FDA pre-market notification submission for medical devices.

510k Electronic Submission Guidance for FDA 510k Submissions

This is an overview of the updated 510k electronic submission guidance document that the FDA released on October 2, 2023.

What’s included in the 510k electronic submission guidance?

As with any FDA guidance, there is an introduction and background regarding the reason for the updated guidance document (i.e., eSTAR guidance). At the very beginning of the document (i.e., page 3) the reference to the RTA Guidance was deleted, because there is no longer an RTA screening process with the implementation of the FDA eSTAR templates. The updated guidance explains on page 6 that “The CDRH Portal will automatically verify that the eSTAR is complete, and therefore we do not expect to receive incomplete 510(k) eSTARs.” In the scope section, the FDA specifies that this document is specific to 510k submissions using the eSTAR template. The document also explains that CBER conducted a pilot with the eSTAR template in June 2022 and now the FDA eSTAR template must be used in conjunction with the CDRH Portal for submission of a 510k to CBER. The FDA has plans to release a similar De Novo submission guidance for using the eSTAR template, but this has not happened in the year since the FDA announced the intention to do so. In the “Significant Terminology” section of the guidance (i.e., Section IV), the FDA provides definitions for each of the different types of submissions: eCopy, eSubmitter, etc. In the “Current Electronic Submission Template Structure, Format, and Use” section of the guidance (i.e., Section V), the FDA modified the term used for the company that is applying for 510k clearance from “Submitter” to “Applicant,” because sometimes a regulatory consultant or 3rd party reviewer is submitting the 510k on behalf of the applicant. On page 12 of the updated guidance, the FDA added “Withdrawal requests” to the list of 510k submissions/information that is exempt from the 510k electronic submission requirements. In the next to last section of the electronic submission guidance, the FDA provides a table outlining all of the sections of the new eSTAR template. The table is reproduced later in this article. If you are interested in a tutorial on completing each section outlined in the table, we recommend purchasing Medical Device Academy’s 510(k) Course. The last section of the eSTAR guidance indicates the timing for compliance with the updated guidance (i.e., October 1, 2023).

Revisions to the FDA eSubmissions Guidance 10 2 2023 1024x620 510k Electronic Submission Guidance for FDA 510k Submissions

What is the deadline for compliance with the guidance?

The deadline has now passed. The new eSTAR template must be used for all 510k and De Novo submissions as of October 1, 2023. You must upload the new FDA eSTAR submissions using the CDRH Portal. You will need to request an account using a registration hyperlink.

What’s missing from this 510k submission guidance?

The updated 510k electronic submission guidance does not provide information regarding the receipt date for electronic submissions made through the new customer collaboration portal (CCP) created by CDRH. The image below is a screen capture of the current CCP upload webpage. It includes the following statement, “Send your submission before 16:00 ET on a business day for us to process it the same day.” This statement was added sometime in August or September, but the FDA has not released a detailed explanation. This statement makes it clear that the FDA is not promising to process a submission the “same day” if the submission is received after 4:00 p.m. ET. However, “processed” does not have the same meaning as “receipt date.”

Another element missing from this updated guidance is a reference to human factors documentation. For any devices that have a user interface that is different from the predicate device, and for software devices, the FDA requires documentation of your human factors process to make sure that differences in the user interface do not result in new or different risks when compared to the predicate device. The 2016 FDA guidance for human factors has not been updated, but FDA reviewers continue to issue deficiencies related to the objective evidence provided in a 510k for human factors validation.

CCP screen capture 1024x619 510k Electronic Submission Guidance for FDA 510k Submissions

The FDA must be consistent in the wording for “Hours for Receipt of Submission” because this affects submissions at the end of the fiscal year, but it also affects any submissions with a deadline for response to an RTA Hold, AI Response, and IDE submissions. The CDER and CBER divisions of the FDA address the need for defining the date of receipt in a guidance document specific to this topic, “Providing Regulatory Submissions in Electronic Format–Receipt Date.” Below is a screen capture copied from page 4 of the guidance.

Electronic Submission 510k Electronic Submission Guidance for FDA 510k Submissions

Another element missing from this new guidance is a reference to human factors documentation. For any devices that have a user interface that is different from the predicate device, and for software devices, the FDA requires documentation of your human factors process to make sure that differences in the user interface do not result in new or different risks when compared to the predicate device. The 2016 FDA guidance for human factors has not been updated, but FDA reviewers continue to issue deficiencies related to the objective evidence provided in a 510k for human factors validation.

What are the new sections for a 510k submission?

In 2019, the FDA released a guidance document on the “Format of Traditional and Abbreviated 510(k)s.” That guidance outlines the 20 sections of a traditional 510k submission that have been used for decades. However, the new 510k electronic submission guidance has no numbering for the sections of the eSTAR template, and there are 22 sections instead of 20 sections. Several of the new sections are elements of the current FDA submission cover sheet (i.e., FDA Form 3514), and some sections exist in the 2019 guidance that were eliminated, such as: “Class III Summary and Certification.” Therefore, Medical Device Academy is recreating 100% of our 510k training webinars to explain how our 510k templates are used with the 510k eSTAR template and how to fill in the PDF form. To prevent confusion between the two formats, we are using letters for each section in the eSTAR template instead of numbers (i.e., A-V instead of 1-20). Table 1 from the new eSTAR guidance is reproduced below for your information.

Information Requested Description
A Submission Type Identification of key information that may be useful to FDA in the initial processing and review of the 510(k) submission, including content from current Form FDA 3514, Section A.
B Cover Letter / Letters of Reference Attach a cover letter and any documents that refer to other submissions.
C Submitter Information Information on submitter and correspondent, if applicable, consistent with content from current Form FDA 3514, Sections B and C.
D Pre-Submission Correspondence & Previous Regulator Interaction Information on prior submissions for the same device included in the current submission, such as submission numbers for a prior not substantially equivalent (NSE) determination, prior deleted or withdrawn 510(k), Q-Submission, Investigational Device Exemption (IDE) application, premarket approval (PMA) application, humanitarian device exemption (HDE) application, or De Novo classification request.
E Consensus Standards Identification of voluntary consensus standard(s) used, if applicable. This includes both FDA-recognized and nonrecognized consensus standards.
F Device Description Identification of listing number if listed with FDA.Descriptive information for the device, including a description of the technological characteristics of the device including materials, design, energy source, and other device features, as defined in section 513(i)(1)(B) of the FD&C Act and 21 CFR 807.100(b)(2)(ii)(A). Descriptive information also includes a description of the principle of operation for achieving the intended effect and the proposed conditions of use, such as surgical technique for implants; anatomical location of use; user interface; how the device interacts with other devices; and/or how the device interacts with the patient.

Information on whether the device is intended to be marketed with accessories.

Identification of any applicable device-specific guidance document(s) or special controls for the device type as provided in a special controls document (or alternative measures identified that provide at least an equivalent assurance of safety and effectiveness) or in a device-specific classification regulation, and/or performance standards. See “The 510(k) Program: Evaluating Substantial Equivalence in Premarket Notifications [510(k)].

G Proposed Indications for Use (Form FDA 3881) Identification of the proposed indications for use of the device. The term indications for use, as defined in 21 CFR 814.20(b)(3)(i), describes the disease or condition the device will diagnose, treat, prevent, cure, or mitigate, including a description of the patient population for which the device is intended.
H Classification Identification of the classification regulation number that seems most appropriate for the subject device, as applicable.
I Predicates and Substantial Equivalence Identification of a predicate device (e.g., 510(k) number, De Novo number, reclassified PMA number, classification regulation reference, if exempt and limitations to exemption are exceeded, or statement that the predicate is a preamendments device).The submission should include a comparison of the predicate and subject device and a discussion why any differences between the subject and predicate do not impact safety and effectiveness [see section 513(i)(1)(A) of the FD&C Act and 21 CFR 807.87(f)]. A reference device should also be included in the discussion, if applicable. See “The 510(k) Program: Evaluating Substantial Equivalence in Premarket Notifications [510(k)].
J Design/Special Controls, Risks to Health, and Mitigation Measures Applicable to Special 510(k) submissions only.Identification of the device changes and the risk analysis method(s) used to assess the impact of the change(s) on the device and the results of the analysis.

Risk control measures to mitigate identified risks (e.g., labeling, verification). See “The Special 510(k) Program.

K Labeling Submission of proposed labeling in sufficient detail to satisfy the requirements of 21 CFR 807.87(e). Generally, if the device is an in vitro diagnostic device, the labeling must also satisfy the requirements of 21 CFR 809.10. Additionally, the term “labeling” generally includes the device label, instructions for use, and any patient labeling. See “Guidance on Medical Device Patient Labeling.
L Reprocessing Information for assessing the reprocessing validation and labeling, if applicable. See “Reprocessing Medical Devices in Health Care Settings: Validation Methods and Labeling.
M Sterility Information on sterility and validation methods, if applicable. See “Submission and Review of Sterility Information in Premarket Notification (510(k)) Submissions for Devices Labeled as Sterile.
N Shelf Life Summary of methods used to establish that device performance is maintained for the entirety of the proposed shelf-life (e.g., mechanical properties, coating integrity, pH, osmolality), if applicable.
O Biocompatibility Information on the biocompatibility assessment of patient contacting materials, if applicable. See “Use of International Standard ISO 10993-1, ‘Biological evaluation of medical devices – Part 1: Evaluation and testing within a risk management process.’”
P Software/Firmware Submission of applicable software documentation, if applicable. See “Guidance for the Content of Premarket Submissions for Software Contained in Medical Devices.
Q Cybersecurity/Interoperability Submission of applicable information regarding the assessment of cybersecurity, if applicable. See “Content for Premarket Submissions for Management of Cybersecurity in Medical Devices” and “Design Considerations and Premarket Submission Recommendations for Interoperable Medical Devices.
R Electromagnetic Compatibility (EMC), Electrical, Mechanical, Wireless and Thermal Safety Submission of the EMC, Electrical, Mechanical, Wireless and Thermal Safety testing for your device or summarize why testing is not needed. See “Electromagnetic Compatibility (EMC) of Medical Devices” and “Radio Frequency Wireless Technology in Medical Devices.
S Performance Testing For non-in vitro diagnostic devices: Provide information on the non-clinical and clinical test reports submitted, referenced, or relied on in the 510(k) for a determination of substantial equivalence. See “Recommended Content and Format of NonClinical Bench Performance Testing Information in Premarket Submissions.”For in vitro diagnostic devices: Provide analytical performance, comparison studies, reference range/expected values, and clinical study information.
T References Inclusion of any literature references, if applicable.
U Administrative Documentation Inclusion of additional administrative forms applicable to the submission, including but not limited to a general summary of submission/executive summary (recommended), a Truthful and Accuracy Statement, and a 510(k) Summary or statement.
V Amendment/Additional Information (AI) response Inclusion of responses to Additional Information requests.

Important information in the eSTAR guidance

In Table 1 above, there are 14 hyperlinks to various FDA guidance documents. These links are extremely helpful when you have questions about a specific question. Unfortunately, the 510k electronic submission guidance document will quickly become out-of-date as guidance documents are updated and made obsolete. In particular, one of the A-list final guidance documents that was planned for FY 2023 was the FDA cybersecurity guidance. The updated cybersecurity guidance was finally released last week.

Predicate selection guidance proposes controversial additions

The FDA released a new draft 510k predicate selection guidance on September 7, but the draft guidance proposes controversial additions.

Draft Guidance on Predicate Selection Best Practices 1024x664 Predicate selection guidance proposes controversial additions
Download the Draft FDA Predicate Selection Guidance

On September 7, 2023, a draft predicate selection guidance document was released by the FDA. Normally the release of a new draft of FDA guidance documents is anticipated and there is an obvious need for the draft. This new draft, however, appears to include some controversial additions that I feel should be removed from the guidance. This specific guidance was developed to help submitters use best practices in selecting a predicate. There is some useful advice regarding the need to review the FDA database for evidence of use-related and design-related safety issues associated with a potential predicate that is being considered. Unfortunately, the last section of the guidance suggests some controversial recommendations that I strongly disagree with.

Please submit comments to the FDA regarding this draft guidance

This guidance is a draft. Your comments and feedback to the FDA will have an impact on FDA policy. We are preparing a redlined draft of the guidance with specific comments and recommended changes. We will make the comments and feedback available for download from our website on our predicate selection webinar page. We are also creating a download button for the original draft in Word (.docx) format, and sharing the FDA instructions for how to respond.

Section 1 – Introduction to the guidance

The FDA indicates that this new draft predicate selection guidance document was created to provide recommendations to implement four (4) best practices when selecting a predicate device to support a 510k submission. This first objective is something that our consulting firm recommended in a training webinar. The guidance indicates that the guidance was also created by the FDA in an attempt to improve the predictability, consistency, and transparency of the 510k pre-market review process. This second objective is not accomplished by the draft guidance and needs to be modified before the guidance is released as a final guidance.

Section 2 – Background

This section of the guidance is divided into two parts: A) The 510k Process, and B) 510k Modernization.

A. The 510k Process

The FDA released a Substantial Equivalence guidance document that explains how to demonstrate substantial equivalence. The guidance document includes a new decision tree that summarizes each of the six questions that 510k reviewers are required to answer in the process of evaluating your 510k submission for substantial equivalence. The evidence of substantial equivalence must be summarized in the Predicates and Substantial Equivalence section of the FDA eSTAR template in your 510k submission, and the guidance document reviews the content that should be provided.

Substantial equivalence is evaluated against a predicate device or multiple predicates. To be considered substantially equivalent, the subject device of your 510k submission must have the same intended use AND the same technological characteristics as the predicate device. Therefore, you cannot use two different predicates if one predicate has the same intended use (but different technological characteristics), and the second predicate has the same technological characteristics (but a different intended use). That’s called a “split predicate,” and that term is defined in the guidance This does not prohibit you from using a secondary predicate, but you must meet the requirements of this guidance document to receive 510k clearance. The guidance document reviews five examples of multiple predicates being used correctly to demonstrate substantial equivalence.

B. 510k Modernization

The second part of this section refers to the FDA’s Safety Action Plan issued in April 2018. The announcement of the Safety Action Plan is connected with the FDA’s announcement of actions to modernize the 510k process as well. The goals of the FDA Safety Action Plan consist of:

  1. Establish a robust medical device patient safety net in the United States
  2. Explore regulatory options to streamline and modernize timely implementation of postmarket mitigations
  3. Spur innovation towards safer medical devices
  4. Advance medical device cybersecurity
  5. Integrate the Center for Devices and Radiological Health’s (CDRH’s) premarket and postmarket offices and activities to advance the use of a TPLC approach to device safety 

Examples of modernization efforts include the following:

  • Conversion of the remaining Class 3 devices that were designated for the 510k clearance pathway to the PMA approval process instead
  • Use of objective performance standards when bringing new technology to the market
  • Use of more modern predicate devices (i.e., < 10 years old)

In this draft predicate selection guidance, the FDA states that feedback submitted to the docket in 2019 has persuaded the FDA to acknowledge that focusing only on modern predicate devices may not result in optimal safety and effectiveness. Therefore, the FDA is now proposing the approach of encouraging best practices in predicate selection. In addition, the draft guidance proposes increased transparency by identifying the characteristics of technological characteristics used to support a 510k submission.

Section 3 – Scope of the predicate selection guidance

The draft predicate selection guidance indicates that the scope of the guidance is to be used in conjunction with the FDA’s 510k program guidance. The scope is also not intended to change to applicable statutory or regulatory standards. 

Section 4 – How to use the FDA’s predicate selection guidance

The FDA’s intended use of the predicate selection guidance is to provide submitters with a tool to help them during the predicate selection process. This guidance suggests a specific process for predicate selection. First, the submitter should identify all of the possible legally marketed devices that also have similar indications for use. Second, the submitter should exclude any devices with different technological characteristics if the differences raise new or different issues of risk. The remaining sub-group is referred to in the guidance as “valid predicate device(s).” The third, and final, step of the selection process is to use the four (4) best practices for predicate selection proposed in the guidance. The diagram below provides a visual depiction of the terminology introduced in this guidance.

Visual diagram of terminology in predicate selection guidance 1024x438 Predicate selection guidance proposes controversial additions

Section 5 – Best Practices (for predicate selection)

The FDA predicate selection guidance has four (4) best practices recommended for submitters to use when narrowing their list of valid predicate devices to a final potential predicate(s). Prior to using these best practices, you need to create a list of legally marketed devices that could be potential predicates. The following FDA Databases are the most common sources for generating a list of legally marketed devices:

  • Registration & Listing Database
    • Trade names of similar devices (i.e., proprietary name)
    • Manufacturer(s) of similar devices (i.e., owner operator name)
  • 510k Database
    • 510k number of similar devices
    • Applicant Name (i.e., owner operator name) of similar devices
    • Device Name (i.e., trade name) of similar device
  • Device Classification Database
    • Device classification name of similar devices
    • Product Code of similar devices
    • Regulation Number of similar devices

Our team usually uses the Basil Systems Regulatory Database to perform our searches. Basil Systems uses data downloaded directly from the FDA, but the software gives us four advantages over the FDA public databases:

  1. The search engine uses a natural-language algorithm rather than a Boolean search.
  2. The database is much faster than the FDA databases.
  3. The results include analytics regarding the review timelines and a “predicate tree.”
  4. Basil Systems also has a post-market surveillance database that includes all of the FDA adverse events and recall data, but it also includes access to data from Health Canada and the Australian TGA.

A. Predicate devices cleared using well-established methods

Some 510k submissions use the same methods used by a predicate device that was used for their substantial equivalence comparison, while other devices use well-established methods. The reason for this may have been that the 510k submission preceded the release of an FDA product-specific, special controls guidance document. In other cases, the FDA may not have recognized an international standard for the device classification. You can search for recognized international standards associated with a specific device classification by using the FDA’s recognized consensus standards database. An example is provided below.

How to search for FLL recognized standards 1024x712 Predicate selection guidance proposes controversial additions

FLL recognized standards 1024x577 Predicate selection guidance proposes controversial additions

New 510k submissions should always use the methods identified in FDA guidance documents and refer to recognized international standards instead of copying the methods used to support older 510k submissions that predate the current FDA guidance or recognized standards. The problem with the FDA’s proposed approach is that the FDA is implying that a device that was not tested to the current FDA guidance or recognized standards is inherently not as safe or effective as another device that was tested to the current FDA guidance or recognized standards. This inference may not be true. Therefore, even though this may be a consideration, it is not appropriate to require manufacturers to include this as a predicate selection criterion. The FDA is already taking this into account by requiring companies to comply with the current FDA guidance and recognized standards for device description, labeling, non-clinical performance testing, and other performance testing. An example of how the FDA PreSTAR automatically notifies you of the appropriate FDA special controls guidance for a product classification is provided below.

Screen capture of PreSTAR classification section 1024x792 Predicate selection guidance proposes controversial additions

B. Predicate devices meet or exceed expected safety and performance

This best practice identified in the FDA predicate selection guidance recommends that you search through three different FDA databases to identify any reported injury, deaths, or malfunctions of the predicate device. Those three databases are:

  1. MAUDE Database
  2. MDR Database
  3. MedSun Database

All of these databases are helpful, but there are also problems associated with each database. In general, adverse events are underreported, and a more thorough review of post-market surveillance review is needed to accurately assess the safety and performance of any device. The MAUDE data represents reports of adverse events involving medical devices and it is updated weekly. The data consists of all voluntary reports since June 1993, user facility reports since 1991, distributor reports since 1993, and manufacturer reports since August 1996. The MDR Data is no longer updated, but the MDR database allows you to search the CDRH database information on medical devices that may have malfunctioned or caused a death or serious injury during the years 1992 through 1996. Medical Product Safety Network (MedSun) is an adverse event reporting program launched in 2002 by CDRH. The primary goal for MedSun is to work collaboratively with the clinical community to identify, understand, and solve problems with the use of medical devices. The FDA predicate selection guidance, however, does not mention the Total Product Life Cycle (TPLC) database which is a more efficient way to search all of the FDA databases–including the recall database and the 510k database.

The biggest problem with this best practice as a basis for selecting a predicate is that the number of adverse events depends upon the number of devices used each year. For a small manufacturer, the number of adverse events will be very small because there are very few devices in use. For a larger manufacturer, the number of adverse events will be larger–even though it may represent less than 0.1% of sales. Finally, not all companies report adverse events when they are required to, while some companies may over-report adverse events. None of these possibilities is taken into consideration in the FDA’s draft predicate selection guidance.

C. Predicate devices without unmitigated use-related or design-related safety issues

For the third best practice, the FDA predicate selection guidance recommends that submitters search the Medical Device Safety database and CBER Safety & Availability (Biologics) database to identify any “emerging signals” that may indicate a new causal association between a device and an adverse event(s). As with all of the FDA database searches, this information is useful as an input to the design process, because it helps to identify known hazards associated with similar devices. However, a more thorough review of post-market surveillance review is needed to accurately assess the safety and performance of any device–including searching databases from other countries where similar devices are marketed.

D. Predicate devices without an associated design-related recall

For the fourth best practice, the FDA predicate selection guidance recommends that submitters search the FDA recalls database. As stated above, the TPLC database includes this information for each product classification. Of the four best practices recommended by the FDA, any predicate device that was to a design-related recall is unlikely to be accepted by the FDA as a suitable predicate device. Therefore, this search should be conducted during the design planning phase or while design inputs are being identified. If you are unable to identify another predicate device that was not the subject of a design-related recall, then you should request a pre-submission meeting with the FDA and provide a justification for the use of the predicate device that was recalled. Your justification will need to include an explanation of the risk controls that were implemented to prevent a similar malfunction or use error with your device. Often recalls result from quality problems associated with a supplier that did not make a product to specifications or some other non-conformity associated with the assembly, test, packaging, or labeling of a device. None of these problems should automatically exclude the use of a predicate because they are not specific to the design.

Section 6 – Improving Transparency

This section of the FDA predicate selection guidance contains the most controversial recommendations. The FDA is proposing that the 510k summary in 510k submissions should include a narrative explaining their selection of the predicate device(s) used to support the 510k clearance. This would be a new requirement for the completion of a 510k summary because that information is not currently included in 510k summaries. The new FDA eSTAR has the ability to automatically generate a 510k summary as part of the submission (see example below), but the 510k summary generated by the eSTAR does not include a section for including a narrative explaining the reasons for predicate selection.

Sections of the 510k summary that are automatically populated in the eSTAR 1024x544 Predicate selection guidance proposes controversial additions

The FDA added this section to the draft guidance with the goals of improving the predictability, consistency, and transparency of the 510k pre-market review process. However, the proposed addition of a narrative explaining the reasons for predicate selection is not the best way to achieve those goals. Transparency is best achieved by eliminating the option of a 510k statement (i.e., 21 CFR 807.93). Currently, the 510k process allows for submitters to provide a 510k statement or a 510k summary. The 510k statement prevents the public from gaining access to any of the information that would be provided in a 510k summary. Therefore, if the narrative explaining the reasons for predicate selection is going to be required in a 510k submission, that new requirement should be added to the substantial equivalence section of the eSTAR instead of only including it in the 510k summary. If the 510k statement is eliminated as an option for submitters, then all submitters will be required to provide a 510k summary and the explanation for the predicate selection can be copied from a text box in the substantial equivalence section.

The FDA eSTAR ensures consistency of the 510k submission contents and format, and tracking of FDA performance has improved the consistency of the FDA 510k review process. Adding an explanation for predicate selection will not impact either of these goals for improving the 510k process. In addition, companies do not select predicates only for the reasons indicated in this FDA predicate selection guidance. One of the most common reasons for selecting a predicate is the cost of purchasing samples of predicate devices for side-by-side performance testing. This only relates to cost, not safety or performance, and forcing companies to purchase more expensive devices for testing would not align with the least burdensome approach. Another flaw in this proposed additional information to be included in the 510k summary is that there is a huge variation in the number of predicates that can be selected for different product classifications. For example, 319 devices were cleared in the past 10 years for the FLL product classification (i.e., clinical electronic thermometer), while 35 devices were cleared in the past 10 years for the LCX product classification (i.e., pregnancy test). Therefore, the approach to selecting a predicate for these two product classifications would be significantly different due to the number of valid predicates to choose from. This makes it very difficult to create a predictable or consistent process for predicate selection across all product classifications. There may also be confidential, strategic reasons for predicate selection that would not be appropriate for a 510k summary.

Section 7 – Examples

The FDA predicate selection guidance provides three examples. In each example, the FDA is suggesting that the submitter should provide a table that lists the valid predicate devices and compare those devices in a table using the four best practices as criteria for the final selection. The FDA is positioning this as providing more transparency to the public, but this information presented in the way the FDA is presenting it would not be useful to the public. This is creating more documentation for companies to submit to the FDA without making devices safer or improving efficacy. This approach would be a change in the required content of a 510k summary and introduce post-market data as criteria for 510k clearance. This is a significant deviation from the current FDA policy.

Example 1 from predicate selection guidance

In this example, the submitter included a table in their 510k submission, along with their rationale for selecting one of the four potential predicates as the predicate device used to support their 510k submission. This example is the most concerning because the summary doesn’t have any details regarding the volume of sales for the potential predicates being evaluated. The number of adverse events and recalls is usually correlated with the volume of sales. The proposed table doesn’t account for this information.

Example 2 from predicate selection guidance

In this example, the submitter was only able to identify one potential, valid predicate device. The submitter provided a table showing that the predicate did not present concerns for three of the four best practices, but the predicate was the subject of a design-related recall. The submitter also explained the measures taken to reduce the risk of those safety concerns in the subject device. As stated above, using the occurrence of a recall as the basis for excluding a predicate is not necessarily appropriate. Most recalls are initiated due to reasons other than the design. Therefore, you need to make sure that the reason for the recall is design-related rather than a quality system compliance issue or a vendor quality issue.

Example 3 from predicate selection guidance

In this example, the submitter identified two potential, valid predicate devices. No safety concerns were identified using any of the four best practices, but the two potential devices have different market histories. One device has 15 years of history, and the second device has three years of history. The submitter chose the device with 15 years of history because the subject device had a longer regulatory history. The problem with this approach is that years since clearance is not an indication of regulatory history. A device can be cleared in 2008, but it might not be launched commercially until several years later. In addition, the number of devices used may be quite small for a small company. In contrast, if the product with three years since the 510k clearance is distributed by a major medical device company, there may be thousands of devices in use every year. 

Medical Device Academy’s recommendations for predicate selection

The following information consists of recommendations our consulting firm provides to clients regarding predicate selection.

Try to use only one predicate (i.e., a primary predicate)

Once you have narrowed down a list of predicates, we generally recommend only using one of the options as a primary predicate and avoiding the use of a second predicate unless absolutely necessary. If you are unsure of whether a second predicate or reference device is needed, this is an excellent question to ask the FDA during a pre-submission teleconference under the topic of “regulatory strategy” (see image below). In your PreSTAR you can ask the following question, “[Your company name] is proposing to use [primary predicate] as a primary predicate. A) Does the FDA have any concerns with the predicate selection? B) Does the FDA feel that a secondary predicate or reference device is needed?”

PreSTAR Topic Selection 1024x330 Predicate selection guidance proposes controversial additions

When and how to use multiple predicates

Recently a client questioned me about the use of a secondary predicate in a 510k submission that I was preparing. They were under the impression that only one predicate was allowed for a 510k submission because the FDA considers the two predicate devices to be a “split predicate.” The video provided above explains the definition of a “split predicate,” and the definition refers to more than the use of two predicates. For many of the 510k submissions, we prepared and obtained clearance for used secondary predicates. An even more common strategy is to use a second device as a reference device. The second device may only have technological characteristics in common with the subject device, but the methods of safety and performance testing used can be adopted as objective performance standards for your 510k submission.

When you are trying to use multiple predicate devices to demonstrate substantial equivalence to your subject device in a 510k submission, you have three options for the correct use of multiple predicate devices:

  1. Two predicates with different technological characteristics, but the same intended use.
  2. A device with more than one intended use.
  3. A device with more than one indication under the same intended use.

If you use “option 1”, then your subject device must have the technological characteristics of both predicate devices. For example, your device has Bluetooth capability, and it uses infrared technology to measure temperature, while one of the two predicates has Bluetooth but uses a thermistor, and the other predicate uses infrared measurement but does not have Bluetooth.

If you use “option 2”, you are combining the features of two different devices into one device. For example, one predicate device is used to measure temperature, and the other predicate device is used to measure blood pressure. Your device, however, can perform both functions. You might have chosen another multi-parameter monitor on the market as your predicate, however, you may not be able to do that if none of the multi-parameter monitors have the same combination of intended uses and technological characteristics. This scenario is quite common when a new technology is introduced for monitoring, and none of the multi-parameter monitors are using the new technology yet.

If you use “option 3”, you need to be careful that the ability of your subject device to be used for a second indication does not compromise the performance of the device for the first indication. For example, bone fixation plates are designed for the fixation of bone fractures. If the first indication is for long bones, and the second indication is for small bones in the wrist, the size and strength of the bone fixation plate may not be adequate for long bones, or the device may be too large for the wrist.

What is MDUFA V?

MDUFA V is the agreement between the FDA and the medical device industry to fund the review of medical device submissions by the FDA.

What is MDUFA V?

The Medical Device User Fee and Modernization Act (MDUFMA or MDUFA) is a set of agreements between the Food and Drug Administration (FDA) and the medical device industry to provide funds for the Office of Device Evaluations (ODE) to review medical device submissions. FDA user fees were first authorized via MDUFMA in 2002 for FY 2003. Each MDUFA reauthorization has lasted five years, and FY 2023 will be the 21st year.

How are the MDUFA V user fees decided?

Section 738A(b)(1) of the FD&C Act requires that the FDA consult with various stakeholders, including representatives from patient and consumer advocacy groups, healthcare professionals, and scientific and academic experts, to develop recommendations for the next MDUFA five-year cycle. The FDA initiated the reauthorization process by holding a public meeting on October 27, 2020, where stakeholders and other public members could present their views on the reauthorization. The following is a list of the four industry groups represented in the MDUFA V negotiations with the FDA:

The FD&C Act further requires that the FDA continue meeting with the representatives of patient and consumer advocacy groups at least once every month during negotiations with the regulated industry to continue discussing stakeholder views on the reauthorization and their suggestions for changes.

What are FDA user fees?

At the very core of it, the FDA user fees fund the FDA Office of Device Evaluation (ODE) budget. Without these user fees, the FDA cannot begin reviewing a medical device submission. This includes 510k, PMA, and De Novo submissions. Before the FDA assigns a reviewer to your submission, you must pay the appropriate device user fee in full unless eligible for a waiver or exemption. If you pay the user fee by credit card, you must allow a few extra days for the user fee to clear. Otherwise, your submission will be placed on “User Fee Hold.” Small businesses may qualify for a reduced fee. The FDA announced the FY 2024 FDA User Fees on July 28, 2023. The FDA will announce the user fees for FY 2025 in a Federal Register notice next August 2024.

When does MDUFA V take effect?

Our team regularly checked the announcement of the MDUFA V user fees from August until the October 5, 2022 announcement. The announcement of the FY 2023 user fees was delayed because Congress did not approve the MDUFA reauthorization until the last week of September. The new user fees were initially expected to take effect on October 1, 2022, but the announcement of actual user fees for 2022 was announced on October 5, 2022. This was two months later than expected.

Why was MDUFA V delayed, and will it happen again?

MDUFA V was delayed because the user fee reauthorization requires an act of Congress. The House of Representatives approved the Food and Drug Amendments of 2022 on June 8, 2022. However, the Senate did not file a bill until after the August recess. There were also differences between the legislation the House and the Senate proposed. Therefore, to ensure that the FDA did not have to furlough employees when MDUFA IV funding expired, the President approved and signed a temporary reauthorization on September 30, 2022. The short-term continuing resolution is a temporary stopgap to fund the FDA until December 16, 2022. However, the continuing resolution covers funding for medical device user fees through September 30, 2027. Therefore, the device industry can expect the FDA to continue to operate regardless of the outcome of temporary policies that expire this December. Still, similar delays occurred with previous MDUFA reauthorization, and we expect more of the same US partisan politics between August 2027 and the November 2027 election.

How much did MDUFA V user fees increase?

The increase is dependent upon the fee type. Annual registration fees are increasing by 14.47% (i.e., $5,672 to $6,493). The MDUFA V user fees increased by a stupendous amount (+55.90%) from $12,745 to $19,870 for the 510k user fees. Yikes! De Novo Classification Requests increased by 17.79% from $112,457 to $132,464. Other submissions increased by similar amounts. For more details, check out the table below (also posted on our homepage).

20190810 075548 300x225 What is MDUFA V?
FDA User Fee FY 2023 represents a 55.90% increase in the 510(k) user fee

FY 2024 User Fees 1024x568 What is MDUFA V?

Do user fees ever decrease?

If we lived in a magical world where gas prices dropped and stayed low, the inflation-adjusted pricing would decrease for FDA user fees. That has happened once, but I fit into skinny jeans once too. The increase in FDA user fees from FY 2023 to FY 2024 was 9.5%, except the Annual Registration Fee, which increased by 17.87% to $7,653.

Why is August 1st important?

August 1st is the first day the FDA accepts Small Business Certification Requests for the new fiscal year. That means any small business that wants to keep small business status needs to reapply, and any new business that qualifies for small business status must also apply. The importance of applying for small business status is how much you could save on your submission. The FDA will complete its review of the Small Business Certification Request within 60 calendar days of receipt. Upon completion of the review by the FDA, the FDA will send you a decision letter with your small business designation number or a justification for denial.

Does small business status expire?

Yes, small business status expires. The small business status expires on September 30 of the fiscal year it is granted. A new MDUFA Small Business Certification Request must be submitted and approved each fiscal year to qualify as a small business. If you forget to reapply for small business status on August 1, you can reapply anytime during the year. Still, you will temporarily lose small business status from October 1 until the qualification is renewed. The good news is there is no fee associated with submitting a Small Business Certification Request. For more information, please visit our webpage dedicated to small business qualifications.

FDA Pre-Submission Format and Content Requirements

The format and content requirements for an FDA pre-submission have not changed, but the launch of the FDA PreSTAR has changed everything.

What is an FDA pre-submission?

An FDA pre-submission aims to get answers to questions you have about a future FDA submission. The pre-submission may consist of one large PDF document or multiple PDF documents. In your pre-submission, you must select either an email response or an email response with a teleconference. One advantage of choosing a teleconference is that you can ask clarifying questions during a one-hour teleconference with the FDA, but you are responsible for submitting draft meeting minutes to the FDA within 15 days of the teleconference. If you select an email response, you do not need to provide meeting minutes to the FDA.

On July 5, 2023, we are kicking off our new 4-part FDA pre-submission webinar series. This will be the Ultimate FDA pre-submission training. Do not miss it.

Register Now for 299 300x129 FDA Pre Submission Format and Content Requirements

Everyone asks us for examples, so in this webinar series, we will be showing you how to complete the entire FDA PreSTAR for a device. If you would like to vote on which device we should use as an example (i.e., Option 1 = Infrared Thermometer or Option 2 = Antimicrobial Gauze), please place your vote on our LinkedIn page.

What is the difference between an FDA pre-submission and a Q-submission?

Every FDA pre-submission is a Q-submission, but not all Q-submissions are pre-submissions. The new PreSTAR template is currently limited to an FDA pre-submission, but the template will be expanded to other types of Q-subs later. The FDA pre-submission template (i.e., PreSTAR) beta version 0.1 is unnecessary for responses to interactive review questions from the FDA. Just email the Lead Reviewer (file size limit is 25 MB for email).

No SIRs 1024x342 FDA Pre Submission Format and Content Requirements

Unfortunately, the beta version 0.1 is also not ready for Submission-in-Review (SIR) meetings or responses to IDE during an interactive review.No SIRs or IDEs 1024x390 FDA Pre Submission Format and Content Requirements

13 other types of submissions might benefit from Q-submissions:

  1. Submission Issue Requests (SIRs)
  2. Study Risk Determinations
  3. Informational Meetings
  4. Breakthrough Device Designation Requests
  5. Informational Meetings
  6. PMA Day 100 meetings
  7. Agreement and Determination meetings
  8. Submissions associated with the STeP program
  9. Accessory classification requests
  10. Requests for FDA feedback on specific questions or cross-cutting policy matters
  11. Requests for recognition of publicly accessible genetic variant databases
  12. Combination product agreement meetings (CPAM), and
  13. Feedback on FDA 483 inspection observations.

We expect the PreSTAR template to eventually be available for a 513(g) request in the future because it was already validated for that purpose.

What is the Q-submission number?

All Q-submissions are assigned a document number beginning with “Q” upon receipt (i.e., Qyyxxxx). The format of the number consists of 2-digits (i.e., “yy”) for the year of submission (e.g., “23” for 2023) and 4-digits (i.e., “xxxx”) that are the following sequential number assigned by the FDA for that calendar year. Therefore, the first Q-submission received by the FDA in January 2023 is Q230001, and between 3,500 and 4,000 new submissions are usually received each year. If the subject device was submitted in a previous Q-submission, the original document number is re-used, and a supplement number is added (i.e., Qyyxxx/S001, Qyyxxx/S002, etc.). Q-submission numbering is explained in more detail in the 2023 FDA guidance.

Does the FDA charge for Q-submissions?

FDA pre-submissions do not require paying an FDA User Fee (i.e., $0).

How long does an FDA pre-submission take?

The days of squishing timelines are gone. The timeline is 70-75 calendar days. On October 5, 2022, MDUFA V was approved. As one of the MDUFA V decision targets, the FDA is tasked with reducing the timeline for responding to pre-sub questions within 70 days for 90% of pre-sub requests. The FDA is tasked with achieving this goal by March 2024. If they are successful, the FDA will receive an increase of 59 headcounts to their budget in 2024. This is approximately a $19 million incentive to respond to your pre-submission meeting questions within 70 days. To reflect these new MDUFA V decision targets, the FDA updated the Q-Sub guidance document to reflect the target date of 70 days for the email response and 75 days for teleconference meetings. The FDA also updated the Customer Collaboration Portal (CCP) to facilitate tracking of FDA pre-submission deadlines.

What is an FDA PreSTAR?

In the past, you had to create your own document(s) for an FDA pre-submission. Some people create one large PDF document divided into sections, while others create separate PDF documents for each requirement of the FDA pre-submission guidance. On June 6, 2023, the FDA released a beta version (i.e., version 0.1) of a new PDF template (i.e., FDA PreSTAR). This new PreSTAR template provides multiple benefits to the FDA:

  1. every company uses the same format,
  2. the template automatically verifies that the pre-submission includes all required elements, and
  3. the inclusion of optional elements will encourage companies to provide more device details than they might otherwise provide.

The PreSTAR also benefits submitters:

  1. you will never forget the required elements of the FDA pre-submission,
  2. you never have to validate an FDA eCopy, and
  3. the similar format and user interface will train you to use the FDA eSTAR.

Note: October 1, 2023, is the FDA eSTAR implementation deadline. 

Do you have to use the PreSTAR template?

Nope. The PreSTAR version 0.1 is a beta version and 100% optional. However, I like it better than my own templates. Your design team can still have individual documents for the user manual, device description, and testing plan. We attach the document using the button that says “Add Attachment” (see screen capture below).

Device Description screen capture for prestar 1024x576 FDA Pre Submission Format and Content Requirements

The PreSTAR template was built by Patrick Macatangga, a Tools & Templates Engineer working at the FDA on the Lifecycle Tools and Templates Team. To help with where to direct questions about the template, he suggested:

  • If you have questions or feedback regarding the voluntary use of the eSTAR for medical devices regulated by CDRH, or if you have general questions about medical devices, please contact the Division of Industry and Consumer Education (DICE).
  • If you find any malfunctions or errors in the eSTAR template for medical devices regulated by CDRH, please contact eSubPilot@fda.hhs.gov.
  • If you have questions regarding 510(k)s, De Novo requests, or Early Submission Requests for medical devices regulated by CDRH, please contact OPEQSubmissionSupport@fda.hhs.gov.

How do you submit an eCopy?

You can submit an FDA eCopy on electronic media (e.g., USB flash drive) and send it via FedEx to the FDA Document Center at the following address: Food and Drug Administration, Center for Devices and Radiological Health, Document Mail Center, 10903 New Hampshire Ave., Bldg. 66, rm. G609, Silver Spring, MD 20993-0002. However, you can also submit an FDA eCopy via a web browser (i.e., CCP…see next section on how to submit a PreSTAR).

If you are submitting an eCopy through the CCP instead of an FDA PreSTAR

How do you submit a PreSTAR?

You have two options for delivery of an FDA pre-submission:

  1. save the pre-sub on electronic media (e.g., USB flash drive) and send it via FedEx to the FDA, and
  2. upload the pre-sub to the new FDA Customer Collaboration Portal (CCP).

As you can guess from the video above, we are only using option 2 for FDA pre-submissions. For option 2, you can upload an eCopy (saved as a zip file) or a PreSTAR (in the native PDF format). The image below shows you how this is done, but the uploading process usually takes about one minute–depending on your file size and bandwidth. You can register for your own CCP account in seconds.

estar and eCopy upload 1024x485 FDA Pre Submission Format and Content Requirements

What is the pre-submission process?

Preparing and uploading your FDA pre-submission meeting request is only the first step of the process. You will receive an automated email confirming that your pre-submission was successfully uploaded, and then you will receive an automated letter via email that gives you the Q-sub number that was assigned. You will also receive an automated email notifying you that the pre-submission was accepted, or the FDA reviewer will contact you if changes are needed. The FDA reviewer assigned will usually contact you by email within the first three weeks to schedule a teleconference if you requested one, but the date/time offered usually does not match the availability of the FDA team, and alternate dates/times may be offered.

You will receive an email response from the FDA for each of your questions within 70 days of receipt by the FDA. If you requested a teleconference, it would typically be about 75 after receipt of the FDA pre-submission meeting request. Your team needs to prepare a detailed discussion plan for the one-hour teleconference. A slide deck is highly recommended to facilitate communication but is not required. If you provide a slide deck, you should email it to the reviewer in advance of the meeting. You will also need to provide a copy of the slide deck with your meeting minutes. At the beginning of the teleconference, someone from your team must commit to submitting draft meeting minutes to the FDA within 15 days. The FDA will reply with acceptance of your meeting minutes, or they will provide an edited version. It is also common to submit a supplement FDA pre-submission with detailed protocols and new questions for the FDA.

Reuqest a call with Lindsey 1024x240 FDA Pre Submission Format and Content Requirements

Artificial Intelligence and Machine Learning Medical Devices

The FDA released a new draft guidance document about artificial intelligence and machine learning (AI/ML) functions in medical devices.

What is a predetermined change control plan for artificial intelligence (AI) software?

The new FDA guidance is specific to predetermined change control plans for marketing submissions. The guidance was released on March 30, 2023, but the document is dated April 3, 2023. The draft guidance applies to artificial intelligence (AI) or Machine Learning-Enabled Device Software Functions (ML-DSF), including modifications automatically implemented by the software and modifications to the models implemented manually.

New Artificial Intelligence PCCP Guidance Document 1024x857 Artificial Intelligence and Machine Learning Medical Devices

A PCCP must be authorized through 510k, De Novo, or PMA pathways, as appropriate. The purpose of including a PCCP in a marketing submission is to seek premarket authorization for these intended device modifications without necessitating additional marketing submissions for each change described in the PCCP.

How do you determine if a 510k is required for a device modification, and how would a PCCP affect this?

Currently, there are three guidance documents relating to the evaluation of changes and determination if a new premarket submission is required:

These guidance documents will still be the first steps in evaluating changes. Only changes specific to artificial intelligence (AI) or ML-DSF that would result in a new pre-market submission could be subject to a PCCP.

Examples of Employing AI/ML-DSF PCCPs

  • Retraining a model with more data to improve device performance while maintaining or increasing sensitivity. If this type of change is pre-approved in the PCCP, the labeling can be updated to reflect the improved performance once the change has been implemented. 
  • Extending the scope of compatible hardware with a device system. For example, if the algorithm was initially trained using one specific camera, ultrasound, defined parameter, etc., then a PCCP could add additional cameras/ultrasounds/modified parameters. 
  • Retraining a model to optimize site-specific performance for a specific subset of patients with a particular condition for whom sufficient data was unavailable. The PCCP could expand the indications once such data were available.

What is the difference between a locked vs. adaptive algorithm?

A locked algorithm is a software function involving human input, action, review, and/or decision-making before implementation. Once the algorithm is designed and implemented, it cannot be changed without modifying the source code.

Locked algorithms contrast with adaptive/automatic algorithms, where the software will implement changes without human intervention. The adaptive/automatic algorithms are designed to adjust according to changing input conditions. The adaptive/automatic algorithm is designed to recognize patterns in the input data and adjust its processing accordingly.

Typically locked algorithms apply to fixed functions such as a decision tree, static look-up table, or complex classifier. For AI/ML-DSF, manually implemented algorithms may involve training the algorithm on a new dataset or serving a new function. Once the training is complete, the algorithm will be implemented into the software. Adaptive algorithms are programmed such that their behavior changes over time as it is run based on the information it processes.

As it relates to a PCCP, the detailed description of the intended modifications needs to specify which algorithm type is being modified.

What is included in a PCCP for artificial intelligence (AI) software?

A PCCP should consist of:

  • Detailed Description of Intended Modifications
  • Modification Protocol describing the verification and validation activities, including pre-defined acceptance criteria
  • Impact Assessment identifying the benefits and risks introduced by the changes

The detailed description of the intended modifications should list each proposed device modification and the rationale for each change. If changes require labeling modifications, that should also be described. It should also be clearly stated whether or not the proposed change is intended to be implemented automatically or manually. The description should describe whether the change will be implemented globally across all devices on the market or locally, specific to different devices based on the unique characteristics of the device’s patient or clinical site.

The types of modifications that are appropriate for a PCCP include modifications related to quantitative measurements of ML-DSF performance specifications, changes related to device inputs, and limited modifications relating to the device’s use and performance. The draft guidance provides some examples of each of those modification types. 

The content of the modification protocol section requires a description of planned data management practices relating to the reference standard and annotation process, a description of re-training practices and processing steps, performance evaluation methods and acceptance criteria, and internal procedures for implementing updates. 

The impact assessment is the documentation of the evaluation of the benefits and risks of implementing the PCCP for the software. Any controls or mitigations of the risks should be described in this section. 

Appendix A of the draft guidance includes example elements of modification protocol components for ML-DSFs. Appendix B includes examples of ML-DSF scenarios employing PCCPs.

If, at some point, the manufacturer wants to make changes to the content of the PCCP relating to either the modifications described or the methods used to validate those changes, that generally would require a new marketing submission for the device. 

Utilizing a PCCP in your QMS Change Control System

When evaluating and implementing changes, the manufacturer shall do so in accordance with their Quality Management System change control processes. This should require a review of planned modifications against the FDA guidance documents for evaluating changes and the PCCP. For the change to be acceptable under the PCCP, it must be specified in the Description of Modifications and implemented in conformance with the methods and specifications described in the Modification Protocol. A new premarket submission is required if it does not meet those requirements.

How quickly will RTA policy take effect for cybersecurity devices?

Breaking news! The FDA just released new guidance on the refusal to accept (RTA) policy for cybersecurity devices.

Picture of new FDA guidance on RTA policy for cybersecurity devices 838x1024 How quickly will RTA policy take effect for cybersecurity devices?

Where can I find the new cybersecurity devices guidance?

The new guidance is titled “Cybersecurity in Medical Devices: Refuse to Accept Policy for Cyber Devices and Related Systems Under Section 524B of the FD&C Act,” and you can download a copy of the PDF directly from our website. This is the first time the FDA has created a definition for a “cyber device,” but this guidance is specific to the refusal to accept policy (RTA) rather than guidance for the format and content of pre-market notification (i.e., 510k) If you want to learn about new guidance documents as they are released, we recommend that you sign up for FDA email notifications. If you want to be notified of when our new blogs are posted, subscribe to our blog email notification list on this page.

What is a “cyber device” in the context of this cybersecurity devices guidance and submissions?

This new guidance defines “cyber device” using the following language:

  1. includes software validated, installed, or authorized by the sponsor as a device or in a device;
  2. has the ability to connect to the internet; and
  3. contains any such technological characteristics validated, installed, or authorized by the sponsor that could be vulnerable to cybersecurity threats.

What does “refusal to accept” (RTA) mean?

“Refusal to accept” or (RTA) is a policy that the FDA implemented for pre-market notification submissions (i.e., 510k) in 2012. The process occurs during the first 15 calendar days of the FDA review process. The FDA assigns a preliminary reviewer to perform the RTA screening of the submission, and the person completes an RTA checklist. The FDA substitutes an RTA screening with a technical screening for FDA eSTAR templates, and this is one of the reasons why Medical Device Academy uses the FDA eSTAR templates for all 510k submissions and De Novo classification requests instead of using the older 510k format and content requirements with 20 sections.

When will the FDA begin rejecting submissions during the RTA processes?

The FDA states directly in the guidance document that they will not reject submissions for cybersecurity for the balance of FY 2023 (i.e., before October 1, 2023). The wording used by the FDA is: “The FDA generally intends not to issue “refuse to accept” (RTA) decisions for premarket submissions for cyber devices that are submitted before October 1, 2023, based solely on information required by section 524B of the FD&C Act. Instead, the FDA will work collaboratively with sponsors of such premarket submissions as part of the interactive and/or deficiency review process.” We believe the FDA will update the eSTAR template to include requirements for cybersecurity on October 1, 2023. It will not be possible to submit a 510k that does not include the cybersecurity requirements in future eSTAR templates, because the eSTAR automatically verifies the completion of each section in the template.

Will there be another cybersecurity guidance released soon?

The FDA announced last October that a new cybersecurity guidance would be replacing the 2014 final guidance for cybersecurity. A draft was released in 2018, and an updated draft was released in 2022. The final updated guidance is included in the A-list of FDA priorities for final guidance documents, but the updated final version has not been released yet. The FDA webpage for cybersecurity was updated to include this new guidance on RTA policy for cybersecurity devices. We believe this indicates that the updated final version will be released soon. When it is released, we will publish a new blog about that guidance.

Regulatory pathway analysis–a case study

This article uses a case study example to explain how to determine the correct regulatory pathway for your medical device through the US FDA.

Regulatory Pathway 1 Regulatory pathway analysis  a case study
How do you select the right regulatory pathway for your device?

Every consultant likes to answer this type of question with the answer, “It depends.” Well, of course, it depends. If there was only one answer, you could google that question, and you wouldn’t need to pay a regulatory consultant to answer the question. A more useful response is to start by asking five qualifying questions:

  1. Does your product meet the definition of a device?
  2. What is the intended purpose of your product?
  3. How many people in the USA need your product annually?
  4. Is there a similar product already on the market?
  5. What are the risks associated with your product?

The first question is important because some products are not regulated as medical devices. If your product does not diagnose, treat, or monitor a medical condition, then your product may not be a device. For example, the product might be considered a general wellness product or clinical decision support software.  In addition, some products have a systemic mode of action, and these products are typically categorized as a drug rather than a device–even if the product includes a needle and syringe.

The intended purpose of a product is the primary method used by the US FDA to determine how a product is regulated. This also determines which group within the FDA is responsible for reviewing a submission for your product. The US regulations use the term “intended use” of a device, but the decision is based upon the “indications for use” which are more specific. To understand the difference, we created a video explaining the difference.

Even regulatory consultants sometimes forget to ask how many people need your product annually, but population size determines the regulatory pathway. Any intended patient population less than 8,000 patients annually in the USA is eligible for a humanitarian device exemption with a special regulatory pathway and pricing constraints. If your product is intended for a population of <8,000 people annually, your device could qualify for a humanitarian device exemption, and the market is small enough that there may not be any similar products on the market.

If similar products are already on the US market, determining the regulatory pathway is much easier. We can look up the competitor product(s) in the FDA’s registration and listing database. In most cases, you must follow the same pathway your competitors took, and the FDA database will tell us your regulatory pathway.

If all of the products on the US market have different indications for use, or the technological characteristics of your product are different from other devices, then you need to categorize your product’s risks. For low-risk devices, general controls may be adequate. For medium-risk devices, special controls are required by the FDA. For the highest-risk devices, the FDA usually requires a clinical study, a panel review of your clinical data, and the FDA requires pre-market approval.

This article will use the example of bipolar forceps used with an electrosurgical generator as a case study.

Bipolar Forceps Regulatory pathway analysis  a case study

What is the US FDA regulatory pathway for your device?

The generic term used for regulator authorization is “approval,” but the US FDA reserves this term for Class 3 devices with a Premarket Approval (PMA) submission. The reason for this is that only these submissions include a panel review of clinical data to support the safety and effectiveness of the device. Approval is limited to ~30 devices each year, and approximately 1,000 devices have been approved through the PMA process since 1976 when the US FDA first began regulating medical devices.

Most Class 2 devices are submitted to the FDA as Premarket Notifications or 510k submissions. This process is referred to as “510k clearance,” because clinical data is usually not required with this submission and there is no panel review of safety and effectiveness data. A 510k was originally planned as a rare pathway that would only be used by devices that are copies of other devices that are already sold on the market. However, the 510k pathway became the defacto regulatory pathway for 95+% of devices that are sold in the USA.

For moderate and high-risk devices that are intended for rare patient populations (i.e., <8,000 patients per year in the USA), the humanitarian device exemption process is the regulatory pathway.

Class 1 devices typically do not require a 510k submission, most of these devices are exempt from design controls, and some are exempt from quality system requirements. These devices still require listing on the FDA registration and listing database, but there is no review of the device by the FDA to ensure you have correctly classified and labeled Class 1 devices.

How do you find a predicate for your 510k submission?

As stated above, one of the most critical questions is, “Is there a similar product already on the market?” For our example of bipolar forceps, the answer is “yes.” There are approximately 169 bipolar forceps that have been 510k cleared by the FDA since 1976. If you are developing new bipolar forceps, you must prepare a 510k submission. The first step of this process is to verify that a 510k submission is the correct pathway and to find a suitable competitor product to use as a “predicate” device. A predicate device is a device that meets each of the following criteria:

  1. it is legally marketing in the USA
  2. it has indications for use that are equivalent to your device
  3. the technological characteristics are equivalent to your device

There are two search strategies we use to verify the product classification of a new device and to find a suitable predicate device. The first strategy is to use the free, public databases provided by the FDA. Ideally, you instantly think of a direct competitor that sells bipolar forceps for electrosurgery in the USA (e.g., Conmed bipolar forceps). You can use the registration and listing database to find a suitable predicate in this situation. First, you type “Conmed” into the database search tool for the name of the company, and then you type “bipolar forceps” in the data search tool for the name of the device.

Registration and Listing for Conmed Bipolar Forceps 1024x443 Regulatory pathway analysis  a case study

If you are unaware of any competitor products, you will need to search using the product classification database instead. Unfortunately, this approach will result in no results if you use the terms “bipolar” or “forceps.” Therefore, you will need to be more creative and use the word “electrosurgical,” which describes a larger product classification that includes both monopolar and bipolar surgical devices that have many sizes and shapes–including bipolar forceps. The correct product classification is seventh out of 31 search results.

GEI Product code 1024x454 Regulatory pathway analysis  a case study

Listing for Conmed Specification Developer 1024x398 Regulatory pathway analysis  a case study

The most significant disadvantage of the FDA databases is that you can only search each database separately. The search is also a boolean-type search rather than using natural language algorithms that we all take for granted. The second strategy is to use a licensed database (e.g., Basil Systems).

Basil systems search for bipolar forceps 1024x427 Regulatory pathway analysis  a case study

Searching these databases is more efficient, and the software will provide additional information that the FDA website does not offer, such as a predicate tree, review time, and models listed under each 510k number are provided below:

Predicate Tree for K190909 1024x539 Regulatory pathway analysis  a case study

What does the predicate tree look like for the predicate device you selected?

Review Time for devices in the GEI product classification code 1024x452 Regulatory pathway analysis  a case study

I’m glad I don’t need to manually enter the 510k review time for 2,263 devices to create the above graph.

Conmed bipolar forceps listed under K854864 1024x323 Regulatory pathway analysis  a case study

Wouldn’t having the model numbers for every device identified in the US FDA listing database be nice?

Another advantage of the Basil Systems software is that the database is lightning-fast, while the FDA is a free government database (i.e., not quite as fast).

How do you create a regulatory pathway strategy for medical devices?

The best strategy for obtaining 510k clearance is to select a predicate device with the same indications for use that you want and was recently cleared by the FDA. Therefore, you will need to review FDA Form 3881 for each of the potential predicate devices you find for your device. In the case of the bipolar forceps, there are 169 devices to choose from, but FDA Form 3881 is not available for 100% of those devices because the FDA database only displays FDA Form 3881 and the 510(k) Summary for devices cleared since 1996. Therefore, you should select a device cleared by the FDA in the past ten years unless there are no equivalent devices with a recent clearance.

K190909 FDA Form 3881 798x1024 Regulatory pathway analysis  a case study

In addition to identifying the correct product classification code for your device and selecting a predicate device, you will also need to develop a testing plan for the verification and validation of your device. For electrosurgical devices, there is an FDA special controls guidance that defines the testing requirements and the content required for a 510k submission. Once you develop a testing plan, you should confirm that the FDA agrees with your regulatory strategy and testing plan in a pre-submission meeting.

Which type of 510k submission is required for your device?

There are three types of 510k submissions:

  1. Special 510k – 30-day review target timeline
  2. Abbreviated 510k – 90-day review target timeline (requires summary reports and use of recognized consensus standards)
  3. Traditional 510k – 90-day review target timeline

The special 510k pathway is intended for minor device modifications from the predicate device. However, this pathway is only eligible to your company if your company also submitted the predicate device. Originally it was only permitted to submit a Special 510k for modifications that require the review of one functional area. However, the FDA recently completed a pilot study evaluating if more than one functional area could be reviewed. The FDA determined that up to three functional areas could be reviewed. However, the FDA decides whether they can complete the review within 30 days or if you need to convert your Special 510k submission to a Traditional submission. Therefore, you should also discuss the submission type with the FDA in a pre-submission meeting if you are unsure whether the device modifications will allow the FDA to complete the review in 30 days.

In 2019 the FDA updated the guidance document for Abbreviated 510k submissions. However, this pathway requires that the manufacturer use recognized consensus standards for the testing, and the manufacturer must provide a summary document for each test report. The theory is that abbreviated reports require less time for the FDA to review than full test reports. However, if you do not provide sufficient information in the summary document, the FDA will place your submission on hold and request additional information. This happens for nearly 100% of abbreviated 510k submissions. Therefore, there is no clear benefit for manufacturers to take the time to write a summary for each report in the 510k submission. This also explains why less than 2% of submissions were abbreviated type in 2022.

The traditional type of 510k is the most common type of 510k submission used by manufacturers, and this is the type we recommend for all new device manufacturers.

Four easy ways 510k and De Novo content is different

It’s a common misconception that FDA De Novo content is very different from FDA 510k submission content, but is that true?

What do you think the De Novo content differences are?

Most people think the difference between a 510k and a De Novo is time and money. That conclusion is based upon a very important assumption: a 510k will not require clinical data, and a De Novo will require clinical data. That assumption is not always correct. 10-15% of 510k submissions include clinical data to support the performance claims, and last year our team submitted three De Novo submissions that did not include any clinical data. So what are the differences between a 510k and a De Novo content?

We use the same FDA eSTAR template for both types of FDA submissions, and on the first page of the eSTAR template, we identify if the submission is a 510k or De Novo. If we select De Novo, the eSTAR will be pre-populated with four unique De Novo content requirements that are not found in a 510k. The four unique requirements are:

  1. identifying alternative practices and procedures for the same indications
  2. recommending a classification, providing a justification for that classification, and explaining what efforts were taken to identify a suitable 510k product code
  3. providing a written benefit/risk analysis starting with the clinical benefits of your device
  4. recommendations for special controls for your new product code based upon the risks to health and the mitigation measures for each risk

Alternate practices and procedures 1024x547 Four easy ways 510k and De Novo content is different

What alternative practices and procedures are currently available?

The unique De Novo content requirement is to provide a description of alternative practices and procedures for treatment or diagnosis of the same indications that you are proposing for your subject device. This is a subsection of the device description section in the FDA eSTAR template. Your should description should include other 510k-cleared products, drugs, and even products that have similar indications but are not identical. The description of alternative practices and procedures must also be attached as a document in the section for benefits, risks, and mitigation measures. To maintain consistency throughout your submission, you should create the document for attachment first and copy and paste the content into the text box at the end of the device description section.

You need to recommend a classification in your De Novo

The unique De Novo content requirement is found in a section titled “Classification.” There is a shorter classification section included in 510k submissions, but the 510k version only has four cells. The first three are populated by selecting one of the options from a dropdown menu, and the fourth cell is only used if your subject device includes other product classification codes.

Classification 1024x346 Four easy ways 510k and De Novo content is different

The De Novo version of the eSTAR is identical for the first row of the classification section, but then you must select a proposed product classification (i.e., Class 1 or Class 2) in accordance with FDA Classification Procedures (i.e., 21 CFR 860). The third cell is a text box for you to enter your justification for the proposed classification. Next, the FDA requires you to enter a proposed classification name. Finally, at the end of the classification section, the FDA requires that you provide a classification summary or reference to a previous NSE 510k submission.

A Benefit/Risk Analysis is required in the De Novo Content

For new devices, the FDA uses a benefit/risk analysis to decide if a device should be authorized for marketing in the USA.  This process includes humanitarian device exemptions, De Novo applications, and Premarket Approval submissions. The FDA has a guidance document that provides guidance for FDA reviewers and the industry. The most important aspect is, to begin with, the benefits of the device and to provide a quantitative comparison of benefits and risks. Many De Novo submissions have been rejected because the submitter did not provide objective evidence of clinical benefits for the subject device.

Benefit Risk Analysis 1024x210 Four easy ways 510k and De Novo content is different

The FDA guidance documents are helpful for creating a benefit/risk analysis, but you can also find information in the ISO/TR 24971:2020–the guidance for the application of ISO 14971:2019. Our company also includes a template for a benefit/risk analysis as part of our risk management procedure (i.e., SYS-010).

What are your recommended Special Controls?

In FDA De Novo Classification Decision Summaries, there is a table provided that identifies the identified risks to health and the recommended mitigation measures for each risk category. In the FDA eSTAR, you are required to add a similar table for De Novo content. The only difference between the table in summary and the eSTAR is that the eSTAR table has a third column where the FDA wants you to reference the supporting data provided for each mitigation measure–including the document and page within the document. The FDA also provided an example table in the eSTAR, copied below.

Risk Mitigation Table Four easy ways 510k and De Novo content is different

The above table for the risks to health and mitigations needs to be translated into a list of recommended Special Controls for Class II devices. Since most De Novo applications are for Class II devices, you will need to convert each of your mitigations into a corresponding Special Control and type these controls into the text box provided in the FDA eSTAR.

Special Controls Four easy ways 510k and De Novo content is different

What else is different from a 510k?

There are no additional mandatory elements that you need to include in a De Novo application, but there are several elements of a 510k submission that are not included in a De Novo. The most obvious of these sections is the Substantial Equivalence Comparison Table in the section labeled “Predicates and Substantial Equivalence.” Another difference is that you are more likely to need clinical data to support a De Novo application than for a 510k submission. It is also possible that subsequent 510k submissions for the same product code may not need to provide clinical data because the 510k process only requires a demonstration of substantial equivalence rather than clinical benefits outweighing risks to health. The FDA review time for a Traditional 510(k) varied between 190 and 210 days in 2022, while the De Novo review timeline averaged 390 days in  2022. Finally, the FDA user fees for 510k submissions are far less than those for a De Novo application.

Best human factors questions?

Best human factors questions to ask the FDA during a pre-submission meeting, and what information content do you need in a 510k?

Best human factors questions to ask the FDA?

The FDA did not start enforcing the requirement to apply human factors and usability engineering to medical device design until 2017 because the final version of the human factors guidance document was not released until February 3, 2016. Approximately ninety percent of the human factors testing reports submitted to the FDA in 510k pre-market submissions are deficient because the 510k submission content only includes the final summative testing report. The FDA needs a complete usability engineering file, and the human factors information needs to comply with FDA guidelines for the format and content of a 510k pre-market submission–not just IEC 62366-1:2015.

What human factors information does the FDA want?

For several years, FDA submission deficiency letters indicated that you should not include the frequency of occurrence in your estimation of use-related risks, but the FDA never provided this information in a guidance document. On December 9, 2022, the FDA finally released a draft human factors guidance regarding the format and content of a 510k pre-market submission. The new draft guidance includes the requirement for a use-related risk analysis (URRA) in table 2 (copied below).

Table 2 example of tabular format for the URRA 1024x354 Best human factors questions?

In this new draft FDA guidance, the FDA identifies three different human factors submission categories. For the first category, only a conclusion and high-level summary are needed. For the second category, a user specification is also needed. For the third category, you need a comprehensive human factors engineering report with the following elements described in Section IV of the draft FDA guidance:

Submission Category 1, 2, and 3

  • Conclusion and high-level summary

Submission Category 2 and 3

  • Descriptions of intended device users, uses, use environments, and training
  • Description of the device-user interface
  • Summary of known use problems

Submission Category 3 only

  • Summary of preliminary analyses and evaluations
  • Use-related risk analysis to analyze hazards and risks associated with the use of the device
  • Identification and description of critical tasks
  • Details of validation testing of the final design

Before you spend tens of thousands or hundreds of thousands of dollars on human factors testing, you want to make sure the FDA agrees with your human factors testing plan. Otherwise, you will pay for the testing twice: once for your initial submission and a second time in your response to the FDA request for additional information to address deficiencies. Testing can cost more than your electrical safety testing. The facility needs to have the right equipment and space for the testing, you need support personnel to set up the equipment, you need to recruit participants, you need to compensate participants, and you need device samples.

When can you ask the FDA human factors questions?

The FDA cannot provide consulting advice on a submission, and the agency will not review data during pre-submission meetings. The FDA can provide feedback on protocols, specifications, and scientific justifications. Therefore, you should submit questions to the FDA in a pre-submission when you have a draft protocol, a draft specification, or a draft justification for why a task is not critical. Pre-submissions are “non-binding.” You can change your design and approach to human factors. Therefore, don’t wait until your information is 100% finalized. Share your documentation at the draft stage during the development phase and before your design freeze. You need these answers when you are planning a study and obtaining quotes. 

What are the best human factors questions to ask in a pre-sub?

In the FDA guidance for pre-submission meetings, the FDA provides suggested questions to ask:

  • Does the Agency have comments on our proposed human factors engineering process?
  • Is the attached use-related risk analysis plan adequate? Does the Agency agree that we have identified all the critical tasks?
  • Does the Agency agree with our proposed test participant recruitment plan for the human factors validation testing?

The above examples are only suggestions, but the best approach is to provide a brief example of what the human factors information will look like and ask the FDA to comment on the examples. The FDA does not have time to review data during a pre-sub meeting, but the FDA can review a few rows extracted from your URRA and comment on your proposed approach to the human factors process.

Human factors questions that are not appropriate

The FDA pre-submission guidance cautions you only to ask 3-4 questions for each meeting request because the FDA has difficulty answering more questions in a 60-minute teleconference. Therefore, you should not ask questions already answered in the FDA guidance. The new draft guidance includes examples of when a device modification can leverage existing human factors information and when new information is needed to support a premarket submission. Instead of asking a question specific to leveraging existing human factors information, instead, provide your rationale for leveraging existing data and ask if the FDA has any concerns with your overall approach to human factors.

Recommended human factors action items

Create a procedure for your human factors process that includes detailed instructions for creating the information required in a usability engineering report and templates for each document.

Software validation documentation for a medical device

Learn why you need to start with software validation documentation before you jump into software development.

When do you create software validation documentation for a medical device or IVD?

At least once a week, I speak with the founder of a new MedTech company that developed a new software application as a medical device (SaMD). The founder will ask me to explain the process for obtaining a 510(k), and they want help with software validation documentation. Many people I speak with have never even heard of IEC 62304.

Even though they already have a working application, usually, validation documentation has not even been started. Although you can create all of your software validation documentation after you create a working application, certain tasks are important to perform before you develop software code. Jumping into software development without the foundational documentation will not get your device to market faster. Instead, you will struggle to create documentation retroactively, and the process will be slower. In the end, the result will be a frustrating delay in the launch of your device.

What are the 11 software validation documents required by the FDA?

In 2005 the FDA released a guidance document outlining software validation documentation content required for a premarket submission. There were 11 documents identified in that guidance:

software validation documentation 1024x385 Software validation documentation for a medical device

What the FDA guidance fails to explain is that some of these documents need to be created before software development begins, or your software validation documentation will be missing critical design elements. Therefore, it is important to create a software development plan that schedules activities that result in those documents at the right time. In contrast, four of the eleven documents can wait until your software development is complete.

Which of the software validation documents can wait until the end?

The level of concern only determines what documents the FDA wants to review in a submission rather than what documents are needed for a design history file. In fact, the level of concern (LOC) document is no longer required as a separate document in premarket submissions using the FDA eSTAR template because the template already incorporates the questions that document your LOC. The revision level history document is simply a summary of revisions made to the software during the development process, and that document can be created manually or automatically at the end of the process, or the revision level history can be a living document that is created as changes are made. The traceability matrix can also be a living document created as changes are made, but its only purpose is to act as a tool to provide traceability from hazards to software requirements, to design specifications, and finally to verification and validation reports. Other software tools, such as Application Lifecycle Management (ALM) Software, are designed to ensure the traceability of every hazard and requirement throughout the entire development process. Finally, unresolved anomalies should only be documented at the time of submission. The list may be incomplete until all verification and validation testing is completed, and the list should be the shortest at the time of submission.

What documentation will be created near the end of development?

The software design specification (SDS) is typically a living document until your development process is completed, and you may need to update the SDS after the initial software release to add new features, maintain interoperability with software accessories, or change security controls. The SDS can not begin, however, until you have software requirements and the basic architecture defined. The verification and validation activities are discrete documents created after each revision of the SDS and must therefore be one of the last documents created–especially when provided to the FDA as a summary of the verification and validation efforts.

Which validation documents do you need first?

At the beginning of software development, you need a procedure(s) that defines your software development process. That procedure should have a section that explains the software development environment–including how patches and upgrades will be controlled and released. If you don’t have a quality system procedure that defines your development process, then each developer may document their coding and validation activities differently. That does not mean that you can’t improve or change the procedure once development has begun, but we recommend limiting the implementation of a revised procedure when making major software changes and discussing how revisions will be implemented for any work that remains in progress or has already been completed.

When do the remaining software validation documents get created?

The remaining four software validation documents required for a premarket submission to the FDA are:

  1. Software description
  2. Software hazard analysis
  3. Software requirements specification (SRS)
  4. Architecture design chart

Your development process will be iterative, and therefore, you should be building and refining these four documents iteratively in parallel with your software code. At the beginning of your project, your design plan will need a brief software description. Your initial software description needs to include the indications for use, a list of the software’s functional elements, and the elements of your user specification (i.e., intended patient population, intended users, and user interface). If you are using lean startup methodology, the first version of your device description will be limited to a minimal viable product (MVP). The target performance of the MVP should be documented as an initial software requirements specification (SRS). This initial SRS might only consist of one requirement, but the SRS will expand quickly. Next, you need to perform an initial software hazard analysis to identify the possible hazards. It is important to remember that software hazards are typically hazardous situations and are not limited to direct physical harm. For each potential hazard you identify in your hazard analysis, you will need a software requirement to address each hazard, and each requirement needs to be added to your SRS. As your software becomes more complex by adding software features, your device description needs to be updated. As you add functions and requirements to your software application, your SRS will need updates too. Finally, your development team will need a tool to track data flow and calculations from one software function to the next. That tool is your architecture design chart, and you will want to organize your SRS to match the various software modules identified in your architecture diagram. This phase is iterative and non-linear, you will always have failures, and typically a team of developers will collaborate virtually. Maintaining a current version of the four software documents is critical to keeping your development team on track.

How do you perform a software hazard analysis?

One of the most important pre-requisite tasks for software developers is conducting a hazard analysis. You can develop an algorithm before you write any code, but if you start developing your application to execute an algorithm before you perform a software hazard analysis, you will be missing critical software requirements. Software hazard analysis is different from traditional device hazard analysis because software hazards are unique to software. A traditional device hazard analysis consists of three steps: 1) answering the 37 questions in Annex A of ISO/TR 24971:2020, 2) systematically identifying hazards by using Table C1 in Annex C of ISO 14971:2019, and 3) reviewing the risks associated with previous versions of the device and similar competitor devices. A software hazard analysis will have very few hazards identified from steps 1 and 2 above. Instead, the best resource for software hazard analysis is IEC/TR 80002-1:2009. You should still use the other two standards, especially if you are developing software in a medical device (SiMD) or firmware, but IEC/TR 80002-1 has a wealth of tables that can be used to populate your initial hazards analysis and to update your hazard analysis when you add new features.

How do you document your hazard analysis?

Another key difference between a traditional hazard analysis and a software hazard analysis is how you document the hazards. Most devices use a design FMEA (dFMEA) to document hazards. The dFMEA is a bottom-up method for documenting your risk analysis by starting with device failure modes. Another tool for documenting hazards is a fault tree diagram.

Fault Tree Example from AAMI TIR 80002 1 2009 300x239 Software validation documentation for a medical device
Copied from Section from AAMI / IEC TIR 80002-1:2009

A fault tree is a top-down method for documenting your risk analysis, where you identify all of the potential causes that contribute to a specific failure mode. Fault tree diagrams lend themselves to complaint investigations because complaint investigations begin with the identification of the failure (i.e., complaint) at the top of the diagram. For software, the FDA will not allow you to use the probability of occurrence to estimate risks. Instead, software risk estimation should be limited to the severity of the potential harm. Therefore, a fault tree diagram is generally a better tool for documenting software risk analysis and organizing your list of hazards. You might even consider creating a separate fault tree diagram for each module of your software identified in the architecture diagram. This approach will also help you identify the potential impact of any software hazard by looking at the failure at the top of the fault tree. The higher the potential severity of the software failure, the more resources the software team needs to apply to developing software risk controls and verifying risk control effectiveness for the associated fault tree.

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