FDA Regulation and Approval of Medical Devices: 1976-2020

Integrated Devices: A New Regulatory Pathway to Promote Revolutionary Innovation

Policy Points Current medical device regulatory frameworks date back half a century and are ill suited for the next generation of medical devices that involve a significant software component. Existing Food and Drug Administration efforts are insufficient because of a lack of statutory authority, whereas international examples offer lessons for improving and harmonizing domestic medical device regulatory policy. A voluntary alternative pathway built upon two-stage review with individual component review followed by holistic review for integrated devices would provide regulators with new tools to address a changing medical device marketplace.

Roadmap for Clinical Translation of Mobile Microrobotics

Medical microrobotics is an emerging field to revolutionize clinical applications in diagnostics and therapeutics of various diseases. On the other hand, the mobile microrobotics field has important obstacles to pass before clinical translation. This article focuses on these challenges and provides a roadmap of medical microrobots to enable their clinical use. From the concept of a "magic bullet" to the physicochemical interactions of microrobots in complex biological environments in medical applications, there are several translational steps to consider. Clinical translation of mobile microrobots is only possible with a close collaboration between clinical experts and microrobotics researchers to address the technical challenges in microfabrication, safety, and imaging. The clinical application potential can be materialized by designing microrobots that can solve the current main challenges, such as actuation limitations, material stability, and imaging constraints. The strengths and weaknesses of the current progress in the microrobotics field are discussed and a roadmap for their clinical applications in the near future is outlined.

Health Care Fraud and Abuse: Lessons From One of the Largest Scandals of the 21st Century in the Field of Spine Surgery

Up to hundreds of billions of dollars are annually lost to fraud and abuse in the US health care, making it a significant burden on the system. This study investigates a specific instance of health care fraud in spine surgery, in which a medical device company ended up paying $75 million to settle violations of the False Claims Act. We review the surgical background regarding the kyphoplasty procedure, as well as its billing and reimbursement details. We also explore the official legal complaint brought by the US Department of Justice to tell the story of how one of the most significant medical innovations in spine surgery in the 21st century turned into a widespread fraudulent marketing scheme. In the sequence, we provide a detailed root cause analysis of this scandal and propose some proactive measures that can be taken to avoid such type of unfortunate events. Ultimately, this historical health care scandal constitutes a valuable lesson to surgeons, health care administrators, medical device companies, and policymakers on how misaligned incentives and subsequent unscrupulous practices can transform a medical innovation into an unfortunate tale of fraud and deceit.

Advances in 3D Inner Ear Reconstruction Software for Cochlear Implants: A Comprehensive Review

Auditory impairment stands as a pervasive global issue, exerting significant effects on individuals' daily functioning and interpersonal engagements. Cochlear implants (CIs) have risen as a cutting-edge solution for severe to profound hearing loss, directly stimulating the auditory nerve with electrical signals. The success of CI procedures hinges on precise pre-operative planning and post-operative evaluation, highlighting the significance of advanced three-dimensional (3D) inner ear reconstruction software. Accurate pre-operative imaging is vital for identifying anatomical landmarks and assessing cochlear deformities. Tools like 3D Slicer, Amira and OTOPLAN provide detailed depictions of cochlear anatomy, aiding surgeons in simulating implantation scenarios and refining surgical approaches. Post-operative scans play a crucial role in detecting complications and ensuring CI longevity. Despite technological advancements, challenges such as standardization and optimization persist. This review explores the role of 3D inner ear reconstruction software in patient selection, surgical planning, and post-operative assessment, tracing its evolution and emphasizing features like image segmentation and virtual simulation. It addresses software limitations and proposes solutions, advocating for their integration into clinical practice. Ultimately, this review underscores the impact of 3D inner ear reconstruction software on cochlear implantation, connecting innovation with precision medicine.

Sleep and Mood Among Women With Histories of Depression When They Used a Responsive Infant Bassinet During the COVID-19 Pandemic

OBJECTIVE

To describe the experiences of women with histories of depression who used a responsive infant bassinet during the first 6 months after birth during the COVID-19 pandemic.

DESIGN

Secondary qualitative descriptive study with analytic expansion.

SETTING

United States.

PARTICIPANTS

Women (N = 139) who gave birth up to 6 months previously and had histories of depression.

METHODS

We used Kyngäs's method of inductive content analysis to analyze 109 open-ended responses that were collected between August 2020 to November 2021 as part of a previously conducted longitudinal study of women who used a responsive bassinet.

RESULTS

Most participants indicated that the responsive bassinet improved their infants' sleep, which, in turn, subjectively improved their sleep and mood. External stressors and challenges presented barriers to good sleep for the participants and their infants, and participants described how these challenges contributed to their symptoms related to mood. When participants reported that they used the responsive bassinet, they shared that their infants were swaddled in the supine sleep position. Participants who did not use the bassinet commonly reported unsafe sleep practices. We identified seven themes from the data: Improved Maternal Sleep Quality, Barriers to Good Maternal Sleep, Mood and Sleep Go Hand and Hand, External Stressors Impair Mood, Improved Infant Sleep Quality, Barriers to Good Infant Sleep, and Safe Sleep Positioning.

CONCLUSION

These findings can be used to inform clinicians on how a responsive bassinet may offer women at high risk for postpartum depression improved sleep and instrumental support. Future researchers should use validated measures to objectively evaluate rates of postpartum depression and sleep quality in high-risk women when using a responsive bassinet.

Beyond the 510(k): The regulation of novel moderate-risk medical devices, intellectual property considerations, and innovation incentives in the FDA's De Novo pathway

Moderate-risk medical devices constitute 99% of those that have been regulated by the U.S. Food and Drug Administration (FDA) since it gained authority to regulate medical technology nearly five decades ago. This article presents an analysis of the interaction between the 510(k) process -the historically dominant path to market for most medical devices- and the De Novo pathway, a more recent alternative that targets more novel devices, including those involving new technologies, diagnostics, hardware, and software. The De Novo pathway holds significant potential for innovators seeking to define new categories of medical devices, as it represents a less burdensome approach than would have otherwise been needed historically. Moreover, it supports the FDA in its effort to modernize the long-established 510(k) pathway by promoting the availability of up-to-date device "predicates" upon which subsequent device applications can be based, reflecting positive spillovers that are likely to encourage manufacturers to adopt current state-of-the-art technologies and modern standards of safety and effectiveness. We analyze the of characteristics all the De Novo classification requests to date, including the submission type, trends, FDA review times, and device types. After characterizing how the De Novo process has been used over time, we discuss its unique challenges and opportunities with respect to medical device software and AI-enabled devices, including considerations for intellectual property, innovation, and competition economics.

Lifecycle evaluation of medical devices: supporting or jeopardizing patient outcomes? A comparative analysis of evaluation models

OBJECTIVES

Lack of evidence regarding safety and effectiveness at market entry is driving the need to consider adopting a lifecycle approach to evaluating medical devices, but it is unclear what lifecycle evaluation means. This research sought to explore the tacit meanings of "lifecycle" and "lifecycle evaluation" as embodied within evaluation models/frameworks used for medical devices.

METHODS

Drawing on qualitative evidence synthesis methods and using an inductive approach, novel methods were developed to identify, appraise, analyze, and synthesize lifecycle evaluation models used for medical devices. Data was extracted (including purpose; audience; characterization; outputs; timing; and type of model) from key texts for coding, categorization, and comparison, exploring embodied meaning across four broad perspectives.

RESULTS

Fifty-two models were included in the synthesis. They demonstrated significant heterogeneity of meaning, form, scope, timing, and purpose. The "lifecycle" may represent a single stage, a series of stages, a cycle of innovation, or a system. "Lifecycle evaluation" focuses on the overarching goal of the stakeholder group, and may use a single or repeated evaluation to inform decision-making regarding the adoption of health technologies (Healthcare), resource allocation (Policymaking), investment in new product development or marketing (Trade and Industry), or market regulation (Regulation). The adoption of a lifecycle approach by regulators has resulted in the deferral of evidence generation to the post-market phase.

CONCLUSIONS

Using a "lifecycle evaluation" approach to inform reimbursement decision-making must not be allowed to further jeopardize evidence generation and patient safety by accepting inadequate evidence of safety and effectiveness for reimbursement decisions.

Physicians' Perspectives On FDA Regulation Of Drugs And Medical Devices: A National Survey

Physicians' knowledge of Food and Drug Administration (FDA) approval processes is important in informing clinical decisions and patient discussions. Among a randomly selected national sample of 509 internists, cardiologists, and oncologists, 41 percent reported moderate or better understanding of the FDA's drug approval process, and 17 percent reported moderate or better understanding of the FDA's medical device approval process. Nearly all physicians thought that randomized, blinded trials that met primary endpoints should be very important factors required to secure regulatory approval. Also, nearly all physicians thought that the FDA should revoke approval for accelerated-approval drugs or breakthrough devices that did not show benefit in postapproval studies. Our findings suggest that physicians commonly lack familiarity with drug and medical device regulatory practices and are under the impression that the data supporting FDA drug and high-risk device approvals are more rigorous than they often are. Physicians would value more rigorous premarket evidence, as well as regulatory action for drugs and devices that do not demonstrate safety and effectiveness in the postmarket setting.

Security vulnerabilities in healthcare: an analysis of medical devices and software

The integration of IoT in healthcare has introduced vulnerabilities in medical devices and software, posing risks to patient safety and system integrity. This study aims to bridge the research gap and provide valuable insights for addressing healthcare vulnerabilities and their mitigation mechanisms. Software vulnerabilities related to health systems from 2001 to 2022 were collected from the National Vulnerability Database (NVD) systematized by software developed by the researchers and assessed by a medical specialist for their impact on patient well-being. The analysis revealed electronic health records, wireless infusion pumps, endoscope cameras, and radiology information systems as the most vulnerable. In addition, critical vulnerabilities were identified, including poor credential management and hard-coded credentials. The investigation provides some insights into the consequences of vulnerabilities in health software products, projecting future security issues by 2025, offers mitigation suggestions, and highlights trends in attacks on life support and health systems are also provided. The healthcare industry needs significant improvements in protecting medical devices from cyberattacks. Securing communication channels and network schema and adopting secure software practices is necessary. In addition, collaboration, regulatory adherence, and continuous security monitoring are crucial. Industries, researchers, and stakeholders can utilize these findings to enhance security and safeguard patient safety.

Considerations for the development of a field-based medical device for the administration of adjunctive therapies for snakebite envenoming

The timely administration of antivenom is the most effective method currently available to reduce the burden of snakebite envenoming (SBE), a neglected tropical disease that most often affects rural agricultural global populations. There is increasing interest in the development of adjunctive small molecule and biologic therapeutics that target the most problematic venom components to bridge the time-gap between initial SBE and the administration antivenom. Unique combinations of these therapeutics could provide relief from the toxic effects of regional groupings of medically relevant snake species. The application a PRISMA/PICO literature search methodology demonstrated an increasing interest in the rapid administration of therapies to improve patient symptoms and outcomes after SBE. Advice from expert interviews and considerations regarding the potential routes of therapy administration, anatomical bite location, and species-specific venom delivery have provided a framework to identify ideal metrics and potential hurdles for the development of a field-based medical device that could be used immediately after SBE to deliver adjunctive therapies. The use of subcutaneous (SC) or intramuscular (IM) injection were identified as potential routes of administration of both small molecule and biologic therapies. The development of a field-based medical device for the delivery of adjunctive SBE therapies presents unique challenges that will require a collaborative and transdisciplinary approach to be successful.

The Challenges in Conducting Economic Evaluations for Rehabilitation Technologies

Background

Health technology assessment (HTA) is an important evidentiary component in the decision-making process for the adoption of new healthcare technologies to the healthcare system. Economic evidence is an important consideration in HTAs. Recent systematic reviews in rehabilitation have shown a limited number of economic evaluations and high levels of uncertainty in the results. It is unclear whether there are challenges related to the field of rehabilitation and the technologies used in rehabilitation that inhibit the development of economic evidence.

Methods

In this study, economic evaluations in rehabilitation were reviewed. This was followed by a summary of the latest evidence on the challenges of conducting HTA for medical devices and the relationship with rehabilitation technologies. Finally, several considerations are suggested to improve the HTA of technologies that target rehabilitation. A literature review of Google Scholar and PubMed was conducted to identify reviews in economic evaluations in rehabilitation. A recent review on the barriers to HTA of medical devices in general was also examined to identify similar concerns with rehabilitation technologies.

Results

The challenges identified include the lack of high-quality studies, the interaction between the technology and the user, the short product life cycle, and estimation of efficacy in technologies with multiple target populations.

Conclusion

Overall, many of the challenges in evaluating medical devices also apply to rehabilitation interventions. Further research and discussion on these issues are necessary to increase the clinical evidence for rehabilitation technologies, strengthen the development of HTAs, and facilitate the use of technologies to improve the health of individuals requiring rehabilitation.

A novel 3D printed type II silk fibroin/polycaprolactone mesh for the treatment of pelvic organ prolapse

Pelvic organ prolapse (POP) is one of the common diseases in middle-aged and elderly women, caused by weakened pelvic floor muscle ligament tissue support. Pelvic floor reconstruction with mesh implantation has been proven to be an effective treatment for POP. However, traditional non-degradable and inflexible pelvic floor implantation meshes have been associated with pain, vaginal infections, and the need for additional surgeries. In this study, novel meshes with pre-designed structures were fabricated with solution-based electrohydrodynamic printing (EHDP) technology, using a series of polycaprolactone/silk fibroin composites as bioinks. The PCL/SF mesh mechanical performances were particularly enhanced with the addition of silk II, leading it to obtain higher adaptability with soft tissue repair. The mesh containing SF showed more robust degradation performance in the in vitro degradation assay. Furthermore, biocompatibility tests conducted on mouse embryonic fibroblasts (NIH/3T3) revealed enhanced cell affinity. Finally, the biocompatibility and tissue repair properties of PCL/SF mesh were verified through the implantation of meshes in the muscle defect site of mice. The results demonstrated that the 3D printed PCL/SF mesh prepared by EHDP exhibits superior mechanical properties, biocompatibility, biodegradability, as well as ligament and muscle fiber repair ability. The novel implantable meshes are promising for curing POP.

3D printing for bone regeneration: challenges and opportunities for achieving predictability

3D printing offers attractive opportunities for large-volume bone regeneration in the oro-dental and craniofacial regions. This is enabled by the development of CAD-CAM technologies that support the design and manufacturing of anatomically accurate meshes and scaffolds. This review describes the main 3D-printing technologies utilized for the fabrication of these patient-matched devices, and reports on their pre-clinical and clinical performance including the occurrence of complications for vertical bone augmentation and craniofacial applications. Furthermore, the regulatory pathway for approval of these devices is discussed, highlighting the main hurdles and obstacles. Finally, the review elaborates on a variety of strategies for increasing bone regeneration capacity and explores the future of 4D bioprinting and biodegradable metal 3D printing.

Characteristics and Results of Pediatric Medical Device Studies: 2017-2022

OBJECTIVES

The development of medical devices for children faces unique challenges that have contributed to a paucity of devices specifically designed and tested for children. Increased knowledge on research activities for pediatric devices can guide optimal study design and ensure timely dissemination of clinical findings.

METHODS

We performed a cross-sectional analysis of interventional studies registered on ClinicalTrials.gov, initiated January 1, 2017, through December 12, 2022, evaluating a Food and Drug Administration-regulated class II or III device, and enrolling any pediatric patients (aged ≤17 years). Data were extracted from ClinicalTrials.gov on study characteristics and from Devices@FDA on device features. For completed studies, we determined whether results were reported in a peer-reviewed publication as of December 27, 2022.

RESULTS

Among 482 studies, 406 (84.2%) examined a class II device and 76 (15.8%) a class III device. The most common device types were diabetes-related devices (N = 57, 11.8%) and monitors and measurement devices (N = 39, 8.1%). Most studies were single-center (N = 326, 67.6%), used a nonrandomized (N = 255, 52.9%), open label (N = 350, 72.6%) design, and were funded by academic institutions (N = 278, 57.7%) or industry (N = 142, 29.5%). A total of 291 (60.4%) studies included a primary outcome of only efficacy without safety endpoints. Among completed studies, more than half (N = 64, 51.6%) enrolled <50 participants and 71.0% (N = 88) <100. After median follow-up of 3.0 years, results were available in publications for 27 (21.8%) completed studies.

CONCLUSIONS

Our findings serve to inform programs and initiatives seeking to increase pediatric-specific device development. In addition to considerations on ensuring rigorous trial design, greater focus is needed on timely dissemination of results generated in pediatric device studies.

The 510(k) Third Party Review Program: Promise and Potential

Every year, the Food and Drug Administration (FDA) clears approximately 3,000 medical devices for marketing via the 510(k) pathway. These constitute 99% of all devices approved for human use and includes the premarket review of many devices incorporating newer technology such as artificial intelligence (AI), machine learning (ML), and other software. As the complexity of these novel technologies and the number of applications is expected to increase in the coming years, statutory changes such as the 2016 21st Century Cures Act, regulations, and guidance documents have increased both the volume and complexity of device review. Thus, the ability to streamline the review of less complex, low-to-moderate risk devices through the 510(k) pathway will maximize the FDA's capability to address other important, future-oriented regulatory questions. For over twenty five years, third party review organizations have served a defined function to assist with the review of 510(k) applications for a set of enumerated device classes. This paper reviews the history of FDA device regulation, the evolution of the 510(k) review pathway, and the recent history of the 510(k) third party review program. Finally, the paper addresses policy concerns from all stakeholders - including the FDA - along with policy suggestions to improve the third party review program and FDA device regulation writ large.

Question-based development of high-risk medical devices: A proposal for a structured design and review process

INTRODUCTION

The recent introduction of the European Medical Device Regulation poses stricter legislation for manufacturers developing medical devices in the EU. Many devices have been placed into a higher risk category, thus requiring more data before market approval, and a much larger focus has been placed on safety. For implantable and Class III devices, the highest risk class, clinical evidence is a necessity. However, the requirements of clinical study design and developmental outcomes are only described in general terms due to the diversity of devices.

METHODS

A structured approach to determining the requirements for the clinical development of high-risk medical devices is introduced, utilizing the question-based development framework, which is already used for pharmaceutical drug development. An example of a novel implantable device for haemodialysis demonstrates how to set up a relevant target product profile defining the device requirements and criteria. The framework can be used in the medical device design phase to define specific questions to be answered during the ensuing clinical development, based upon five general questions, specified by the question-based framework.

RESULTS

The result is a clear and evaluable overview of requirements and methodologies to verify and track these requirements in the clinical development phase. Development organizations will be guided to the optimal route, also to abandon projects destined for failure early on to minimize development risks.

CONCLUSION

The framework could facilitate communication with funding agencies, regulators and clinicians, while highlighting remaining 'known unknowns' that require answering in the post-market phase after sufficient benefit is established relative to the risks.

An Empirical Review of Key Glucose Monitoring Devices: Product Iterations and Patent Protection

INTRODUCTION

Each year, people with diabetes and their insurers or governments spend billions of dollars on blood glucose monitors and their associated components. These monitors have evolved substantially since their introduction in the 1970s, and manufacturers frequently protect original medical devices and their modifications by applying for and obtaining patent protection.

RESEARCH DESIGN AND METHODS

We tracked the product iterations of five widely used blood glucose monitors-manufactured by LifeScan, Dexcom, Abbott, Roche, and Trividia-from information published by the U.S. Food and Drug Administration (FDA), and extracted relevant U.S. patents.

RESULTS

We found 384 products made by the five manufacturers of interest, including 130 devices cleared through the 510(k) pathway, 251 approved via the premarket approval (PMA) pathway or via PMA supplements, and three for which de novo requests were granted. We identified 8095 patents potentially relevant to these devices, 2469 (31%) of which were likely to have expired by July 2021.

CONCLUSIONS

Manufacturers of blood glucose monitoring systems frequently modified their devices and obtained patent protection related to these device modifications. The therapeutic value of these new modifications should be critically evaluated and balanced against their additional cost. Older glucose monitoring devices that were marketed in decades past are now in the public domain and no longer protected by patents. Newer devices will join them as their patents expire. Increased demand from people with diabetes and the health care system for older, off-patent devices would provide an incentive for the medical device industry to make these devices more widely available, enabling good care at lower cost when such devices are substantially equivalent in effectiveness and safety. In turn, availability and awareness of older, off-patent devices could help stimulate such demand.

Biomarker Reproducibility Challenge: A Review of Non-Nucleotide Biomarker Discovery Protocols from Body Fluids in Breast Cancer Diagnosis

Breast cancer has now become the most commonly diagnosed cancer, accounting for one in eight cancer diagnoses worldwide. Non-invasive diagnostic biomarkers and associated tests are superlative candidates to complement or improve current approaches for screening, early diagnosis, or prognosis of breast cancer. Biomarkers detected from body fluids such as blood (serum/plasma), urine, saliva, nipple aspiration fluid, and tears can detect breast cancer at its early stages in a minimally invasive way. The advancements in high-throughput molecular profiling (omics) technologies have opened an unprecedented opportunity for unbiased biomarker detection. However, the irreproducibility of biomarkers and discrepancies of reported markers have remained a major roadblock to clinical implementation, demanding the investigation of contributing factors and the development of standardised biomarker discovery pipelines. A typical biomarker discovery workflow includes pre-analytical, analytical, and post-analytical phases, from sample collection to model development. Variations introduced during these steps impact the data quality and the reproducibility of the findings. Here, we present a comprehensive review of methodological variations in biomarker discovery studies in breast cancer, with a focus on non-nucleotide biomarkers (i.e., proteins, lipids, and metabolites), highlighting the pre-analytical to post-analytical variables, which may affect the accurate identification of biomarkers from body fluids.

Radiology Technologists' Perspective on Medical Imaging Device Use and Related Technologies: a Cross-sectional Survey with Respect to Hospital Type

This study aimed to evaluate radiology technicians' view on the use of medical imaging devices and related technology. A total of 142 radiology technicians from Turkey were included on a voluntary basis in this cross-sectional questionnaire-based study. The questionnaire form elicited items on sociodemographic and occupational characteristics and personal opinions regarding the use of medical imaging devices and related technology. Majority of technicians agreed or strongly agreed that they prefer the latest technology medical imaging devices (32.4 and 54.2%) and there is an increase in the number of medical imaging devices (36.6 and 35.9%) and medical imaging examinations (32.4 and 43.7%), while the growing societal demands in field of health have a role in the increase in the number of medical imaging devices (34.5 and 32.4%). However, a relatively lower percentage of technicians agreed or strongly agreed that the latest technology medical imaging devices should be purchased no matter how much it costs (31.7 and 33.8%) and the yearly increase in the number of imaging examinations indicates provision of an improved healthcare (21.1 and 23.2%). A higher agreement was reported by private hospital (3.9 ± 1.1, p = 0.035) and university hospital (4.1 ± 1.1, p = 0.009) employees vs. state hospital employees (3.4 ± 1.3) on the growing societal demands in field of health to have a role in the increase in the number of medical imaging devices. Apart from this, no significant difference was noted in opinions of technicians on the use of medical imaging devices and related technology with respect to hospital types. Our findings indicate that radiology technicians report a considerable imaging workload volume and a preference for working with higher number of medical imaging devices particularly those with the latest technology, whereas they also emphasize that the yearly increase in the number of imaging examinations does not indicate provision of an improved healthcare, and the cost should always be a criterion when purchasing the latest technology devices.

Use of Recalled Devices in New Device Authorizations Under the US Food and Drug Administration's 510(k) Pathway and Risk of Subsequent Recalls

IMPORTANCE

In the US, nearly all medical devices progress to market under the 510(k) pathway, which uses previously authorized devices (predicates) to support new authorizations. Current regulations permit manufacturers to use devices subject to a Class I recall-the FDA's most serious designation indicating a high probability of adverse health consequences or death-as predicates for new devices. The consequences for patient safety are not known.

OBJECTIVE

To determine the risk of a future Class I recall associated with using a recalled device as a predicate device in the 510(k) pathway.

DESIGN AND SETTING

In this cross-sectional study, all 510(k) devices subject to Class I recalls from January 2017 through December 2021 (index devices) were identified from the FDA's annual recall listings. Information about predicate devices was extracted from the Devices@FDA database. Devices authorized using index devices as predicates (descendants) were identified using a regulatory intelligence platform. A matched cohort of predicates was constructed to assess the future recall risk from using a predicate device with a Class I recall.

MAIN OUTCOMES AND MEASURES

Devices were characterized by their regulatory history and recall history. Risk ratios (RRs) were calculated to compare the risk of future Class I recalls between devices descended from predicates with matched controls.

RESULTS

Of 156 index devices subject to Class I recall from 2017 through 2021, 44 (28.2%) had prior Class I recalls. Predicates were identified for 127 index devices, with 56 (44.1%) using predicates with a Class I recall. One hundred four index devices were also used as predicates to support the authorization of 265 descendant devices, with 50 index devices (48.1%) authorizing a descendant with a Class I recall. Compared with matched controls, devices authorized using predicates with Class I recalls had a higher risk of subsequent Class I recall (6.40 [95% CI, 3.59-11.40]; P<.001).

CONCLUSIONS AND RELEVANCE

Many 510(k) devices subjected to Class I recalls in the US use predicates with a known history of Class I recalls. These devices have substantially higher risk of a subsequent Class I recall. Safeguards for the 510(k) pathway are needed to prevent problematic predicate selection and ensure patient safety.

Association Between Regulatory Submission Characteristics and Recalls of Medical Devices Receiving 510(k) Clearance

IMPORTANCE

Most regulated medical devices enter the US market via the 510(k) regulatory submission pathway, wherein manufacturers demonstrate that applicant devices are "substantially equivalent" to 1 or more "predicate" devices (legally marketed medical devices with similar intended use). Most recalled medical devices are 510(k) devices.

OBJECTIVE

To examine the association between characteristics of predicate medical devices and recall probability for 510(k) devices.

DESIGN, SETTING, AND PARTICIPANTS

In this exploratory cross-sectional analysis of medical devices cleared by the US Food and Drug Administration (FDA) between 2003 and 2018 via the 510(k) regulatory submission pathway, linear probability models were used to examine associations between a 510(k) device's recall status and characteristics of its predicate medical devices. Public documents for the 510(k) medical devices were collected using FDA databases. A text extraction algorithm was applied to identify predicate medical devices cited in 510(k) regulatory submissions. Algorithm-derived metadata were combined with 2003-2020 FDA recall data.

EXPOSURES

Citation of predicate medical devices with certain characteristics in 510(k) regulatory submissions, including the total number of predicate medical devices cited by the applicant device, the age of the predicate medical devices, the lack of similarity of the predicate medical devices to the applicant device, and the recall status of the predicate medical devices.

MAIN OUTCOMES AND MEASURES

Class I or class II recall of a 510(k) medical device between its FDA regulatory clearance date and December 31, 2020.

RESULTS

The sample included 35 176 medical devices, of which 4007 (11.4%) were recalled. The applicant devices cited a mean of 2.6 predicate medical devices, with mean ages of 3.6 years and 7.4 years for the newest and oldest, respectively, predicate medical devices. Of the applicant devices, 93.9% cited predicate medical devices with no ongoing recalls, 4.3% cited predicate medical devices with 1 ongoing class I or class II recall, 1.0% cited predicate medical devices with 2 ongoing recalls, and 0.8% cited predicate medical devices with 3 or more ongoing recalls. Applicant devices citing predicate medical devices with 3 or more ongoing recalls were significantly associated with a 9.31-percentage-point increase (95% CI, 2.84-15.77 percentage points) in recall probability compared with devices without ongoing recalls of predicate medical devices, or an 81.2% increase in recall probability relative to the mean recall probability. A 1-SD increase in the total number of predicate medical devices cited by the applicant device was significantly associated with a 1.25-percentage-point increase (95% CI, 0.62-1.87 percentage points) in recall probability, or an 11.0% increase in recall probability relative to the mean recall probability. A 1-SD increase in the newest age of a predicate medical device was significantly associated with a 0.78-percentage-point decrease (95% CI, 1.29-0.30 percentage points) in recall probability, or a 6.8% decrease in recall probability relative to the mean recall probability.

CONCLUSIONS AND RELEVANCE

This exploratory cross-sectional study of 510(k) medical devices cleared by the FDA between 2003 and 2018 demonstrated significant associations between 510(k) submission characteristics and recalls of medical devices. Further research is needed to understand the implications of these associations.

The Assessment of Medical Device Software Supporting Health Care Services for Chronic Patients in a Tertiary Hospital: Overarching Study

BACKGROUND

Innovative digital health tools are increasingly being evaluated and, in some instances, integrated at scale into health systems. However, the applicability of assessment methodologies in real-life scenarios to demonstrate value generation and consequently foster sustainable adoption of digitally enabled health interventions has some bottlenecks.

OBJECTIVE

We aimed to build on the process of premarket assessment of 4 digital health interventions piloted at the Hospital Clinic de Barcelona (HCB), as well as on the analysis of current medical device software regulations and postmarket surveillance in the European Union and United States in order to generate recommendations and lessons learnt for the sustainable adoption of digitally enabled health interventions.

METHODS

Four digital health interventions involving prototypes were piloted at the HCB (studies 1-4). Cocreation and quality improvement methodologies were used to consolidate a pragmatic evaluation method to assess the perceived usability and satisfaction of end users (both patients and health care professionals) by means of the System Usability Scale and the Net Promoter Score, including general questions about satisfaction. Analyses of both medical software device regulations and postmarket surveillance in the European Union and United States (2017-2021) were performed. Finally, an overarching analysis on lessons learnt was conducted considering 4 domains (technical, clinical, usability, and cost), as well as differentiating among 3 different eHealth strategies (telehealth, integrated care, and digital therapeutics).

RESULTS

Among the participant stakeholders, the System Usability Scale score was consistently higher in patients (studies 1, 2, 3, and 4: 78, 67, 56, and 76, respectively) than in health professionals (studies 2, 3, and 4: 52, 43, and 54, respectively). In general, use of the supporting digital health tools was recommended more by patients (studies 1, 2, 3, and 4: Net Promoter Scores of -3%, 31%, -21%, and 31%, respectively) than by professionals (studies 2, 3, and 4: Net Promoter Scores of -67%, 1%, and -80%, respectively). The overarching analysis resulted in pragmatic recommendations for the digital health evaluation domains and the eHealth strategies considered.

CONCLUSIONS

Lessons learnt on the digitalization of health resulted in practical recommendations that could contribute to future deployment experiences.

Knowledge mapping and visualization analysis of pelvic organ prolapse repair with mesh from 2001 to 2021

Aims: In recent decades, extensive attention has been paid to the application of mesh to repair pelvic floor defects. However, a large body of related literature has not been system summarized. The purpose of this study is to summarize and visualize the literature on pelvic organ prolapse (POP) repair with mesh using bibliometrics. Methods: Medical literature regarding POP repair with mesh were searched and obtained in the Web of Science™ Core (WoSCC) database from 2001 to 2021. Microsoft Excel 2020, CiteSpace and VOSviewer were used to conduct the bibliometric and knowledge-map analysis. Results: In the past 20 years, a total of 2,550 articles and reviews have been published in 35 journals, and the published and cited results show a growing trend. Cosson M and International Urogynecology Journal were the authors and journals with the highest output, respectively. The United States, France and the United Kingdom are among the top three countries/organizations in relevant publications in worldwide. 584 key words in the literature are divided into 8 clusters, which are mainly related to prolapse type, risk factors, surgical methods, imaging, quality of life and bioengineering. Using clinical research and tissue engineering technology to reduce mesh complications is the current hot spot in this field. Conclusion: Reasonable application of mesh and avoiding mesh complications are still the most concerned topics in POP research. Although clinical research, surgical improvement, biological mesh and bioengineering technology have shown promising results, it is still urgent to carry out clinical transformation application research.

Digitalized transcranial electrical stimulation: A consensus statement

OBJECTIVE

Although relatively costly and non-scalable, non-invasive neuromodulation interventions are treatment alternatives for neuropsychiatric disorders. The recent developments of highly-deployable transcranial electric stimulation (tES) systems, combined with mobile-Health technologies, could be incorporated in digital trials to overcome methodological barriers and increase equity of access. The study aims are to discuss the implementation of tES digital trials by performing a systematic scoping review and strategic process mapping, evaluate methodological aspects of tES digital trial designs, and provide Delphi-based recommendations for implementing digital trials using tES.

METHODS

We convened 61 highly-productive specialists and contacted 8 tES companies to assess 71 issues related to tES digitalization readiness, and processes, barriers, advantages, and opportunities for implementing tES digital trials. Delphi-based recommendations (>60% agreement) were provided.

RESULTS

The main strengths/opportunities of tES were: (i) non-pharmacological nature (92% of agreement), safety of these techniques (80%), affordability (88%), and potential scalability (78%). As for weaknesses/threats, we listed insufficient supervision (76%) and unclear regulatory status (69%). Many issues related to methodological biases did not reach consensus. Device appraisal showed moderate digitalization readiness, with high safety and potential for trial implementation, but low connectivity.

CONCLUSIONS

Panelists recognized the potential of tES for scalability, generalizability, and leverage of digital trials processes; with no consensus about aspects regarding methodological biases.

SIGNIFICANCE

We further propose and discuss a conceptual framework for exploiting shared aspects between mobile-Health tES technologies with digital trials methodology to drive future efforts for digitizing tES trials.

Use of linked registry claims data for long term surveillance of devices after endovascular abdominal aortic aneurysm repair: observational surveillance study

OBJECTIVE

To evaluate long term outcomes (reintervention and late rupture of abdominal aortic aneurysm) of aortic endografts in real world practice using linked registry claims data.

DESIGN

Observational surveillance study.

SETTING

282 centers in the Vascular Quality Initiative Registry linked to United States Medicare claims (2003-18).

PARTICIPANTS

20 489 patients treated with four device types used for endovascular abdominal aortic aneurysm repair (EVAR): 40.6% (n=8310) received the Excluder (Gore), 32.2% (n=6606) the Endurant (Medtronic), 16.0% (n=3281) the Zenith (Cook Medical), and 11.2% (n=2292) the AFX (Endologix). Given modifications to AFX in late 2014, patients who received the AFX device were categorized into two groups: the early AFX group (n=942) and late AFX group (n=1350) and compared with patients who received the other devices, using propensity matched Cox models.

MAIN OUTCOME MEASURES

Reintervention and rupture of abdominal aortic aneurysm post-EVAR; all patients (100%) had complete follow-up via the registry or claims based outcome assessment, or both.

RESULTS

Median age was 76 years (interquartile range (IQR) 70-82 years), 80.0% (16 386/20 489) of patients were men, and median follow-up was 2.3 years (IQR 0.9-4.1 years). Crude five year reintervention rates were significantly higher for patients who received the early AFX device compared with the other devices: 14.9% (95% confidence interval 13.7% to 16.2%) for Excluder, 19.5% (18.1% to 21.1%) for Endurant, 16.7% (15.0% to 18.6%) for Zenith, and early 27.0% (23.7% to 30.6%) for the early AFX. The risk of reintervention for patients who received the early AFX device was higher compared with the other devices in propensity matched Cox models (hazard ratio 1.61, 95% confidence interval 1.29 to 2.02) and analyses using a surgeon level instrumental variable of >33% AFX grafts used in their practice (1.75, 1.19 to 2.59). The linked registry claims surveillance data identified the increased risk of reintervention with the early AFX device as early as mid-2013, well before the first regulatory warnings were issued in the US in 2017.

CONCLUSIONS

The linked registry claims surveillance data identified a device specific risk in long term reintervention after EVAR of abdominal aortic aneurysm. Device manufacturers and regulators can leverage linked data sources to actively monitor long term outcomes in real world practice after cardiovascular interventions.

Laser Sintering Approaches for Bone Tissue Engineering

The adoption of additive manufacturing (AM) techniques into the medical space has revolutionised tissue engineering. Depending upon the tissue type, specific AM approaches are capable of closely matching the physical and biological tissue attributes, to guide tissue regeneration. For hard tissue such as bone, powder bed fusion (PBF) techniques have significant potential, as they are capable of fabricating materials that can match the mechanical requirements necessary to maintain bone functionality and support regeneration. This review focuses on the PBF techniques that utilize laser sintering for creating scaffolds for bone tissue engineering (BTE) applications. Optimal scaffold requirements are explained, ranging from material biocompatibility and bioactivity, to generating specific architectures to recapitulate the porosity, interconnectivity, and mechanical properties of native human bone. The main objective of the review is to outline the most common materials processed using PBF in the context of BTE; initially outlining the most common polymers, including polyamide, polycaprolactone, polyethylene, and polyetheretherketone. Subsequent sections investigate the use of metals and ceramics in similar systems for BTE applications. The last section explores how composite materials can be used. Within each material section, the benefits and shortcomings are outlined, including their mechanical and biological performance, as well as associated printing parameters. The framework provided can be applied to the development of new, novel materials or laser-based approaches to ultimately generate bone tissue analogues or for guiding bone regeneration.

Pediatric Medical Device Development and Regulation: Current State, Barriers, and Opportunities

Few medical devices are designed and marketed specifically for children. Instead, adult devices are often repurposed and used off-label in pediatrics. The innovation gap between pediatric and adult devices is complex and multifactorial. This review aims to summarize the medical device landscape, describe barriers to pediatric device development, and provide an update on current strategies to help overcome these limitations. Medical devices are regulated by the Food and Drug Administration. They are registered, cleared, or approved on the basis of a 3-tier risk classification system and a differentiated set of regulatory pathways. This includes some for products that receive special designations on the basis of specific aspects that warrant more rapid review and approval. Pediatric devices number only one-quarter of those developed for adults for multiple reasons. Clinically, innovators must adjust their products to address the smaller sizes, growth, and longer duration of use in children. Smaller sample sizes and population heterogeneity also challenge the ability to obtain sufficient safety data for regulatory submissions. Financial concerns stem from lower pediatric reimbursement rates coupled with a lack of nationally standardized coverage. There are a number of promising initiatives, including the Pediatric Device Consortia Program, Early Feasibility Studies, and the new System of Hospitals for Innovation in Pediatrics - Medical Devices. However, the gap will likely not be narrowed without broad cooperation across stakeholders from industry, academia, patient advocacy groups, health care providers, investors, payors, regulators, and Congress.

Validation of an indirect linkage algorithm to combine registry data with Medicare claims

INTRODUCTION

Linkage of registries to Medicare claims data can help extend follow-up for patients receiving medical devices. This study sought to test and validate an algorithm that does not require patient identifiers to link a national vascular registry and Medicare claims data.

METHODS

We used data from the Vascular Quality Initiative (VQI), a registry capturing data from more than 600 centers on several different vascular procedures and Medicare claims from 2003 to 2018. We restricted to patients aged 65 years and older who had fee-for-service entitlement at the time of the procedure for this study. We performed an indirect linkage to combine VQI with Medicare at the patient level using a sequential algorithm based on patient's date of birth, sex, zip code, procedure date, and procedure facility. We compared this against a gold standard of a cohort directly linked using social security numbers (SSNs). We calculated the matching rate and accuracy overall, and before and after October 2015 when the ICD-10 system was adopted in the US.

RESULTS

A total of 144,045 VQI-Medicare linked patients were in the gold standard cohort. Using the indirect linking algorithm, we matched 133,966 of the 144,045 VQI patients to their Medicare claims (matching rate: 93.0%). Among these, 133,104 patients were correctly matched (matching accuracy: 99.4%). The matching rate was higher when the indirect linkage was implemented in ICD-10 coded data than in ICD-9 coded data (94.0% vs. 92.2%). Accuracy of the indirect linkage remained high for all procedure modules post-ICD-10 coding change (overall 99.4%, range 99.0-99.7%).

CONCLUSION

In this study, we successfully used indirect identifiers to link the VQI to Medicare claims with more than 90% success and more than 99% accuracy. When direct linkage of registry-claims data using SSNs is not possible because of availability, confidentiality, or both, this method for indirect linkage provides a suitable alternative. The matching rate and accuracy help ensure the accuracy of long-term follow-up and the completeness and representativeness of linked databases for relevant research and quality improvement initiatives.

Advancing Patient Safety Surrounding Medical Devices: A Health System Roadmap to Implement Unique Device Identification at the Point of Care

Background

The US Food and Drug Administration’s Unique Device Identification System Rule of 2013 mandated manufacturers to assign unique device identifiers (UDIs) to their medical devices. Most high-risk (Class III), moderate-risk (Class II) and implantable devices now have UDIs. To achieve the necessary next step for a comprehensive UDI-enabled system for patient safety, UDIs must be electronically documented during patient care, a process not routinely done. The purpose of this research was to study the implementation experiences of diverse health systems in order to develop a roadmap for UDI implementation at the point of care.

Methods

Semi-structured interviews were conducted with personnel at health systems that had implemented UDI for implantable devices in their cardiac catheterization labs or operating rooms. Interviews were audio-recorded, transcribed, and analyzed using the framework methodology of Ritchie and Spencer. Data interpretation involved development of a conceptual model and detailed recommendations for UDI implementation. An expert panel evaluated and provided input on the roadmap.

Results

Twenty-four interviews at ten health systems were conducted by phone. Participants described implementation steps, factors and barriers impacting implementation. Findings populated a UDI implementation roadmap, that includes Foundational Themes, Key Components, Key Steps, UDI Use, and Outcomes.

Conclusions and Implications

The UDI implementation roadmap provides a framework for health systems to address the necessary steps and multilevel factors that underpin UDI implementation at the point of care. It is intended to guide and advance routine electronic documentation of UDIs for devices used during clinical care, the critical next step for a comprehensive UDI-enabled system to enhance medical device safety and effectiveness for patients.