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September 2018 (Volume 96)
Quarterly Article
Stephanie R. Fox-Rawlings
Laura B. Gottschalk
Laurén A. Doamekpor
Diana M. Zuckerman
Nov 5, 2024
Oct 30, 2024
Oct 23, 2024
Back to The Milbank Quarterly
Policy Points:
Context: Demographic differences can influence the safety and effectiveness of medical devices; however, clinical trials of devices for adults have historically underrepresented women, people of color, and patients over age 65. The US Food and Drug Administration (FDA) Safety and Innovation Act became law in 2012, encouraging greater diversity and subgroup analyses. In 2013, the FDA reported that there was diversity in clinical trials considered “pivotal” for approval decisions and that subgroup analyses were conducted for most applications for the highest-risk medical devices. However, the FDA’s report did not specify whether analyses included sufficient numbers to be meaningful, whether analyses were conducted for most major subgroups, or whether analyses included safety, effectiveness, or accuracy.
Methods: We examined publicly available documents for all 22 medical devices that the FDA designated “highest risk” or “novel,” were reviewed through the premarket approval pathway, and were scrutinized at FDA public meetings from 2014 to 2017.We evaluated patient demographics and subgroup analyses for all pivotal trials.
Findings: Only 3 (14%) of the devices provided subgroup analyses for both effectiveness and safety or both sensitivity and selectivity for gender, race, and age. However, 55% of the devices reported both of those subgroup analyses for at least 1 of the 3 subgroups. Whether analyses were reported or not, the number of patients in most subgroups was too small to draw meaningful conclusions. Subgroup analyses were more likely to be reported to the FDA’s Advisory Committees than in the FDA’s public reviews or labeling.
Conclusions: Despite a law encouraging more diversity and subgroup analyses in pivotal trials used as the basis for FDA approval, the results of our study indicate relatively few subgroup analyses are publicly available for the highest-risk and novel medical devices. The lack of subgroup analyses makes it impossible to inform patients or physicians as to whether many newly approved medical devices are safe and effective for specific demographic subgroups defined by gender, race, and age.
Keywords: US Food and Drug Administration (FDA), clinical trials, device approval, diversity, subgroup analysis.
Read on Wiley Online Library
Volume 96, Issue 3 (pages 499-529) DOI: 10.1111/1468-0009.12344 Published in 2018
