What type of clinical evidence is needed to assess medical devices?

Regional Citrate Anticoagulation Versus Systemic Heparin in Continuous Kidney Replacement Therapy: Examining the Role of Evidence in Health Technology Assessment

INTRODUCTION

Continuous kidney replacement therapy (CKRT) is an established treatment supporting kidney function in patients with severe acute kidney disease. Systemic heparin and regional citrate anticoagulation (RCA) are the main anticoagulation strategies to prevent dialysis filter loss due to clotting, a complication of all KRT, including CKRT. The present study aims to comprehensively compare two anticoagulation strategies by collecting available clinical and economic evidence for an adult population under CKRT through a systematic literature review and meta-analysis.

METHODS

Randomized controlled trials, prospective/retrospective observational studies and economic analyses, involving systemic heparin or RCA, were searched through PubMed and Web of Science databases. Extracted data focused on clinical parameters, adverse events and cost items. Meta-analyses were conducted on data points with numeric outcomes to compare the two anticoagulation techniques. An evaluation of the quality of the evidence was also conducted using the GRADE system.

RESULTS

Seventy-two studies were eligible for this meta-analysis. Statistically significant differences between heparin and RCA were observed in ionized calcium levels (mmol/l; heparin 1.19, RCA 1.13), bleeding events (heparin 12.6%, RCA 2.4%), filter lifespan (hours; heparin 16.43, RCA 36.69), clotting issues (heparin 50.7%, RCA 21.3%), filter failure rate (heparin 67.7%, RCA 13.5%), hypocalcemia (heparin 0.1%, RCA 4.4%) and alkalosis (heparin 0.4%, RCA 6.6%) rates. Limitations include heterogeneity across studies, particularly for RCA, and potential biases, although the overall methodological quality ranged from moderate to low.

CONCLUSIONS

Based on the evidence presented, despite higher rates of hypocalcemia and alkalosis, RCA demonstrates advantages over heparin, including a reduction in bleeding events, prevention of filter clotting and improvement in filter lifespan. Additionally, the cost outcome demonstrated comparable statistics depending on the RCA protocol considered, which supports the potential cost-effectiveness of RCA. RCA provides clear clinical and potential organizational benefits and comparable cost statistics with a reasonable level of confidence in the evidence for the economic data.

An international consensus panel on the potential value of Digital Surgery

OBJECTIVES

The use of digital technology in surgery is increasing rapidly, with a wide array of new applications from presurgical planning to postsurgical performance assessment. Understanding the clinical and economic value of these technologies is vital for making appropriate health policy and purchasing decisions. We explore the potential value of digital technologies in surgery and produce expert consensus on how to assess this value.

DESIGN

A modified Delphi and consensus conference approach was adopted. Delphi rounds were used to generate priority topics and consensus statements for discussion.

SETTING AND PARTICIPANTS

An international panel of 14 experts was assembled, representing relevant stakeholder groups: clinicians, health economists, health technology assessment experts, policy-makers and industry.

PRIMARY AND SECONDARY OUTCOME MEASURES

A scoping questionnaire was used to generate research questions to be answered. A second questionnaire was used to rate the importance of these research questions. A final questionnaire was used to generate statements for discussion during three consensus conferences. After discussion, the panel voted on their level of agreement from 1 to 9; where 1=strongly disagree and 9=strongly agree. Consensus was defined as a mean level of agreement of >7.

RESULTS

Four priority topics were identified: (1) how data are used in digital surgery, (2) the existing evidence base for digital surgical technologies, (3) how digital technologies may assist surgical training and education and (4) methods for the assessment of these technologies. Seven consensus statements were generated and refined, with the final level of consensus ranging from 7.1 to 8.6.

CONCLUSION

Potential benefits of digital technologies in surgery include reducing unwarranted variation in surgical practice, increasing access to surgery and reducing health inequalities. Assessments to consider the value of the entire surgical ecosystem holistically are critical, especially as many digital technologies are likely to interact simultaneously in the operating theatre.

Systematic review for the development of a core outcome set for monofocal intraocular lenses for cataract surgery

Introduction

The aim of the study was to define a core outcome set (COS) to be measured following cataract surgery for the postoperative evaluation of monofocal intraocular lenses (IOLs). Compared to current COSs, the present work provides updates considering the advances in the technology due to the development of new generation monofocal IOLs, which are characterized by a safety profile comparable to standard monofocal IOLs but with an extended range of intermediate vision.

Methods

Healthcare professionals (ophthalmologist surgeons) and patients were involved in the selection of outcomes to be included in the COS, starting from a list of indicators retrieved from a systematic literature search. The search considered observational studies with both a retrospective or prospective design, case studies and classic randomized controlled trials (RCTs). A mixed methodology integrating a Delphi-driven and an expert panel approach was adopted to reach an agreement among clinicians, while patients were involved in the completion of a questionnaire.

Results

The final COS included 15 outcomes. Eleven outcomes, all clinical, were considered for inclusion after a joint discussion among ophthalmologists; seven outcomes were linked to visual acuity, while the remaining to contrast sensitivity, refractive errors, aberrations and adverse events. Measurement metrics, method of aggregation and measurement time point of these outcomes were specified. The most important aspects for the patients were (1) quality of life after cataract surgery, (2) the capacity to perform activities requiring good near vision (e.g., reading), (3) spectacle independence, and (4) safety of movements without fear of getting hurt or falling (intermediate vision).

Discussion

In a context with limited healthcare resources, it is important to optimize their use considering also the preferences of end-users, namely patients. The proposed COS, developed involving both ophthalmologists and patients, provides an instrument for the postoperative evaluation of different technologies in the context of monofocal IOLs, which can be used not only in clinical trials but also in clinical practice to increase the body of real-world evidence.

Quality and Utility of European Cardiovascular and Orthopaedic Registries for the Regulatory Evaluation of Medical Device Safety and Performance Across the Implant Lifecycle: A Systematic Review

BACKGROUND

The European Union Medical Device Regulation (MDR) requires manufacturers to undertake post-market clinical follow-up (PMCF) to assess the safety and performance of their devices following approval and Conformité Européenne (CE) marking. The quality and reliability of device registries for this Regulation have not been reported. As part of the Coordinating Research and Evidence for Medical Devices (CORE-MD) project, we identified and reviewed European cardiovascular and orthopaedic registries to assess their structures, methods, and suitability as data sources for regulatory purposes.

METHODS

Regional, national and multi-country European cardiovascular (coronary stents and valve repair/replacement) and orthopaedic (hip/knee prostheses) registries were identified using a systematic literature search. Annual reports, peer-reviewed publications, and websites were reviewed to extract publicly available information for 33 items related to structure and methodology in six domains and also for reported outcomes.

RESULTS

Of the 20 cardiovascular and 26 orthopaedic registries fulfilling eligibility criteria, a median of 33% (IQR: 14%-71%) items for cardiovascular and 60% (IQR: 28%-100%) items for orthopaedic registries were reported, with large variation across domains. For instance, no cardiovascular and 16 (62%) orthopaedic registries reported patient/ procedure-level completeness. No cardiovascular and 5 (19%) orthopaedic registries reported outlier performances of devices, but each with a different outlier definition. There was large heterogeneity in reporting on items, outcomes, definitions of outcomes, and follow-up durations.

CONCLUSION

European cardiovascular and orthopaedic device registries could improve their potential as data sources for regulatory purposes by reaching consensus on standardised reporting of structural and methodological characteristics to judge the quality of the evidence as well as outcomes.

The Challenges for Manufacturers of the Increased Clinical Evaluation in the European Medical Device Regulations: A Quantitative Study

The European Union Medical Device Regulations 2017/745 entered into force on May 2021 with changes related to strengthening the clinical evaluation requirements, particularly for high-risk devices. This study investigates how the increased requirements on medical device manufacturers in relation to how clinical evaluation will challenge manufacturers. A quantitative survey study was utilized with responses from 68 senior or functional area subject matter experts working in medical device manufacturing Regulatory or Quality roles. The findings from the study demonstrated that the highest source of reactive Post-Market Surveillance data was customer complaints and proactive data were Post-Market Clinical Follow-Up. In contrast, the top 3 sources for generating clinical evaluation data for legacy devices under the new Medical Device Regulations were Post-Market Surveillance data, Scientific literature reviews, and Post-Market Clinical Follow-Up studies. Manufacturers' biggest challenge under the new Medical Device Regulations is determining the amount of data needed to generate sufficient clinical evidence, while over 60% of high-risk device manufacturers have outsourced the writing of their clinical evaluation reports. Manufacturers also reported a high investment in clinical evaluation training and highlighted inconsistencies in the requirements for clinical data by different notified bodies. These challenges may lead to a potential shortage of certain medical devices in the E.U. and a delay in access to new devices, negatively impacting patient quality of life (1). This study provides a unique insight into the challenges currently experienced by medical device manufacturers as they transition to the MDR clinical evaluation requirements and the subsequent impact on the continued availability of medical devices in the E.U.

Time-Driven Activity-Based Costing for Capturing the Complexity of Healthcare Processes: The Case of Deep Vein Thrombosis and Leg Ulcers

Time-driven activity-based costing (TDABC) is suggested to assess costs within the value-based healthcare approach, but there is a paucity of applications in chronic diseases such as deep vein thrombosis (DVT) and leg ulcers. In this context, we applied TDABC in a cost-effectiveness analysis comparing venous stenting to compression ± anticoagulation (standard of care-SOC) from both hospital and societal perspectives in Italy. TDABC was applied to both treatments to assess costs that were included in a cost-effectiveness model. Clinical inputs were retrieved from the literature and integrated with real-world data. The Incremental Cost Utility Ratio (ICUR) of stenting compared to SOC was EUR 10,270/QALY and EUR 8962/QALY for hospital and societal perspectives, respectively. The mean cost per patient for venous stenting of EUR 5082 was higher than the Diagnosis-Related Group (DRG) reimbursement (EUR 4742). For SOC, an ulcer healing in 3 months costs EUR 1892, of which EUR 302 (16%) is borne by the patient versus a reimbursement of EUR 1132. TDABC showed that venous stenting may be cost-effective compared with SOC but that reimbursement rates may not completely cover the real costs, which are partially sustained by the patients. A more efficient policy for covering the real costs may be beneficial for both clinical centers and patients.

Impella Versus VA-ECMO for Patients with Cardiogenic Shock: Comprehensive Systematic Literature Review and Meta-Analyses

Impella and VA-ECMO are two possible therapeutic courses for the treatment of patients with cardiogenic shock (CS). The study aims to perform a systematic literature review and meta-analyses of a comprehensive set of clinical and socio-economic outcomes observed when using Impella or VA-ECMO with patients under CS. A systematic literature review was performed in Medline, and Web of Science databases on 21 February 2022. Nonoverlapping studies with adult patients supported for CS with Impella or VA-ECMO were searched. Study designs including RCTs, observational studies, and economic evaluations were considered. Data on patient characteristics, type of support, and outcomes were extracted. Additionally, meta-analyses were performed on the most relevant and recurring outcomes, and results shown using forest plots. A total of 102 studies were included, 57% on Impella, 43% on VA-ECMO. The most common outcomes investigated were mortality/survival, duration of support, and bleeding. Ischemic stroke was lower in patients treated with Impella compared to the VA-ECMO population, with statistically significant difference. Socio-economic outcomes including quality of life or resource use were not reported in any study. The study highlighted areas where further data collection is needed to clarify the value of complex, new technologies in the treatment of CS that will enable comparative assessments focusing both on the health impact on patient outcomes and on the financial burden for government budgets. Future studies need to fill the gap to comply with recent regulatory updates at the European and national levels.

Decision-analytic modeling for early health technology assessment of medical devices - a scoping review

Objective

The goal of this review was to identify decision-analytic modeling studies in early health technology assessments (HTA) of high-risk medical devices, published over the last three years, and to provide a systematic overview of model purposes and characteristics. Additionally, the aim was to describe recent developments in modeling techniques.

Methods

For this scoping review, we performed a systematic literature search in PubMed and Embase including studies published in English or German. The search code consisted of terms describing early health technology assessment and terms for decision-analytic models. In abstract and full-text screening, studies were excluded that were not modeling studies for a high-risk medical device or an in-vitro diagnostic test. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram was used to report on the search and exclusion of studies. For all included studies, study purpose, framework and model characteristics were extracted and reported in systematic evidence tables and a narrative summary.

Results

Out of 206 identified studies, 19 studies were included in the review. Studies were either conducted for hypothetical devices or for existing devices after they were already available on the market. No study extrapolated technical data from early development stages to estimate potential value of devices in development. All studies except one included cost as an outcome. Two studies were budget impact analyses. Most studies aimed at adoption and reimbursement decisions. The majority of studies were on in-vitro diagnostic tests for personalized and targeted medicine. A timed automata model, to our knowledge a model type new to HTA, was tested by one study. It describes the agents in a clinical pathway in separate models and, by allowing for interaction between the models, can reflect complex individual clinical pathways and dynamic system interactions. Not all sources of uncertainty for in-vitro tests were explicitly modeled. Elicitation of expert knowledge and judgement was used for substitution of missing empirical data. Analysis of uncertainty was the most valuable strength of decision-analytic models in early HTA, but no model applied sensitivity analysis to optimize the test positivity cutoff with regard to the benefit-harm balance or cost-effectiveness. Value-of-information analysis was rarely performed. No information was found on the use of causal inference methods for estimation of effect parameters from observational data.

Conclusion

Our review provides an overview of the purposes and model characteristics of nineteen recent early evaluation studies on medical devices. The review shows the growing importance of personalized interventions and confirms previously published recommendations for careful modeling of uncertainties surrounding diagnostic devices and for increased use of value-of-information analysis. Timed automata may be a model type worth exploring further in HTA. In addition, we recommend to extend the application of sensitivity analysis to optimize positivity criteria for in-vitro tests with regard to benefit-harm or cost-effectiveness. We emphasize the importance of causal inference methods when estimating effect parameters from observational data.

Statistical methods for handling compliance in randomized controlled trials of device interventions: a systematic review

OBJECTIVES

We aimed to review the extent to which analysis of randomized controlled trials (RCTs) of device interventions includes methods to handle compliance to the study intervention as described in the protocol.

STUDY DESIGN AND SETTING

We conducted a systematic review of the statistical methods used to handle compliance to a device intervention when estimating the effect of the device compared to another intervention in RCTs. We searched Embase, MEDLINE, PsychInfo, and the Cochrane Central Register of Controlled Trials. We sought to evaluate what methods were used and how using these methods impacted the estimate of the effect size.

RESULTS

One hundred fifty eight RCTs were identified for inclusion, of which only 21 (13%) described using a method to account for compliance to the device intervention, consisting of alternative analysis populations such as per-protocol, modified intention-to-treat, or as-treated, alongside a primary intention-to-treat analysis. No causal inference methods were used. Fourteen (9%) studies included compliance as a factor in the analysis and investigated its effect on outcomes.

CONCLUSION

Although some studies consider methods to handle compliance, causal inference methods have not been well adopted in the analysis of device trials. An increased awareness of the applications of statistical methods to adjust for compliance is needed.

Randomised controlled trials in medical AI: ethical considerations

In recent years, there has been a surge of high-profile publications on applications of artificial intelligence (AI) systems for medical diagnosis and prognosis. While AI provides various opportunities for medical practice, there is an emerging consensus that the existing studies show considerable deficits and are unable to establish the clinical benefit of AI systems. Hence, the view that the clinical benefit of AI systems needs to be studied in clinical trials-particularly randomised controlled trials (RCTs)-is gaining ground. However, an issue that has been overlooked so far in the debate is that, compared with drug RCTs, AI RCTs require methodological adjustments, which entail ethical challenges. This paper sets out to develop a systematic account of the ethics of AI RCTs by focusing on the moral principles of clinical equipoise, informed consent and fairness. This way, the objective is to animate further debate on the (research) ethics of medical AI.

Coverage with evidence development for medical devices in Europe: Can practice meet theory?

Health economists have written extensively on the design and implementation of coverage with evidence development (CED) schemes and have proposed theoretical frameworks based on cost-effectiveness modeling and value of information analysis. CED may aid decision-makers when there is uncertainty about the (cost-)effectiveness of a new health technology at the time of reimbursement. Medical devices are potential candidates for CED schemes, as regulatory regimes do not usually require the same level of efficacy and safety data normally needed for pharmaceuticals. The purpose of this research is to assess whether the actual practice of CED for medical devices in Europe meets the theoretical principles proposed by health economists and whether theory and practice can be more closely aligned. Based on decision-makers' perceptions of the challenges associated with CED schemes, plus examples from the schemes themselves, we discuss a series of proposals for assessing the desirability of schemes, their design, implementation, and evaluation. These proposals, while reflecting the practical challenges with developing CED programs, embody many of the principles suggested by economists and should support decision-makers in dealing with uncertainty about the real-world performance of devices.

Nuclear Medicine and Artificial Intelligence: Best Practices for Evaluation (the RELAINCE Guidelines)

An important need exists for strategies to perform rigorous objective clinical-task-based evaluation of artificial intelligence (AI) algorithms for nuclear medicine. To address this need, we propose a 4-class framework to evaluate AI algorithms for promise, technical task-specific efficacy, clinical decision making, and postdeployment efficacy. We provide best practices to evaluate AI algorithms for each of these classes. Each class of evaluation yields a claim that provides a descriptive performance of the AI algorithm. Key best practices are tabulated as the RELAINCE (Recommendations for EvaLuation of AI for NuClear medicinE) guidelines. The report was prepared by the Society of Nuclear Medicine and Molecular Imaging AI Task Force Evaluation team, which consisted of nuclear-medicine physicians, physicists, computational imaging scientists, and representatives from industry and regulatory agencies.

Real-world evidence in health technology assessment of high-risk medical devices: Fit for purpose?

Health technology assessment (HTA) of medical devices (MDs) increasingly rely on real-world evidence (RWE). The aim of this study was to evaluate the type and the quality of the evidence used to assess the (cost-)effectiveness of high risk MDs (Class III) by HTA agencies in Europe (four European HTA agencies and EUnetHTA), with particular focus on RWE. Data were extracted from HTA reports on the type of evidence demonstrating (cost-)effectiveness, and the quality of observational studies of comparative effectiveness using the Good Research for Comparative Effectiveness principles. 25 HTA reports were included that incorporated 28 observational studies of comparative effectiveness. Half of the studies (46%) took important confounding and/or effect modifying variables into account in the design and/or analyses. The most common way of including confounders and/or effect modifiers was through multivariable regression analysis. Other methods, such as propensity score matching, were rarely employed. Furthermore, meaningful analyses to test key assumptions were largely omitted. Resulting recommendations from HTA agencies on MDs is therefore (partially) based on evidence which is riddled with uncertainty. Considering the increasing importance of RWE it is important that the quality of observational studies of comparative effectiveness are systematically assessed when used in decision-making.

Cost-effectiveness analysis of personalised versus standard dosimetry for selective internal radiation therapy with TheraSphere in patients with hepatocellular carcinoma

Aims

To perform a cost-effectiveness analysis (CEA) comparing personalised dosimetry with standard dosimetry in the context of selective internal radiation therapy (SIRT) with TheraSphere for the management of adult patients with locally advanced hepatocellular carcinoma (HCC) from the Italian Healthcare Service perspective.

Materials and methods

A partition survival model was developed to project costs and the quality-adjusted life years (QALYs) over a lifetime horizon. Clinical inputs were retrieved from a published randomised controlled trial. Health resource utilisation inputs were extracted from the questionnaires administered to clinicians in three oncology centres in Italy, respectively. Cost parameters were based on Italian official tariffs.

Results

Over a lifetime horizon, the model estimated the average QALYs of 1.292 and 0.578, respectively, for patients undergoing personalised and standard dosimetry approaches. The estimated mean costs per patient were €23,487 and €19,877, respectively. The incremental cost-utility ratio (ICUR) of personalised versus standard dosimetry approaches was €5,056/QALY.

Conclusions

Personalised dosimetry may be considered a cost-effective option compared to standard dosimetry for patients undergoing SIRT for HCC in Italy. These findings provide evidence for clinicians and payers on the value of personalised dosimetry as a treatment option for patients with HCC.

Generating Appropriate and Reliable Evidence for Value Assessment of Medical Devices: An Ispor Medical Devices and Diagnostics Special Interest Group Report

Background: Health Technology Assessment methods have become an important health policy tool. Yet recommendations for what constitutes appropriate and reliable evidence for assessment of medical devices are still debated because methods to evaluate pharmaceuticals are often, and incorrectly, the starting point for assessments.

Objectives:

The study aims to: (i) propose recommendations on appropriate methodologies to assess the evidence on medical devices (ii) identify assessment methods that can be used to measure device value and (iii) suggest key areas for future work

Methods:

ISPOR's Medical Devices and Diagnostics Special Interest Group conducted a comprehensive search of databases and gray literature on evidence development and value assessment on medical devices. The literature search was supplemented with hand searching from high impact journals in the related field. The 10-person expert working group obtained written comments through multiple rounds of review from internal and external stakeholders. Recommendations were made to guide future research.

Results:

Multi-criteria decision analysis was identified as a useful approach to assess the value of treatment. Consideration should be given to resource use measures; valid and reliable functional status questionnaires; and general and disease-specific, health-related, quality-of-life measures in economic evaluations of device use. For future work, best practices for value framework design.

Conclusions:

Integration of value-based evidence in an evidence-generation and -synthesis process is needed to support market access and adoption. Methodological recommendations for measuring value can be challenging when the selection of domains and assessment of value are not device-specific.

Observational study investigating Ectoin® Rhinitis Nasal Spray as natural treatment option of acute rhinosinusitis compared to treatment with Xylometazoline

Introduction

Symptomatic relief of acute rhinosinusitis is commonly achieved with nasal decongestants. The current observational study investigated the efficacy and safety of treatment of acute rhinosinusitis with Ectoin^® Rhinitis Spray compared to or in combination with Xylometazoline-containing decongesting nasal spray.

Methods

Patients with acute rhinosinusitis applied either Ectoin^® Rhinitis Spray, Xylometazoline nasal spray or a combination of both products. Rhinosinusitis symptoms were assessed, and nasal oedema and endonasal redness were determined by rhinoscopy. Patient diaries based on the validated SNOT (Sino Nasal Outcome Test) questionnaire evaluated rhinosinusitis parameters over time and influences of the disease on quality of life. Following treatment, investigators and patients judged the efficacy and tolerability.

Results

Ectoin^® Rhinitis Spray diminished common rhinosinusitis symptoms such as nasal obstruction, nasal secretion, facial pain/headache, and smell/taste impairment. Upon treatment over 7 days, rhinosinusitis sum scores decreased statistically significantly (p < 0.001) by − 64.25%, which was comparable to that achieved with Xylometazoline-containing decongesting nasal spray (− 67.60%). No side effects were observed during treatment with Ectoin^® Rhinitis Spray, whereas treatment with Xylometazoline-containing nasal spray resulted in nasal mucosa dryness. Concomitant treatment with both products diminished the development of nasal dryness and required fewer applications of Xylometazoline-containing nasal spray.

Conclusion

Ectoin^® Rhinitis Spray is an effective, natural treatment option for acute rhinosinusitis, which may be used as monotherapy or as add-on treatment with a Xylometazoline-containing nasal spray. The concomitant use of Ectoin^® Rhinitis Spray might reduce the needed dose of decongestant nasal spray and counteract bothersome side effects such as dry nasal mucosa.

Trial registration

The current study was registered in the ClinicalTrials.gov database under the identifier: NCT03693976 (date of registration: Oct 3, 2018).

Do existing real-world data sources generate suitable evidence for the HTA of medical devices in Europe? Mapping and critical appraisal

AIM

Technological and computational advancements offer new tools for the collection and analysis of real-world data (RWD). Considering the substantial effort and resources devoted to collecting RWD, a greater return would be achieved if real-world evidence (RWE) was effectively used to support Health Technology Assessment (HTA) and decision making on medical technologies. A useful question is: To what extent are RWD suitable for generating RWE?

METHODS

We mapped existing RWD sources in Europe for three case studies: hip and knee arthroplasty, transcatheter aortic valve implantation (TAVI) and mitral valve repair (TMVR), and robotic surgery procedures. We provided a comprehensive assessment of their content and appropriateness for conducting the HTA of medical devices. The identification of RWD sources was performed combining a systematic search on PubMed with gray literature scoping, covering fifteen European countries.

RESULTS

We identified seventy-one RWD sources on arthroplasties; ninety-five on TAVI and TMVR; and seventy-seven on robotic procedures. The number, content, and integrity of the sources varied dramatically across countries. Most sources included at least one health outcome (97.5%), with mortality and rehospitalization/reoperation the most common; 80% of sources included resource outcomes, with length of stay the most common, and comparators were available in almost 70% of sources.

CONCLUSIONS

RWD sources bear the potential for the HTA of medical devices. The main challenges are data accessibility, a lack of standardization of health and economic outcomes, and inadequate comparators. These findings are crucial to enabling the incorporation of RWD into decision making and represent a readily available tool for getting acquainted with existing information sources.

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.

Lifecycle evidence requirements for high-risk implantable medical devices: a European perspective

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.

Sousa L, Marques IA, Costa P, Cortez S, Carneiro F, Cruz A, Salgueiro-Oliveira A. Development of an innovative double-chamber syringe for intravenous therapeutics and flushing: Nurses' involvement through a human-centred approach

BACKGROUND

In nursing practice, flushing the catheters pre and post-drug administration is considered an important clinical procedure to prevent complications, and requires the use of several syringes to comply with international standards of care. We envisioned an innovative double-chamber syringe that enables the filling and administration of both solutions. Following current international recommendations, the development of new medical devices should integrate Health Technology Assessment. The Human-centred design is usually used for that assessment purposes, as a method that actively include end-users in the devices development process.

METHOD

Application of the Human-Centred Design through the involvement of nurses in the initial stages of the device development in order to accomplish the initial stages of Technology Readiness Level. A multi-method approach was used, including literature/guidelines review, focus groups with end-users and expert panels.

RESULTS

The involvement of nurses enabled the definition of user requirements and contexts of use, as well as the evaluation of design solutions and prototypes in order to accomplish with usability and ergonomic features of the medical device.

CONCLUSIONS

Significant contributions were made regarding the final design solution of this innovative double-chamber syringe.

Endovascular versus surgical creation of arteriovenous fistula in hemodialysis patients: Cost-effectiveness and budget impact analyses

Objectives:

The aim of the present study was to perform cost-effectiveness and budget impact analyses comparing endovascular arteriovenous fistula creation to surgical arteriovenous fistula creation in hemodialysis patients from the National Healthcare Service (NHS) perspective in Italy.

Methods:

A systematic literature review has been conducted to retrieve complications’ rates after arteriovenous fistula creation procedures. One study comparing endovascular arteriovenous fistula creation, performed with WavelinQ device, to the surgical approach through propensity score matching was preferred to single-arm investigations to execute the economic evaluations. This study was chosen to populate a Markov model to project, on a time horizon of 1 year, quality adjusted life years and costs associated with endovascular arteriovenous fistula (WavelinQ) and surgical arteriovenous fistula options for both cohorts of incident and prevalent hemodialysis patients.

Results:

For both incident and prevalent hemodialysis patients, endovascular arteriovenous fistula creation, performed with WavelinQ, was the dominant strategy over surgical arteriovenous fistula approach, showing less cost and better patients’ quality of life. Compared to the current scenario, progressively increasing utilization rates of WavelinQ over surgical arteriovenous fistula creation in the next 5 years in incident hemodialysis patients are expected to save globally 30–36 million euros to the NHS.

Conclusion:

Endovascular arteriovenous fistula creation performed with WavelinQ could be a cost-saving strategy in comparison with the surgical approach for patients in hemodialysis. Future studies comparing different devices for endovascular arteriovenous fistula creation versus the surgical option would be needed to confirm or reject the validity of this preliminary evaluation. In the meantime, decision-makers can use these results to take decisions on the diffusion of endovascular procedures in Italy.

WHO guidance for digital health: What it means for researchers

In healthcare, digital solutions have been adopted with zeal, but there is paucity of evidence for benefits and harms of these solutions. The impact, immediate or long term, of digital applications on healthcare has not been assessed. With the overwhelming numbers and types of digital solutions, it is becoming increasingly important to develop evidence-based insights for the integration of these solutions in routine medical care. Digitalization can certainly empower and enable patients and physicians to achieve health objectives. The World Health Organisation has released guidance for digital health after a critical review of available evidence for the benefits, harms, acceptability, feasibility, resource use and equity considerations of digital health interventions. This guidance can potentially inspire and impact future research endeavors for digital applications. In this paper, the guidance has been reviewed in context of the current research situation and insights are shared for researchers engaged in the design and assessment of digital interventions.

The Expanding Role of Real-World Evidence Trials in Health Care Decision Making

Real-world evidence (RWE) is the clinical evidence about benefits or risks of medical products derived from analyzing real world data (RWD), which are data collected through routine clinical practice. This article discusses the advantages and disadvantages of RWE studies, how these studies differ from randomized controlled trials (RCTs), how to overcome barriers to current skepticism about RWE, how FDA is using RWE, how to improve the quality of RWE, and finally the future of RWE trials.

Propensity Score Methods in Health Technology Assessment: Principles, Extended Applications, and Recent Advances

Randomized clinical trials (RCT) are accepted as the gold-standard approaches to measure effects of intervention or treatment on outcomes. They are also the designs of choice for health technology assessment (HTA). Randomization ensures comparability, in both measured and unmeasured pretreatment characteristics, of individuals assigned to treatment and control or comparator. However, even adequately powered RCTs are not always feasible for several reasons such as cost, time, practical and ethical constraints, and limited generalizability. RCTs rely on data collected on selected, homogeneous population under highly controlled conditions; hence, they provide evidence on efficacy of interventions rather than on effectiveness. Alternatively, observational studies can provide evidence on the relative effectiveness or safety of a health technology compared to one or more alternatives when provided under the setting of routine health care practice. In observational studies, however, treatment assignment is a non-random process based on an individual’s baseline characteristics; hence, treatment groups may not be comparable in their pretreatment characteristics. As a result, direct comparison of outcomes between treatment groups might lead to biased estimate of the treatment effect. Propensity score approaches have been used to achieve balance or comparability of treatment groups in terms of their measured pretreatment covariates thereby controlling for confounding bias in estimating treatment effects. Despite the popularity of propensity scores methods and recent important methodological advances, misunderstandings on their applications and limitations are all too common. In this article, we present a review of the propensity scores methods, extended applications, recent advances, and their strengths and limitations.

Evaluation of the diagnostic accuracy of smartphone electrocardiogram recorder compared to standard 12 lead electrocardiography in hospital settings

OBJECTIVES

To evaluate Smartphone-based Electrocardiogram Recorders (S-ECG-R) diagnostic accuracy compared to standard 12 lead ECG.

METHODS

A cross-sectional comparative study was conducted in a tertiary cardiac center in Riyadh, Kingdom of Saudi Arabia from December 2017 to February 2018. A total of 403 patients underwent both standard 12 leads ECG and S-ECG-R recordings in the same time. All recordings were checked initially by an electrophysiologist to confirm the accurate diagnosis. Then, the 806 recordings were randomly distributed among 6 certified cardiologists to interpret the rhythms and to evaluate rhythms quality.

RESULTS

In this study 211 (52%) males and 192 (48%) females were included, with a mean age of 52±18 years. Of the included rhythms,149 (37%) were abnormal. The majority of which were atrial fibrillation 46 (11%), sinus tachycardia 35 (9%) and premature ventricular contractions 33 (8%). Analysis revealed an overall similar diagnostic sensitivity and specificity of S-ECG-R to the standard 12 lead ECG recording, sensitivity (97.3% versus (vs) 98%) and specificity (99.6% vs. 99.6%). However, cardiologists were more confident during interpreting standard ECG recordings in 91% of the recordings while in 71% of S-ECG-R recordings. Conclusion: The ECG rhythms produced by smartphone accessory have a good diagnostic accuracy in diagnosing arrhythmias. The utility of using S-ECG-R for out-patient is to be determined.

Retrospective Analysis of 3-Month Real-World Glucose Data After the MiniMed 670G System Commercial Launch

Real-world data from the first 3141 patients who completed 3 months of SmartGuard™ Auto Mode-enabled MiniMed™ 670G system use during the MiniMed 670G System Commercial Launch are reported. CareLink™ system data uploaded by real-world patients in the Commercial Launch from March 17, 2017 to December 31, 2017 were deidentified and analyzed. Comparisons of overall and night (10:00 PM-07:00 AM) time spent below, within, and above target glucose range (TIR) (70-180 mg/dL) between the baseline Manual Mode and closed-loop Auto Mode periods were made. These were evaluated alongside data from the 124 patients (aged 14-75 years) who completed the 3-month MiniMed 670G system pivotal trial (NCT 2463097), from June 2, 2015 to March 7, 2016. Real-world patients used Auto Mode a median 80.8% of the time (19 h and 24 min of the day). The overall mean of time spent in TIR was 66.0% during baseline Manual Mode versus 73.3% during Auto Mode (P < 0.001); the mean percentage of sensor glucose values <70 mg/dL was 2.7% versus 2.1% (P < 0.001); and that >180 mg/dL was 31.4% versus 24.6% (P < 0.001). The nighttime and early morning (03:00 AM-06:00 AM) TIR during Auto Mode was greater than that during baseline Manual Mode (nighttime: 77.2% vs. 67.4% [P < 0.001], early morning: 70.9% vs. 84.6% [P < 0.001]). Similar differences between Manual Mode and Auto Mode TIR were observed across different age groups. A slight increase in total insulin delivered was also observed. Consistent with improved glycemic control demonstrated in the pivotal trial, analysis of CareLink system data from >3000 real-world patients who completed 3 months of Auto Mode-enabled MiniMed 670G system use demonstrated increased TIR and decreased time below and above TIR compared with baseline. These improved clinical outcomes were observed across a broad age range of patients with type 1 diabetes.

Efficacy and Safety of PARACHUTE® Device: systematic review

SUMMARY INTRODUCTION Heart failure due to an acute myocardial infarction is a very frequent event, with a tendency to increase according to improvements in the treatment of acute conditions which have led to larger numbers of infarction survivors. OBJECTIVE The aim of this study is to synthesize the evidence, through a systematic review, on efficacy and safety of the device in patients with this basic condition. METHODS Studies published between January 2002 and October 2016 were analysed, having as reference databases Embase, Medline, Cochrane Library, Lilacs, Web of Science and Scopus. The selection of studies, data extraction and methodological quality assessment of studies were examined by two independent reviewers, with disagreements resolved by consensus. RESULTS Only prospective studies without control group were identified. Six studies were included, with averages of 34 participants and follow-up of 13 months. Clinical, functional, hemodynamic and quality of life outcomes were evaluated. The highest mortality rate was 8.4% with 12-month follow-up for unspecified cardiovascular reasons, and heart failure rehospitalization was 29.4% with 36-month follow-up. Statistically significant improvements were found only in some of the studies which evaluating changes in left ventricular volume indices, the distance measured by the six-minute walk test, New York Heart Association functional classification, and quality of life, in pre and post-procedure analysis. CONCLUSIONS The present review indicates that no available quality evidence can assert efficacy and safety of PARACHUTE® in the treatment of heart failure after apical or anterior wall myocardial infarction.

Retraining Reflexes: Clinical Translation of Spinal Reflex Operant Conditioning

Neurological disorders, such as spinal cord injury, stroke, traumatic brain injury, cerebral palsy, and multiple sclerosis cause motor impairments that are a huge burden at the individual, family, and societal levels. Spinal reflex abnormalities contribute to these impairments. Spinal reflex measurements play important roles in characterizing and monitoring neurological disorders and their associated motor impairments, such as spasticity, which affects nearly half of those with neurological disorders. Spinal reflexes can also serve as therapeutic targets themselves. Operant conditioning protocols can target beneficial plasticity to key reflex pathways; they can thereby trigger wider plasticity that improves impaired motor skills, such as locomotion. These protocols may complement standard therapies such as locomotor training and enhance functional recovery. This paper reviews the value of spinal reflexes and the therapeutic promise of spinal reflex operant conditioning protocols; it also considers the complex process of translating this promise into clinical reality.

Cost–effectiveness analysis of treatments involving radioembolization in intermediate-stage hepatocellular carcinoma

Aim: We evaluated two treatment sequences, transarterial radioembolization followed by transarterial chemoembolization and possibly sorafenib (=TTS) versus transarterial radioembolization followed by sorafenib alone (=TS), to identify the most cost-effective pathway to treat intermediate-stage hepatocellular carcinoma from the Italian healthcare system perspective. Materials & methods: A Markov model was developed to project costs and health outcomes for TTS and TS over a lifetime horizon. Data available at three hospitals in Italy were collected. Healthcare resource utilization was derived from standard clinical protocols. Costs were obtained from official regional tariffs. Results & Conclusion: Taking into consideration 16 patients for TTS and 22 patients for TS pathways, the TTS sequence provided a dominant strategy in comparison to TS. Further evidence is desirable to confirm these results.

Scientific Evidence in Health Technology Assessment Reports: An In-Depth Analysis of European Assessments on High-Risk Medical Devices

BACKGROUND

The aim of this study was to examine the scientific evidence on clinical effectiveness and safety used in health technology assessments (HTAs) of high-risk medical devices (MDs) in Europe.

METHODS

We applied a systematic approach to identify European institutions involved in HTA and to select reports assessing MDs considered high-risk according to the definition in the new German health care regulation §137h. Reports published between 2010 and 2015 were considered in our subsequent analysis. We used a structured tool based on widely accepted methodologic principles from Drummond's framework to extract key information on the clinical evidence considered in the reports.

RESULTS

Out of 1376 identified reports, 93 were eligible for analysis. All reports based their assessment primarily on direct evidence, in most cases (68%) identified through an independent systematic literature search. In more than half the identified studies considered in the reports, clinical evidence for demonstration of effectiveness and safety was of moderate or low quality. Even when systematic reviews and randomized controlled trials were available for assessment, most studies showed an unclear or high risk of bias.

CONCLUSIONS

This study confirms that the quality of scientific evidence used in HTA of high-risk MDs is low and therefore the use of evidence needs improvement. The European Commission recently updated the regulation on MDs but mainly focused on the safety of materials and the CE (Conformité Européene [European Conformity]) mark. Our results show that additional changes are necessary, specifically with regard to the marketing authorization process of MDs, with stricter quality requirements based on methodologically robust trials, possibly in combination with other evidence sources.

Real-World Data for the Evaluation of Transarterial Radioembolization versus Sorafenib in Hepatocellular Carcinoma: A Cost-Effectiveness Analysis

OBJECTIVES

To perform a cost-effectiveness analysis comparing the use of transarterial radioembolization (TARE) with that of sorafenib in the treatment of patients with intermediate or advanced hepatocellular carcinoma (HCC) according to the Barcelona Clinic Liver Cancer staging system.

METHODS

Patient-level data were consecutively recorded and collected at three oncology centers in Italy. A propensity score matching was performed to compare patients with similar clinical characteristics who underwent TARE or sorafenib treatment. Clinical data from the matched cohorts were used to populate a Markov model to project, on a lifetime horizon, life years, quality-adjusted life years, and economic outcomes associated with TARE and sorafenib for both intermediate and advanced HCC stages.

RESULTS

Starting from data covering 389 and 241 patients who underwent TARE and sorafenib treatment, respectively, the propensity score matching yielded a total of 308 matched patients. For intermediate-stage patients, the model estimated for TARE versus sorafenib an incremental cost-utility ratio of €3,302/QALY (incremental cost-effectiveness ratio of €1,865 per life year gained), whereas for patients in advanced stage TARE dominated (lower costs and greater health improvements) compared with sorafenib.

CONCLUSIONS

From an Italian health care service perspective, TARE could be a cost-effective strategy in comparison with sorafenib for patients with intermediate or advanced HCC. The results from forthcoming randomized controlled trials comparing TARE with sorafenib will be able to confirm or reject the validity of this preliminary evaluation. In the meantime, decision makers can use these results to control and coordinate the diffusion of the technology.

Improving the Methods for the Economic Evaluation of Medical Devices

Medical devices (MDs) have distinctive features, such as incremental innovation, dynamic pricing, the learning curve and organisational impact, that need to be considered when they are evaluated. This paper investigates how MDs have been assessed in practice, in order to identify methodological gaps that need to be addressed to improve the decision-making process for their adoption. We used the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist supplemented by some additional categories to assess the quality of reporting and consideration of the distinctive features of MDs. Two case studies were considered: transcatheter aortic valve implantation (TAVI) representing an emerging technology and implantable cardioverter defibrillators (ICDs) representing a mature technology. Economic evaluation studies published as journal articles or within Health Technology Assessment reports were identified through a systematic literature review. A total of 19 studies on TAVI and 41 studies on ICDs were analysed. Learning curve was considered in only 16% of studies on TAVI. Incremental innovation was more frequently mentioned in the studies of ICDs, but its impact was considered in only 34% of the cases. Dynamic pricing was the most recognised feature but was empirically tested in less than half of studies of TAVI and only 32% of studies on ICDs. Finally, organisational impact was considered in only one study of ICDs and in almost all studies on TAVI, but none of them estimated its impact. By their very nature, most of the distinctive features of MDs cannot be fully assessed at market entry. However, their potential impact could be modelled, based on the experience with previous MDs, in order to make a preliminary recommendation. Then, well-designed post-market studies could help in reducing uncertainties and make policymakers more confident to achieve conclusive recommendations. © 2017 The Authors. Health Economics published by John Wiley & Sons, Ltd.

Getting approval for new therapeutic medical devices versus drugs: are the differences justified?

In the so-called evidence-based medicine (EBM) era, pre-market clinical trials showing equivalent or superior benefit from new drugs versus existing therapies are required by regulatory bodies, while the process for approval of medical devices is less stringent [1]. The expansion of device-based therapies for cardiovascular conditions makes cardiology the ideal setting for analysing the peculiarities of this process [2].

Lessons learned from cardiology: the process for approval of medical therapeutic devices must be redesigned http://ow.ly/bJPm3017ySH