FDA classifies each medical device type intended for human use into one of three classes based on the level of risk it poses to the patient or the user and the controls necessary to reasonably ensure its safety and effectiveness. Examples of types of devices in each class include the following: Class I: tongue depressors, elastic bandages, reading glasses, and Class II: electrocardiographs, powered bone drills, and mercury Class III: pacemakers and replacement heart valves. Before medical devices may be legally marketed in the United States, they are generally subject to one of two types of FDA premarket review processes. Premarket approval (PMA) process: Class III device types are typically required to obtain FDA approval through the PMA process. Under this process, the medical device sponsor must submit an application that includes—among other things—full reports of investigations, typically including clinical data, providing reasonable assurance that the new device is safe and effective. The PMA process is the most stringent type of premarket review. A successful application results in FDA’s approval to market the device. From 2001 through 2016, medical device sponsors submitted 651 PMA applications, and FDA approved for marketing 506 of those submissions. (See fig. 1.) Premarket notification, or 510(k), process: Most medical devices requiring premarket review are subject to FDA’s premarket notification or 510(k) process. This includes class I and II device types that are not specifically exempted from the 510(k) notification requirement. Under this process, the medical device sponsor must notify FDA at least 90 days before it intends to market a new device and demonstrate to FDA that the new device is substantially equivalent to a predicate device, and therefore does not require a PMA. For most 510(k) notifications, clinical data are not required and substantial equivalence will normally be determined based on comparative descriptions of intended device uses and technological characteristics, and may include performance data. A successful 510(k) submission results in FDA’s clearance to market the device. From 2001 through 2016, medical device sponsors submitted 61,439 premarket notifications and FDA cleared 51,028 devices for market. (See fig. 2.) During premarket review under both the PMA and 510(k) processes, FDA and the medical device sponsor may engage in an interactive process. To start, there may be a pre-submission meeting between FDA and the sponsor, during which the parties discuss the upcoming review and try to resolve potential obstacles for approval or clearance. Then, FDA receives the premarket submission, makes a determination to accept or not accept the submission, and assigns a reviewer. In making its assessment whether to approve, or clear, a submission, FDA relies on the sponsor to provide supporting data as part of the submission. However, the agency can request additional information in the course of the review in order to make a determination of reasonable assurance of safety and effectiveness, or of substantial equivalence. This additional information can be obtained through informal interactions, such as a phone call or email. Alternatively, for more significant issues, FDA may make a more formal request for additional information, known as a deficiency letter in the case of a PMA application and additional information (AI) letter for a 510(k) notification. FDA will issue such requests if the submission lacks significant information necessary for FDA to complete its review, and the agency will request the sponsor amend the submission to provide the necessary information regarding the device. If a sponsor disagrees with an FDA regulatory decision concerning a medical device submission, including a CDRH employee’s decision to request additional information or a significant decision regarding approval or clearance of a medical device, it can take multiple actions. Specifically, a sponsor can, among other things, (1) contact the CDRH Ombudsman for assistance, (2) file an internal appeal of an FDA decision, or (3) request that the disagreement be resolved through CDRH’s Medical Device Dispute Resolution Panel, as described below. Ombudsman: According to FDA’s guidance, prior to the agency reaching a regulatory decision, the most effective means of resolving a dispute between CDRH and an external stakeholder is through discussion and agreement. The CDRH Ombudsman is available to assist in clarifying issues, mediate meetings and teleconferences, and conduct discussions with the parties in an effort to resolve disagreements short of a formal review or internal appeal. Internal Appeal: Once FDA makes a regulatory decision, a sponsor can request a supervisory review of that decision, which we refer to as an internal appeal. For this process, the supervisor of an FDA employee will, at the request of a medical device sponsor, review a decision or action of the employee and issue a decision. The decision rendered by the supervisor, acting as the review authority, customarily takes one of the following forms: overturning the decision of the employee; upholding the employee decision; or, in some circumstances, referring the matter back to the employee for reconsideration under defined conditions. Medical Device Dispute Resolution Panel: If the dispute remains unresolved, the sponsor may request that FDA convene the Medical Device Dispute Resolution Panel. The panel is intended to provide a means for independent review of a scientific controversy or dispute between a sponsor and FDA, and make a recommendation to the Center director. According to FDA’s guidance, the panel is primarily intended to address scientific controversies rather than other issues such as regulatory, legal, or statutory authority disputes. As part of its commitments associated with the Medical Device User Fee Amendments of 2012 (MDUFA III), FDA agreed to participate in an independent, comprehensive assessment of the medical device submission review process. Acting on recommendations from the contractor that conducted the assessment, FDA established working groups for each submission type, including PMAs and 510(k)s, which studied existing review processes and made recommendations. In August 2017, the Medical Device User Fee Amendments of 2017 (MDUFA IV) reauthorized FDA’s medical device user fee program, and FDA committed to another independent assessment. FDA has committed to hiring a contractor to conduct this assessment by the end of December 2017 with a second phase to begin in 2020. In 1997, FDAMA added a requirement that the agency use the least burdensome approach during certain parts of PMA and 510(k) reviews. These requirements were intended to reduce unnecessary burdens associated with the premarket approval and clearance processes; however, they did not lower the statutory criteria for demonstrating a reasonable assurance of safety and effectiveness or substantial equivalence. While the language in FDAMA differs slightly for the PMA and 510(k) processes, in both instances FDA was directed to consider the “least burdensome” means of requesting information needed for its review. Specifically, FDAMA requires that when the agency specifies data that must be submitted as part of a PMA application, the agency must consider the least burdensome appropriate means of evaluating device effectiveness that would have a reasonable likelihood of resulting in approval. The agency must similarly consider the least burdensome appropriate means of demonstrating substantial equivalence when requesting information under the 510(k) notification process. In both cases, FDA is statutorily required to request only information that is necessary to support the determination that there is reasonable assurance of effectiveness or substantial equivalence, respectively. Subsequent laws have clarified the least burdensome requirements. In 2012, the Food and Drug Administration Safety and Innovation Act clarified that the term “necessary” means the minimum required information that would support either a determination that a PMA application provides reasonable assurance of the effectiveness of the device or a determination, for a 510(k) notification, of substantial equivalence between a new device and a predicate device. In 2016, the 21st Century Cures Act added a provision applying the least burdensome concept to FDA’s requests for additional information in the PMA process. The law also applied the least burdensome concept to significant decisions, such as denials of PMA applications, requiring such decisions to include a brief statement regarding how least burdensome requirements were considered and applied. Additionally, the law mandated each FDA employee involved in premarket submission reviews, including supervisors, to receive training on the least burdensome provisions, and required the agency to conduct an audit of the training, among other things, no later than June 2018. Although FDA officials have noted that the least burdensome principles are broad and could apply to all activities within the PMA and 510(k) premarket review process, they noted that the requests for additional information represent a key juncture for the application of least burdensome requirements. According to agency officials and industry representatives, the requests for additional information—deficiency letters in the case of PMAs and AI letters for its 510(k) reviews—are when FDA and the sponsor could disagree on whether the requested information is necessary for the agency to reach a final decision on the medical device under review. Following the enactment of FDAMA in 1997, FDA went through a process in collaboration with the medical device industry to define the least burdensome concept and develop an approach to implement the provisions. Based on this, FDA released multiple guidance documents related to least burdensome requirements from 2000 through 2002. In November 2000 guidance, FDA outlined a four-part approach— referred to as “four-part-harmony” by FDA staff—for communicating deficiencies to medical device sponsors in accordance with the least burdensome requirements. The guidance helps reviewers describe deficiencies identified in submissions in ways that are direct, concise, and complete, thus ensuring a more effective use of reviewers’ and sponsors’ time, effort, and resources. It also provides a suggested format for sponsors to respond to FDA. FDA updated this guidance in September 2017. In 2002 guidance, FDA described its principles for implementing the least burdensome requirements and its activities to assess implementation. The guidance outlines FDA’s interpretation of the least burdensome concept as described in FDAMA, and explains its application to activities associated with PMA and 510(k) reviews. The guidance also states that FDA was in the process of developing tools to be used by both agency staff and its stakeholders to periodically assess the implementation of the least burdensome principles. It noted some measurement tools had already been developed and that additional tools were also needed to assess the impact of the least burdensome approach on expediting the development of new medical technologies. In addition, FDA has included language about those requirements in other guidance documents. For example, in 2014, FDA issued guidance on the 510(k) program that describes how the least burdensome principles may affect the type of information necessary to demonstrate substantial equivalence at different decision points in the review of a 510(k). FDA requested sponsors provide additional information for a majority of the PMAs and 510(k)s it reviewed. For the period 2001 through 2016, FDA issued a large number of deficiency and AI letters relative to the number of submissions, although there was variation annually. For PMAs, the number of deficiency letters as a percentage of new PMA applications submitted ranged from about 54 percent to 113 percent annually, or 82 percent on average, from 2001 through 2016. For the years 2006 through 2010, this percentage, as well as the total number of letters was higher, and FDA issued more deficiency letters than there were PMA applications submitted. Similarly, AI letters as a percentage of total 510(k) notifications received ranged from about 58 percent to more than 174 percent annually, or about 106 percent on average, from 2001 through 2016. While the number of 510(k) notifications remained similar across the time period we examined, from 2009 through 2012, the number of AI letters issued each year was, on average, nearly double the number in other years. During this period, FDA issued more AI letters than there were 510(k) notifications submitted. Since 2014, these percentages have been lower for both PMAs and 510(k)s. FDA officials acknowledged the historical increase in the number of deficiency and AI letters and noted the more recent decrease. The officials attributed this decrease to a number of changes the agency agreed to in MDUFA III. For example, FDA implemented a policy to review submissions for administrative completeness prior to accepting the submission. They said this allowed the agency to limit deficiency and AI letters to issues related to the quality of the data provided and the studies conducted in support of the submission rather than to administrative issues. Also as a result of MDUFA III, the agency implemented an interactive review process to increase informal interaction between FDA and applicants and to minimize the number of review questions communicated through deficiency and AI letters. (See table 1.) We identified changes in how the deficiency letters and AI letters referenced the least burdensome requirements. Based on our sample of 73 letters from 1997 through 2016, FDA included an explicit acknowledgment of the least burdensome requirements in the letters issued from 2001 through 2009. However, based on our review, this practice ended in 2010, and later letters did not include this standard language. Representatives from the medical device industry told us that including the least burdensome language in the deficiency letters was a good practice because it raised awareness of the least burdensome principles. In September 2017, FDA released updated deficiencies guidance that, according to FDA officials, instructs staff how to better articulate the reason that the information is needed in accordance with the least burdensome requirements. This guidance does not set forth boilerplate language regarding the least burdensome requirements for use in deficiency letters, but does include examples of well-constructed deficiencies, definitions for major and minor deficiencies, and a statement that FDA will attempt to resolve minor deficiencies interactively. The least burdensome requirements were often a significant contributing factor in disagreements raised by medical device sponsors, according to FDA officials and available FDA data. According to FDA, the most effective means of resolving disagreements is through discussion and mediation, and to that end, the Ombudsman’s office is routinely involved in discussions between firms and medical device reviewers during the review process. For example, in 2016, the CDRH Ombudsman was involved with PMA and 510(k) medical device reviews 360 times out of 3,444 submissions. Although the agency was unable to identify which of these interactions were related to least burdensome requirements, agency officials told us that a substantial number likely resulted from a difference of opinion between the applicant and FDA on the appropriate level of scientific evidence, a portion of which likely have a least burdensome component. The least burdensome provisions were also frequently related to issues that applicants raised during internal agency appeals of FDA decisions of PMA and 510(k) reviews. Although FDA did not have readily available data on appeals that occurred prior to 2013, the agency was able to provide information about the 63 appeals of significant decisions that occurred from 2013 through 2016. Of these 63 appeals, FDA identified 33 appeals—2 related to PMAs and 31 related to 510(k)s—in which the issue identified by the sponsor was related to least burdensome principles. According to medical device industry representatives, sponsors may not always pursue an appeal, so the number of official appeals may not represent the extent of least burdensome-related issues that sponsors experience. They said the sponsor may determine it is best to avoid conflict that could complicate future device submissions and comply with the request for additional information, even if it disagrees. Of these 33 appeals, FDA agreed, or partially agreed with the sponsor for 11 appeals, which resulted in FDA overturning the decision or reopening the file and continuing the review. For the remaining 22 appeals, the agency upheld the initial reviewer decision. The following presents examples of appeals where the issue identified by the sponsor was related to the least burdensome requirements. In one appeal related to a 510(k) review, the sponsor objected to the reviewer’s finding that the device was not substantially equivalent to a device already on the market. The sponsor stated that it had provided sufficient data for a substantial equivalence determination, and the FDA reviewer’s request for additional risk mitigation measures and supplemental testing was unwarranted and inappropriate. The review authority determined that, while the information provided in the 510(k) premarket submission was not sufficient to establish substantial equivalence, some of FDA’s requests were unwarranted. As a result of the appeal, FDA reopened the file and provided the sponsor an opportunity to respond to a new set of requests for additional information. In an appeal related to a PMA review, the sponsor contended that FDA’s not approvable decision reflected an inconsistent and erroneous interpretation of the clinical data supporting the safety and effectiveness of the subject device, and that the data it had provided was sufficient for FDA to reach an approved decision. The sponsor further contended that the review staff failed to utilize the principles outlined in FDA guidance. The review authority upheld FDA’s initial decision and determined there was not sufficient valid scientific evidence to demonstrate a reasonable assurance that the subject device was safe and effective under the proposed conditions of use. The Medical Device Dispute Resolution Panel, which provides another avenue to resolve disagreements between sponsors and the agency, has also addressed issues related to the least burdensome requirements. Since the panel was created following FDAMA in 1997, medical device sponsors have requested that FDA resolve three disagreements through this avenue, each related to PMAs. Although not tracked by FDA, at our request, officials reviewed the records and found that one of the three disputes was related to the least burdensome requirements. Specifically, for a September 2001 dispute, FDA officials said the sponsor requested the panel after FDA initially found that the data from the clinical study submitted by the sponsor did not sufficiently support effectiveness. After reviewing evidence from the applicant and from FDA, the dispute resolution panel determined that the sponsor had provided sufficient evidence to prove effectiveness, and the device was ultimately approved. FDA officials indicated that training specific to the least burdensome requirements was held in the years following the enactment of FDAMA in 1997. FDA was unable to provide records of that training, including its content. However, officials told us that the training was specific to the least burdensome requirements and offered from 1997 through 1999. FDA officials said the agency offered other presentations in subsequent years that they said covered similar least burdensome topics. For example, the agency provided slides from a presentation created in 2000 that provided an overview of FDA’s implementation of the requirements. Although FDA officials told us this least burdensome specific training was not offered after 1999, they identified various other trainings that they said incorporated the least burdensome concept. For example, a 2005 presentation on clinical trial design has multiple slides on least burdensome requirements, and specifically states that a course objective is to “understand how least burdensome principles apply.” Least burdensome requirements are also mentioned in other training materials where they may not be the focus—for example one slide of a presentation on biomarkers included a mention of least burdensome requirements. Officials also identified the training program for new reviewers that FDA implemented in 2011 as a source of training on least burdensome principles. Specifically, the Reviewer Certification Program is a training curriculum that FDA has required most new device reviewers to complete since 2011. The training curriculum covers a wide variety of courses on topics related to a reviewer’s responsibilities. While none of these courses is specific to the least burdensome requirements, there are courses covering related topics. For example, there is one course on technical writing that includes FDA’s guidance on developing deficiencies with least burdensome principles. Five other courses on different topics mention either the least burdensome requirements or related principles, such as a course on FDA’s legislative history that included a slide identifying the least burdensome statutory provisions as an element of FDAMA, though the slide did not explain the least burdensome requirements or provide additional context. Of the 490 staff assigned to review PMAs and 510(k)s, FDA indicated that as of the end of calendar year 2016, 335 had completed the Reviewer Certification Program, 150 started working on premarket submissions prior to the beginning of 2011, and the remaining 5 individuals did not complete the training for varying reasons. In response to the 21st Century Cures Act, enacted in December 2016, FDA is providing mandatory online training specific to the least burdensome requirements. FDA indicated that the training focuses on key behaviors that reflect the least burdensome approaches as documented in updated guidance that FDA issued in September 2017. FDA officials told us that, as of October 31, 2017, 91 percent of CDRH staff had received the new least burdensome specific training. In addition to the online training, FDA plans other activities, such as follow-up office-level briefings to address questions or concerns and an introductory podcast from the CDRH director. In addition to providing this training to current employees, FDA plans to incorporate least burdensome requirement training into new employee orientation and the Reviewer Certification Program, and plans to include ongoing support and promotion of least burdensome principles through a center working group on the least burdensome requirements. In addition to course-based training, FDA officials told us that least burdensome concepts are conveyed to reviewers through mentoring. Officials explained that much of the training on the least burdensome requirements occurs through mentoring and conversations with supervisors, and that those encounters are not documented. While FDA has not had processes in place to evaluate its medical device training, it is implementing such processes for all training, including courses related to the least burdensome requirements. In its June 2014 report, the contractor performing the independent evaluation noted that CDRH did not have mechanisms in place to measure the quality and effectiveness of its training programs. The report noted that FDA should identify metrics and incorporate methods to better assess review process training satisfaction, learning, and staff behavior changes. FDA officials explained that while they had customer reaction evaluations for trainings for at least 24 years, they started evaluating training participant learning with the Reviewer Certification Program starting in 2010. FDA is in the process of implementing a training evaluation model, which includes various levels of evaluation, from assessing participant response to the training to evaluating its impact on the agency. As of 2017, FDA reported it was evaluating training programs to determine participant learning and preparing to evaluate whether that learning changed participant behavior. Officials told us they anticipate beginning to conduct evaluations that assess agency impact in fiscal year 2018, and they plan to have the model completely implemented for all trainings by fiscal year 2020. FDA currently evaluates its Reviewer Certification Program to determine participant learning, and though the least burdensome requirements are not specifically addressed in the Reviewer Certification Program evaluation materials FDA provided to us, they did include questions on topics related to least burdensome requirements. In addition to its current training evaluation plan, FDA is also required by the 21st Century Cures Act to conduct an audit of the training and its effectiveness in implementing the least burdensome requirements. Specifically, the training audit is to be conducted by the ombudsman responsible for premarket reviews, identified by FDA as the CDRH Ombudsman. According to a draft plan, FDA plans to conduct training evaluations, a process review of 510(k) and PMA documentation to assess reviewer compliance with FDA procedures, and seek feedback from industry on its experience with the premarket review process and how the least burdensome requirements are applied. Officials indicated that criteria are still under development and that they hoped to have them further developed in the first quarter of 2018, with the authorizing legislation requiring completion of the audit by June 2018, 18 months after enactment of the law. Some stakeholders and others have raised concerns about the consistency and clarity of FDA’s requests for additional information during medical device reviews. For the past 17 years, FDA has required reviewers to only request information that is necessary to make a PMA determination of “reasonable assurance of safety and effectiveness” or a 510(k) determination of “substantial equivalence” in their review of a submission. Representatives of one of the organizations representing the medical device industry noted the high percentages of medical device submissions that involve a letter, and some of their member companies have said that FDA reviewers may request additional information as a result of intellectual curiosity rather than a “need to know.” In addition, the independent assessment’s 2014 report, funded by FDA as part of MDUFA III, found inconsistent decision-making among FDA review staff throughout various stages of the review process, including additional information requests. While the 2014 report did not address least burdensome requirements explicitly, it examined related processes. For example, according to the report, there was inconsistent decision-making among FDA review staff throughout various stages of the review process, including a lack of clarity regarding FDA reviewer thresholds for triggering deficiency letters. The report recommended that FDA develop criteria and establish mechanisms to improve consistency in decision-making throughout the review process. To address problems identified during the independent assessment, FDA is implementing several initiatives to improve center processes. FDA officials told us that, in anticipation of MDUFA IV, they recognized a need for a dedicated quality management infrastructure. In 2014, FDA established a Quality Management Unit to improve center processes, which they said would include those related to the least burdensome requirements. The unit completed a framework that outlined its vision and mission and established organizational objectives, such as developing a document control system, providing training, and conducting quality assessments, audits, and management reviews. In addition, FDA officials told us that starting in October 2017, FDA planned to fulfill its MDUFA IV commitments to improve the clarity and consistency of its deficiency letters and AI letters after releasing updated guidance. In September 2017, FDA published guidance reflecting the commitments under MDUFA IV that all deficiency letters and AI letters include a statement indicating the specific basis for any cited deficiencies. According to FDA officials, this new approach will help ensure that the letters more consistently ground requests for information in the specific reason that FDA is requesting the information from the sponsor. For example, FDA may cite a law, final rule, or specific scientific issue as the basis for its request, rather than providing a more general statement of the request’s relevance. According to industry representatives, in the past, FDA reviewers have, at times, asked for additional information without including justification, and may have requested additional information as a result of intellectual curiosity rather than a “need to know.” The representatives stated that this new policy may better ensure the reviewers apply the least burdensome approach to their review. The updated guidance also explains that all deficiency letters and AI letters will undergo supervisory review prior to issuance to ensure that the information requested is relevant to a marketing authorization decision, all four elements of the deficiency are included, deficiencies are prioritized from most to least significant, and each deficiency is appropriate to include in light of the totality of all deficiencies. Officials told us that while supervisory concurrence was previously needed, under the new guidance, supervisors are now expected to review for certain criteria. For example, in the past, supervisors may have considered whether four-part harmony was addressed in each deficiency letter, but under the updated guidance this is now an expected practice. Officials said this will increase the extent to which deficiency letters are consistently constructed. In the MDUFA IV commitment letter, FDA agreed to base all deficiency letters and AI letters on a complete review of the submission and include all deficiencies. Therefore, FDA officials told us that any deficiencies identified following that letter would generally be limited to issues raised as a result of new information. For example, if FDA asked for information on bio-compatibility testing, FDA will first review that information, and based on that review may ask for new information. In that instance, the information responding to the initial deficiency is new information. FDA officials said that past letters should also have included all deficiencies, but this may have been done inconsistently. To further standardize its process for reviewing medical device submissions and developing requests for additional information, FDA is developing and implementing smart templates. FDA officials told us that these templates guide device reviewers through a standardized process for each submission. For example, they help reviewers identify the types of information necessary and include prewritten deficiency letters that have been approved by internal experts. FDA has had a smart template in place for the 510(k) process since 2013, according to FDA reports. FDA indicated that the template is already required for certain offices and divisions within CDRH, and plans for full adoption in the future. FDA officials told us that the agency also developed templates for de novo premarket submissions, which are currently available for voluntary use and will likely be mandatory in fiscal year 2018. Officials told us they plan to hire a person to develop a template to guide PMA reviews, which will likely take most of 2018. They told us the use of the smart template for PMAS will likely become mandatory for use by all reviewers in 2019. In addition to improving the consistency of deficiency letters, FDA officials said the information generated from the templates could be used to track deficiencies and requests for additional information, as well as provide information on the number and type of deficiencies in the letters. FDA officials told us that the plans for database and back-end analytical capabilities using information from the smart templates were less certain and dependent on available resources, and they pointed out that the information technology infrastructure can present unforeseen challenges. FDA has not established performance metrics that would allow it to evaluate its implementation of the least burdensome provisions. FDA officials told us that the agency does not track concerns related to the least burdensome requirements, such as by examining dispute data to identify those that may be related. According to FDA’s 2002 guidance, the agency was in the process of developing tools to be used by both agency staff and its stakeholders to periodically assess the implementation of the least burdensome requirements. The FDA guidance identified a need for additional tools to accurately assess the agency’s incorporation of the least burdensome principles into its various regulatory activities and to assess the impact of the least burdensome approach on expediting the development of new medical technologies. Agency officials told us FDA had not developed these tools, but was now in the process of making other tools available. For example, they cited the development of the smart templates that will guide reviewers as they evaluate medical device submissions and generate deficiency letters. Officials noted that, given the scientific nature of the inquiry, and because least burdensome is a general principle, developing a metric specific to the least burdensome requirements is a challenge. While this can be a challenge, FDA officials have noted that they are attempting to identify surrogate measures that can provide an indication that the reviewer considered the least burdensome requirements when making a request. According to federal standards for internal control, performance metrics are important for management to have relevant, reliable, and timely information available for management decision–making and external reporting purposes. Without such a metric, FDA may be asking medical device sponsors to provide information unnecessarily or in less efficient ways that are not in compliance with the requirement to use the least burdensome approach to medical device reviews. FDA is in the process of developing an audit program that could provide it with information on its implementation of the least burdensome requirements. FDA has committed to conducting annual quality audits, which will be led by CDRH’s Quality Management Unit. Accordingly, FDA plans to identify, with industry input, areas to audit at least once per year. Initially, the agency has agreed to complete an audit of deficiency letters and pre-submissions by the end of fiscal year 2020. As of August 2017, FDA was still planning the deficiency letters audit, and developing its methodology and identifying audit outcomes. FDA officials told us the agency plans to finalize a deficiency letters audit plan by the spring of 2018 and begin data collection by early summer of 2018. Officials explained that the audit will focus on processes—for example, the audit will not examine the scientific content of deficiency letters but will instead focus on whether CDRH has followed existing policies and procedures surrounding deficiency letters. In addition, the Quality Management Unit was still in the process of hiring most of its staff. As of August 2017, FDA officials told us the unit had 6 staff reporting to an Associate Director, and CDRH plans to gradually hire 20 more staff by 2020, starting once MDUFA IV funds are available beginning in October 2017. In addition to these more specific efforts, FDA also plans to continue its overall evaluation of the medical device review process. The 2016 independent assessment resulting from MDUFA III broadly evaluated FDA’s device review process, and although it mentioned least burdensome requirements only briefly, it addressed a number of related elements, including the quality of the review process and staff training. Under MDUFA IV, FDA committed to another independent assessment in two phases: (1) an evaluation of FDA’s implementation of the corrective action plan FDA developed in response to the MDUFA III assessment and (2) an evaluation of FDA’s premarket device review program to identify efficiencies that should be realized as a result of the process improvements and investments under MDUFA III and IV, among other things. As with the prior assessment, the new assessment will likely examine processes related to the least burdensome requirements, though the extent to which it will address the requirements is not yet known. Agency officials told us that FDA has committed to hiring a contractor by the end of December 2017. FDA must balance the need to obtain sufficient data to determine the safety and effectiveness of medical devices under review, with the potential for undue burden and approval delays if unnecessary data is requested. Assuring that the agency uses the least burdensome method to complete its review helps to ensure it is able to make decisions about medical device approval in a timely way. While FDA implemented guidance and training related to the least burdensome requirements following the passage of FDAMA in 1997, it has taken few steps to develop performance metrics to evaluate the extent to which reviewers are using a least burdensome approach when reviewing medical device submissions. Recently, FDA implemented several changes that have the potential to improve its oversight of the least burdensome requirements and the clarity with which reviewers communicate the need for additional information. While planned audits of FDA’s medical device review process have the potential to provide the agency with evaluation tools through which to assess performance, these audits are still early in their development and the extent to which they will allow FDA to assess implementation of the least burdensome requirements is unclear. A complete and thorough assessment will be important for the agency to assure itself and external stakeholders that its reviews adhere to the least burdensome principles and requirements and thus are appropriately balanced. We are making the following recommendation to FDA: The Commissioner of FDA should develop performance metrics and use them to evaluate the implementation of the least burdensome requirements, such as during its planned audits of medical device deficiency letters. (Recommendation 1) We provided a draft of this report to HHS. HHS concurred with our recommendation and provided written comments, which are reprinted in appendix I. In its written comments, HHS agreed that appropriate implementation of the least burdensome requirements is essential to FDA’s evaluation of its PMA and 510(k) medical device submissions, and agreed that it is important for FDA to evaluate how successfully it is implementing the requirements. HHS also reiterated FDA’s commitment to the least burdensome principles and provided an overview of its related efforts, several of which were noted in our draft report. HHS noted its concern that our draft report did not sufficiently capture all of FDA’s efforts. While HHS cited FDA’s efforts related to improving the science underlying its regulatory decisions, which could reduce burden on medical device sponsors, our review focused on the steps involved in FDA’s review process. In this regard, HHS concurred with our recommendation that it develop performance metrics and use them to evaluate the implementation of the least burdensome requirements, such as during its planned audits of medical device deficiency letters. In response to this recommendation, HHS indicated that FDA intends to assess how it follows least burdensome requirements as part of these audits. We continue to encourage FDA to develop the evaluation tools necessary to ensure it conducts a complete and thorough assessment of its implementation of the least burdensome requirements. In addition to these general comments, HHS provided technical comments, which we incorporated as appropriate. As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies of this report to the Secretary of Health and Human Services and other interested parties. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or crossem@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made major contributions to this report are listed in appendix II. In addition to the contact above, William Hadley (Assistant Director), Matthew Byer (Analyst-in-Charge), Luke Baron, and William Garrard made key contributions to this report. Also contributing were Sam Amrhein and Jennifer Rudisill.

Summary: Determining that a new medical device is safe and effective is a substantial investment of time and resources for the sponsor and FDA, the agency that regulates medical devices. FDA relies on the device sponsor to provide supporting data at the time of its original submission, and the agency can request additional information during the review. The Federal Food, Drug, and Cosmetic Act, as amended, requires that when FDA requests additional information from sponsors, the agency consider the least burdensome means of evaluating a medical device. GAO was asked to provide information on FDA's implementation of the least burdensome requirements in its medical device review process. This report (1) describes FDA's requests for additional information and sponsor disagreements, (2) describes its least burdensome training efforts, and (3) describes FDA actions to improve its requests for additional information and examines the extent to which it has evaluated its implementation of the least burdensome requirements. GAO reviewed FDA documents and guidance and interviewed agency officials. GAO also interviewed officials from four relevant medical device manufacturing associations. Since 1997, the Food and Drug Administration (FDA) has been required to consider the least burdensome means of evaluating certain types of medical devices for marketing, including when requesting that sponsors—generally manufacturers—seeking to market their medical devices provide information in addition to what was provided in their submissions. GAO found that, from 2001 through 2016, FDA issued letters asking sponsors to provide such information for a majority of the more than 62,000 medical device submissions that it reviewed. Sponsors may formally disagree with the request on the grounds that it is not the least burdensome method needed for FDA to review the submission. For example, sponsors appealed FDA decisions internally to agency management 63 times from 2013 through 2016, and of these, FDA identified 33 such appeals in which the sponsor raised an issue related to least burdensome requirements. FDA agreed or partially agreed with the sponsors in 11 of these appeals. Medical device industry representatives noted that these appeals may not fully represent the number of such disagreements, because applicants are generally concerned that an appeal would damage their relationship with FDA and potentially negatively affect future device applications. FDA provided staff training that was specifically dedicated to addressing the least burdensome requirements from 1997 through 1999. Since 1999, FDA has not offered a course dedicated to the least burdensome requirements, but has incorporated related concepts into other training programs, such as in a training mandatory for most new reviewers. In response to the 21st Century Cures Act, enacted in 2016, FDA is providing new least burdensome training to all relevant employees, and said that 80 percent had received the training as of October 2, 2017. Although FDA did not specifically evaluate the effectiveness of past training on least burdensome requirements, it is implementing an evaluation of all device-related training, including the new least burdensome training. It also plans to complete a required audit of training on least burdensome requirements by June 2018. FDA has not specifically evaluated implementation of the least burdensome requirements. However, in response to broader evaluations, such as an independent assessment of its medical device review process, the agency is in the early stages of developing processes that may improve its requests for additional information. For example, FDA plans to conduct an audit of letters requesting additional information. FDA is developing the audit's methodology and expects it will assess whether the agency's process was followed. However, due to their early stage, the extent to which these efforts will allow FDA to assess implementation of the least burdensome requirements is unclear. In 2002, FDA stated that it planned to periodically assess the implementation of the least burdensome principles, and federal internal control standards identify the importance of performance metrics for such assessments. However, the agency has yet to develop performance metrics to do so. Until such measures are developed and used, FDA will not be able to evaluate whether it effectively and consistently applies a least burdensome approach in its medical device reviews. GAO is making one recommendation that FDA develop and use performance metrics to evaluate the implementation of the least burdensome requirements. The Department of Health and Human Services agreed with GAO's recommendation.