Draft Recommendations Report by the Heart …

1 Embargoed until April 26, 2006 Draft Recommendations Report by the Heart Rhythm Society Task Force on Device Performance Policies and GuidelinesDRAFTA p r i l 2 6 , 2 0 0 6 Heart Rhythm Society Draft Recommendations ReportTABLE OF CONTENTSS ummary of Recommendations ..4 Introduction ..7 Device Performance and 8 Communication of Device Performance ..8 Table 1 ..10 Table 2 ..11 Surveillance ..12 Analysis of Data Roles of Industry, FDA, and Physicians ..14 Terminology and Threshold for Activation of Device Recalls and Advisory Notices ..15 Table 3 ..16 Communication After Device Malfunction is Identified ..16 Physician Device Advisory Notification ..18 Patient Notification Letter .. 19 Recommendations for Clinicians Managing Device Advisory Notices ..20 Table 4 ..22 References.

2 22F R O M T H E T A S K F O R C E O N D E V I C E P E R F O R M A N C E P O L I C I E S A N D G U I D E L I N E S Ta s k F o r c eMark D. Carlson, MD, MA, Task Force Chair University Hospitals of Cleveland and Case Western Reserve University, OHs e cT i o n c h a i r sBruce L. Wilkoff, MD, Chair, Device Performance and Communication of Device PerformanceCleveland Clinic Foundation, OHWilliam H. Maisel, MD, MPH, Chair, SurveillanceBeth Israel Deaconess Medical, MAMark D. Carlson, MA, Chair, Analysis of DataUniversity Hospitals of Cleveland and Case Western Reserve University, OHKenneth A. Ellenbogen, MD, Chair, Terminology and Threshold Activation of Device Recalls and Advisory NoticesVCU Medical Center, VALeslie A. Saxon, MD, Chair, Communication After Device Malfunction is IdentifiedUSC University Hospital, CAEric N.

3 Prystowsky, MD, Chair, Recommendation for Clinicians Managing Device Advisory NoticesThe Care Group, LLC, INm e m b e r sJoseph S. Alpert, MD, University of Arizona, AZMichael E. Cain, MD, Washington Univ . School of Medicine, MOElizabeth A. Ching, RN, Cleveland Clinic Foundation, OHAnne B. Curtis, MD, University of South Florida, FLD. Wyn Davies, MD, St . Mary s Hospital, UKStephen C. Hammill, MD, Mayo Clinic College of Medicine, MNRobert G. Hauser, MD, Minneapolis Heart Institute, MNRachel Lampert, MD, Yale University School of Medicine, CTDouglas P. Zipes, MD, Krannert Institute of Cardiology, INDRAFTDRAFTSummAry OF rECOmmENdATiONSThe Heart Rhythm Society believes that patient and physician knowledge, confidence, and trust can be enhanced and strengthened through: Greater transparency in post-market surveillance, analysis, and reporting of information, Enhanced systems to increase the return of devices to manufacturers and to improve the analysis and reporting of device performance and malfunction information, and Cooperation among industry, the FDA, and physicians to make every effort to prevent injuries and deaths due to device malfunctions.

4 Specific Recommendations for industry, FDA, CMS, Congress, physicians and others, follow .d e v i c e p e rF o r m a n c eRecommendationThe Heart Rhythm Society recommends that manufacturers establish standards of performance for their devices and the key components including batteries, pulse generators, and leads . The Heart Rhythm Society recommends that manufacturers publish annually malfunction rates for each device type based on documented device malfunctions reported to the FDA as indexed to the number of devices at risk (implanted) in the US population during the same calendar year .c o m m u n i c aT i o n oF d e v i c e p e rF o r m a n c eRecommendationsIndustry: At the national Policy Conference on Pacemaker and ICD Performance (17), the Heart Rhythm Society recommended that manufacturers of cardiac rhythm management device provide standardized device performance reports semiannually in hard copy and in a format available to the public on the Internet.

5 The reports should include all device information pertinent to patient care, and be presented in an unbiased manner and in a consistent and usable format . The Heart Rhythm Society recommends that manufacturers establish expected standards of performance for their particular device models including key components such as batteries, pulse generators, and leads . In addition, the Heart Rhythm Society recommends that manufacturers provide public access to the standards of performance and all information regarding any product performance issues, including sporadic or component malfunctions in the semiannual product performance reports . Information should include changes made in response to field observations .Physicians: The Heart Rhythm Society recommends that physicians (or other medical personnel), in addition to informing patients of procedural benefits and risks, inform patients of expected device performance, including battery life and potential malfunction rate, at the time of initial device implantation and at replacement.

6 S u rv e iL La n c e RecommendationsIndustry: The Heart Rhythm Society recommends that cardiac rhythm management device manufacturers develop and utilize wireless and remote monitoring technologies to: Identify abnormal device behavior as early as possible . Reduce underreporting of device malfunctions by determining the functional status of an implanted device more frequently and more accurately . FDA: Changes to the current post market surveillance system are required to improve the timely identification of cardiac rhythm management devices that do not perform according to expectations and which may pose a danger to patients . The Heart Rhythm Society recommends that the FDA enhance the Manufacturer and User Device Experience (MAUDE) database by: Utilizing a specialized form for cardiac rhythm management devices to permit better and more precise reporting of adverse events.

7 Tracking devices that are returned to manufacturers for analysis and updating publicly available adverse event reports with root cause analyses . Facilitating links to data from international sources .General Recommendation: The Heart Rhythm Society recommends that the NCDR ICD Registry, administered by the Heart Rhythm Society and the American College of Cardiology be modified to: Collect detailed device-specific longitudinal performance data including a Report of device performance at the time of device replacement or death . Collect data regarding adverse device events, date of the event, and the outcome of the event or cause of each patient s death .This adjunctive information can assist in tracking device performance and the consequences of malfunctions . Implementation of this recommendation will require additional funding and resources from the federal government, private payers, device manufacturers, and hospitals.

8 Congress: The Heart Rhythm Society urges Congress to recognize that post-market surveillance, analysis, and reporting of ICD and pacemaker performance is a high priority for ensuring patient safety . Additionally, Congress is urged to recognize and address the issue that the FDA does not currently have adequate resources to perform this function . The enhancements to the surveillance system that the Heart Rhythm Society recommends, particularly those to the MAUDE database and the NCDR ICD Registry, will require additional resources . The Heart Rhythm Society recommends that Congress ensure that FDA receives the resources and funding necessary to enhance the MAUDE database and provide improved post-market surveillance of pacemakers, ICDs, and leads as described in this section .Physicians: T he Heart Rhythm Society recommends that all devices be returned to the manufacturer for analysis after explantation.

9 This includes returning devices to the manufacturer at the time of device replacement whether the replacement is routine or because of device malfunction . F R O M T H E T A S K F O R C E O N D E V I C E P E R F O R M A N C E P O L I C I E S A N D G U I D E L I N E SHeart Rhythm Society Draft Recommendations Report A p r i l 2 6 , 2 0 0 6 The Heart Rhythm Society recommends the following actions in order to achieve this goal . Post mortem device interrogation, explantation, and return to the manufacturer should be strongly encouraged, particularly in cases of sudden or unexpected death . The Heart Rhythm Society should work to educate physicians, nurses, allied health professionals, patients, families, pathologists, and morticians of the importance of notifying the physician following the device immediately after the patient dies and returning the patient s device to the manufacturer.

10 Whenever possible and indicated, patients should be asked to consent for post-mortem ICD evaluation including interrogation and removal . This consent should be legally binding . In the absence of prior discussion with the patient, family members should be asked to consent to device interrogation, removal and return to the manufacturer after the patient s death .Other Recommendations : The Heart Rhythm Society recommends that physicians be compensated appropriately for post mortem evaluation of cardiac rhythm management devices and reporting of device adverse events . CPT codes should be established for these activities . a n aLy s i s oF d aTa r o L e s oF i n d u sT ry, Fd a, a n d p h y s i c i a n sRecommendationsThe Heart Rhythm Society recommends that experts who are not full-time employees of industry or the FDA should analyze device performance data and provide advice on a regular basis and when life-threatening device malfunctions are identified.