Medical device companies face evidence requirements that differ fundamentally from pharmaceutical development. According to research published by the National Evaluation System for Health Technology Coordinating Center (NESTcc), the unique characteristics of medical devices create specific challenges for real-world evidence generation: devices undergo frequent design modifications, performance depends heavily on operator skill and technique, and data infrastructure for tracking specific device versions remains fragmented across healthcare systems.
The regulatory framework has matured substantially to address these challenges. The FDA's December 2023 draft guidance on using real-world evidence for medical devices builds on the 2017 guidance, providing expanded recommendations on data quality assessment, submission requirements, and device-specific considerations. Simultaneously, NESTcc has established operational infrastructure with 19 network collaborators and completed cloud-based systems for real-world data collection while protecting patient privacy. This infrastructure creates practical opportunities for manufacturers to generate regulatory-grade evidence more efficiently than building proprietary systems.
Why Device Evidence Requires Different Approaches
Several factors distinguish medical device real-world evidence from pharmaceutical applications. The Agency for Healthcare Research and Quality's comprehensive guide on medical device registries identifies critical differences: devices are modified frequently during their lifecycle (unlike pharmaceuticals, which remain chemically identical post-approval), device performance varies substantially based on operator experience and institutional volume, and unique device identifiers (UDIs) are not consistently captured in electronic health records despite FDA requirements.
The operator-dependent nature of device performance creates particular challenges. A cardiovascular stent or surgical robot performs differently based on operator skill, and real-world studies must account for this variability through study design and statistical approaches. This differs from pharmaceutical studies where the drug formulation remains constant regardless of who prescribes it.
Strategic Post-Market Surveillance
Post-market surveillance represents the most visible application of real-world data for medical devices. The FDA can require manufacturers to conduct post-market surveillance for Class II and III devices under Section 522 authority when device failure could have serious health consequences or when devices are used in specific high-risk contexts. Research analyzing FDA recall data found that approximately 55% of device recalls involve post-market issues rather than premarket design problems, underscoring the importance of ongoing surveillance.
What I've observed in successful surveillance programs is a shift from purely compliance-focused approaches to strategic evidence generation. Rather than simply tracking adverse events, leading device companies design surveillance to answer business questions: which patient subpopulations show optimal performance, what clinical settings produce the best outcomes, and where additional operator training might improve results.
A 2020 BMJ study comparing surveillance approaches found that leveraging existing professional association registries (such as those maintained by the Society for Vascular Surgery or American College of Cardiology) was significantly more cost-effective than conducting traditional industry-led studies. These established registries provide validated infrastructure and regulatory credibility while enabling access to larger, more representative patient populations.
Regulatory Applications and Label Expansions
The FDA has published specific examples of real-world evidence successfully supporting device regulatory decisions, demonstrating applications across 510(k) submissions, substantial equivalence determinations, and device labeling expansions. Research published in the Journal of Comparative Effectiveness Research, analyzing 18 NESTcc pilot projects, identified key factors for successful regulatory use of real-world data: adequate sample sizes within data networks, clear documentation of data quality procedures, and appropriate statistical methods to address confounding.
The practical challenge involves designing observational studies that produce credible results despite lack of randomization. Early FDA engagement through pre-submission meetings is critical. These discussions clarify what real-world evidence approaches the agency will accept for your specific regulatory question before you invest in data collection.
Comparative Effectiveness for Market Access
Beyond regulatory requirements, real-world data enables comparative effectiveness research that addresses questions increasingly important to payers and hospital systems: how does a device perform relative to alternatives under real-world conditions? Research on cardiovascular device registries found that while the National Cardiovascular Data Registry has collected data on over one million device implants, its potential for comparative effectiveness research examining device performance across different products and clinical contexts remains underutilized.
The methodological challenge involves creating meaningful comparisons when device selection is not randomized. The AHRQ registry guide emphasizes that comparative effectiveness studies require careful attention to confounding variables and patient selection patterns. When device choice follows predictable clinical criteria that are well-documented, analytical approaches like propensity score methods can create valid comparisons. When selection is highly variable and poorly documented, comparative conclusions become less reliable.
Long-Term Performance Evidence
Many implantable devices are designed for decades of use, yet premarket trials typically follow patients for much shorter periods. The AHRQ guide notes that device registries play an increasingly important role in "bridging the gap between device performance in clinical trials and their use in routine practice over time," particularly for assessing long-term durability and revision rates.
The practical challenge is maintaining patient follow-up over extended periods. Unlike pharmaceutical studies where patients return for prescription refills, device patients may not return unless complications arise, creating potential for bias. The solution I've seen work effectively involves linking registry data with claims databases to track outcomes even when patients change providers or healthcare systems. This requires careful data governance and privacy protections but enables meaningful long-term surveillance.
Practical Considerations
For device companies developing real-world evidence strategies, several lessons from experience and published research stand out. First, working with established registry networks rather than building proprietary infrastructure is typically faster and more cost-effective, as documented in the BMJ analysis comparing surveillance approaches.
Second, data quality documentation is as important as the analysis itself. The FDA evaluates real-world data on both relevance (does it address the regulatory question?) and reliability (can you demonstrate data quality?). NESTcc research emphasizes that successful regulatory submissions maintain detailed documentation of data sources, validation procedures, and quality assessments.
Third, clear research questions should drive data selection. The most common misstep I observe is collecting data before defining specific questions, which often results in datasets that lack critical variables or populations needed for meaningful analysis.
Moving Forward
The medical device regulatory environment for real-world evidence has evolved from post-market requirement to strategic opportunity. The FDA's 2023 guidance provides clear direction, NESTcc infrastructure is operational, and methodological approaches for addressing observational data challenges are well-established. Organizations building real-world evidence capabilities now, and integrating them throughout device development rather than as post-market afterthoughts, will be positioned for both regulatory success and competitive advantage.
Exploring how real-world evidence could support your device development or market access strategy? Schedule a consultation to discuss your specific evidence questions.
In the next post in this series, I'll explore how biotech and biopharma companies use real-world data for rare disease development and accelerated approval pathways, where real-world evidence often provides the only feasible approach to generating regulatory-grade evidence.
Sources:
Concannon, T.W., et al. (2024). Lessons on the use of real-world data in medical device research: findings from the National Evaluation System for Health Technology Test-Cases. Journal of Comparative Effectiveness Research. DOI: 10.57264/cer-2024-0078
FDA. (2023). Use of Real-World Evidence to Support Regulatory Decision-Making for Medical Devices (Draft Guidance). Federal Register, December 19, 2023. https://www.federalregister.gov/documents/2023/12/19/2023-27852
Agency for Healthcare Research and Quality. (2014). Registries for Evaluating Patient Outcomes: A User's Guide, 3rd Edition, Chapter 22: Medical Device Registries. https://www.ncbi.nlm.nih.gov/books/NBK208640/
BMJ Surgical Interventions & Health Technologies. (2020). Postmarket surveillance of high-risk medical devices needs transparent, comprehensive and independent registries. DOI: 10.1136/bmjsit-2020-000065
NCBI Bookshelf. (2014). Food and Drug Administration Postmarket Surveillance Activities and Recall Studies of Medical Devices, Public Health Effectiveness of the FDA 510(k) Clearance Process. https://www.ncbi.nlm.nih.gov/books/NBK209652/
Journal of the American Heart Association. (2019). Landscape of Cardiovascular Device Registries in the United States. DOI: 10.1161/JAHA.119.012756
FDA. (2024). Realizing the Promise of Real-World Evidence. FDA Voices. https://www.fda.gov/news-events/fda-voices/realizing-promise-real-world-evidence
