Specific rules for medical devices
Design of a medical device study
The design of a medical device study shall be based on the research question or hypothesis to be answered or tested. The study should be planned in such a way that the data collected is of good quality and can be used to answer the question involved. The question and study design can vary depending on what the purpose of the study is, but also depending on the development stage the medical device is at. You can read more about different study designs and statistical aspects in the Analysis section.
In addition to considering scientific aspects, you also need to ensure that the design that is best from a purely scientific viewpoint is also ethically and practically feasible. It is also a good idea to consider how the study design impacts on the quality of the data collected. A complex study design may require greater educational efforts for users and personnel, or a comprehensive plan for monitoring, to avoid failings in data quality compared to a design that largely follows the normal healthcare procedures.
Medical device aspects on ethical review
In addition to the requirements set by the Ethical Review Authority on the written information to be given to study participants, there are specific requirements on information to the participants in a medical device study. ISO 14155, Item 4.7.4 has recommendations for the information to be included.
When it comes to insurance for study participants, there are also circumstances that are specific for studies involving medical devices. If the studies are conducted as part of the healthcare principals activities, the patient insurance the healthcare principal is obliged to have is valid. On the other hand, there is no equivalent to the Medicinal Products Act (SFS 1992:859) covering medical devices.
Does the study need a permit from the Medical Products Agency?
In addition to being approved by the Ethical Review Authority, some studies involving medical devices must also be notified to the Medical Products Agency. Products that already have CE-marking and that will also be used in the study within the framework for the manufacturer’s intended use are not covered by the notification duty. Nor do studies of products of own manufacture according to the Swedish National Board of Health and Welfare’s regulation SOSFS 2008:1 (in Swedish) need to be notified to the Medical Products Agency. Clinical studies involving in vitro diagnostic products may in some cases require a permit.
Studies that need to be notified include:
- all clinical studies involving medical devices that are neither CE-marked nor own production products
- all clinical studies involving CE-marked medical devices when the plan is to use the product in a way that is not covered by the intended use
Contact the Medical Product Agency for advice if needed.
Medical device studies abroad
If you plan to conduct a clinical study involving medical devices in another country, you must inform yourself about the applicable legislation in that country. The European Clinical Research Infrastructure Network, ECRIN, has summarised information on regulatory requirements for many European countries. The US Food and Drug Administration is the regulatory authority for medical devices in USA, and China Food and Drug Administration is the Chinese equivalent, just to mention some.
An adapted clinical investigation plan is needed for notification to the Medical Products Agency
If you need a permit from the Medical Products Agency for a clinical study involving medical devices, you will need to adapt your research protocol before submitting the notification. The research protocol for a clinical trial involving medical devices is called a clinical investigation plan, or CIP. ISO 14155, Annex A, has detailed information on what it needs to include. There is also a guidance document on the EU Commission’s website describing how the national authorities assess the contents of the clinical investigation plan. The requirements on the contents of a clinical investigation plan are more comprehensive than the Ethical Review Authority’s specification for what must be included in a research plan, and therefore the more detailed clinical investigation plan shall be appended to the application for ethical review. An identical version of the clinical investigation plan shall be appended to the notification to the Medical Products Agency.
Important parts of the clinical investigation plan are the description of the data to be collected, which statistical considerations form the basis for the study design, and how data is to be analysed. Other important parts are a description of the study population, the procedures the study participants are expected to undergo, how informed consent is obtained, and a risk-benefit assessment relating to study participation.
In addition to the clinical investigation plan, a number of further appendices shall also be included in the notification to the Medical Products Agency. Information about mandatory appendices and their content is available in the notification form and associated instructions on the website of the Medical Products Agency.
Constructing a data collection tool
For a study involving medical devices that needs a permit, there must be a CRF, either in paper format or as an electronic system. An electronic CRF (e-CRF) can form the foundation for a database created for analyses, while a paper CRF needs to be converted into electronic data at a later stage. Irrespective of format, a CRF shall be constructed as a number of questions or tick-boxes that the study personnel fill in as the study participants answer questions or undergoes various investigations that generate measurement values. Data from the patient notes can also be filled in in a CRF. Annex C of ISO 14155 has an example of what a CRF may include.
If you use an e-CRF, there are specific requirements for system functionality and security. For example, an e-CRF must have a “logging function” to register who makes any changes to input data. The requirements on electronic systems in a studying involving medical devices are shown in ISO 14155, Item 6.8.3. You are also responsible for how the electronic processing of sensitive personal data is done, and you must know whether the electronic system entails personal data being processed abroad, or in any other operation than that of the research principal.
Remember that all the data collected in a CRF must be described in the clinical investigation plan, which must be approved by both a ethical review board and by the Medical Products Agency. No other data may be collected.
Allocating roles and responsibilities
According to ISO 14155, there are a number of roles with varying responsibility to allocate when planning to carry out a clinical study involving medical devices that requires a permit.
The manufacturer is the person responsible for construction, manufacture, marking, instructions, packaging and who states the designated purpose of a medical device, and who thereafter releases the device on the market in their own name. It is the manufacturer who shall CE-mark the product, irrespective of who has carried out the practical manufacture.
The sponsor is the individual or organisation responsible for starting and implementing a clinical study requiring a permit. It is common for the sponsor to also be the manufacturer of the medical device, but it is not a requirement.
The sponsor has overall responsibility for the implementation of the study, and is responsible for issues such as:
- planning and implementation of the clinical study
- communication with regulatory authorities
- quality assurance and control
- any contracting of subcontractors for tasks and functions
A full description of the sponsor’s role and responsibility is available in ISO 14155, Section 8.
The principal investigator is the person responsible for the implementation of a clinical study at a clinic. If the study is conducted at several clinics, there shall be a principal investigator at each site. The principal investigator shall have documented education and experience within the area the medical device is to be used in. The competence needs for the principal investigator shall be assessed based on the area of use of the device.
The principal investigator’s tasks include:
- leading the work on the study at the clinic
- ensuring that informed consent is obtained from study participants according to applicable rules and the clinical investigation plan
- ensuring that the study is conducted according to the clinical investigation plan
- being responsible for ensuring the study participants receive the medical care necessary during and after the implementation of the study
- implementing safety reporting
- ensuring that reliable data are generated
The principal investigator has overall responsibility for the study at the clinic, but may delegate tasks on condition that the delegation is done in writing to a person with suitable education and experience. A signature and delegation list must be drawn up and kept updated in the event of any personnel changes during the course of the study. A task must first be delegated before it may be executed by any person other than the principal investigator.
A full description of the principal investigator’s role and responsibility is available in ISO 14155, Section 9.
The monitor is a person appointed by the sponsor, whose responsibility it is to make independent checks that the study is conducted according to the clinical investigation plan and other applicable regulations. The monitor shall carry out the checks by visiting the clinics participating in the study, scrutinising the work and informing about recommended measures to improve the work on the study. After the visit, the monitor shall write a report to the sponsor.
In order to enable the monitor to monitor a study, he or she needs to have scientific and/or clinical prior knowledge, and also knowledge about:
- ISO 14155
- the device being tested and how it is to be used
- the clinical investigation plan
- the approved procedure for obtaining informed consent
- the sponsor’s procedures
- regulatory requirements
A full description of the monitor’s role and responsibility is available in ISO 14155, Section 8.2.4.
Collaboration between business, universities and healthcare
Clinical studies can be carried out at the initiative of healthcare, but it is also common for a company or an academic researcher to have an idea for a new or changed medical device.
When the medical device sector and healthcare collaborate in the development of medical devices, for example by conducting a clinical study together, the collaboration rules (in Swedish) shall be complied with.
When planning a clinical study in collaboration with healthcare, you should be aware that specific roles with a certain type of competence must be appointed. Read more about roles and liabilities in the section above. In addition to the competence that has to be recruited to fulfil the requirements of ISO 14155, the main rule is also that the person listed as the researcher responsible in an ethical review application shall have a doctoral degree. The researcher responsible in an ethical review application is often the same person as the principal investigator in the study. For a multi-centre study, the researcher responsible in an ethical review application is the person responsible for the trial site in the region from which the ethical review application is sent.
For help with contacting clinic that may be interested in implementing your planned study, you can use the service for coordinated feasibilities at the regional nodes.
Drawing up contracts and managing financial agreements
If the clinical study is implemented as commissioned research, that is to say some principal other than healthcare takes the initiative for the study, then a contract shall always be drawn up between the sponsor and the clinic or operation conducting the study. The contract shall regulate the allocation of responsibility for the study and any financial agreements. The healthcare principal will often require compensation for the additional costs the implementation of the study will entail for the operation. Financial agreements relating to commissioned research shall also be reported in the ethical review application.
If the healthcare principal takes the initiative for the clinical study, it is still recommended that a written agreement between the researcher and the operational manager is drawn up, governing aspects such as how additional costs to the clinic shall be financed.
Further agreements may need to be signed, for example if the study requires any X-ray or pathology input or a sample handling procedure via a central laboratory.