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Hoogervorst LA, van Tilburg MM, Lübbeke A, Wilton T, Nelissen RGHH, Marang-van de Mheen PJ. Validating Orthopaedic Data Evaluation Panel (ODEP) Ratings Across 9 Orthopaedic Registries: Total Hip Implants with an ODEP Rating Perform Better Than Those without an ODEP Rating. J Bone Joint Surg Am 2024:00004623-990000000-01110. [PMID: 38820172 DOI: 10.2106/jbjs.23.00793] [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] [Indexed: 06/02/2024]
Abstract
BACKGROUND Orthopaedic Data Evaluation Panel (ODEP) ratings of total hip (TH) and total knee (TK) implants are informative for assessing implant performance. However, the validity of ODEP ratings across multiple registries is unknown. Therefore, we aimed to assess, across multiple registries, whether TH and TK implants with a higher ODEP rating (i.e., an A* rating) have lower cumulative revision risks (CRRs) than those with a lower ODEP rating (i.e., an A rating) and the extent to which A* and A-rated implants would be A*-rated on the basis of the pooled registries' CRR. METHODS Implant-specific CRRs at 3, 5, and 10 years that were reported by registries were matched to ODEP ratings on the basis of the implant name. A meta-analysis with random-effects models was utilized for pooling the CRRs. ODEP benchmark criteria were utilized to classify these pooled CRRs. RESULTS A total of 313 TH cups (54%), 356 TH stems (58%), 218 TH cup-stem combinations (34%), and 68 TK implants (13%) with unique brand names reported by registries were matched to an ODEP rating. Given the low percentage that matched, TK implants were not further analyzed. ODEP-matched TH implants had lower CRRs than TH implants without an ODEP rating at all follow-up time points, although the difference for TH stems was not significant at 5 years. No overall differences in CRRs were found between A* and A-rated TH implants, with the exception of TH cup-stem combinations, which demonstrated a significantly lower CRR for A*A*-rated cup-stem combinations at the 3-year time point. Thirty-nine percent of A*-rated cups and 42% of A*-rated stems would receive an A* rating on the basis of the pooled registries' CRR at 3 years; however, 24% of A-rated cups and 31% of A-rated stems would also receive an A* rating, with similar findings demonstrated at longer follow-up. CONCLUSIONS At all follow-up time points, ODEP-matched TH implants had lower CRRs than TH implants without an ODEP rating. Given that the performance of TH implants varied across countries, registries should first validate ODEP ratings with use of country-specific revision data to better guide implant selection in their country. Data source transparency and the use of revision data from multiple registries would strengthen the ODEP benchmarks. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lotje A Hoogervorst
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Maartje M van Tilburg
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Anne Lübbeke
- Division of Orthopaedic Surgery and Traumatology, Geneva University Hospitals, Geneva Switzerland
- University of Geneva, Geneva, Switzerland
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Tim Wilton
- Department of Orthopaedics, Derby Teaching Hospitals NHS Foundation Trust, Derby, United Kingdom
- Orthopaedic Data Evaluation Panel, United Kingdom
- Beyond Compliance Steering Committee, Halesowen, United Kingdom
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Perla J Marang-van de Mheen
- Safety & Security Science, Centre for Safety in Healthcare, Delft University of Technology, Delft, The Netherlands
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Windecker S, Gilard M, Achenbach S, Cribier A, Delgado V, Deych N, Drossart I, Eltchaninoff H, Fraser AG, Goncalves A, Hindricks G, Holborow R, Kappetein AP, Kilmartin J, Kurucova J, Lüscher TF, Mehran R, O'Connor DB, Perkins M, Samset E, von Bardeleben RS, Weidinger F. Device innovation in cardiovascular medicine: a report from the European Society of Cardiology Cardiovascular Round Table. Eur Heart J 2024; 45:1104-1115. [PMID: 38366821 DOI: 10.1093/eurheartj/ehae069] [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] [Indexed: 02/18/2024] Open
Abstract
Research performed in Europe has driven cardiovascular device innovation. This includes, but is not limited to, percutaneous coronary intervention, cardiac imaging, transcatheter heart valve implantation, and device therapy of cardiac arrhythmias and heart failure. An important part of future medical progress involves the evolution of medical technology and the ongoing development of artificial intelligence and machine learning. There is a need to foster an environment conducive to medical technology development and validation so that Europe can continue to play a major role in device innovation while providing high standards of safety. This paper summarizes viewpoints on the topic of device innovation in cardiovascular medicine at the European Society of Cardiology Cardiovascular Round Table, a strategic forum for high-level dialogue to discuss issues related to the future of cardiovascular health in Europe. Devices are developed and improved through an iterative process throughout their lifecycle. Early feasibility studies demonstrate proof of concept and help to optimize the design of a device. If successful, this should ideally be followed by randomized clinical trials comparing novel devices vs. accepted standards of care when available and the collection of post-market real-world evidence through registries. Unfortunately, standardized procedures for feasibility studies across various device categories have not yet been implemented in Europe. Cardiovascular imaging can be used to diagnose and characterize patients for interventions to improve procedural results and to monitor devices long term after implantation. Randomized clinical trials often use cardiac imaging-based inclusion criteria, while less frequently trials randomize patients to compare the diagnostic or prognostic value of different modalities. Applications using machine learning are increasingly important, but specific regulatory standards and pathways remain in development in both Europe and the USA. Standards are also needed for smart devices and digital technologies that support device-driven biomonitoring. Changes in device regulation introduced by the European Union aim to improve clinical evidence, transparency, and safety, but they may impact the speed of innovation, access, and availability. Device development programmes including dialogue on unmet needs and advice on study designs must be driven by a community of physicians, trialists, patients, regulators, payers, and industry to ensure that patients have access to innovative care.
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Affiliation(s)
- Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Martine Gilard
- Département de Cardiologie, Hospital La Cavale Blanche, La Cavale Blanche Hospital Boulevard Tanguy Prigent, 29200 Brest, France
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen-Nürnberg, Germany
| | - Alain Cribier
- Department of Cardiology, Inserm U1096, Univ Rouen Normandie, F-76000 Rouen, France
| | - Victoria Delgado
- Department of Cardiology, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Nataliya Deych
- Regulatory Affairs, Edwards Lifesciences, Nyon, Switzerland
| | | | - Hélène Eltchaninoff
- Department of Cardiology, University Hospital Charles Nicolle, Rouen, France
| | - Alan G Fraser
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Alexandra Goncalves
- Precision Diagnostics, Philips, Cambridge, MA, USA
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto Medical School, Porto, Portugal
| | - Gerhard Hindricks
- Department of Cardiology, German Heart Center Charite, Berlin, Germany
| | | | | | | | - Jana Kurucova
- Transcatheter Heart Valve Division, Edwards Lifesciences, Nyon, Switzerland
| | - Thomas F Lüscher
- Department of Cardiology, Royal Brompton and Harefield Hospitals and Imperial College and King's College, London, UK
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Roxana Mehran
- Icahn School of Medicine, Mount Sinai Hospital, New York, NY, USA
| | | | - Mark Perkins
- GE Healthcare Cardiology Solutions, Harrogate, UK
| | - Eigil Samset
- GE Healthcare Cardiology Solutions, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
| | | | - Franz Weidinger
- 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse, Vienna, Austria
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Siontis GCM, Coles B, Häner JD, McGovern L, Bartkowiak J, Coughlan JJ, Spirito A, Galea R, Haeberlin A, Praz F, Tomii D, Melvin T, Frenk A, Byrne RA, Fraser AG, Windecker S. Quality and transparency of evidence for implantable cardiovascular medical devices assessed by the CORE-MD consortium. Eur Heart J 2024; 45:161-177. [PMID: 37638967 DOI: 10.1093/eurheartj/ehad567] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND AIMS The European Union Medical Device Regulation 2017/745 challenges key stakeholders to follow transparent and rigorous approaches to the clinical evaluation of medical devices. The purpose of this study is a systematic evaluation of published clinical evidence underlying selected high-risk cardiovascular medical devices before and after market access in the European Union (CE-marking) between 2000 and 2021. METHODS Pre-specified strategies were applied to identify published studies of prospective design evaluating 71 high-risk cardiovascular devices in seven different classes (bioresorbable coronary scaffolds, left atrial appendage occlusion devices, transcatheter aortic valve implantation systems, transcatheter mitral valve repair/replacement systems, surgical aortic and mitral heart valves, leadless pacemakers, subcutaneous implantable cardioverter-defibrillator). The search time span covered 20 years (2000-21). Details of study design, patient population, intervention(s), and primary outcome(s) were summarized and assessed with respect to timing of the corresponding CE-mark approval. RESULTS At least one prospective clinical trial was identified for 70% (50/71) of the pre-specified devices. Overall, 473 reports of 308 prospectively designed studies (enrolling 97 886 individuals) were deemed eligible, including 81% (251/308) prospective non-randomized clinical trials (66 186 individuals) and 19% (57/308) randomized clinical trials (31 700 individuals). Pre-registration of the study protocol was available in 49% (150/308) studies, and 16% (48/308) had a peer-reviewed publicly available protocol. Device-related adverse events were evaluated in 82% (253/308) of studies. An outcome adjudication process was reported in 39% (120/308) of the studies. Sample size was larger for randomized in comparison to non-randomized trials (median of 304 vs. 100 individuals, P < .001). No randomized clinical trial published before CE-mark approval for any of the devices was identified. Non-randomized clinical trials were predominantly published after the corresponding CE-mark approval of the device under evaluation (89%, 224/251). Sample sizes were smaller for studies published before (median of 31 individuals) than after (median of 135 individuals) CE-mark approval (P < .001). Clinical trials with larger sample sizes (>50 individuals) and those with longer recruitment periods were more likely to be published after CE-mark approval, and were more frequent during the period 2016-21. CONCLUSIONS The quantity and quality of publicly available data from prospective clinical investigations across selected categories of cardiovascular devices, before and after CE approval during the period 2000-21, were deemed insufficient. The majority of studies was non-randomized, with increased risk of bias, and performed in small populations without provision of power calculations, and none of the reviewed devices had randomized trial results published prior to CE-mark certification.
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Affiliation(s)
- George C M Siontis
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Bernadette Coles
- Velindre University NHS Trust Library and Knowledge Service, Cardiff, UK
| | - Jonas D Häner
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Laurna McGovern
- Department of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, Dublin, Ireland
| | - Joanna Bartkowiak
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - J J Coughlan
- Department of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Alessandro Spirito
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Roberto Galea
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Andreas Haeberlin
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Daijiro Tomii
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Tom Melvin
- School of Medicine, Trinity College Dublin, Ireland
| | - André Frenk
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Robert A Byrne
- Department of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, Dublin, Ireland
| | - Alan G Fraser
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
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