Medical device assessment: scientific evidence examined by the French national agency for health – a descriptive study

By the late 1990s, the US Food and Drug Administration (FDA) had given marketing approval to around 500,000 medical devices, produced by approximately 23,000 different manufacturers, and it has been estimated that 4% of the US population has at least one implanted medical device [1, 2]. The US medical device market was estimated in 2011 at US$105.8 billion. In Europe, there are almost 22,500 medical technology firms, which generate annual sales of €95 billion [3]. In 2006, the medical device market in France comprised €19 billion in sales, representing 12% of medical and health care consumption [4].

Most new medical technologies are intended to improve quality of care but they also increase health spending [5]. For this reason Health Technology Assessment (HTA), which is defined as the systematic evaluation of the properties, effects, and/or impacts of healthcare technology [6], has been developed to inform healthcare providers, payers and patients about technology-related clinical and cost effectiveness. In France, the government set up the French National Authority for Health (Haute Autorité de Santé, HAS) in August 2004, whose activities are designed to improve the quality of patient care and guarantee equity within the healthcare system. These activities include the assessment of medical devices based on scientific expertise, carried out by a dedicated committee (Commission Nationale d’Evaluation des Dispositifs Médicaux et Technologies de Santé, CNEDIMTS) [7]. The aim of these assessments is to provide “opinions” to health authorities that contain the information needed to support decisions regarding the reimbursement. All assessed medical devices qualified with “sufficient expected clinical benefit” are included on the list of products and services qualifying for reimbursement [8].

In this context, a manufacturer who seeks reimbursement by the French Health Insurance system for the cost of a medical device has two options. If the medical device responds to a generic definition already included on the list qualifying for reimbursement, it can be registered directly. In case there is no generic definition for the medical device, the manufacturer has to apply for specific CNEDIMTS’ assessment (brand name registration), and to submit a dossier containing clinical data. These data should demonstrate the value of the medical device, i.e. what is the expected clinical benefit and whether it is sufficient to justify its inclusion on the list qualifying for reimbursement, and should propose what improvement in terms of clinical benefit may be expected in comparison with the existing standard of care. The CNEDIMTS’ members base their scientific assessment on the synthesis of information performed by internal assessors, from clinical data provided by the manufacturers or retrieved from an in-house scientific literature search. They focus specifically on the following features of studies: methodological quality; selection of a relevant population; main outcome measure; and adverse events and complications related to the procedure. For every assessment, a public document summarising supportive clinical data and providing the opinion is available on the French National Authority for Health’s website [7].

Previous studies have shown that the approval process for high-risk medical devices in the USA is often based on insufficiently robust studies, suggesting that evidence prior to marketing may not be adequate [9, 10]. This study aimed to ascertain what level of evidence was available for IMDs access to reimbursement in France. Therefore, we have described the scientific evidence, in terms of the methodology and characteristics of the clinical studies used by CNEDIMTS for implantable medical device assessment, after marketing but prior to the decision on reimbursement.

In 2008, among the clinical studies with the highest level of evidence assessed by CNEDIMTS, less than half were RCTs or meta-analysis of RCTs. The EB for the CNEDIMTS’ opinions on IMDs correlated to the clinical studies’ level of evidence: low levels of evidence were observed in insufficient EB or low levels of IEB. When no clinical data was available for assessment, the opinion was more likely to conclude on insufficient EB.

To our knowledge, this study is the first to provide a description of the methodological characteristics of studies used during medical device assessment by the French National Authority for Health, and one of the first assessments of the decisions issued by a national competent authority. Its main limitation is the use of publicly available opinions as a data source: some data may have been omitted from public documents, as the opinions do not reveal the complexity of the committee’s decision-making process.

The level of evidence of the clinical studies carried out is expected to impact coverage and reimbursement determinations, which indirectly impacts the diffusion of implantable medical devices in healthcare practices. This issue is complicated for manufacturers, who argue that increasing the level of evidence required will create a financial and time barrier to putting new products on the market and restrict patients’ access to new medical technologies [12, 13]. This is even more difficult for smaller firms, which represent most of medical technology firms, which may not have the capital to conduct trials and are not equipped to meet regulatory and methodological requirements [14].

In Europe, studies assessing the clinical efficacy of implantable medical devices were not systematically required for CE marking until the 2007 European Directive [15]. The regulatory approval for CE marking focuses on safety, device quality and performance. Very often only scarce information is available when a new medical device first comes onto the market. Indeed, methodological issues are encountered when designing a clinical study for medical devices evaluation [16]. RCTs, commonly used in drug development and considered to be the study design which provides the highest level of evidence for assessing the efficacy of health products, are particularly prone to methodological challenges when considering IMDs [17]. Blinding is not always feasible (or unethical, for instance sham surgery). Interaction between device and operator might induce heterogeneity in clinical efficacy and safety, such as learning curve effect, teams’ expertise and habits (need for procedure standardisation), or continuous technological evolution. Inclusions in such studies might be difficult, since target populations are often small.

In the USA, the safety and effectiveness of high-risk medical devices, such as implantable medical devices, are assessed by the FDA during the Premarket Approval (PMA) process which relies on clinical data. Two studies have shown that PMA for cardiovascular devices between 2000 and 2007 was often based on studies which were insufficiently robust and possibly prone to bias, as only 27% of studies used to support PMA were randomised [9, 10]. Furthermore, 65% of PMAs were based on a single study, suggesting that there may not be adequate evidence prior to marketing [9]. Even if most Class III devices should require PMA, it has been discussed that a large percentage avoid this process and go through 510(k) submission, which is known to be less rigorous with no systematic need for supportive clinical evidence [18]. In 2003-2007 fiscal years, 228 Class III devices had been cleared by FDA through 510(k) process, while 217 had been submitted through original PMA [19].

We showed that a new opinion was given up to 12 years after CE marking. During this time, a new device may be distributed and widely used by physicians in their standard practice of care, especially in the case of innovative devices [20]. Once the medical device has been distributed, it becomes difficult to assess its clinical benefit and cost in relation to existing strategies [21]. The main constraint in performing RCTs after device distribution is that randomisation may not be accepted, not only by physicians, but also by patients who are well informed about new technologies and are keen to access them. Therefore, to determine efficacy and safety, alternative approaches to conventional trial designs might be considered, e.g. use of historical controls and acceptance of p values greater than 0.05 [22]. It has also been suggested that well-designed comparative observational studies may provide information for clinical and effectiveness assessments [23‐25]. Such studies may be performed within a post-marketing surveillance program. In first place, post-marketing surveillance has been set up to explore safety concerns such as rare adverse events, through vigilance reporting. However, specific post-marketing clinical studies have to be developed as they can offer the opportunity to collect outcomes data [26], not only for safety but for efficacy purpose. It has been suggested for high-risk medical devices that a post-marketing surveillance program should be in place at the time of market authorisation as a continuum of clinical studies from pre-market to routine use, within a new regulatory approach [27]. A new model based on temporary authorisations and post-marketing studies could be developed. Currently, post market registries are being increasingly set up to provide real life data about use, safety and efficacy of IMDs.

HTA for medical devices can guide collective choices in terms of access to technology, with a view to ensuring their effectiveness and cost-effectiveness. The lack of scientific data raises ethical issues as offering a new, unapproved technique outside of a clinical research context may put the patient at risk. The timely diffusion of such techniques is vital as there are risks associated with the premature introduction of a device without sufficient clinical evaluation, just as an excessive waiting period may be detrimental to patients. There is a serious question as to when the assessment should be carried out: if it is done early in the development process, both the device and procedure may undergo changes and the learning curve effect has to be incorporated, and the findings of the assessment may rapidly become obsolete [28]. Procedures to ensure the “safe” diffusion of innovations has been implemented in European countries as programmes for funding innovation under the framework of clinical research. A programme to support innovative and costly technologies was created in the early 2000s by the French Ministry of Health, with the aim of supervising their diffusion whilst simultaneously assessing their clinical and cost effectiveness. In the United Kingdom, a procedure for temporary reimbursement has been set up for innovative devices when used only in research for the purposes of generating clinical data and good practice guidelines [29].

This study confirmed that level of evidence of clinical evaluation of IMDs is low and needs to be improved, since less than half of clinical studies with the highest level of evidence assessed by CNEDIMTS in 2008 were RCTs or meta-analysis of RCTs. Future work should design new recommendations in this field by investigating the determinants and the solutions needed to improve quality of clinical evaluation of medical devices, in connection with small and medium firms, clinicians and authorities.