Setting the Bar for Blood Glucose Meter Performance

By: Courtney Lias

Courtney Lias is Director of the Division of Chemistry and Toxicology Devices within the Office of In Vitro Diagnostics and Radiological Devices at FDA’s Center for Devices and Radiological HealthMany of the nearly 19 million Americans diagnosed with diabetes must monitor their blood glucose (sugar) frequently throughout the day using an at-home meter to make sure that their blood glucose is within a safe range. The ability to measure blood glucose at home has given people with this serious and chronic condition the ability to better control their blood sugar and thus avoid potential complications.

In the last 10 years there has been much advancement in the development of glucose meters. They are now smaller, require a smaller blood sample for each test and produce faster results.  However, their accuracy has improved little.

At FDA’s public meeting in March 2010 on this topic, the clinical and patient communities challenged the agency to improve performance of glucose meters. Feedback gathered from that meeting directly informed the creation of two draft guidance documents released this week. These documents set forth recommendations, which are justified to help ensure that these important devices are designed to be more accurate and reliable for the patients who need them. To address this need, this week we are proposing new recommendations for labeling, meter performance evaluation, manufacturing controls, and cleaning and disinfection procedures to help improve the accuracy and performance of blood glucose meters.

FDA recognized the need to optimize the safe use of blood glucose meters in two distinct settings: self-monitoring using devices purchased over-the-counter, and use in a clinical setting by health care professionals. FDA believes that by distinguishing where these devices are used, they can be better designed to meet the needs of their intended populations and ensure greater safety and efficacy.

Historically, devices used in these two settings have been studied using the same methods and standards. However, it has become increasingly clear that meters used in these different settings have unique characteristics and different design specifications. For example, critically ill patients in health care settings may have physiological variables, like abnormal oxygen levels, that could interfere with the accuracy of the blood glucose meter. Patients who use over-the-counter glucose meters and test strips at home vary in age, how much they know about how to use blood glucose tests, and other critical factors that might affect the  accurate use of the device.

To distinguish between FDA recommendations for blood glucose meters used in health-care facilities, and those intended for self-monitoring by lay-persons, the agency is issuing separate draft guidances for each one, that is:

  • prescription-use blood glucose meters, for use in point-of-care professional health-care settings, and
  • blood glucose devices purchased over-the-counter, intended for self-monitoring by lay-persons.

We believe that these recommendations will help ensure that glucose meters meet critical standards for accuracy in the hands of people with diabetes, who rely on them to manage their disease. Please help us in this effort by providing specific comments to these draft guidance documents to let us know if you agree with our recommendations or whether you have suggestions to further improve them.

Improving the quality of blood glucose meters will not solve all challenges for those who live with diabetes, but it may help millions of people to avoid complications and better achieve their health goals.

Courtney Lias is Director of the Division of Chemistry and Toxicology Devices within the Office of In Vitro Diagnostics and Radiological Devices at FDA’s Center for Devices and Radiological Health

FDA Brings Patients Into the Process

By: Michelle McMurry-Heath, M.D., Ph.D. 

What do patients really want? 

At the FDA, we ask that question every day and in all kinds of contexts. Earlier this year, the Center for Devices and Radiological Health (CDRH) began to explore new ways to identify and incorporate the patient voice into our decision-making on medical devices. 

We’re calling this effort the Patient Preference Initiative. As part of this effort, we held a public workshop the past two days with patients, caregivers, health care providers, researchers, and industry to discuss ways to incorporate patient preferences as we weigh the risks and benefits of the products we regulate both before and after the product goes to market. 

In trying to incorporate patient preferences into our regulatory decisions, it’s important to know how to accurately and reliably measure their preferences for treating and diagnosing their conditions. So, we’re also trying to advance the tools and methods that could be used to do so. 

For example, there is a risk of injury with many medical devices. How much of a risk is acceptable to a patient in the context of the potential benefits of the device? If patients enter a clinical trial, how much of a chance are they willing to take on an unproven treatment? If a device could greatly improve a patient’s health, but is not portable or cannot be used at home, would a patient find this too limiting? If a device has new-found risks but is the only one of its kind on the market, should it be recalled? 

In appropriate cases, we foresee approving devices for which a fully-informed subset of patients would accept the risks as weighed against the benefits, if patients and their practitioners can be provided with the information they need to make their own well-informed decision and the information can be presented in a manner that can be understood by the practitioners and patients. 

At the workshop, we invited attendees to actively explore such issues as clinical trial design and ways to facilitate getting new, safe and effective, innovative devices out to the patients who may need them. Our panels weighed in on such questions as: 

  • How do we integrate patient preferences into clinical trial design?
  • How can we build partnerships to collect this information?
  • How can we use data on patient preference for post-market and compliance issues?
  • What disease areas or device types are best suited for the patient preference approach?
  • Which diseases or device types are best suited for patient preference input?
  • How can we ensure that patients, families and caregivers are well informed so that they understand the choices they have and the decisions they are making? 

We also announced that we will be establishing a new Patient Engagement Panel as part of our Medical Device Advisory Committee to provide advice on issues important to patients, such as more understandable labeling and the use of medical devices at home. 

Throughout the workshop, it was clear that determining the benefits and risks of medical devices is one of the most important things we do. 

In 2012, the FDA published a document to help industry understand the key factors we consider when making benefit-risk determinations for certain medical devices. Importantly, it discusses collecting patient-centric metrics to measure benefit and ways of measuring a patient’s tolerance for risks. 

But the last two days have been all about the patients who may need these products, the caregivers who would be helping patients use them, and the health care professionals who may prescribe them. What do they want? What do they need? 

The FDA is committed to giving patients in the United States access to safe and effective medical devices of high quality and we work hard to improve the predictability, consistency and transparency of the pre-market review process. We’re pleased at the progress we’ve made over the last two days as part of our effort to invite patients into the regulatory process, and we look forward to more close collaboration with patients in the future. 

Patients, after all, are at the core of our mission and the focus of our vision. 

Michelle McMurry-Heath, M.D., Ph.D., is the Associate Director for Science at the FDA’s Center for Devices and Radiological Health

Considering Women’s Needs in Developing Medical Devices: Here’s ‘HoW’

By: Michelle McMurry-Heath, MD, Ph.D. 

Women differ from men in anatomy, physiology, risk factors and disease symptoms. They are also likely to use more medical devices over the course of their lives than men do.

That is why FDA is actively trying to learn more about how medical devices uniquely affect women, and how women can be better served by them.

This month we published a snapshot of how FDA is doing with such efforts. A congressionally-required report (Section 907 of the Food and Drug Administration Safety and Innovation Act) looked at the inclusion and analysis of women and other demographic subgroups in clinical studies supporting the approval of medical devices and other FDA-regulated medical products. After reviewing 2011 product applications, including 37 premarket approval applications, or PMAs, for devices, we found that in the majority of cases, sponsors provide information about women, conduct subset analyses and share information with the public in a variety of ways.

One specific activity highlighted in the report was a workshop sponsored earlier this summer by the Center for Devices and Radiological Health (CDRH) to formally launch a new program designed to more closely look at medical device use and the health of women (HoW). The three main goals of HoW are to:

  • Improve the availability, consistency and communication of information to patients and providers that is specific to women’s needs for the safe and effective use of medical devices.
  • Address identified gaps and unmet needs through targeted resources.
  • Foster the development of innovative strategies, technology and clinical study models.

Nearly 200 representatives from industry, academia, health care, federal agencies, patient and advocacy groups, gathered to discuss the issues related to medical devices and health in women and to brainstorm about effective strategies to address clinical research needs in this population.

This work builds on a December 2011 draft guidance, also highlighted in this month’s 907 report. That guidance outlined CDRH’s proposed expectations regarding sex-specific enrollment in clinical studies, data analysis, and reporting of study information. Ideally, the final guidance will provide a clear decision-making framework for when and how to analyze and communicate data involving women in device clinical studies.

The CDRH HoW program also plans to complement this by developing, in partnership with other stakeholders, strategies for communicating information about differences to the people who most need to know: health care professionals, clinical investigators, the medical device industry, and most importantly, patients.

With these activities, we are laying the groundwork for making sure the unique health needs of women are considered in research agendas and device innovation. The goal is to strengthen the focus of FDA, industry and the clinical community in developing medical devices designed to meet the unique clinical needs of women, and to communicate new information as we learn more about how differences affect treatment options and outcomes.

Now, with the issuance of the 907 report, and an accompanying docket to receive comments from the public, we hope to gain an even more in-depth understanding about demographic subgroups. The input we receive will become the starting point for developing an Action Plan, to be released next year.

These are all important steps towards ensuring that medical devices developed will take into account the unique needs of women.

Michelle McMurry-Heath, M.D., Ph.D., is the Associate Director for Science at the FDA’s Center for Devices and Radiological Health

Salute to Science: FDA’s Student Poster Symposium

By: Margaret A. Hamburg, M.D.

Margaret Hamburg, M.D.For many people, the hot summer months in the nation’s capital mean a time to depart for the beach or other less humid destinations. But one of the events I look forward to each year takes place during the hottest days of summer, right here on FDA’s White Oak Campus just outside of Washington, DC. It’s when I get to participate in the annual Salute to Science Student Poster Symposium.  Each of the posters on display offers a detailed and stimulating summary of the approximately 100 projects undertaken by FDA student interns during their internships.

Now celebrating its 8th year, the internship program provides high school students, college undergraduates and even postgraduates with a great training ground for the next stage of their scientific education. Each intern takes on a hands-on research topic to pursue under the watchful eye of a scientific mentor from either FDA’s Center for Devices and Radiological Health (CDRH), the Center for Veterinary Medicine (CVM) or from the U.S. Air Force Wind Tunnel, which is located next door to our White Oak Campus.

As I looked over the posters and talked to the students about their projects, I was struck by their scientific sophistication as well as the remarkable range of topics addressed, ranging from a “virtual human head simulator,” which provides electrical stimulation that could be used to design novel neuro-prosthetic devices, optimize treatments, and assess the safety of medical devices such as MRIs, to the evaluation of a laser beam profile on optical properties of intraocular lens implants. The array of work demonstrated not only the promise of these students, but the breadth of scientific work undertaken here at FDA.

I was especially pleased to see so many young women participating in our internship program, given that women make up only 24 percent of the nation’s overall science and engineering workforce. The fact is, FDA is a welcoming place for female scientists and engineers; in addition to me, many of our top scientific positions are held by women.

This internship, and the Commissioner’s Fellowship Program for health care professionals, scientists, and engineers who may not have considered FDA in planning their career path, are helping to lay the groundwork for and train the next generation of FDA scientists.

They are part of our efforts to integrate strong science and research training requirements and programs, cultivate the expert institutional knowledge and innovation necessary to address gaps and challenges posed by novel products and areas, and continue to ensure safety and efficacy in the service of medicine and public health.

I am confident that the bright, creative, enthusiastic, and hard-working students who participated in FDA’s intern program will be part of the next generation of scientific leaders and innovators, and seeing their efforts gives me great hope for the future of this agency, and of the nation.

Margaret A. Hamburg, M.D., is Commissioner of the U.S. Food and Drug Administration

Improving Patient Care by Making Sure Devices Work Well Together

By: Bakul Patel 

Interoperability refers to the ability of medical devices to interact and for electronic health record systems to talk to each other using a common vocabulary. It is similar to the concept of “plug and play” computer attachments like a web cam or mouse, which are made so that products can operate with different brands and models of computers.

While it may seem abstract, successful interoperability among medical devices can improve patient care, reduce errors, and lower costs.

As medical devices become increasingly connected to other medical devices, hospital information systems and electronic health records, there is a growing expectation that they will be interoperable – and that the data they transmit will be secure.

A few examples illustrate the need: 

  • An infusion pump that administers medication to a patient also connects to the hospital’s electronic health record system where the physician inputs orders for specific amounts of medication to be delivered at specific times. If the infusion pump and the electronic health record are not interoperable, with clocks that are synchronized, medication errors could occur. 
  • A patient in surgery is connected to a ventilator and a central monitoring station. If the two devices are not interoperable, the monitor may send a false alarm, or fail to send a needed alarm. Either error could increase the risk to the patient. 
  • Two patients with different medical conditions both have electrocardiogram (EKG) monitors attached to check their hearts’ electrical activity. Both monitors are connected to the same computer system that records the data for later review by a physician. It’s critical that the computer system and the EKG monitors are interoperable so transmission errors do not confuse one patient’s data with the other patient’s data.

Making sure devices are interoperable requires the creation, validation, and recognition of standards that help manufacturers develop products that are harmonious and can “plug and play.”  

We at the FDA have been hard at work on this issue with hospitals, health care providers, manufacturers, standards development organizations, and other interested parties. A 2012 summit organized by FDA and the Association for the Advancement of Medical Instrumentation (AAMI), for example, brought together 266 experts from many disciplines to further the goal of improving patient care and cybersecurity — while at the same time fostering innovation — through interoperability.

As a first step, FDA has recognized a set of voluntary standards that will help manufacturers create devices that work well together and are secure.

We hope this first set of voluntary standards will encourage further efforts to identify standards and create new ones for our review, because improving the care of patients through medical devices increasingly depends on those devices and information systems being “interoperable.”

Bakul Patel is senior policy advisor in FDA’s Center for Devices and Radiological Health.

Keeping Up With Mobile App Innovations

By: Christy Foreman

A smart phone that can perform an electrocardiogram (ECG)—measuring the electrical activity of a person’s heart to determine whether he or she is having a heart attack—is in my opinion an extremely smart phone. That is just one example of how mobile medical applications are transforming health care.

As we testified today before Congress, FDA has no intention of stifling innovation in this exciting and rapidly growing field. The fact is, only a fraction of mobile apps would require FDA review. However, when a mobile app is doing the job of a medical device that requires FDA clearance or approval, it’s only logical that both should be governed by the same rules. These are the small percentage of mobile apps that pose a risk of serious illness or death to patients. With these considerations in mind, FDA in coming weeks will be issuing a final guidance document that will help companies determine whether their product will require FDA clearance or approval.

They would be limited to mobile apps that meet the definition of device and are intended for use: 

  • to transform a mobile device into a medical device already regulated by FDA
  • as an accessory to a medical device already regulated by FDA

In addition to the smart phone that performs an ECG, other examples include a mobile medical app that controls the delivery of insulin; another that acts as a stethoscope; a mobile medical app that takes patient-specific information and provides a clinician with radiation dosage calculations, and mobile medical apps that allow doctors to view X-rays or other imaging on smart phones and tablets.

These examples show why FDA has a public health concern about the potential consequences of a malfunctioning mobile medical app. 

FDA’s Center for Devices and Radiological Health has been reviewing mobile medical apps for more than 10 years and in that period we have reviewed about 100 applications and each review has taken about 60 days to complete. We’re confident that the center has the expertise to continue the timely review of the small number of submissions we expect to receive from mobile app developers.

Our final guidance will be informed by some 130 public comments, most of which were overwhelmingly supportive of our risk-based, narrowly-focused approach proposed in the draft guidance. Once the guidance is released, we are confident that the public will see that it represents a careful balance between the need to encourage innovative technology with our mission of providing reasonable assurance that medical products are safe and effective.

Christy L. Foreman is Director, Office of Device Evaluation, at FDA’s Center for Devices and Radiological Health

FDA Commemorates 30th Anniversary of the Orphan Drug Act

By: Gayatri R. Rao, M.D., J.D.

Gayatri R. Rao, M.D., J.D., is Director of FDA's Office of Orphan Products Development

When President Reagan signed the Orphan Drug Act 30 years ago, he enacted a critically important piece of health care legislation. The passage of this Act on January 4, 1983, was monumental because it created—for the first time—incentives to develop desperately needed medical products for Americans suffering with rare diseases. Until that point, development of such products was very limited. For instance, in the decade leading up to the passage of the Orphan Drug Act, only 10 industry-supported products for rare diseases were brought to market.

The Office of Orphan Products Development (OOPD) was formed at FDA more than 30 years ago, prior to the passage of the Orphan Drug Act, because FDA recognized that rare diseases, when taken together, posed a significant national public health issue. Once the Orphan Drug Act was passed, OOPD became responsible for administering the incentive programs created to spur the development of medical products for rare diseases, namely the Orphan Drug Designation Program and the Orphan Products Grants Program. These products include drugs, biologics, medical devices, and medical foods for the treatment of rare diseases.

As FDA commemorates the passage of this important legislation, we look back over the last 30 years with pride. Since its passage, over 2700 products in development have been designated as orphan drugs through the Orphan Drug Designation Program and over $290 million has been awarded to clinical studies through the Orphan Products Grants Program.  These programs, along with the critical, collective efforts of the Center for Drug Evaluation and Research’s (CDER) Rare Diseases Program, and those of many individuals across FDA, have helped to bring over 400 orphan products for rare diseases to the market.

We also commemorate the more than 30 years of dedicated service from every member of the rare disease community:

  • the patient advocates, who spurred national awareness about the challenges that people with rare diseases face and who continue to support families, educate the community, and drive research into their diseases;
  • the legislators who heard the voices of rare disease advocates and worked to champion the passage of the Orphan Drug Act;
  • the research community, which continues to leverage resources and foster collaborations among academia and industry stakeholders;
  • the clinicians, who support the medical needs of families with rare diseases and work to advocate on behalf of the community;
  • and industry, including pharmaceutical and biotech companies, angel investors, and venture capitalists who, in the spirit of the Orphan Drug Act, have come together to develop products for rare diseases.

Our many successes give us a reason to celebrate 30 years of hard work to provide diagnostic or treatment options to those with rare diseases. But we are keenly aware that there is still a challenging road ahead. We at FDA remain firmly committed to working with the rare disease community to tackle those challenges and to find new diagnostic tools and treatments for the millions of patients with rare diseases.

Gayatri R. Rao, M.D., J.D., is Director for The Office of Orphan Products Development