Barriers and facilitators of patient access to medical devices in Europe: A systematic literature review

Cost-Effectiveness of Ultrasound Renal Denervation for Resistant Hypertension in Belgium, France and The Netherlands

BACKGROUND

Endovascular ultrasound renal denervation (uRDN) with the Paradise System has emerged as an adjunctive treatment option for the management of uncontrolled resistant hypertension (rHTN). This study assesses the cost-effectiveness of uRDN for rHTN across three European countries-Belgium, France and the Netherlands.

METHODS

On the basis of a previously developed state-transition Markov model, we projected costs, life years (LYs) and quality adjusted life years (QALYs) with the addition of uRDN to standard of care (SoC) compared with SoC alone over patient lifetime. Analyses were based on the RADIANCE-HTN TRIO trial, which demonstrated a mean reduction in office systolic blood pressure from a baseline of 8.5 mmHg at 2 months post-uRDN among patients with rHTN. Mortality and costs data were separately sourced and applied for each country independently. Country-specific discount rates were applied to both cost and outcomes. One-way and probabilistic sensitivity analyses were conducted to assess the uncertainty surrounding the model inputs and sensitivity of the model results to changes in parameter inputs. Results were reported as incremental cost-effectiveness ratios (ICERs).

RESULTS

The base-case analyses of the models for all three countries show uRDN plus SoC results in improvement in both LYs and QALYs per patient and higher costs compared with SoC alone. The mean ICERs for each country model fall well below the respective country-specific willingness-to-pay thresholds (WTPs)-Belgium: WTP €40,000 and ICER €4426/QALY gained; France: WTP €50,000 and ICER €6261/QALY gained; and the Netherlands: WTP €20,000 and ICER €1654/QALY gained. Results were robust across scenarios and sensitivity analyses.

CONCLUSIONS

The addition of endovascular uRDN offers clinicians and payers a cost-effective adjunctive treatment approach alongside hypertensive medication for the management of rHTN in the healthcare systems of Belgium, France and the Netherlands.

Improving antibiotic prescribing - Recommendations for funding and pricing policies to enhance use of point-of-care tests

Introduction

Diagnostics can contribute to the improved quality of antibiotic prescribing. However, there is potential to enhance the use of point-of-care tests (POCTs) in general practice. This paper presents fit-for-purpose policy recommendations related to funding and pricing for POCTs applied for community-acquired acute respiratory tract infections (CA-ARTIs).

Methods

The development of the recommendations was informed by an analysis of the current status of funding and pricing policy frameworks for CA-ARTI POCTs in European countries, and an identification of barriers and facilitators for their uptake. Draft recommendations were developed and subsequently revised based on written and verbal feedback from meetings with experts.

Results

The proposal includes four recommendations for policy interventions related to funding and three recommendations regarding pricing policies. Two of the funding policy-related recommendations concern physicians' remuneration, and two relate to product-specific reimbursement (public coverage) of the CA-ARTI POCTs. The pricing-related recommendations include a proposal to explore the introduction of price regulation, to pilot subscription-fee procurement models and to enhance more strategic approaches in public procurement of CA-ARTI POCTs.

Conclusions

Optimised pricing and funding policies could make a difference in enhancing uptake of CA-ARTI POCTs. It is crucial for the successful implementation of policies to consider country settings. Additionally, supportive policy action is recommended, including the systematic use of health technology assessment, stakeholder communication, and monitoring and evaluation.

Barriers to and facilitators of paediatric medical device innovation: a scoping review protocol

INTRODUCTION

The development of paediatric medical devices continues to lag adult medical devices and contributes to issues of inequity, safety, quality and patient outcomes. New legislation and funding mechanisms have been introduced over the past two decades, but the gap remains. Clinical trials have been identified as a pain point, but components of effective clinical research infrastructure are poorly understood. As part of a multimodal research strategy, the Pediatric Device Consortia (PDC) will conduct a scoping review to better understand infrastructural barriers to and facilitators of paediatric medical device clinical research identified in the health sciences literature.

METHODS AND ANALYSIS

The following databases will be included for this review: Medline, Embase, Cochrane CENTRAL, Web of Science and IEEE Xplore. Additional grey literature will be sought out through Google Scholar and reviewing the citations of included studies. Included studies will discuss medical devices according to the U.S. Food and Drug Administration classification, focus on the paediatric population (ages 0-21 years) and involve human premarket or postmarket research. All study types that were published in 2007-present in English, Spanish, French or Italian will be included. Using Covidence web-based software, two independent reviewers will screen the resulting titles, abstracts and the full text of potential studies. Conflicts will be resolved by the primary investigator during both phases. REDCap will be used for quantitative and qualitative data charting, generating data tables and narrative synthesis.

ETHICS AND DISSEMINATION

This research did not require research ethics board consideration as it does not involve human participants and all data will be collected from published literature. We will share our findings through peer-reviewed manuscripts, clinical and research conference presentations and professional networks available to the PDC.

STUDY REGISTRATION

Open Science Framework (https://osf.io/k72bn).

Smart Tattoo Sensors 2.0: A Ten-Year Progress Report through a Narrative Review

The increased interest in sensing tattoos reflects a shift in wearable technology, emphasizing their flexible, skin-adherent nature. These devices, driven by advancements in nanotechnology and materials science, offer highly sensitive and customizable sensors. The growing body of research in this area indicates a rising curiosity in their design and applications, with potential uses ranging from vital sign monitoring to biomarker detection. Sensing tattoos present a promising avenue in wearable healthcare technology, attracting attention from researchers, clinicians, and technology enthusiasts. The objective of this study is to analyze the development, application, and integration of the sensing tattoos in the health domain. A review was conducted on PubMed and Scopus, applying a standard checklist and a qualification process. The outcome reported 37 studies. Sensing tattoos hold transformative potential in health monitoring and physiological sensing, driven by their focus on affordability, user-friendly design, and versatile sensorization solutions. Despite their promise, ongoing refinement is essential, addressing limitations in adhesion, signal quality, biocompatibility, and regulatory complexities. Identified opportunities, including non-invasive health monitoring, multiplexed detection, and cost-effective fabrication methods, open avenues for personalized healthcare applications. However, bridging gaps in medical device standards, cybersecurity, and regulatory compliance is imperative for seamless integration. A key theme calls for a holistic, user-centric approach, emphasizing interdisciplinary collaboration. Balancing innovation with practicality, prioritizing ethics, and fostering collaboration are crucial for the evolution of these technologies. The dynamic state of the field is evident, with active exploration of new frontiers. This overview also provides a roadmap, urging scholars, industry players, and regulators to collectively contribute to the responsible integration of sensing tattoos into daily life.

Barriers and Facilitators in Pricing and Funding Policies of European Countries That Impact the Use of Point-of-Care Diagnostics for Acute Respiratory Tract Infections in Outpatient Practices

Antimicrobial resistance is a major global health threat, which is increased by the irrational use of antibiotics, for example, in the treatment of respiratory tract infections in community care. By using rapid point-of-care diagnostics, overuse can be avoided. However, the diagnostic tests are rarely used in most European countries. We mapped potential barriers and facilitators in health technology assessment (HTA), pricing, and funding policies related to the use of rapid diagnostics in patients with community-acquired acute respiratory tract infections. Expert interviews were conducted with representatives of public authorities from five European case study countries: Austria, Estonia, France, Poland, and Sweden. Barriers to the HTA process include the lack of evidence and limited transferability of methods established for medicines to diagnostics. There was no price regulation for the studied diagnostics in the case study countries, but prices were usually indirectly determined via procurement. The lack of price regulation and weak purchasing power due to regional procurement processes were mentioned as pricing-related barriers. Regarding funding, coverage (reimbursement) of the diagnostic tests and the optimized remuneration of physicians in their use were mentioned as facilitators. There is potential to strengthen peri-launch policies, as optimized policies may promote the uptake of POCT.

Utilization of innovative medical technologies in German inpatient care: does evidence matter?

BACKGROUND

The reimbursement of new technologies in inpatient care is not always linked to a requirement for evidence-based evaluation of patient benefit. In Germany, every new technology approved for market was until recently eligible for reimbursement in inpatient care unless explicitly excluded. The aim of this work was (1) to investigate the type of evidence that was available at the time of introduction of 25 innovative technologies and how this evidence evolved over time, and (2) to explore the relationship between clinical evidence and utilization for these technologies in German inpatient care.

METHODS

This study combined different methods. A systematic search for evidence published between 2003 and 2017 was conducted in four bibliographic databases, clinical trial registries, resources for clinical guidelines, and health technology assessment-databases. Information was also collected on funding mechanisms and safety notices. Utilization was measured by hospital procedures captured in claims data. The body of evidence, funding and safety notices per technology were analyzed descriptively. The relationship between utilization and evidence was explored empirically using a multilevel regression analysis.

RESULTS

The number of included publications per technology ranges from two to 498. For all technologies, non-comparative studies form the bulk of the evidence. The number of randomized controlled clinical trials per technology ranges from zero to 19. Some technologies were utilized for several years without an adequate evidence base. A relationship between evidence and utilization could be shown for several but not all technologies.

CONCLUSIONS

This study reveals a mixed picture regarding the evidence available for new technologies, and the relationship between the development of evidence and the use of technologies over time. Although the influence of funding and safety notices requires further investigation, these results re-emphasize the need for strengthening market approval standards and HTA pathways as well as approaches such as coverage with evidence development.

Gaps in the evidence underpinning high-risk medical devices in Europe at market entry, and potential solutions

AIM

To determine the level of evidence for innovative high-risk medical devices at market entry.

METHODS

We reviewed all Belgian healthcare payer (RIZIV-INAMI) assessor reports on novel implants or invasive medical devices (n = 18, Class IIb-III) available between 2018 to mid-2019 on applications submitted for inclusion on their reimbursement list. We also conducted a review of the literature on evidence gaps and an analysis of relevant legal and ethical frameworks within the European context.

FINDINGS

Conformity assessment of medical devices is based on performance, safety, and an acceptable risk-benefit balance. Information submitted for obtaining CE marking is confidential and legally protected, limiting access to clinical evidence. Seven out of the 18 RIZIV-INAMI assessor reports (39%) included a randomized controlled trial (RCT) using the novel device, whilst 2 applications (11%) referred to an RCT that used a different device. The population included was inappropriate or unclear for 3 devices (17%). Only half of the applications presented evidence on quality of life or functioning and 2 (11%) presented overall survival data. Four applications (22%) included no data beyond twelve months. The findings from the literature demonstrated similar problems with the study design and the clinical evidence.

DISCUSSION AND CONCLUSIONS

CE marking does not indicate that a device is effective, only that it complies with the law. The lack of transparency hampers evidence-based decision making. Despite greater emphasis on clinical benefit for the patient, the provisions of the European Medical Device Regulation (MDR) are not yet fully aligned with international ethical standards for clinical research. The MDR fails to address key issues, such as the lack of access to data submitted for CE marking and a failure to require evidence of clinical effectiveness. Indeed, a first report shows no improvement in the clinical evidence for implantable devices generated under the MDR. Thus, patients may continue to be exposed to ineffective or unsafe novel devices. The Health Technology Assessment Regulation plans for Joint Scientific Consultations for specific high-risk devices before companies begin their pivotal clinical investigations. The demanded comparative evidence should facilitate payer decisions. Nevertheless, there is also a need for legislation requiring comparative RCTs assessing patient-relevant outcomes for high-risk devices to ensure implementation, including development and implementation of common specifications for study designs.

Implementation of coverage with evidence development schemes for medical devices: A decision tool for late technology adopter countries

Experiences with coverage with evidence development (CED) schemes are fairly limited in Central and Eastern European (CEE) countries, which are usually late adopters of new health technologies. Our aim was to put forward recommendations on how CEE health technology assessment bodies and payer organizations can apply CED to reduce decision uncertainty on reimbursement of medical devices, with a particular focus on transferring the structure and data from CED schemes in early technology adopter countries in Western Europe. Structured interviews on the practices and feasibility of transferring CED schemes were conducted and subsequently, a draft tool for the systematic classification of decision alternatives and recommendations was developed. The decision tool was reviewed in a focus group discussion and validated within a wider group of CEE experts in a virtual workshop. Transferability assessment is needed in case of (1) joint implementation of a CED scheme; (2) transferring the structure of an existing CED scheme to a CEE country; (3) reimbursement decisions that are linked to outcomes of an ongoing CED scheme in another country and (4) real-world evidence transferred from completed CED schemes. Efficient use of available resources may be improved by adequately transferring evidence and policy tools from early technology adopter countries.

Assessing, Pricing and Funding Point-of-Care Diagnostic Tests for Community-Acquired Acute Respiratory Tract Infections-Overview of Policies Applied in 17 European Countries

Point-of-care diagnostic tests for community-acquired acute respiratory tract infections (CA-ARTI) can support doctors by improving antibiotic prescribing. However, little is known about health technology assessment (HTA), pricing and funding policies for CA-ARTI diagnostics. Thus, this study investigated these policies for this group of devices applied in the outpatient setting in Europe. Experts from competent authority responded to a questionnaire in Q4/2020. Information is available for 17 countries. Studied countries do not base their pricing and funding decision for CA-ARTI diagnostics on an HTA. While a few countries impose price regulation for some publicly funded medical devices, the prices of CA-ARTI diagnostics are not directly regulated in any of the surveyed countries. Indirect price regulation through public procurement is applied in some countries. Reimbursement lists of medical devices eligible for public funding exist in several European countries, and in some countries these lists include CA-ARTI diagnostics. In a few countries, the public payer funds the health professional for performing the service of conducting the test. Given low levels of regulation and few incentives, the study findings suggest room for strengthening pricing and funding policies of CA-ARTI diagnostics to contribute to increased acceptance and use of these point-of-care tests.

Rise of Clinical Studies in the Field of Machine Learning: A Review of Data Registered in ClinicalTrials.gov

Although advances in machine-learning healthcare applications promise great potential for innovative medical care, few data are available on the translational status of these new technologies. We aimed to provide a comprehensive characterization of the development and status quo of clinical studies in the field of machine learning. For this purpose, we performed a registry-based analysis of machine-learning-related studies that were published and first available in the ClinicalTrials.gov database until 2020, using the database's study classification. In total, n = 358 eligible studies could be included in the analysis. Of these, 82% were initiated by academic institutions/university (hospitals) and 18% by industry sponsors. A total of 96% were national and 4% international. About half of the studies (47%) had at least one recruiting location in a country in North America, followed by Europe (37%) and Asia (15%). Most of the studies reported were initiated in the medical field of imaging (12%), followed by cardiology, psychiatry, anesthesia/intensive care medicine (all 11%) and neurology (10%). Although the majority of the clinical studies were still initiated in an academic research context, the first industry-financed projects on machine-learning-based algorithms are becoming visible. The number of clinical studies with machine-learning-related applications and the variety of medical challenges addressed serve to indicate their increasing importance in future clinical care. Finally, they also set a time frame for the adjustment of medical device-related regulation and governance.

Quo Vadis HTA for Medical Devices in Central and Eastern Europe? Recommendations to Address Methodological Challenges

Objectives: Methodological challenges in the evaluation of medical devices (MDs) may be different for early and late technology adopter countries, as well as the potential health technology assessment (HTA) solutions to tackle them. This study aims to provide guidance to Central and Eastern European (CEE) countries on how to address key challenges of HTA for MDs with special focus on the transferability of scientific evidence.

Methods: As part of the COMED Horizon 2020 project, a comprehensive list of issues related to MD HTA were identified based on a targeted literature review. Health technology assessment issues which pose a greater challenge or require different solutions in late technology adopter countries were selected. Draught recommendations to address these issues were developed and discussed in a focus group. The recommendations were then validated with a wider group of experts, including HTA and reimbursement decision makers from CEE countries in May and June 2020.

Results: A consolidated list of 11 recommendations were developed in 3 major areas: (1) clinical value assessment, focusing on the use of joint EU work, relying on real-world evidence, use of coverage with evidence development schemes, transferring evidence from foreign countries and addressing the challenges of learning curve and centre effect; (2) economic value assessment, covering cost calculation of complex medical devices and transferability of economic evaluations of MDs; (3) HTA processes, related to the frequent product modifications and various indications of MDs.

Conclusions: Central and Eastern European countries with limited resources for conducting HTA, can benefit from HTA methods and evidence generated in early technology adopter countries. Considering the appropriate reuse of international HTA materials, late technology adopter countries can still implement HTA, even for MDs, which have a more limited evidence base compared with pharmaceuticals.

A Digital Innovation for the Personalized Management of Adherence: Analysis of Strengths, Weaknesses, Opportunities, and Threats

Introduction: Personalized medicine and management of adherence are potential solutions for the suboptimal use of medicines. Digital medication management innovations currently under development combine both aspects. This research aims to investigate facilitators for and barriers to the translation of digital innovations for personalized medicine and adherence management into clinical practice from the policymaker and regulator perspective.

Methods: A mixed-method study was used combining a scoping review to identify main interests, semi-structured interviews (n = 5) with representatives of European health policymaking and regulatory organizations, and a supplementary literature review to investigate key subthemes. The SWOT analysis was used for the qualitative analysis.

Results: The literature reviews and the qualitative interviews suggested that digital solutions can facilitate the personalized management of medications and improve quality and safety, especially as the openness for digital health solutions is increasing. Digital solutions may, on the other hand, add complexity to the treatment, which can be perceived as a potential barrier for their uptake. As more multidisciplinary and participative structures are emerging, digital solutions can promote the implementation of new services. Nevertheless, change progresses slowly in the task-oriented structures of health systems. Integration of digital solutions depends on all stakeholders' willingness and abilities to co-create this change. Patients have different capabilities to self-manage their medical conditions and use digital solutions. Personalization of digital health solutions and integration in existing service structures are crucial to ensure equality among population segments. Developments in the digital infrastructure, although they are partly slow and not well-aligned, enable the implementation of innovations in clinical practice leading to further advances in data generation and usage for future innovations.

Discussion: This study suggests that digital solutions have the potential to facilitate high-quality medication management and improve adherence to medications, enable new service structures, and are essential to drive further innovations in health care. Nevertheless, increasing the self-responsibility of patients can have undesirable effects on health outcomes, especially within vulnerable population segments. Digital health solutions can be an opportunity to optimize the use of medicines and thus their efficiency. Well-conceived development and implementation processes are needed to also realize improvements in equality and solidarity within health systems.

A Review of Bioresorbable Implantable Medical Devices: Materials, Fabrication, and Implementation

Implantable medical devices (IMDs) are designed to sense specific parameters or stimulate organs and have been actively used for treatment and diagnosis of various diseases. IMDs are used for long-term disease screening or treatments and cannot be considered for short-term applications since patients need to go through a surgery for retrieval of the IMD. Advances in bioresorbable materials has led to the development of transient IMDs that can be resorbed by bodily fluids and disappear after a certain period. These devices are designed to be implanted in the adjacent of the targeted tissue for predetermined times with the aim of measurement of pressure, strain, or temperature, while the bioelectronic devices stimulate certain tissues. They enable opportunities for monitoring and treatment of acute diseases. To realize such transient and miniaturized devices, researchers utilize a variety of materials, novel fabrication methods, and device design strategies. This review discusses potential bioresorbable materials for each component in an IMD followed by programmable degradation and safety standards. Then, common fabrication methods for bioresorbable materials are introduced, along with challenges. The final section provides representative examples of bioresorbable IMDs for various applications with an emphasis on materials, device functionality, and fabrication methods.