Hi Wayde,

Thanks for the question! It’s a particularly fitting one because it is part of the discussion in the extended version of this project’s write up.

One recommendation is to encourage both more and earlier dialogue between innovators and regulators. A common complaint among innovators is that they simply do not know what regulators will ask for ex ante and that their negotiations with the FDA often don’t begin until after clinical trials are already underway. Among other things, more and earlier dialogue between device innovators and the FDA would reduce informational uncertainties about the burden of proof expected by regulators in clinical trials.

Another suggestion would be the establishment of more transparent guidelines for clinical trials and defining categories of endpoints for such trials, so that innovators can better plan trials that are likely to meet the FDA’s expectations and clinical evidence requirements.

Neither of the above are mutually exclusive. While devices are very diverse and the specifics of future clinical trials are hard to anticipate, it is also almost certainly the case that more can be done to reduce informational uncertainties around bringing new innovations to market.

Hi Sandra,

Thanks for your questions. I hope that my answer above is also useful.

As far as researching barriers to regulatory review goes: I actually do some of this with the data that I already have. Specifically, I can look at differences in the ratios of review staff to new device applications as well as differential policies across different advisory committees (e.g. different policies for those regulating cardiac vs. radiological devices) to start to undersand which scenarios are most conducive to efficient review processes.

I also consider a number of firm-specific effects as well as categories of applicant firms. For example, if there is some learning in the regulatory process, then we should observe more established firms experiencing shortened approval times relative to firms with fewer devices already on the market. Additionally, we should expect to see firms improving their approval rates as well as approval times as they increase their portfolio of successful applications. I am working on testing many of these theories in the next phase of the project.

There are also a number of complementary research topics to this one, including issues around health insurance coverage and reimbursement. Perhaps the most significant one for public finance is that new device approvals by the FDA are often tantamount to Medicare coverage for their use. This means that many new device approvals also amount to additional product availability for publicly insured individuals. The cost implications of these approvals are ambiguous: while some new device approvals are likely to represent very expensive new technologies, other new device approvals (e.g. for diabetes management) have the potential to reduce Medicare expenditures as well as socioeconomic health disparities.

Hi Aurora, thanks for your questions.
The data are simply the FDA’s full database of all historical premarket approvals. The FDA wasn’t given a mandate to regulate medical devices until 1976 (when Congress passed the Medical Device Amendments act, which gave the FDA primary authority to regulate devices sold in the US); the database I use is a full catalog of all PMA device approvals since that time. Please also note that the PMA process is one of 3 types of approval processes for new devices and the one that is designated for the highest risk device. To your next question, I have a few points: 1) The focus of this project is on devices rather than pharmaceuticals. 2) There have nevertheless been several medical device recalls in recent years. However, the vast majority of these recalls have been for devices regulated through the less-stringent 510(k) process, rather than the more extensive PMA process, which is the focus of this project (Zuckerman et. al.’s 2011 paper in the Archives of internal medicine is the most recent documentation of this phenomenon). 3) It is absolutely important to weigh greater efficiency against the the public safety risks inherent in medical technology. This project does not make any value judgments at all about the extent to which the latter should be traded off in the interest of the former, so I want to be clear about that. What is the case however, is that conditional on being the kind of device that ultimately gets approval (and is not subsequently withdrawn for safety reasons) it is true that more novel devices experience longer regulatory times than follow-on innovations and this is precisely the opposite of the pattern observed for new chemical drugs.

Hi Jeffrey, in short: absolutely! However, the implications of my findings are that this period of time in which device manufacturers are the only only producers on the market is necessarily shortened by the dynamics of the approval system, whereas the effective monopoly of the first entrant is effectively EXTENDED in the pharmaceutical industry, where approval times exhibit the opposite pattern. This means that the relative advantage of coming up with a very novel technology is smaller in the medical device industry than elsewhere.

Hi Gary, great question! In fact, approval times are significantly shorter in the EU than in the US. Kramer et. al. have a 2012 paper in the New England Journal of Medicine on “Regulation of Medical Devices in the United States and European Union” that does a really nice job of outlining differences between the two systems. In short, regulatory times are longer in the US than in other developed countries and that difference has been growing over the past decade. This means that a lot of class 3 devices (in particular, a lot of cardiology devices) reach the European market a few years before they are brought to market in the US. One salient example is the “MitraClip” (for Mitral valve repair), which was approved for use in the EU in March of 2008 and is still awaiting FDA approval. This means that European patients often can benefit from new technologies earlier than US patients. Moreover, since 7 of the 10 largest device manufacturers in the world are US companies and since the US is by far the world’s largest market for medical devices, this also implies delayed profits for device companies.

Hi William,
Thanks for the question! The number of committees has been relatively constant, but the number of high risk devices approved each year has steadily increased over time (there is a scatter plot of this on the poster if you want to have a more detailed look at the annual data). As far as the internet goes, it’s always hard to say what the impact has been, but the review process itself takes place within the FDA (and between the FDA and applicant firms), so the advent of the internet almost certainly has streamlined communications, etc., but I don’t know of any specific ways in which it has changed the nature of the review process itself, which is typically carried out by experienced regulators (e.g. engineers and biostatisticians) within the FDA.
Best,
Ariel