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Merenda M, Earnest A, Ruseckaite R, Tse WC, Elder E, Hopper I, Ahern S. Patient-Reported Outcome Measures in High-Risk Medical Device Registries: A Scoping Review. Aesthet Surg J Open Forum 2024; 6:ojae015. [PMID: 38650972 PMCID: PMC11033681 DOI: 10.1093/asjof/ojae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Abstract
Little is known about the methods and outcomes of patient-reported outcome measure (PROM) use among high-risk medical device registries. The objective of this scoping review was to assess the utility and predictive ability of PROMs in high-risk medical device registries. We searched Ovid Medline, Embase, APA PsychINFO, Cochrane Library, and Scopus databases for published literature. After searching, 4323 titles and abstracts were screened, and 262 full texts were assessed for their eligibility. Seventy-six papers from across orthopedic (n = 64), cardiac (n = 10), penile (n = 1), and hernia mesh (n = 1) device registries were identified. Studies predominantly used PROMs as an outcome measure when comparing cohorts or surgical approaches (n = 45) or to compare time points (n = 13) including pre- and postintervention. Fifteen papers considered the predictive ability of PROMs. Of these, 8 treated PROMs as an outcome, 5 treated PROMs as a risk factor through regression analysis, and 2 papers treated PROMs as both a risk factor and as an outcome. One paper described PROMs to study implant survival. To advance methods of PROM integration into clinical decision-making for medical devices, an understanding of their use in high-risk device registries is needed. This scoping review found that there is a paucity of studies using PROMs to predict long-term patient and clinical outcomes in high-risk medical device registries. Determination as to why PROMs are rarely used for predictive purposes in long-term data collection is needed if PROM data are to be considered suitable as real-world evidence for high-risk device regulatory purposes, as well as to support clinical decision-making. Level of Evidence 4
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Affiliation(s)
- Michelle Merenda
- Corresponding Author: Mrs Michelle Merenda, Level 3, 553 St Kilda Rd, Melbourne, Victoria 3004, Australia. E-mail:
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Táborský M, Skála T, Dušek L, Kautzner J, Aiglová R, Fedorco M, Jarkovský J, Benešová K, Májková P. Clinical characteristics and mortality in all Czech patients after pacemaker implantation in the last decade. Front Cardiovasc Med 2023; 10:1248145. [PMID: 38144370 PMCID: PMC10739293 DOI: 10.3389/fcvm.2023.1248145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/13/2023] [Indexed: 12/26/2023] Open
Abstract
Background and aims Analysis of mortality from the national health registries and data from a specific central registry dealing with the implantation of pacemakers (REPACE) in Czech patients. Methods and results Retrospective observational analysis of pacemakers' implantation in all Czech patients [n = 82,791; 47,070 (56.9%) men, 75.9 ± 10.4 years old] between 2010 and 2021. Almost 114,000 pacemakers were implanted between 2010 and 2021, of which 27.9% were single-chamber, 67.4% were dual-chamber and 4.6% were biventricular. The annual number of implantations has been steadily increasing with a 6% annual decline in 2020 with increased mortality and reductions in care provided, likely related to COVID-19. The observed 5-year relative survival was 88.6% (overall survival 60.6%) and the 10-year relative survival was 75.9% (overall survival 32.7%). Causes of death 5ary according to the age of the patient. The highest difference 1n the reported numbers in the REPACE Registry did not exceed 2% in comparison with the National Register of Reimbursed Health Services. Conclusion This study followed all Czech patients with pacemaker's implantation in between 2010 and 2021. The annual number of 1mplantations has been steadily 1ncreasing. Patients with implanted pacemakers had a significantly higher mortality than the average population. Number of patients in the registry corresponded almost perfectly with the National Register of Reimbursed Health Services.
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Affiliation(s)
- Miloš Táborský
- Department of Internal Medicine I—Cardiology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Tomáš Skála
- Department of Internal Medicine I—Cardiology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Ladislav Dušek
- Institute of Health Information and Statistics of the Czech Republic, Praha, Czech Republic
| | - Josef Kautzner
- Cardiac Centre, Institute for Clinical and Experimental Medicine—IKEM, Praha, Czech Republic
| | - Renata Aiglová
- Department of Internal Medicine I—Cardiology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Marián Fedorco
- Department of Internal Medicine I—Cardiology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Jiří Jarkovský
- Institute of Health Information and Statistics of the Czech Republic, Praha, Czech Republic
- Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Kamenice, Czech Republic
| | - Klára Benešová
- Institute of Health Information and Statistics of the Czech Republic, Praha, Czech Republic
- Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Kamenice, Czech Republic
| | - Petra Májková
- Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Kamenice, Czech Republic
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Pascucci S, Langella F, Franzò M, Tesse MG, Ciminello E, Biondi A, Carrani E, Sampaolo L, Zanoli G, Berjano P, Torre M. National spine surgery registries' characteristics and aims: globally accepted standards have yet to be met. Results of a scoping review and a complementary survey. J Orthop Traumatol 2023; 24:49. [PMID: 37715871 PMCID: PMC10505129 DOI: 10.1186/s10195-023-00732-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 08/15/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND Surgery involving implantable devices is widely used to solve several health issues. National registries are essential tools for implantable device surveillance and vigilance. In 2017, the European Union encouraged Member States to establish "registries and databanks for specific types of devices" to evaluate device safety and performance and ensure their traceability. Spine-implantable devices significantly impact patient safety and public health; spine registries might help improve surgical outcomes. This study aimed to map existing national spine surgery registries and highlight their features and organisational standards to provide an essential reference for establishing other national registries. METHODS A scoping search was performed using the Embase, PubMed/Medline, Scopus, and Web of Science databases for the terms "registry", "register", "implantable", and all terms and synonyms related to spinal diseases and national registries in publications from January 2000 to December 2020. This search was later updated and finalised through a web search and an ad hoc survey to collect further detailed information. RESULTS Sixty-two peer-reviewed articles were included, which were related to seven national spine registries, six of which were currently active. Three additional active national registries were found through the web search. The nine selected national registries were set up between 1998 and 2021. They collect data on the procedure and use patient-reported outcome measures (PROMs) for the follow-up. CONCLUSION Our study identified nine currently active national spine surgery registries. However, globally accepted standards for developing a national registry of spine surgery are yet to be established. Therefore, an international effort to increase result comparability across registries is highly advisable. We hope the recent initiative from the Orthopaedic Data Evaluation Panel (ODEP) to establish an international collaboration will meet these needs.
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Affiliation(s)
- Simona Pascucci
- Scientific Secretariat of the President's Office, Italian National Institute of Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161, Rome, Italy
- Department of Mechanical and Aerospace Engineering, La Sapienza University of Rome, Rome, Italy
| | | | - Michela Franzò
- Department of Medico-Surgical Sciences and Biotechnologies, Rome, Italy
| | - Marco Giovanni Tesse
- Orthopaedics Section, Department of Neuroscience and Organs of Sense, Faculty of Medicine and Surgery, University of Bari, AOU Consorziale Policlinico, 70124, Bari, Italy
| | - Enrico Ciminello
- Scientific Secretariat of the President's Office, Italian National Institute of Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161, Rome, Italy
| | - Alessia Biondi
- Scientific Secretariat of the President's Office, Italian National Institute of Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161, Rome, Italy
| | - Eugenio Carrani
- Scientific Secretariat of the President's Office, Italian National Institute of Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161, Rome, Italy
| | - Letizia Sampaolo
- National Centre for Disease Prevention and Health Promotion, Italian National Institute of Health, Rome, Italy
| | | | | | - Marina Torre
- Scientific Secretariat of the President's Office, Italian National Institute of Health, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161, Rome, Italy.
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Gumbie M, Costa M, Erb M, Dissanayake G. Innovative technologies for reverse total shoulder arthroplasty in Australia: Market access challenges and implications for patients, decision-makers, and manufacturers. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2022; 11:2154420. [PMID: 36506841 PMCID: PMC9731581 DOI: 10.1080/20016689.2022.2154420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 06/17/2023]
Abstract
PURPOSE The success of reverse total shoulder arthroplasty (RTSA) has expanded its use for a broader range of shoulder indications worldwide. Evidence regarding the relative efficacy and long-term safety of medical technologies used in RTSA is subjected to rigorous assessment. Nonetheless, substantial challenges impede market access for innovative shoulder implant technologies for RTSA in Australia, resulting in delayed patient access. APPROACH This paper addresses the key challenges associated with generating evidence for the health technology assessments of innovative medical technologies for RTSA that are required for access to the Australian market. The transition to value-based care requires establishing a benchmarking reference that incorporates patient-reported outcome measures (PROMs) and combines revision outcomes with additional clinical outcomes to increase patient cohort sizes. Establishing the benchmark would require agreement on the outcome measures to be collected for each indication, and investment in reporting patient-reported outcomes for RTSA to the national orthopaedic registry. IMPLICATIONS FOR PRACTICE The need for increased flexibility in developing evidence for health technology assessment of RTSA medical technologies is required. Optimised approaches for benchmarking RTSA require extensive stakeholder discussions, including the agreement on evidence requirements and follow-up periods, selection of clinical outcomes, as well as pre-operative and post-operative PROMs as a value assessment.
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Affiliation(s)
- Mutsa Gumbie
- Macquarie University Centre for the Health Economy, Sydney, NSW, Australia
- Johnson & Johnson MedTech, North Ryde, NSW, Australia
| | | | | | - Gnanadarsha Dissanayake
- New South Wales Ministry of Health, St Leonards, NSW, Australia
- School of Mathematics and Statistics, University of Sydney, Sydney, NSW, Australia
- Statistical Society of Australia, Belconnen, NSW, Australia
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Clinical registries data quality attributes to support registry-based randomised controlled trials: A scoping review. Contemp Clin Trials 2022; 119:106843. [DOI: 10.1016/j.cct.2022.106843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/23/2022] [Accepted: 06/26/2022] [Indexed: 11/19/2022]
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Wierda E, de Mol BAJM, van Veghel D, Ploem MC. New EU law on medical devices: will it truly protect patients from malfunctioning cardiac implantable electronic devices? EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 8:1-3. [PMID: 34498662 DOI: 10.1093/ehjqcco/qcab064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 08/25/2021] [Accepted: 09/06/2021] [Indexed: 11/13/2022]
Affiliation(s)
- E Wierda
- Department of Cardiology, Department of Cardiology, Amsterdam University Medical Center
| | - B A J M de Mol
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center
| | - D van Veghel
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital Eindhoven
| | - M C Ploem
- Department of Ethics, Law and Medical Humanities, Health Law Section, Amsterdam University Medical Center
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Zecchin M, Torre M, Carrani E, Sampaolo L, Ciminello E, Ortis B, Ricci R, Proclemer A, Sinagra G, Boriani G. Seventeen-year trend (2001-2017) in pacemaker and implantable cardioverter-defibrillator utilization based on hospital discharge database data: An analysis by age groups. Eur J Intern Med 2021; 84:38-45. [PMID: 32933841 DOI: 10.1016/j.ejim.2020.09.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 08/31/2020] [Accepted: 09/02/2020] [Indexed: 10/23/2022]
Abstract
AIMS To analyze temporal trends (2001 -2017) of Pacemakers (PM) and Implantable Cardioverter-Defibrillators (ICD) procedures in Italy, according to the national Hospital Discharge Database (HDD). METHODS Frequency and implant rate (IR) in the Italian population were analyzed by age groups (<50, 50-79, ≥80 years). RESULTS From 2001 (2009 for Cardiac Resynchronization Therapy-Defibrillator - CRT-D) to 2017, first PM implants (1stPM) increased from 36,823 (637/million inhabitants) to 49,716 (820/million), ICD implants from 3,141 (54/million) to 24,255 (400/million) and CRT-D from 2,915 (49/million, 16.5% of ICD) to 8,595 (142/million, 35.4% of ICD). ICD implants due to ventricular tachycardia or ventricular fibrillation decreased from 55.6% to 13.5% and from 15.9% to 4.5% respectively, while the proportion increased among patients with heart failure (from 22.9% to 46.8%), hypertension (from 11.1% to 15.0%), diabetes (from 6.5% to 10.9%), and renal insufficiency (from 4.4% to 7.6%). Both PM and ICD procedures markedly increased in patients ≥80 years old. However, while IR for ICDs increased from 82/million to 1,038/million inhabitants, IR of 1stPM only changed from 6,111/million to 6,212/million as the population in this age group nearly doubled in Italy. CONCLUSION Since 2001, the increase of 1stPM in Italy was mainly due to the ultra-octogenarian population growth. No differences were observed for IR in each PM age group, while the absolute number and IR increased in all groups (especially ≥80 years old) for ICDs and CRT-Ds. An increase in comorbidities and a reduction in implants for secondary prevention were observed in the ICD population.
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Affiliation(s)
- Massimo Zecchin
- Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy.
| | | | | | | | - Enrico Ciminello
- Istituto Superiore di Sanità, Roma, Italy; "La Sapienza" University of Rome, Italy
| | - Benedetta Ortis
- Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Renato Ricci
- Associazione Italiana Aritmologia e Cardiostimolazione, Roma, Italy
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Tarricone R, Ciani O, Torbica A, Brouwer W, Chaloutsos G, Drummond MF, Martelli N, Persson U, Leidl R, Levin L, Sampietro-Colom L, Taylor RS. Lifecycle evidence requirements for high-risk implantable medical devices: a European perspective. Expert Rev Med Devices 2020; 17:993-1006. [PMID: 32975149 DOI: 10.1080/17434440.2020.1825074] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The new European Union (EU) Regulations on medical devices and on in vitro diagnostics provide manufacturers and Notified Bodies with new tools to improve pre-market and post-market clinical evidence generation especially for high-risk products but fail to indicate what type of clinical evidence is appropriate at each stage of the whole lifecycle of medical devices. In this paper we address: i) the appropriate level and timing of clinical evidence throughout the lifecycle of high-risk implantable medical devices; and ii) how the clinical evidence generation ecosystem could be adapted to optimize patient access. AREAS COVERED The European regulatory and health technology assessment (HTA) contexts are reviewed, in relation to the lifecycle of high-risk medical devices and clinical evidence generation recommended by international network or endorsed by regulatory and HTA agencies in different jurisdictions. EXPERT OPINION Four stages are relevant for clinical evidence generation: i) pre-clinical, pre-market; ii) clinical, pre-market; iii) diffusion, post-market; and iv) obsolescence & replacement, post-market. Each stage has its own evaluation needs and specific studies are recommended to generate the appropriate evidence. Effective lifecycle planning requires anticipation of what evidence will be needed at each stage.
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Affiliation(s)
- Rosanna Tarricone
- Department of Social and Political Science, Bocconi University , Milan, Italy.,SDA Bocconi School of Management , Milan, Italy.,SDA Bocconi School of Management, Centre for Research on Health and Social Care Management (CERGAS) , Milan, Italy
| | - Oriana Ciani
- SDA Bocconi School of Management, Centre for Research on Health and Social Care Management (CERGAS) , Milan, Italy.,Institute of College and Medicine, University of Exeter, South Cloisters, St Luke's Campus , Exeter, UK
| | - Aleksandra Torbica
- Department of Social and Political Science, Bocconi University , Milan, Italy.,SDA Bocconi School of Management , Milan, Italy
| | - Werner Brouwer
- Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam , Rotterdam, PA, The Netherlands
| | - Georges Chaloutsos
- Biomedical Engineering Department, Onassis Cardiac Surgery Centre & Director , Athens, Greece
| | - Michael F Drummond
- Professor of Health Economics, Centre for Health Economics, University of York , York, UK
| | - Nicolas Martelli
- Associate Clinical Professor, Hôpital Européen Georges Pompidou , Paris, France
| | - Ulf Persson
- IHE, Swedish Institute for Health Economics , Lund, Sweden
| | - Reiner Leidl
- Institute of Health Economics and Healthcare Management, Helmholtz Zentrum München - German Research Center for Environmental Health (Gmbh) , Neuherberg, Germany
| | - Les Levin
- Chief Executive Officer & Scientific Officer, EXCITE International , Canada
| | - Laura Sampietro-Colom
- Deputy Director of Innovation, Head of Health Technology Assessment Unit at Hospital Clinic Barcelona , Spain
| | - Rod S Taylor
- Institute of Health and Wellbeing, University of Glasgow , Glasgow, UK
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Miclăuş T, Valla V, Koukoura A, Nielsen AA, Dahlerup B, Tsianos GI, Vassiliadis E. Impact of Design on Medical Device Safety. Ther Innov Regul Sci 2020; 54:839-849. [PMID: 32557299 PMCID: PMC7362883 DOI: 10.1007/s43441-019-00022-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/14/2019] [Indexed: 12/13/2022]
Abstract
The growing number of emerging medical technologies and sophistication of modern medical devices (MDs) that improve both survival and quality of life indexes are often challenged by alarming cases of vigilance data cover-up and lack of sufficient pre- and post-authorization controls. Combining Quality with Risk Management processes and implementing them as early as possible in the design of MDs has proven to be an effective strategy to minimize residual risk. This article aims to discuss how the design of MDs interacts with their safety profile and how this dipole of intended performance and safety may be supported by Human Factors Engineering (HFE) throughout the Total Product Life-Cycle (TPLC) of an MD in order to capitalize on medical technologies without exposing users and patients to unnecessary risks.
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Affiliation(s)
- Teodora Miclăuş
- Evnia Group, Copenhagen Business Center, Hellerup Strandvejen 60, 2900, Copenhagen, Denmark
| | - Vasiliki Valla
- Evnia Group, Copenhagen Business Center, Hellerup Strandvejen 60, 2900, Copenhagen, Denmark
| | - Angeliki Koukoura
- Evnia Group, Copenhagen Business Center, Hellerup Strandvejen 60, 2900, Copenhagen, Denmark
| | - Anne Ahlmann Nielsen
- Evnia Group, Copenhagen Business Center, Hellerup Strandvejen 60, 2900, Copenhagen, Denmark
| | - Benedicte Dahlerup
- Evnia Group, Copenhagen Business Center, Hellerup Strandvejen 60, 2900, Copenhagen, Denmark
| | | | - Efstathios Vassiliadis
- Evnia Group, Copenhagen Business Center, Hellerup Strandvejen 60, 2900, Copenhagen, Denmark
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Zhang S, Gaiser S, Kolominsky-Rabas PL. Cardiac implant registries 2006-2016: a systematic review and summary of global experiences. BMJ Open 2018; 8:e019039. [PMID: 29654008 PMCID: PMC5898296 DOI: 10.1136/bmjopen-2017-019039] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 01/10/2018] [Accepted: 03/06/2018] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES The importance of Cardiac Implant Registry (CIR) for ensuring a long-term follow-up in postmarket surveillance has been recognised and approved, but there is lack of consensus standards on how to establish a CIR. The aim of this study is to investigate the structure and key elements of CIRs in the past decade (2006-2016) and to provide recommendations on 'best practice' approaches. SETTINGS AND PARTICIPANTS A systematic search on CIR was employed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following databases were searched: the PubMed (Medline), ScienceDirect and the Scopus database, EMBASE. After identifying the existing CIRs, an aggregative approach will be used to explore key elements emerging in the identified registries. RESULTS The following 82 registries were identified: 18 implantable cardioverterdefibrillator (ICD) registries, 7 cardiac resynchronisation therapy (CRT) registries, 5 pacemaker registries and 6 cardiovascular implantable electronic device registries which combined ICD, pacemaker and CRT implantation data; as well as 22 coronary stent registries and 24 transcatheteraortic heart valve implantation registries. While 71 national or local registries are from a single country, 44 are from European countries and 9 are located in USA. The following criteria have been summarised from the identified registries, including: registry working group, ethic issues, transparency, research objective, inclusion criteria, compulsory participation, endpoint, sample size, data collection basement, data collection methods, data entry, data validation and statistical analysis. CONCLUSIONS Registries provide a 'real-world' picture for patients, physicians, manufacturers, payers, decision-makers and other stakeholders. CIRs are important for regulatory decisions concerning the safety and therefore approval issues of the medical device; for payers CIRs provide evidence on the medical device benefit and drive the decision whether the product should be reimbursed or not; for hospitals CIRs' data are important for sound procurement decisions, and CIRs also help patients and their physicians to joint decision-making which of the products is the most appropriate.
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Affiliation(s)
- Shixuan Zhang
- Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health (IZPH), Friedrich- Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
- National Leading-Edge Cluster Medical Technologies "Medical Valley EMN", Erlangen, Germany
| | | | - Peter L Kolominsky-Rabas
- Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health (IZPH), Friedrich- Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
- National Leading-Edge Cluster Medical Technologies "Medical Valley EMN", Erlangen, Germany
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