No Surgical Innovation Without Evaluation: Evolution and Further Development of the IDEAL Framework and Recommendations

Allison Hirst, Yiannis Philippou, Jane Blazeby, Bruce Campbell, Marion Campbell, Joshua Feinberg, Maroeska Rovers, Natalie Blencowe, Christopher Pennell, Tom Quinn, Wendy Rogers, Jonathan Cook, Angelos G. Kolias, Riaz Agha, Philipp Dahm, Art Sedrakyan, Peter McCulloch, IDEAL Collaboration

Research output: Contribution to journalArticlepeer-review

244 Citations (Scopus)
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Objective: To update, clarify and extend IDEAL concepts and recommendations.

Background: New surgical procedures, devices and other complex interventions need robust evaluation for safety, efficacy and effectiveness. Unlike new medicines, there is no internationally agreed evaluation pathway for generating and analysing data throughout the life cycle of surgical innovations. The IDEAL Framework and Recommendations were designed to provide this pathway and they have been used increasingly since their introduction in 2009. Based on a Delphi survey, expert workshop and major discussions during IDEAL conferences held in Oxford (2016) and New York (2017), this article updates and extends the IDEAL Recommendations, identifies areas for future research, and discusses the ethical problems faced by investigators at each IDEAL stage.

Methods: The IDEAL Framework describes five stages of evolution for new surgical therapeutic interventions – Idea, Development, Exploration, Assessment and Long Term Study. This comprehensive update proposes several modifications. First, a “Pre-IDEAL” stage describing pre-clinical studies has been added. Second we discuss potential adaptations to expand the scope of IDEAL (originally designed for surgical procedures) to accommodate therapeutic devices, through an IDEAL-D variant. Third, we explicitly recognise the value of comprehensive data collection through registries at all stages in the Framework and fourth, we examine the ethical issues that arise at each stage of IDEAL and underpin the recommendations. The Recommendations for each stage are reviewed, clarified and additional detail added.

Conclusions: The intention of this article is to widen the practical use of IDEAL by clarifying the rationale for and practical details of the Recommendations. Additional research based on the experience of implementing these Recommendations is needed to further improve them.
Original languageEnglish
Pages (from-to)211-220
Number of pages10
JournalAnnals of Surgery
Issue number2
Early online date24 Apr 2018
Publication statusPublished - 1 Feb 2019

Bibliographical note

No specific funding was obtained for this update of IDEAL. The discussion meeting was funded as part of the IDEAL International Conference in Oxford on 7th April 2016 by several sponsors as follows: the Oxford Academic Health Science network (Oxford AHSN), The Health Foundation, Medtronic and Johnson and Johnson (J&J). It was also supported by BMJ and the Lancet. IDEAL is funded by the Oxford NIHR Biomedical Research Centre, educational grants and meetings income (PMcC and AH). JMB is an NIHR Senior Investigator supported in part by the Medical Research Council (MRC) ConDuCT-II (Collaboration and innovation for Difficult and Complex randomized controlled Trials In Invasive procedures) Hub (MR/K025643/1) and the NIHR Bristol Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol. The views expressed are those of the author and not necessarily those of the UK National Health Service, National Institute for Health Research, or Department of Health.


  • ethics
  • IDEAL framework and recommendations
  • medical devices
  • randomized controlled trials
  • registries
  • research methodology
  • surgical innovation
  • MESH
  • registries


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