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1. PERFORMANCE EVALUATION Performance evaluation of a device is a continuous process by which data are assessed and analysed to demonstrate the scientific validity, analytical performance and clinical performance of that device for its intended purpose as stated by the manufacturer. To plan, continuously conduct and document a performance evaluation, the manufacturer shall establish and update a performance evaluation plan. The performance evaluation plan shall specify the characteristics and the performance of the device and the process and criteria applied to generate the necessary clinical evidence. The performance evaluation shall be thorough and objective, considering both favourable and unfavourable data. Its depth and extent shall be proportionate and appropriate to the characteristics of the device including the risks, risk class, performance and its intended purpose.

1.1. Performance evaluation plan As a general rule, the performance evaluation plan shall include at least:

— a specification of the intended purpose of the device;

— a specification of the characteristics of the device as described in Section 9 of Chapter II of Annex I and in point (c) of Section 20.4.1. of Chapter III of Annex I;

— a specification of the analyte or marker to be determined by the device;

— a specification of the intended use of the device;

— identification of certified reference materials or reference measurement procedures to allow for metrological traceability;

— a clear identification of specified target patient groups with clear indications, limitations and contra-indications;

— an identification of the general safety and performance requirements as laid down in Sections 1 to 9 of Annex I that require support from relevant scientific validity and analytical and clinical performance data;

— a specification of methods, including the appropriate statistical tools, used for the examination of the analytical and clinical performance of the device and of the limitations of the device and information provided by it;

— a description of the state of the art, including an identification of existing relevant standards, CS, guidance or best practices documents;

— an indication and specification of parameters to be used to determine, based on the state of the art in medicine, the acceptability of the benefit-risk ratio for the intended purpose or purposes and for the analytical and clinical performance of the device;

— for software qualified as a device, an identification and specification of reference databases and other sources of data used as the basis for its decision making;

— an outline of the different development phases including the sequence and means of determination of the scientific validity, the analytical and clinical performance, including an indication of milestones and a description of potential acceptance criteria;

— the PMPF planning as referred to in Part B of this Annex. Where any of the above mentioned elements are not deemed appropriate in the Performance Evaluation Plan due to the specific device characteristics a justification shall be provided in the plan.

1.2. Demonstration of the scientific validity and the analytical and clinical performance: As a general methodological principle the manufacturer shall:

— identify through a systematic scientific literature review the available data relevant to the device and its intended purpose and identify any remaining unaddressed issues or gaps in the data;

— appraise all relevant data by evaluating their suitability for establishing the safety and performance of the device;

— generate any new or additional data necessary to address outstanding issues.

1.2.1. Demonstration of the scientific validity The manufacturer shall demonstrate the scientific validity based on one or a combination of the following sources:

— relevant information on the scientific validity of devices measuring the same analyte or marker;

— scientific (peer-reviewed) literature;

— consensus expert opinions/positions from relevant professional associations;

— results from proof of concept studies;

— results from clinical performance studies. The scientific validity of the analyte or marker shall be demonstrated and documented in the scientific validity report.

1.2.2. Demonstration of the analytical performance

The manufacturer shall demonstrate the analytical performance of the device in relation to all the parameters described in point (a) of Section 9.1 of Annex I, unless any omission can be justified as not applicable. As a general rule, the analytical performance shall always be demonstrated on the basis of analytical performance studies. For novel markers or other markers without available certified reference materials or reference measurement procedures, it may not be possible to demonstrate trueness. If there are no comparative methods, different approaches may be used if demonstrated to be appropriate, such as comparison to some other well-documented methods or the composite reference standard. In the absence of such approaches, a clinical performance study comparing performance of the novel device to the current clinical standard practice is required. Analytical performance shall be demonstrated and documented in the analytical performance report.

1.2.3. Demonstration of the clinical performance

The manufacturer shall demonstrate the clinical performance of the device in relation to all the parameters described in point (b) of Section 9.1. of Annex I, unless any omission can be justified as not applicable. Demonstration of the clinical performance of a device shall be based on one or a combination of the following sources:

— clinical performance studies;

— scientific peer-reviewed literature;

— published experience gained by routine diagnostic testing. Clinical performance studies shall be performed unless due justification is provided for relying on other sources of clinical performance data. Clinical performance shall be demonstrated and documented in the clinical performance report.

1.3. Clinical evidence and performance evaluation report

1.3.1. The manufacturer shall assess all relevant scientific validity, analytical and clinical performance data to verify the conformity of its device with the general safety and performance requirements as referred to in Annex I. The amount and quality of that data shall allow the manufacturer to make a qualified assessment whether the device will achieve the intended clinical benefit or benefits and safety, when used as intended by the manufacturer. The data and conclusions drawn from this assessment shall constitute the clinical evidence for the device. The clinical evidence shall scientifically demonstrate that the intended clinical benefit or benefits and safety will be achieved according to the state of the art in medicine.

1.3.2. Performance evaluation reportThe clinical evidence shall be documented in a performance evaluation report. This report shall include the scientific validity report, the analytical performance report, the clinical performance report and an assessment of those reports allowing demonstration of the clinical evidence. The performance evaluation report shall in particular include:

— the justification for the approach taken to gather the clinical evidence;

— the literature search methodology and the literature search protocol and literature search report of a literature review;

— the technology on which the device is based, the intended purpose of the device and any claims made about the device's performance or safety;

— the nature and extent of the scientific validity and the analytical and clinical performance data that has been evaluated;

— the clinical evidence as the acceptable performances against the state of the art in medicine;

— any new conclusions derived from PMPF reports in accordance with Part B of this Annex.

1.3.3. The clinical evidence and its assessment in the performance evaluation report shall be updated throughout the life cycle of the device concerned with data obtained from the implementation of the manufacturer's PMPF plan in accordance with Part B of this Annex, as part of the performance evaluation and the post-market surveillance system referred to in Article 10(9). The performance evaluation report shall be part of the technical documentation. Both favourable and unfavourable data considered in the performance evaluation shall be included in the technical documentation.

2. CLINICAL PERFORMANCE STUDIES 2.1. Purpose of clinical performance studies

The purpose of clinical performance studies is to establish or confirm aspects of device performance which cannot be determined by analytical performance studies, literature and/or previous experience gained by routine diagnostic testing. This information is used to demonstrate compliance with the relevant general safety and performance requirements with respect to clinical performance. When clinical performance studies are conducted, the data obtained shall be used in the performance evaluation process and be part of the clinical evidence for the device.

2.2. Ethical considerations for clinical performance studies Each step in the clinical performance study, from the initial consideration of the need for and justification of the study to the publication of the results, shall be carried out in accordance with recognised ethical principles.

2.3. Methods for clinical performance studies 2.3.1. Clinical performance study design type Clinical performance studies shall be designed in such a way as to maximize the relevance of the data while minimising potential bias.

2.3.2. Clinical performance study plan