This article will help you ensure that you will still be able to offer laboratory developed tests (LDTs) after May 26, 2022 and will explain the three options open to you for avoiding legal disputes.
Laboratory developed tests (LDT) are a type of in vitro diagnostic test. But do regulatory requirements such as the IVDR also apply to these “in-house tests”? This article provides an overview not just for medical laboratories.
The EU legislator is regulating laboratory developed tests for the first time with EU Regulation 2017/746 on In Vitro Diagnostic Medical Devices. As a result, its requirements apply directly to laboratories that offer tests they developed themselves.
Most of these requirements are not new, but the additional requirements mean that you, as a medical laboratory, are no longer allowed to offer certain LDTs. For example, this is the case if a manufacturer offers a comparable CE-IVD device on the EU market.
What this means for you and how to avoid this problem will be explained later in this article. But first let us address the basics.
a) Definition of terms
Medical laboratories examine specimens derived from the human body: Tissue and body fluids (e.g., blood, urine, cerebrospinal fluid, etc.). To make diagnoses or to obtain information relevant for the diagnosis, laboratories use:
Accordingly, the US authority the FDA defines the term LDT as follows:
“A laboratory developed test (LDT) is a type of in vitro diagnostic test that is designed, manufactured and used within a single laboratory.”
The German Medizinproduktegesetz (MPG) calls these tests ‘in vitro diagnostic medical devices from own production.
“In vitro diagnostic medical devices from own production are in vitro diagnostic medical devices which are manufactured in the laboratories of health facilities and used in these laboratories or in their direct proximity, without being placed on the market. […]“
The IVDR calls LDTs “devices manufactured and used only within health institutions established in the Union”, but does not define the term explicitly.
LDTs, or ‘in vitro diagnostic medical devices from own production’, must themselves be differentiated from ‘medical devices from own production’. In the case of a ‘medical device from own production’, we would talk about in-house production according to Article 5(5) MDR.
Read more here on the in-house production of medical devices, the definition of the term own production, and the difference between placing on the market, parameterization and combination.
b) Where laboratory developed tests are used
Anywhere CE-IVD devices are used, LDTs can be used as an alternative. However, the IVDR limits the use of LDTs to what it calls health institutions and defines such institutions as follows:
“‘health institution’ means an organisation the primary purpose of which is the care or treatment of patients or the promotion of public health;”
Medical laboratories provide patients or the physicians treating them with medical information for a diagnosis. That is why medical laboratories can be considered health facilities according to the definition.
Each IVD test in a medical laboratory begins with a specimen being taken from the patient. Ideally, it ends with a result that is helpful for deciding on further treatment. Figure 1 shows the usual steps in an IVD test process from the taking of the specimen through to the results. CE-IVD devices or LDTs can be used for all these steps.
An LDT is not usually a self-developed product but rather a procedure that uses self-developed devices in the test sub-steps. However, it is not usually clear to the patients or the physicians treating them whether a test is carried out with an LDT or a CE-IVD device (see Figure 2).
For this reason, a medical laboratory creates an LDT when it:
If one or more of these criteria apply to your tests, the requirements in the next section apply in full to your medical laboratory.
a) Existing requirements for LDTs in Germany
Putting in vitro diagnostic medical devices from own production into service is currently only permitted according to section 12 of the MPG if the essential requirements of EU Directive 98/79/EC on In Vitro Diagnostic Medical Devices (IVDD) have been met. This means that if you offer an LDT, you must comply with Annex I of the IVDD.
Medical laboratories also have to comply with the “Richtlinie der Bundesärztekammer zur Qualitätssicherung laboratoriumsmedizinischer Untersuchungen” the Rili-BÄK for short. This is established in the Medizinprodukte-Betreiberverordnung (MPBetreibV). Alternatively, a lot of laboratories can be accredited according to the international standard ISO 15189.
Some laboratories with LDTs assume that the requirements have exploded with the IVDR. A closer look shows this is not true, because the requirements for LDTs and their operators have been around for many years, including in the MPG as well as the MPSV, MPV, MPBetreibV and, indirectly, through the reference to the essential requirements, in the IVDD as well.
b) New requirements in the IVDR:
On the one hand, the IVDR wants to continue to permit “in-house” devices without the involvement of notified bodies and without CE marking (whereas clauses 28 and 29 in the foreword section). As a result, in Article 5(5), the IVDR sets out the requirements that laboratories must meet for tests manufactured and used only(!) within health institutions. These include:
The Johner Institut supports medical laboratories in the implementation of all IVDR requirements. Contact us if you have any questions.
c) FDA requirements for laboratory developed tests
At this point, it is worth taking a look across the pond because the FDA has been considering the regulation of LDTs since at least 2010, but has not yet been able to fully enforce anything. It is aware of the risks posed by incorrect or inappropriate treatment of patients that can result from the use of insufficiently controlled “high-risk LDTs”.
The FDA no longer considers the previous “enforcement discretion” to be adequate for all LDTs.
Therefore, in 2014 the FDA published a draft “FDA Notification and Medical Device Reporting for Laboratory Developed Tests (LDT)” and collected feedback. This flowed into a “Discussion Paper” which the FDA published in January 2017.
In this document, the FDA wrote that it considers it problematic that a test developed by an IVD manufacturer is regulated differently to an identical test developed by a laboratory. This would undermine its risk-based approach. Surveillance should be risk-based and not dependent on who develops the test.
The risk-based approach and feedback that the FDA received to its “notification” led to some LDTs being exempted from the FDA's surveillance , including for example:
And other exemptions.
d) Summary of the legal requirements
Almost all requirements found in the IVDR already exist in the same or a similar way within the framework of the MPG and the associated ordinances.
Although the new Annex I of the IVDR is longer than Annex I of the IVDD, the key elements still include:
IT security is a major new requirement.
Completely new and therefore the “biggest chunk”: If there is an equivalent CE-marked IVD device on the market that has the same performance level as the in-house developed device, the CE-IVD device must be used (Article 5(5) d). In such a case, there is no longer a legal basis for the use of the device developed in-house and so the LDT can no longer be offered.
Exemptions from surveillance for certain LDTs (e.g. LDTs for the diagnosis of rare diseases), as implemented by the FDA, are currently not planned.
In Germany, the respective Land authorities are responsible for the surveillance of the laboratories. They check whether laboratories are complying with the MPBetreibV and thus explicitly ensure compliance with the Rili-BÄK. If your laboratory is accredited according to ISO 15189, DAkkS is responsible for surveilling your laboratory. For IVD manufacturers, it is the Land authorities and, depending on the class of the device, the notified bodies that are responsible for surveillance.
The assumption that, at least in the case of the Land authorities, the same bodies are responsible for the surveillance of manufacturers and laboratories is not always justified. For example, in Baden-Württemberg, the regional council in Freiburg is responsible for IVD device manufacturers and the regional council in Tübingen is responsible for laboratories.
a) The IVDR makes concrete demands of laboratories
Although the MPG already required the essential requirements of Annex I of the IVDD to be met, comprehensive compliance with these requirements was not achieved.
The IVDR now establishes uniform requirements for laboratories across Europe.
The previous system was also difficult to understand: why should the regulatory requirements for a laboratory test depend on whether it was developed by a laboratory or an IVD manufacturer?
A lot of medical laboratories are not fully aware of the existing and the new requirements. It’s high time they got busy. Tougher competition between laboratories and legal disputes with IVD manufacturers should be expected.
b) Your next steps as a medical laboratory
It would be best to research the market immediately: look for devices whose performance promises for the same patient target group are the same as for your LDT.
Is there no such device on the market? Congratulations, you can offer your LDT! You should comply with the following requirements:
Add the extended requirements of Annex I of the IVDR
Get your free copy of the Johner Institut’s checklist for Annex I of the IVDR in our starter kit.
But if there is an equivalent device on the market that offers the same level of performance, you need to urgently think about your strategy for 2022. The Johner Institut will be delighted to provide support.
(Depending on the risk class of the device) create device-specific technical documentation and declare conformity.
The IVD team will support you as a medical laboratory in your adjustment to the IVDR and help you ensure that you comply with the requirements for LDTs. For example, we can hold an individual workshop to create the conditions needed to make your company and your devices fit for the future or review your documentation.