Incentivizing research into the effectiveness of medical devices

Introduction Medical devices (MDs) often obtain market authorization with much less clinical evidence than other health technologies, especially pharmaceuticals. This is due to a number of reasons. First, in contrast to pharmaceuticals, there is no legal requirement to conduct adequately controlled clinical studies, other than for ‘high-risk’ devices in some jurisdictions. In the US for example, high-risk devices and innovative lower-risk devices are required to demonstrate ‘reasonable assurance of safety and effectiveness’, which may imply clinical evidence based on randomized studies in many instances. In contrast, in the EU the requirement is to demonstrate adequate performance and safety, which can often be achieved by conducting observational studies such as registries [1, 2]. Secondly, the devices industry comprises many small and medium-size enterprises (SMEs), which would find the cost of conducting clinical studies, especially randomized controlled trials, prohibitive. However, although some larger manufacturers do undertake clinical studies of some of their products, manufacturers with similar products (called ‘fast-followers’) can often claim ‘substantial equivalence’ to a product that already has market authorization, thus avoiding the need to conduct costly and timeconsuming clinical studies. Since regulatory agencies often accept these claims of equivalence, for example under the 510(k) process in the US [3], this further reduces the incentives for manufacturers to conduct expensive clinical studies. Therefore, although device manufacturers have patent protection, they are often not granted data exclusivity in the same way as pharmaceutical manufacturers. Finally, unlike pharmaceuticals, devices are often modified once on the market, meaning that even if clinical evidence was available for the original version of the product, it may not necessarily be available for the version currently being marketed. For example in the US, one analysis showed that for 77 original market authorization applications for cardiac implantable electronic devices (e.g., pacemakers, implantable cardioverter-defibrillators) since 1979, the FDA approved 5829 ‘supplements’ reflecting product modifications in the period up until 2012. Of course, many of these product modifications were minor and unlikely to affect the performance of the device, but 37 % involved a change to the device’s design. In the vast majority of these cases the FDA deemed that new clinical data were not necessary for approval [4]. The lack of clinical evidence prior to product launch, especially evidence of comparative effectiveness, limits the possibilities for health technology assessment [2]. However, it should be remembered that clinical evidence can be gathered both pre-market (i.e., through conducting controlled clinical trials in an experimental setting), and postmarket, through clinical studies undertaken in regular clinical practice. Post-market effectiveness research may be more important for MDs than pharmaceuticals, as the performance of the device often depends on the interaction with the user (the so-called learning curve) [5]. This suggests that solutions to the problem of inadequate clinical evidence should address the issue of conducting clinical research in both the pre- and post-market phase. In this editorial we consider ways in which MD manufacturers could be incentivized to produce more clinical evidence to facilitate health technology assessments, including economic evaluations.