bias and not confound data interpretation, the use of objective endpoints and blinding patients, study staff, core labs, and clinical endpoint committees to treatment assignment are helpful approaches. Anticipation of potential bias should be considered and planned for prospectively in a cardiovascular device trial. Prospective, single-arm studies (often referred to as registry studies) can provide additional data in some cases. They are subject to selection bias even when carefully designed; thus, they are generally not acceptable as the sole basis for pre-market approval of high risk cardiovascular devices. However, they complement the evidence base and fill the gaps unanswered by randomized trials. Registry studies present device safety and effectiveness in day-to-day clinical practice settings and detect rare adverse events in the post-market period. No single research design will be appropriate for every cardiovascular device or target patient population. The type of trial, appropriate control group, and optimal length of follow-up will depend on the specific device, its potential clinical benefits, the target patient population and the existence (or lack) of effective therapies, and its anticipated risks. Continued efforts on the part of investigators, the device industry, and government regulators are needed to reach the optimal approach for evaluating the safety and performance of innovative devices for the treatment of cardiovascular disease.
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Affiliation(s)
- Faiez Zannad
- INSERM, Centre d'Investigation Clinique 9501 Unité 1116, Centre Hospitalier Universitaire, France; Department of Cardiology, Université de Lorraine, Nancy, France.
| | - Wendy Gattis Stough
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | - Ileana L Piña
- Department of Medicine, Division of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - Roxana Mehran
- Cardiovascular Research Foundation, New York, NY, USA; Mount Sinai Medical Center, New York, NY, USA
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - Stefan D Anker
- Applied Cachexia Research, Department of Cardiology, Charité Medical School, Campus Virchow-Klinikum, Berlin, Germany
| | | | - Andrew Farb
- U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Nancy L Geller
- National Heart Lung and Blood Institute, Bethesda, MD, USA
| | | | - Cecilia Linde
- Department of Cardiology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | | | | | | | - Holger Woehrle
- ResMed Science Center, ResMed, Martinsried, Germany; Sleep and Ventilation Center Blaubeuren/Lung Center, Ulm, Germany
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Abstract
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.
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Affiliation(s)
- Benjamin N. Rome
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, 1620 Tremont St., Suite 3030, Boston, MA 02120, USA
- Harvard Medical School, 25 Shattuck St., Boston, MA 02215, USA
| | - Daniel B. Kramer
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, 1620 Tremont St., Suite 3030, Boston, MA 02120, USA
- Harvard Medical School, 25 Shattuck St., Boston, MA 02215, USA
- Beth Israel Deaconess Medical Center, 185 Pilgrim Road, West Campus B4, Boston, MA 02215, USA
- Hebrew SeniorLife Institute for Aging Research, Roslindale, MA, USA
| | - Aaron S. Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, 1620 Tremont St., Suite 3030, Boston, MA 02120, USA
- Harvard Medical School, 25 Shattuck St., Boston, MA 02215, USA
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