Contains Nonbinding Recommendations 
 
Factors to Consider When Making 
Benefit-Risk Determinations for 
Medical Device Investigational Device 
Exemptions  
 
Guidance for Investigational Device 
Exemption Sponsors, Sponsor-
Investigators and  
Food and Drug Administration Staff  
 
Document issued on January 13, 2017. 
This guidance will have a 60 day implementation period.  
The draft of this document was issued on June 18, 2015. 
 
For questions about this document regarding CDRH-regulated devices, contact the Office of 
Device Evaluation, Office of the Director, Investigational Device Exemptions (IDE) Staff at 
301-796-5640. For questions about this document for CBER-regulated devices, contact the 
Office of Communication, Outreach and Development at 1-800-335-4709 or 240-402-8010. 
    
U.S. Department of Health and Human Services 
Food and Drug Administration 
 
Center for Devices and Radiological Health 
Center for Biologics Evaluation and Research 
 
Preface 
  1  Contains Nonbinding Recommendations 
 
Public Comment 
You may submit electronic comments and suggestions at any time for Agency consideration to 
http://www.regulations.gov . Submit written comments to the Division of Dockets Management, 
Food and Drug Administration, 5630 Fishers Lane, Room 1061, (HFA-305), Rockville, MD 
20852. Identify all comments with the docket number [FDA-2015-D-1777]. Comments may not be 
acted upon by the Agency until the document is next revised or updated. 
Additional Copies  
CDRH 
Additional copies are available from the Internet. You may also send an e-mail request to 
CDRH-Guidance@fda.hhs.gov to receive a copy of the guidance. Please use the document 
number 1783 to identify the guidance you are requesting.  
CBER 
Additional copies are available from the Center for Biologics Evaluation and Research (CBER) 
by written request from the Office of Communication, Outreach and Development (OCOD), 
10903 New Hampshire Ave., WO71, Room 3128, Silver Spring, MD 20993-0002, or by calling 
1-800-835-4709 or 240-402-8010, by email, ocod@fda.hhs.gov, or from the Internet at  
http://www.fda.gov/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformatio
n/Guidances/default.htm.  
  2  Contains Nonbinding Recommendations 
 
Table of Contents 
I.  INTRODUCTION..............................................................................................................5
II.  SCOPE .................................................................................................................................7
III.  INFORMED CONSENT AND IDE DECISIONS ...........................................................7
A.  Informed Consent .................................................................................................................8
B.  Regulatory Standard for IDE Decisions..............................................................................9
C.  Types of IDE Decisions ..................................................................................................... 10
D.  Study Design Considerations ............................................................................................. 12
IV. IDE APPLICATION ASSESSMENT IN THE CONTEXT OF A DEVICE 
DEVELOPMENT PATHWAY ....................................................................................... 12
A.   Stages of Device Development .......................................................................................... 12
B.   Applying Benefit-Risk Framework to IDE Decision-Making ........................................... 14
V. ASSESSING BENEFITS AND RISKS FOR IDE APPLICATIONS ................................ 15
A.  Assessment of Risks to Study Subjects ............................................................................. 17
B.  Assessment of Other Risks Considerations of Investigational Study ................................ 22
C.  Assessment of Direct Benefits to the Study Subject .......................................................... 22
D.  Assessment of Benefits to Others ...................................................................................... 23
E.  Other Factors to Consider When Assessing Benefit-Risk for IDE Applications .............. 24
F.  Overall IDE Benefit Risk Determination ........................................................................... 26
APPENDIX A  RECOMMENDED GENERAL FRAMEWORK FOR BENEFIT-RISK 
ASSESSMENT .................................................................................................................. 27
APPENDIX B  HYPOTHETICAL EXAMPLES OF SUMMARY BENEFIT-RISK 
ASSESSMENTS ............................................................................................................... 29
APPENDIX C  REFERENCE GUIDE: DESCRIPTION OF INVESTIGATIONAL 
DEVICE ............................................................................................................................ 35
APPENDIX D  GLOSSARY OF RISK MANAGEMENT TERMS .................................... 37
  3  Contains Nonbinding Recommendations 
 
  4  Contains Nonbinding Recommendations 
 
Factors to Consider When Making 
Benefit-Risk Determinations for 
Medical Device Investigational Device 
Exemptions  
Guidance for Investigational Device 
Exemption Sponsors, Sponsor-
Investigators and  
Food and Drug Administration Staff 
This guidance represents the current thinking of the Food and Drug Administration (FDA or 
Agency) on this topic. It does not establish any rights for any person and is not binding on 
FDA or the public. You can use an alternative approach if it satisfies the requirements of the 
applicable statutes and regulations. To discuss an alternative approach, contact the FDA staff 
or Office responsible for this guidance as listed on the title page.  
I.  INTRODUCTION 
FDA is committed to improving U.S. patient access to new devices by strengthening and 
streamlining the clinical trial enterprise so that medical device clinical trials are conducted in the 
U.S. in an efficient and cost-effective manner, while maintaining appropriate patient and 
research participant protections.   
The purpose of this guidance is to provide greater clarity for FDA staff and investigational 
device exemption (IDE) sponsors and sponsor-investigators1 regarding the principal factors that 
FDA considers when assessing the benefits and risks of IDE applications for human clinical 
studies.   
                                                 
1 Sponsor and sponsor-investigator are defined in 21 CFR 812.3. 
  5  Contains Nonbinding Recommendations 
 
Consistent with applicable laws and regulations, FDA may disapprove an IDE application if, 
among other reasons, [t]here is reason to believe that the risks to the subjects are not 
outweighed by the anticipated benefits to the subjects and the importance of the knowledge to be 
gained.2 In many cases, the Agency believes that effective risk management, including the 
application of risk controls, which includes risk mitigation measures, can result in a favorable 
IDE benefit-risk determination.   
FDA recognizes that in assessing risks and anticipated benefits, the medical device total product 
lifecycle should be considered, and that earlier stages of device development and investigational 
clinical study are typically associated with greater uncertainty (i.e., a lower level of evidence). A 
primary goal of this guidance is to clarify the factors that FDA considers when assessing risks 
and anticipated benefits as significant contributors to the decision to approve IDE studies, and 
how uncertainty may be offset by a variety of risk mitigation measures which can ensure 
appropriate patient and research participant protections in investigational research settings. For 
proposed IDE studies, at earlier stages of device development, FDA considers appropriate 
mitigation measures for anticipated possible risks and unanticipated risks, whereas in later 
stages, FDA considers whether risk mitigation measures focus on the most probable risks.   
Another important goal of this guidance is to characterize benefits in the context of 
investigational research, which includes direct benefits to the subject and benefits to others (to 
the extent there are indirect benefits to subjects such as knowledge to be gained from the study 
or information that may contribute to developing a treatment). 
As with the benefit-risk framework for evaluating marketing applications, FDA assessment of 
benefits and risks for an IDE application takes into account the contextual setting in which the 
study is being proposed, including but not limited to characterization of the disease or condition 
being treated or diagnosed, the availability of and risks associated with alternative treatments or 
diagnostics. When available, information characterizing subject tolerance for risk and their 
perspective on benefit may provide useful context during this assessment. See for more 
information FDA Guidance, Factors to Consider When Making Benefit-Risk Determinations in 
Medical Device Premarket Approval and De Novo Classifications  
(http://www.fda.gov/ucm/groups/fdagov-public/@fdagov-meddev-
gen/documents/document/ucm517504.pdf). 
FDA believes use of this benefit-risk framework will facilitate the incorporation of evidence and 
knowledge from different domainsclinical, nonclinical, and patientto support a 
comprehensive, balanced decision-making approach. FDA envisions this will facilitate a 
common understanding between FDA and sponsors/sponsor-investigators by highlighting which 
factors are critical in the benefit-risk assessment for a specific application, and clearly explaining 
how these factors influence FDAs decisions. This guidance document will also help improve the 
predictability, consistency, and transparency of the review process for IDE applications.   
                                                 
2 21 CFR 812.30(b)(4). 
  6  Contains Nonbinding Recommendations 
 
FDAs guidance documents, including this one, do not establish legally enforceable 
responsibilities. Instead, guidance documents describe the Agencys current thinking on a topic 
and should be viewed only as recommendations, unless specific regulatory or statutory 
requirements are cited. The use of the word should in Agency guidance documents means that 
something is suggested or recommended, but not required. 
II.  SCOPE 
This guidance document explains the principal factors that FDA considers when assessing 
benefits and risks of original IDE applications, IDE amendments and IDE supplements for 
human clinical investigations of certain medical devices to determine safety and effectiveness. 
The approach discussed in this guidance is applicable to studies subject to the IDE requirements 
in 21 CFR part 812, including postmarket studies. In general, IDE applications are required for 
clinical investigations of significant risk devices to determine safety and effectiveness.3 This 
guidance applies to both diagnostic and therapeutic devices. This guidance is not intended to 
provide recommendations regarding device-specific data or study requirements. 
III.  INFORMED CONSENT AND IDE DECISIONS 
The purpose of the IDE regulations, as set forth in Title 21 CFR part 812, is to encourage, to the 
extent consistent with the protection of public health and safety and with ethical standards, the 
discovery and development of useful devices intended for human use, and to maintain optimum 
freedom for scientific investigators in their pursuit of this purpose.4 Title 21 CFR part 812 
applies to all clinical investigations of devices to determine safety and effectiveness with some 
exceptions, as described in 21 CFR 812.2(c).    
FDA approval of an IDE application prior to study initiation is typically required for a clinical 
investigation conducted in the U.S. of a significant risk device that is not approved or cleared for 
the indication being studied.5 As defined in 21 CFR 812.3(m), a significant risk device means an 
investigational device that: 
1.  Is intended as an implant and presents a potential for serious risk to the health, safety, or 
welfare of a subject; 
2.  Is purported or represented to be for a use in supporting or sustaining human life and presents 
a potential for serious risk to the health, safety, or welfare of a subject; 
3.  Is for a use of substantial importance in diagnosing, curing, mitigating, or treating disease, or 
otherwise preventing impairment of human health and presents a potential for serious risk to 
the health, safety, or welfare of a subject; or 
4.  Otherwise presents a potential for serious risk to the health, safety, or welfare of a subject. 
                                                 
3 21 CFR 812.2 and 20. 
4 21 CFR 812.1. 
5 See section 520(g) of the Federal Food, Drug and Cosmetic Act (FD&C Act) and 21 CFR 812.2(b) for conditions 
under which an IDE application is required prior to study initiation. 
  7  Contains Nonbinding Recommendations 
 
An approved IDE application exempts the study sponsor from certain provisions of the Federal 
Food, Drug, and Cosmetic Act (FD&C Act) (such as certain requirements for a marketing 
submission and good manufacturing practice). However, IDE studies must comply with the 
applicable requirements set forth in 21 CFR part 812, including requirements for informed 
consent under 21 CFR part 50, labeling of devices for investigational use only, study monitoring, 
records and reporting, and approval by an Institutional Review Board (IRB) in accordance with 
21 CFR part 56.6 
A.  Informed Consent 
A key tenet of FDAs IDE benefit-risk framework is appropriate protection of human subjects 
and a key principle of human subject protection in clinical investigations is the informed consent 
process.7 This process goes beyond obtaining a signature on an informed consent form. The 
informed consent process provides the prospective subject or his or her legally authorized 
representative with adequate information about the study, including pertinent information about 
the investigational device, its risks and benefits, alternatives, and what is expected of the subject 
in order to participate in the study (e.g., study visits, procedures, maintaining subject diaries).8 
The subject or his or her legally authorized representative must be given sufficient opportunity to 
consider whether or not to participate in the clinical study under circumstances that minimize the 
possibility of coercion or undue influence.9 
An informed consent process should allow an individual to decide to accept potential risks 
associated with a study in exchange for the potential for anticipated benefits to the subjects and 
the importance of the knowledge to be gained. The informed consent process allows individuals 
to exercise their personal tolerance of risks as weighed against other factors, including the 
reasonably expected benefits and the alternatives to the study.  
The informed consent process ensures that each individual makes a determination about study 
participation after being informed of the study, including the risks and benefits of study 
participation, and, if applicable, the possibility of receiving no direct benefit. The informed 
consent regulations in 21 CFR part 50 describe the informed consent aspects of human subject 
protection in clinical investigations subject to FDA regulations. For example 21 CFR 50.20, 
states the following: 
Except as provided in 50.23 and 50.24, no investigator may involve a human being as a 
subject in research unless the investigator has obtained the legally effective informed 
consent of the subject or the subjects legally authorized representative.   
                                                 
6 Section 520(g)(3) of the FD&C Act. 
7 See generally, 21 CFR part 50. 
8 See 21 CFR 50.25. 
9 See 21 CFR 50.20. 
  8  Contains Nonbinding Recommendations 
 
In addition, 21 CFR 50.25(a)(2) states that the informed consent must include a description of 
any reasonably foreseeable risks or discomforts to the subject.  
B.  Regulatory Standard for IDE Decisions 
Under section 520(g)(4)(B) of the FD&C Act, an IDE application may only be disapproved if 
FDA finds that the investigation does not conform to the procedures and conditions prescribed 
under regulations. The purpose of the IDE process is to encourage, to the extent consistent with 
the protection of the public health and safety and with ethical standards, the discovery and 
development of useful devices intended for human use and to that end to maintain optimum 
freedom for scientific investigators in their pursuit of that purpose.10  
FDAs decision-making process for IDE applications was modified with the passage of the Food 
and Drug Administration Safety and Innovation Act (FDASIA) of 2012 (Pub. L. No. 112-144). 
Section 601 of FDASIA amended Section 520(g) of the FD&C Act to specify certain situations 
in which FDA cannot disapprove an IDE application. Section 520(g)(4)(C) of the FD&C Act 
states that, consistent with section 520(g)(1), FDA shall not disapprove an IDE application 
because: 
(i)  the investigation may not support a substantial equivalence or de novo classification 
determination or approval of the device; 
(ii)  the investigation may not meet a requirement, including a data requirement, relating 
to the approval or clearance of a device; or  
(iii)  an additional or different investigation may be necessary to support clearance or 
approval of the device. 
Considering the above criteria, when the objective of a proposed study is to support a marketing 
submission, the sponsor may benefit from learning whether there are protocol modifications that 
FDA believes are needed for the study to adequately support product approval or clearance. FDA 
intends to convey such considerations to the sponsor to provide greater clarity and predictability. 
For more information, see the FDA Guidance, FDA Decisions for Investigational Device 
Exemption (IDE) Clinical Investigations, 
(http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidancedocumen
ts/ucm279107.pdf), issued August 19, 2014 (hereinafter, FDA Decisions for IDE Guidance).  
In accordance with 21 CFR 812.30(b), FDA may disapprove or withdraw approval of an IDE 
application for any of the following reasons: 
(1) There has been a failure to comply with any requirement of this part or the act, any other 
applicable regulation or statute, or any condition of approval imposed by an IRB or FDA. 
(2) The application or a report contains an untrue statement of a material fact, or omits 
material information required by this part. 
                                                 
10 Section 520(g)(1) of the FD&C Act.  
  9  Contains Nonbinding Recommendations 
 
(3) The sponsor fails to respond to a request for additional information within the time 
prescribed by FDA. 
(4) There is reason to believe that the risks to the subjects are not outweighed by the 
anticipated benefits to the subjects and the importance of the knowledge to be gained 
[emphasis added], or informed consent is inadequate, or the investigation is scientifically 
unsound, or there is reason to believe that the device as used is ineffective.  
(5) It is otherwise unreasonable to begin or to continue the investigation owing to the way in 
which the device is used or the inadequacy of:  
(i) The report of prior investigations or the investigational plan; 
(ii) The methods, facilities, and controls used for the manufacturing, processing, 
packaging, storage, and, where appropriate, installation of the device; or  
(iii) Monitoring and review of the investigation. 
Consistent with this regulation, FDA will generally disapprove an IDE application if potential 
risks of the proposed study are not justified, or if data provided are insufficient to adequately 
characterize the safety profile of the device such that, based on the data contained in the IDE 
application, human clinical investigation is not considered reasonable.   
This guidance document provides greater clarity regarding regulatory assessment of: 
  risks and benefits associated with clinical investigational device use proposed in IDE 
applications;11 and  
  inadequacy or uncertainty regarding the clinical or nonclinical data from prior investigations, 
the proposed study, the manufacturing, transport and storage of a device, or monitoring 
oversight of the proposed study.12 
C.  Types of IDE Decisions 
FDA regulations13 provide for three major categories of decision on an IDE application  
approval, approval with conditions, and disapproval.  
If FDA approves an IDE application the sponsor may begin subject enrollment upon receipt of 
IRB approval and in accordance with the limits described in FDAs decision letter, including the 
maximum numbers of U.S. subjects and investigational sites. See FDA Decisions for IDE 
Guidance, page 6. 
If FDA approves an IDE application with conditions, the sponsor may begin subject enrollment 
upon receipt of IRB approval and in accordance with the limits described in FDAs decision 
letter, including the maximum numbers of U.S. subjects and investigational sites, and FDA 
                                                 
11 21 CFR 812.30(b)(4). 
12 21 CFR 812.30(b)(5). 
13 21 CFR 812.30(a).  
  10  Contains Nonbinding Recommendations 
 
expects that the sponsor will submit information addressing the issues identified as conditions of 
approval in FDAs letter within 45 days. See FDA Decisions for IDE Guidance, page 7. 
If an IDE application is disapproved, the sponsor may not initiate enrollment in the clinical 
investigation until the sponsor submits an amendment to the IDE to respond to the deficiencies 
identified in FDAs letter and subsequently receives a new letter from FDA granting approval or 
approval with conditions. See FDA Decisions for IDE Guidance, page 10. 
Where appropriate, FDA may allow additional flexibility in how outstanding issues can be 
addressed (i.e., future considerations, study design considerations, contingent approval, staged 
approval), to allow clinical investigations to commence without unnecessary delay, while 
ensuring that human subjects are adequately protected.14 For discussion of contingent approval, 
see FDA Guidance, Investigational Device Exemptions (IDEs) for Early Feasibility Medical 
Device Clinical Studies, Including Certain First in Human (FIH) Studies 
(http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidancedocumen
ts/ucm279103.pdf), issued October 1, 2013 (hereinafter, FDA Early Feasibility Guidance). 
In some cases, FDA may grant staged approval or staged approval with conditions for a portion 
of the planned study cohort or grant a limited number of subjects enrolled while outstanding 
questions that may affect the benefit-risk profile for the proposed IDE study are addressed. See 
FDA Decisions for IDE Guidance for more information on staged approvals, page 8.15 Staged 
approval permits the clinical investigation to begin in a timely manner while maintaining 
appropriate subject protections. Without this mitigation measure, the benefit-risk profile of the 
proposed investigation may not support study initiation. 
FDA may grant approval with conditions when there are outstanding issues that do not raise 
concerns that preclude initiation of the proposed clinical investigation, provided that the sponsor 
addresses the recommended modifications to the study. Resolution of these issues is not required 
prior to initiation of study subject enrollment, with exception of issues related to the informed 
consent document, which must be addressed before enrollment begins, in accordance with 21 
CFR part 50 - Protection of Human Subjects. 
Initial IDE application approval decisions reflect the benefit-risk profile of the proposed 
investigation at the time of FDAs assessment. Changes in approval status (e.g., from 
disapproval to approval) may be appropriate as new information becomes available which:  
  changes the understanding of risks and benefits or their associated level of uncertainty;  
  changes confidence in risk control or mitigation measures (refer to Appendix D); or  
                                                 
14   See FDA Decisions for IDE Guidance 
(http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidancedocuments/ucm279107.pdf) 
for more information.  
15 See FDA Decisions for IDE Guidance 
(http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidancedocuments/ucm279107.pdf) 
for more information on staged approvals, page 8.   
  11  Contains Nonbinding Recommendations 
 
  changes the disease or clinical diagnostic/treatment landscape in a manner which alters the 
benefit-risk profile of the IDE device relative to alternatives. 
If necessary, FDA may take appropriate regulatory actions to protect study subjects, including 
placing a clinical hold on the study. FDA can place a study on clinical hold when, taking into 
consideration the factors in section 520(g)(8) of the FD&C Act,  the device involved represents 
an unreasonable risk to the safety of the persons who are the subjects of the clinical 
investigation. If the study is placed on hold, no additional subjects may be enrolled. 
D.  Study Design Considerations 
Although FDA will not disapprove an IDE because the investigational plan for a pivotal study 
may not support approval or clearance of a marketing submission in accordance with section 
520(g)(4)(C) of the FD&C Act, study design has a direct bearing on the knowledge that can be 
gained from that study. A poorly designed study may produce evidence which leads to false 
conclusions that have significant negative public health implications. A poorly designed study 
could produce data, which are inconclusive or difficult to interpret and thereby limit the degree 
to which useful knowledge is generated from the study.   
In contrast, well-designed studies are more likely to produce important knowledge about a 
device or disease. FDA believes it is most efficient, and consistent with least-burdensome 
principles, to encourage the conduct of studies which are designed to meet stated 
objectives. FDA may inform the sponsor of recommended modifications to the study design  
Study Design Considerations (SDCs)16 that FDA believes will improve the quality of the 
information and knowledge generated by the study which the sponsor is encouraged but not 
required to address.   
IV. IDE APPLICATION ASSESSMENT IN THE CONTEXT OF A DEVICE 
DEVELOPMENT PATHWAY 
A.   Stages of Device Development 
When making IDE benefit-risk assessments, FDA considers: 1) the stage of development of the 
device, 2) the maturity of the proposed technology, and 3) the availability of non-clinical testing 
to complement or replace the need for clinical testing.   
FDAs Early Feasibility Guidance (page 6) defines the following device study types:  
                                                 
16See FDA Decisions for IDE Guidance 
(http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidancedocuments/ucm279107.pdf)  
for more information on the topic of SDCs.  
  12  Contains Nonbinding Recommendations 
 
First in Human (FIH): A first in human study is a type of study in which a device for a 
specific indication is evaluated for the first time in human subjects.  
Early Feasibility: An early feasibility study is a limited clinical investigation of a device 
early in development, typically before the device design has been finalized, for a specific 
indication (e.g. innovative device for a new or established intended use, marketed device for 
a novel clinical application).  
Traditional Feasibility: A traditional feasibility study is a clinical investigation that is 
commonly used to capture preliminary safety and effectiveness information on a near-final or 
final device design to adequately plan an appropriate pivotal study.  
Pivotal Study: A pivotal study is a clinical investigation designed to collect definitive 
evidence of the safety and effectiveness of a device for a specified intended use, typically in 
a statistically justified number of subjects.  
In some cases, IDE studies may also be designed for  investigation of marketed products. For 
example, an IDE study may be conducted to expand the indications for use or update the device 
labeling.   
The approach to benefit-risk assessment in IDE applications should be tailored to the stage of 
device development, because device investigations during different stages of development are 
generally associated with different types of risk, and different levels of uncertainty. Specifically, 
a greater degree of uncertainty is expected for novel technologies, and at earlier stages of device 
development, such as first in human or early feasibility trials, while relatively more certainty is 
expected in traditional feasibility and pivotal trials. At earlier stages, the focus is on whether the 
proposed investigation has appropriate risk control measures for anticipated possible risks and 
unanticipated risks, whereas in later stages focus shifts increasingly to mitigating the most 
probable risks. Additionally, early development clinical studies are typically designed to assess 
initial safety and proof of concept about the proposed device use. Later stage studies, particularly 
those intended to support future regulatory applications, are typically designed to assess safety 
and effectiveness outcomes in an intended patient population, with additional information to 
quantify uncertainty in each of these outcomes. IDE benefit-risk assessments should take into 
consideration whether the level of uncertainty is appropriate to the stage of development for the 
investigational device. It should be noted that regardless of the stage of development, risk 
mitigation measures may be needed for certain serious events that have a low rate of occurrence 
in order to support a favorable benefit-risk assessment. 
For IDE benefit-risk determinations throughout all stages of device development, it is also 
important to recognize that non-clinical and prior clinical data play a critical role. Medical 
devices often have attributes that cannot be tested by clinical methods alone and that play a 
major role in the performance, safety or effectiveness of the device. In some cases, non-clinical 
testing (e.g., in vitro tests, animal studies, and computer modeling and simulation) can obviate or 
reduce the need for additional clinical testing to evaluate certain aspects of device design or 
performance. Both clinical and non-clinical testing methods may be used to assess the 
likelihood/probability or severity of a given risk, and/or the success of risk control measures, 
  13  Contains Nonbinding Recommendations 
 
including risk mitigation measures. Data from early clinical studies and/or studies conducted 
outside the U.S. may inform the benefit/risk assessment and the appropriate risk mitigation and 
control measures for future IDE studies.  
For a reference guide to the information FDA considers when assessing benefit-risk in the 
context of a device development pathway, refer to Appendix A. 
B.   Applying Benefit-Risk Framework to IDE Decision-Making 
A benefit-risk framework is used both for supporting IDE decision-making, as well as decisions 
related to marketing submissions (e.g., PMA, de novo, and for certain aspects of 510(k) 
substantial equivalence determinations). Importantly, however, benefit-risk decision-making is 
fundamentally different for IDE applications because clinical investigations, by their very 
definition, are research studies with inherent uncertainty regarding the relative benefits and risks 
of a given device, technology, or treatment.   
Therefore, FDA intends to permit appropriate latitude for the conduct of IDE studies within the 
boundaries of applicable laws and regulations. In considering whether risks outweigh the  
potential benefits to the subjects and the importance of the knowledge to be gained, absence of 
definitive evidence of benefit or the presence of purely hypothetical risks are not sufficient 
justification, in and of themselves, to disapprove an IDE application (see Section III.B. of this 
guidance). 
Given the more limited level of evidence typically associated with IDE applications compared to 
marketing applications  especially for earlier stages of investigation  decisions about IDE 
applications are made in settings involving relatively greater uncertainty and a lower level of 
evidence. The inherent uncertainty present in clinical investigations can often be offset by 
appropriately tailored risk control / risk mitigation measures which can help ensure appropriate 
patient and research participant protections in investigational research settings (some forms of 
risk controls that may be applied to IDE studies are listed in Section III.A.4.). In considering 
benefits of investigational research, FDA considers direct benefits to the subject and benefits to 
others (to the extent there are indirect benefits to subjects such as knowledge to be gained from 
the study or information that may contribute to developing a treatment). 
  14  Contains Nonbinding Recommendations 
 
As with the benefit-risk framework for marketing applications,17 FDA assessment of benefits and 
risks for an IDE application takes into account the contextual setting, including characterization 
of the disease or condition being treated or diagnosed; and the availability of alternative 
therapies, including their associated benefits and risks. When available, information 
characterizing subject tolerance for risk and perspective on benefit may provide useful context 
during this assessment. 
V. ASSESSING BENEFITS AND RISKS FOR IDE APPLICATIONS 
The approach outlined in this section describes FDAs key considerations when assessing 
benefits and risks of IDE studies. FDA recommends using a benefit-risk framework to facilitate 
the incorporation of evidence and knowledge from different domainsclinical, nonclinical, and 
patientto support a comprehensive, balanced decision-making approach. The framework 
should focus on relevant facts, uncertainties, and key areas of judgment to add clarity and 
predictability to the regulatory process. FDA envisions that these factors will facilitate common 
understanding between sponsors and FDA by highlighting which factors are critical in the 
benefit-risk assessment for a specific application, and clearly explaining how these factors 
should influence FDAs decision.   
FDA recommends IDE sponsors provide as part of the IDE application a section that summarizes 
the key considerations for the IDE benefit-risk assessment  For an outline of the general 
framework for IDE benefit-risk assessment, please refer to Appendix A. Appendix B contains 
generic examples of IDE benefit-risk determinations for illustrative purposes.   
Patient Preferences 
When applying a benefit-risk framework to decisions on IDE applications, FDAs assessment 
depends on the value assigned to various risks and anticipated benefits to the patients. In the 
context of a clinical study, anticipated benefits include not only direct benefits to the patient but 
also societal benefits in terms of knowledge to be gained from the study.  
It is important to acknowledge that individual patient preferences vary, and that a patient may 
not assign the same values to various risks and anticipated benefits as their physician, family 
member, or other individual. Furthermore, patient preferences vary, both in preferred modality of 
treatment/diagnostic procedure (often devices are one option to be considered in a treatment care 
path which may include surgery or medication), as well as in risk tolerance. Some patients are 
willing to take on higher risks to potentially achieve a small benefit, whereas others are more 
risk averse. In certain circumstances, some patients may be willing to participate in clinical 
studies that offer no or limited direct benefit to subjects, but have anticipated societal benefits in 
advancing medical science. Please see FDA Guidance, Patient Preference Information--
                                                 
17 See FDA Guidance, Factors to Consider When Making Benefit-Risk Determinations in Medical Device 
Premarket Approval and De Novo Classifications (http://www.fda.gov/ucm/groups/fdagov-public/@fdagov-
meddev-gen/documents/document/ucm517504.pdf).  
  15  Contains Nonbinding Recommendations 
 
Voluntary Submission, Review in Premarket Approval Applications, Humanitarian Device 
Exemption Applications, and De Novo Requests, and Inclusion in Decision Summaries and 
Device Labeling 
(http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidancedocumen
ts/ucm446680.pdf).   
It may be appropriate to approve an IDE application where only a subset of the eligible study 
subject population would accept the potential risks as weighed against the potential benefits, 
including the benefit of the importance of the knowledge to be gained provided there is enough 
information on those potential risks and benefits and an adequate informed consent process in 
place for study participants to make informed decisions. However, if, for a certain IDE 
application, the potential risks outweigh the anticipated benefits for all subjects, FDA would 
disapprove the IDE application in accordance with 21 CFR 812.30(b).  
Patient preference information, as it relates to the participants in the study, may be particularly 
informative in helping to weigh the risks and benefits in certain challenging device areas. For 
example:  
  life-saving but high-risk devices (e.g., ventricular assist devices (VADs) for end-stage heart 
failure);  
  devices intended to directly affect health-related quality of life (e.g., for seizure prevention, 
sleep apnea); 
  devices intended to yield significant health benefits (e.g., obesity devices); 
  devices intended to yield significant appearance benefits (e.g., breast implants, wrinkle 
fillers); 
  devices for use in conditions where alternatives include non-device options such as surgical 
procedures or medical therapy (e.g., minimally invasive alternatives to open surgery). 
When available, information characterizing subject tolerance for risk and perspective on benefit 
may provide useful context for assessing the benefits and risks of a proposed clinical 
investigation.  
Investigational Device Description 
Fundamental to an assessment of benefits and risks associated with investigational device use is 
an understanding of the investigational device itself. Title 21 CFR 812.25(d) requires that the 
investigational plan include a: 
description of this device (a description of each important component, ingredient, 
property, and principle of operation of the device and any anticipated changes in the 
device during the investigation). 
Deficiencies related to an incomplete or inadequate investigational device description 
are the single most common type of non-protocol related deficiency in IDE applications 
that fail to attain full approval. Appendix C lists the device attributes that FDA 
recommends be included in the IDE application device description section. 
  16  Contains Nonbinding Recommendations 
 
Assessment of Risks Associated with Investigational Device Use 
The investigational plan must include a risk analysis, which describes and analyzes all increased 
risks to which subjects will be exposed by the investigation.18 FDA compares the risks associated 
with the investigation with not participating in the study. FDA also considers the manner in 
which these risks will be minimized, a justification for the investigation, and a description of the 
patient population including number, age, sex, and condition. The investigational-use risk 
analysis should align with the device-specific risk analysis (e.g., Failure Modes and Effects 
Analysis (FMEA)) as part of the overall device history file and risk management process.  
FDA recommends that IDE sponsors use an accepted method of risk assessment, where 
appropriate. For example, this guidance incorporates principles from ANSI/AAMI/ISO 14971: 
Medical Devices  Application of risk management to medical devices, an FDA-recognized 
standard, which provides a framework for systematically managing risks of medical devices 
throughout the total product life cycle.  
In addition, there are several key concepts, which are not commonly well described in IDE 
applications received by FDA and should be included in the application when assessing risks 
during the investigation: 
  Harms. Specifying how a hazard could lead to clinical sequelae including length of time 
experienced and residual affect (if any) or other harmful event is important because it allows 
more precise estimation of risk severity and likelihood. 
  Likelihood. Focusing on severity of a risk along with likelihood is important for a complete 
estimation of that risk. 
  Residual risk and completeness of risk control. Many identified risks are reduced to an 
acceptable level through effective risk controls. FDAs benefit-risk assessment of IDE 
applications focuses on completeness of risk control measures and whether residual risk 
outweighs anticipated benefits to the subjects. 
FDA may disapprove an IDE application if there is reason to believe that the risks to the subjects 
outweigh the anticipated benefits to the subjects and the importance of the knowledge to be 
gained.19 Assessment of benefits and risks should not necessarily be made in comparison to the 
most technologically advanced alternative but rather to commonly used therapies and treatments 
for a specific disease or condition. 
A.  Assessment of Risks to Study Subjects 
                                                 
18 21 CFR 812.25(c). 
19 21 CFR 812.30(b)(4). 
  17  Contains Nonbinding Recommendations 
 
In general, the sponsors assessment of risks to IDE subjects focuses on risks whose existence 
and characteristics are supported by objective scientific evidence and are reasonably foreseeable. 
The assessment of risks must include a description and analysis of all incremental risks to which 
subjects will be exposed by the investigation, and the manner in which these risks will be 
minimized.20 While it is not necessary to include specific mitigations for hypothetical risks that 
are not supported by scientific evidence or risks that are determined to be negligible due to a low 
probability of occurrence and low severity of harm, it is recommended to identify all possible 
risks in the risk assessment and include information on how the level of risk was determined. 
Relationship between Hazards and Harm21 
Risk assessment involves describing the relationships between a hazard (a potential source of 
harm) and the ultimate harm in terms of injury or damage. As part of FDAs IDE decision-
making, this relationship should specifically describe the foreseeable sequences of events, 
hazardous situations, and associated possible harm. This should include (as applicable): 
  the initiating hazard, failure mode, or circumstance; 
  the sequence of events that could lead to a hazardous situation occurring; 
  the likelihood of such a situation arising; 
  the likelihood that the hazardous situation leads to harm; 
  the nature of the harm that could result. 
The extent of risk(s)/harm(s) associated with an IDE study is assessed by taking into account the 
following factors, individually and in aggregate: 
A.1 Type(s) of risk(s), including severity:  The various risks, including the severity of the 
risk, assumed by the subject from participation in the investigation should be considered. 
These include: 
o  Basic Safety  protection against physical hazards, which should be addressed and 
mitigated with a reasonable level of certainty. For example, an active device should 
not be unsafe from an electrical safety perspective (e.g., the devices should not 
deliver an unintended electrical shock and surface temperature increases should not 
unintentionally burn the patient or operator).   
o  Device-related serious adverse events  events attributable to the investigational 
use of the device which produce an injury or illness that is life-threatening, results in 
permanent impairment or damage to the body, or requires medical or surgical 
intervention to prevent permanent harm to the body. 
 
o  Device-related non-serious adverse events  events attributable to the 
investigational use of the device which do not produce an injury or illness that is life-
threatening, do not result in permanent impairment or damage to the body, or do not 
require medical or surgical intervention to prevent permanent harm to the body.  
                                                 
20 21 CFR 812.25(c). 
21See Appendix D for a glossary of risk management terms.  
  18  Contains Nonbinding Recommendations 
 
o  Procedure-related complications due to the investigation  this includes not just 
the device use but risks related to the investigation itself to which the subject would 
otherwise not be exposed, e.g. risk of anesthesia during procedures involving an 
investigational device. 
o  Risks associated with the study itself  risks the subject may be exposed to that do 
not directly result from use of the device and would not be expected as part of usual 
care outside of the investigational setting. Examples include additional procedures 
(such as medical imaging) for ascertainment of study endpoints. 
o  Risk from false-positive or false-negative results for diagnostics  if a diagnostic 
device gives a false-positive result, the subject might be exposed to risks associated 
with unnecessary additional diagnostic procedures and tests, or potentially 
unnecessary treatment, as well as the ramifications of falsely diagnosing a disease. If 
a false-negative result is given, the subject might not receive effective treatment 
(thereby missing benefits that treatment would confer), or might not be diagnosed 
with the correct disease or condition. Failure to correctly diagnose a transmissible 
disease could also result in transmissions to other individuals which would present a 
broader public health issue. 
A.2 Likelihood or probability of risk(s): Various approaches are commonly employed to 
estimate probabilities of risks including but not limited to: use of relevant historical data; 
prediction of probabilities of risk using analytical or simulation techniques; use of 
experimental data from prior investigations; reliability estimates; production data; post-
production information; and use of expert judgment. The use of multiple approaches may be 
considered as this might serve to increase confidence in the results. During earlier 
development stages, greater uncertainty may exist around these estimates, in which case it 
may be useful to consider a qualitative approach to risk probability analysis. Such an analysis 
may include qualitative or semi-quantitative probability levels when the probability cannot 
be precisely determined, but is known or expected to be within an estimated range.     
The likelihood or probability of risk(s) includes the likelihood of the hazard resulting in a 
harmful event. If known, this includes the number of harmful events per patient or the 
number of harmful events per unit of time, the proportion of the intended population that 
would be expected to experience a harmful event, as well as the likelihood of a given subject 
or study group experiencing a harmful event. FDA considers whether an event occurs once or 
repeatedly in assessing the probability of risks.   
A.3 Duration of risk(s): Some studies expose subjects to temporary, minor harm; some can 
cause repeated but reversible harm; others can cause permanent, debilitating injury. Duration 
(i.e., how long the adverse consequence lasts) should be considered along with severity of 
risk, as described in above in A.1. 
  19  Contains Nonbinding Recommendations 
 
A.4 Risk Management:22 Risk Management provides a summary and assessment of any 
efforts that could help to mitigate the identified safety concerns, or ensure that device use is 
directed to those participants for whom the risk is considered acceptable because it does not 
outweigh the potential for benefit.   
Risk control measures (including risk mitigation efforts) should be applied, where 
appropriate, to reduce the likelihood and severity of harm to study subjects and improve the 
benefit-risk profile of the proposed IDE study. Risk control measures are intended to reduce 
the risk to an acceptable level. Sponsors should conduct an initial determination regarding 
which risk controls are appropriate for their proposed IDE study. Benefit-risk assessment for 
IDE decisions should focus on residual risk, and whether residual risk has been reduced to 
acceptable levels relative to the anticipated benefits to the subjects. The sponsor must 
provide in the IDE application a clear justification for the investigation, having considered 
risks for the intended study population and the manner in which those risks will be 
minimized.23 
Risk control measures may include device design features/modifications and risk mitigation 
may include protective measures (e.g., study design features), and communication of safety 
information (e.g., training of investigational staff). Forms of risk controls that may be applied 
to IDE studies may include but are not limited to: 
Safety by Design 
  Device design features and/or modifications 
Protective Measures 
  Physical protective measures (e.g., user & subject radiation shielding) 
  Preparation and readiness of personnel and equipment for anticipated adverse 
events (e.g., crash carts) 
  Study design24 
o  Staged enrollment with limited initial human subject exposure and interim 
pre-specified subject safety assessment (e.g., IDE staged approval) 
o  Staged/graded exposure to device intervention (e.g., low level stimulation 
before high level stimulation) 
o  Pre-specified clinical management of potential adverse events; more 
frequent reporting 
o  Pre-specified monitoring of study conduct, particularly for aspects critical 
to safety 
o  Pre-specified stopping rules or guidelines 
                                                 
22 For additional information on risk management for medical devices, refer to ANSI/AAMI/ISO 14971 Medical 
DevicesApplication of risk management to medical devices.  
23 21 CFR 812.25(c). 
24 See Section A.5  Residual risk evaluation section of this guidance. 
  20  Contains Nonbinding Recommendations 
 
o  If appropriate, a narrow study population that consists of a subset where 
the benefit-risk profile is more favorable (e.g., limit high risk novel 
therapy to treatment-refractory patients) 
  Performance of study at trained or specialized sites or investigators meeting 
certain criteria (e.g., multidisciplinary heart team). 
  Study oversight  
o  Institutional review board/ethics oversight 
o  Use of a Clinical Events Committee, Data Monitoring Committee / Data 
Safety and Monitoring Board25or other Quality by Design features  
o  IDE Progress Reports 
o  Clinical Hold Authority26 
  Adverse Event reporting27 
o  More frequent reporting of serious adverse events (e.g., after each 
occurrence, monthly, quarterly, annually) 
o  Accurate reporting of adverse events, including the timing and clinical 
context and a description of any medical interventions that were provided 
and the associated outcomes 
Communication of Safety Information 
All clinical investigations include some risk. After taking appropriate steps to mitigate 
risk through device design features/modifications and protective measures, sponsors are 
required to communicate relevant safety information about residual risks in the following 
ways:28 
  Informing study subjects about reasonably foreseeable risks of study 
participation    
  Optimizing communication among study sites regarding safety information 
(e.g., investigator and study coordinator calls concerning safety-related 
actions (Risk control measures.) 
  Communicating safety information with the IRB overseeing the study to 
determine whether any additional human subject protection measures are 
needed 
Note that the preferred hierarchy of risk management including risk control measures is 
to first attempt to eliminate the risk, then if this is not possible, to design and implement 
protective measures (e.g., reduce the probability of occurrence of risk or the extent of 
potential harm as well as is reasonably possible)) and communicate the residual risk to 
study subjects and operators (e.g., through informed consent or labeling). 
                                                 
25 See FDA Guidance, Establishment and Operation of Clinical Trial Data Monitoring Committees (March 2006), 
(http://www.fda.gov/downloads/RegulatoryInformation/Guidances/ucm127073.pdf).  
26 See Section 606 of FDASIA Clinical Holds on Investigational Device Exemptions. 
27See 21 CFR 812.150. 
28 21 CFR 50.25. 
  21  Contains Nonbinding Recommendations 
 
 
A.5 Residual risk evaluation: After risk control measures are applied, the following 
measures may be considered when evaluating any residual risk, particularly in cases where 
there are substantial risks associated with the study: 
  Risk communication and disclosure of residual risk during the informed consent 
process, including information as to how subjects can/should act to further control or 
mitigate risk 
  When reliable information is available, consideration of subject perspective and 
tolerance for  assuming risk relative to anticipated benefit 
  Performance of initial limited study in subjects most likely to experience benefits or 
select a participant subset where the benefit-risk profile is more favorable (e.g., 
treatment-refractory patients) 
B.  Assessment of Other Risks Considerations of Investigational Study 
Consistent with section 520(g)(4)(B) of the FD&C Act, FDA may consider the risks discussed in 
Section A above  these risks  to protect  the public health and safety. FDA review of risk 
management measures will focus on appropriate measures to control these risks. 
B.1 Risks related to interpretation of the study data and the benefit of knowledge that 
could be gained:  
  Risk of drawing a false conclusion based on clinical data obtained  
  Risk of data which are inconclusive or difficult to interpret29 
B.2 Risks to others: Certain investigations may involve risks to others that should be 
considered. For example: 
  Risk of radiation exposure of health care practitioner 
  If treated subjects become drowsy while operating a vehicle  
C.  Assessment of Direct Benefits to the Study Subject 
In general, the assessment of anticipated benefits to IDE subjects does not include purely 
hypothetical benefits, and instead focuses on those direct benefits whose existence and 
characteristics are supported by valid scientific evidence commensurate with the stage of 
development for the device, including diagnostics. FDAs assessment of anticipated benefits of 
study participation includes the direct benefits to the subject  benefits that may be realized by 
the subjects participating in the research, including: 
                                                 
29Refer to Section III.D. in this guidance for further discussion on this point. 
  22  Contains Nonbinding Recommendations 
 
C.1  Type of benefit(s): Examples include but are not limited to the devices anticipated 
impact on clinical management, subject health, and subject satisfaction in the target 
population, such as improving clinical management and quality of life, reducing the 
probability of death, aiding improvement of subject function, reducing the probability of loss 
of function, and providing relief from symptoms. For diagnostics, an anticipated benefit may 
be due to its ability to identify a specific disease (thereby enabling measures that prevent its 
spread or progression), predict future disease onset, provide earlier diagnosis of diseases, 
reduce the frequency of diagnostic and ancillary testing, or identify participants more likely 
to respond to a given therapy.  
C.2 Magnitude of the benefit(s): Determined by the anticipated change in subjects 
condition or clinical management, or as determined by an improvement or worsening of the 
endpoint. Variation in the magnitude of the benefit across a population may also be 
considered. Perceived benefit derived from various sources, such as human factors 
simulation testing, questionnaire analysis and other published data with similar devices may 
also provide an insight into the subjects preference or whether their experience is positive or 
negative.  
C.3 Probability of the participant experiencing one or more benefit(s): Based on the 
evidence provided from prior investigations, it is sometimes possible to predict which 
subjects may be more or less likely to experience a benefit. In other cases, however, 
particularly at earlier stages of device development, it may not be possible to assess the 
probability of a participant experiencing one or more benefits or identifying subgroups most 
likely to experience a benefit.  
C.4 Duration of effect(s): (i.e., how long the benefit can be expected to last for the 
participant): Some treatments are curative, whereas, some may need to be repeated 
frequently over the patients lifetime. To the extent that it is known, the duration of a 
treatments effect may directly influence how its anticipated benefit is defined. Treatments 
that must be repeated over time may introduce greater cumulative risk, or the benefit 
experienced may diminish each time the treatment is repeated.  
D.  Assessment of Benefits to Others  
In addition to assessing the anticipated direct benefits to IDE subjects, an IDE benefit-risk 
assessment also includes a consideration of the anticipated benefits to others (to the extent they 
are indirect benefits to subjects such as knowledge to be gained from the study or information 
that may contribute to developing a treatment). 
A required element of the informed consent is a description of any benefits to the subject or to 
others [emphasis added] which may reasonably be expected from the research.30 Benefits to 
                                                 
30 21 CFR 50.25(a)(3). 
  23  Contains Nonbinding Recommendations 
 
others that may also indirectly benefit the subjects include benefits to caregivers or family 
members and healthcare professionals.   
A benefit to others of an investigational study is the importance of the knowledge to be 
gained.31 This is not a direct benefit to the subject, but rather is considered a societal benefit in 
terms of increasing the understanding of a disease condition and potential treatment or diagnostic 
applications. This benefit is unique to research and does not apply to marketing applications. A 
greater degree of uncertainty about the benefits and risks of study participation typically exists in 
IDE submissions, and one should consider the possibility that study subjects will receive no 
direct benefit from study participation. However, subjects may still be willing to participate 
because of the indirect benefits such as knowledge to be gained from the study or information 
that may contribute to developing a treatment. Studies which are well-designed may be 
considered to have greater benefits in this regard, because they generate knowledge that can 
inform safe device use and may lead to earlier patient access to high quality, safe and effective 
devices.   
In assessing an IDE study for the importance of the knowledge to be gained, a key consideration 
is the likelihood that the study will yield generalizable knowledge about the disorder or 
condition being studied. Additional safeguards may be necessary for the inclusion of children in 
clinical investigations that are likely to yield generalizable knowledge about the subjects 
disorder or condition, but that involve greater than minimal risk with no prospect of direct 
benefit to individual subjects, as described in 21 CFR 50.53.   
E.  Other Factors to Consider When Assessing Benefit-Risk for IDE Applications  
The assessment of benefits and risks for an IDE study takes into account the uncertainty 
surrounding the knowledge and available evidence, the contextual setting in which the study is 
being proposed, including characterization of the disease or condition being treated or 
diagnosed, and availability of alternatives and risks associated with them. When available, 
information characterizing subject tolerance for risk and perspective on benefit may provide 
useful context during this assessment. Such information could be derived from a variety of 
sources including literature and/or patient reported outcome tools.  
E.1 Characterization of the disease:  The treated or diagnosed condition, its clinical 
manifestation and severity (e.g., temporary or permanent loss of function), how it affects the 
subjects who have it, how and whether a diagnosed condition is treated, and the conditions 
natural history and progression (i.e., does it get progressively better or worse for the subject 
and at what expected rate) are all important factors that FDA considers when characterizing a 
disease and assessing benefits and risks. For instance, with conditions that have more severe 
symptoms in  the course of the natural disease relatively fewer and less effective treatment 
options, and less chance of responding to current treatment options, tolerating greater risk in 
a study (consistent with patient preferences) may be warranted. 
                                                 
31 21 CFR 812.30(b)(4). 
  24  Contains Nonbinding Recommendations 
 
E.2 Availability of alternatives: When characterizing the availability of alternatives, 
important factors that FDA considers are treatment (or diagnostic) options, treatment strategy 
(if applicable, such as for chronic diseases) and the safety and effectiveness of alternatives 
including the potential for adverse events. If alternative therapies (or diagnostic options) 
exist, are effective for the subject population, and are associated with relatively fewer 
adverse events, then subjects may not tolerate a higher degree of risk of study participation. 
Assessment should not necessarily be made in comparison to the most technologically 
advanced alternative but rather to commonly used therapies and treatments for the specific 
disease or condition. 
E.3 Subject tolerance for risk and perspective on benefit: Risk tolerance varies among 
subjects, and this will affect individual subject decisions to participate in a study. When 
evaluating benefits and risks, FDA recognizes that tolerance for risk and a subject-centric 
assessment of risk may reveal reasonable individuals who are willing to tolerate a high level 
of risk to achieve an anticipated benefit, especially if that benefit results in an improvement 
in quality of life or achieves societal benefit from knowledge gained. In addition, a thorough 
informed consent process serves to assure that prospective subjects are informed of, among 
other information, the risks and benefits of study participation, and agree to the risks of study 
participation given other factors, including the potential benefits.   
E.4 Uncertainty:  There is always some uncertainty when weighing benefits and risks prior 
to clinical study conduct. However, the degree of certainty is a factor FDA considers when 
assessing benefit-risk for IDE applications.  
  Quality of prior nonclinical and clinical investigations: Well-conducted non-
clinical and clinical prior investigations can help reduce uncertainty, particularly 
related to identified potential hazards. However, poor study design or conduct, or 
inadequate analysis of prior study data, can produce data which are inconclusive or 
difficult to interpret.  
  Predictive capability of evidence from prior investigations:32 The ability of the 
nonclinical testing and prior clinical experience to predict clinical performance in the 
proposed study is an important consideration, as is the generalizability of early results 
to the intended study and user population. This should include insights gathered from 
other studies sponsored and not sponsored by the applicant, including international 
peer-reviewed investigations, applicable to the current study design. For example, if 
the device requires in-depth user training or specialization, the clinical study should 
be designed to address this issue to ensure appropriate risk mitigation. It is important 
to distinguish between purely hypothetical risks, actual hazards, and the likelihood of 
subject harm.    
                                                 
32 21 CFR 812.27. 
  25  Contains Nonbinding Recommendations 
 
  Different uncertainty considerations at different stages of development:  
Different questions of uncertainty may arise at different stages of study. A higher 
level of uncertainty is expected and may be acceptable in the early stages of device 
development. Generally, while the types of uncertainty (and questions to be 
answered) vary across the stage of investigation and development, the overall degree 
of uncertainty of risks and benefits should decline as more data are collected 
throughout device development and exploration.   
E.5 Least burdensome study design:  When considering elements of study design, 
incorporating additional elements often involves trade-offs in terms of time, cost and 
practicality of study conduct, which may affect other aspects of clinical trial start-up, such 
as IRB approval and feasibility of subject enrollment. While FDA does not generally 
consider cost to the sponsor when deciding to approve an IDE application, the potential 
impact of study design elements on trial start-up, IRB approvability, and feasibility of 
subject enrollment should be considered. For example, although it may be desirable to 
implement an additional diagnostic procedure to screen out potential subjects who may be 
less likely to benefit from the study, if the diagnostic procedure itself is so time-consuming, 
costly or burdensome on subjects or investigators that enrollment in the study becomes 
impractical, FDA will consider these challenges in its decision making. 
F.  Overall IDE Benefit Risk Determination 
Consistent with applicable statute and regulations, FDA may disapprove an IDE application if, 
among other reasons, there is reason to believe that the risks to the subjects outweigh the 
anticipated benefits to the subjects and the importance of the knowledge to be gained. In many 
cases, the Agency believes that effective risk management, including the application of risk 
control measures, including risk mitigation measures, can reduce the residual risk and result in a 
favorable IDE benefit-risk determination.   
FDA believes that the use of a common framework and structured approach to assessing IDE 
benefits and risks will facilitate not only the submission of relevant evidence and knowledge but 
also a clear rationale for why the submitted information is sufficient to justify the initiation of the 
proposed study. Application of the factors listed in this guidance document can ultimately 
improve the predictability, consistency, and transparency of  FDAs IDE decision-making, 
resulting in the strengthening and streamlining of the clinical trial enterprise in the U.S. so that 
medical device clinical trials are conducted in an efficient and cost-effective manner, while 
maintaining appropriate patient and research participant protections. 
  26  Contains Nonbinding Recommendations 
 
APPENDIX A  RECOMMENDED GENERAL FRAMEWORK FOR BENEFIT-RISK 
ASSESSMENT 
FDA recommends IDE sponsors provide as part of the IDE application a section that 
summarizes the key considerations in the IDE benefit-risk assessment. The benefit-risk summary 
should provide a concise synopsis and may reference relevant sections in the IDE application 
where supporting information and evidence can be found. The intent of this summary is not to 
provide an all-encompassing summary of the benefit-risk assessment, but rather to focus on 
those items which are likely to significantly affect FDAs decision or recommendation. Of note, 
the Device Evaluation Strategy worksheet recommended in FDAs Early Feasibility Guidance 
provides similar information and can also be used to address the recommendations provided 
here. 
FDA recommends that the benefit-risk summary address the following key elements: 
1. CONTEXT OF THE PROPOSED INVESTIGATION  
Provide a summary of the disease or condition to be treated or diagnosed, a description of the 
device in the context of currently available treatment or diagnostic options, and a brief 
description of the investigation (its objective and design). 
2. ASSESSMENT OF RISKS OF THE PROPOSED INVESTIGATION 
A summary of the key risk elements identified in Section 5 of the guidance including risk 
characterization, risk control measures, and residual risk. 
3. ASSESSMENT OF BENEFITS OF THE PROPOSED INVESTIGATION 
A summary of the key benefits of the proposed investigation as identified in Section 5 of the 
guidance including direct benefits to study subjects of the proposed investigation and 
benefits to others (to the extent they are indirect benefits to subjects such as knowledge to be 
gained from the study or information that may contribute to developing a treatment). 
4. CONSIDERATION OF PATIENT PREFERENCE INFORMATION 
A summary of available patient preference information, if any is available. If none, state that 
none was available. 
5. ASSESSMENT OF UNCERTAINTY 
Summarize key sources of uncertainty in the available evidence and proposed investigation 
as identified in Section 5 of the guidance, and provide a rationale for why the level of 
uncertainty is acceptable for the proposed investigation.   
  27  Contains Nonbinding Recommendations 
 
6. CONCLUSIONS 
Summarize how the consideration of the factors discussed in this summary justify the 
decision to proceed with human clinical investigation.  
  28  Contains Nonbinding Recommendations 
 
APPENDIX B  HYPOTHETICAL EXAMPLES OF SUMMARY BENEFIT-RISK 
ASSESSMENTS  
FDA recommends IDE sponsors provide as part of the IDE application a section that 
summarizes the key considerations in the IDE benefit-risk assessment. The benefit-risk summary 
should provide a concise synopsis and may reference relevant sections in the IDE application 
where supporting information and evidence can be found (see Appendix A for details). 
The examples below are simplified and offered for illustrative purposes only. The decisions 
described in these examples are intended to demonstrate how to present the factors described in 
this guidance when making benefit-risk assessments and how FDA may analyze these factors.  
Example 1  Pivotal study proposal for a device to treat a life-threatening condition with 
poor alternative treatments  
CONTEXT OF THE PROPOSED INVESTIGATION  
A company has developed a permanently implantable device to treat a disease that affects adults 
and is associated with a high risk of mortality. Generally there is progression to advanced disease 
within 12 months, and 30% of patients die within 24 months. While pharmacological treatments 
are available, they primarily offer only transient symptomatic relief and are associated with 
significant complications. The sponsor proposes a prospective randomized study to assess the 
use of a device to treat the condition compared with a standard pharmacological treatment.   
ASSESSMENT OF RISKS OF THE PROPOSED INVESTIGATION 
The device has risks associated with both the surgical procedure required for implantation and 
long-term use. These risks have been evaluated in animal studies and a small short-term clinical 
feasibility study. The risks are potentially severe and the likelihood of occurrence is only 
partially understood.  
Based on the information gained from the previous non-clinical and clinical studies, the sponsor 
has proposed minor changes to the implant procedure that may reduce the risk. Additional risk 
mitigation procedures include: careful subject selection, the use of specialized/experienced study 
investigators, subject monitoring procedures, and use of an independent Data Safety and 
Monitoring Board. 
ASSESSMENT OF BENEFITS OF THE PROPOSED INVESTIGATION 
Initial data from the previous nonclinical and clinical studies demonstrated the potential for 
clinically relevant reductions in morbidity and mortality from the condition, although the amount 
of data available is limited and a control group was not used. In addition, the long-term 
effectiveness of the device has not yet been explored. 
 
 
  29  Contains Nonbinding Recommendations 
 
CONSIDERATION OF PATIENT PREFERENCE INFORMATION 
Given the lack of effective current treatments and the significant morbidity and mortality 
associated with the disease, patients are expected to have a high risk tolerance for considering 
potential new treatments. However, definitive patient preference data are lacking. 
ASSESSMENT OF UNCERTAINTY 
The greatest degree of uncertainty is regarding the anticipated benefits of the device. While the 
nonclinical and clinical feasibility study data are encouraging, it is unclear whether clinically 
relevant benefits will be demonstrated in a controlled study with long-term follow-up. There is 
also uncertainty regarding the risk profile, and whether the changes in the implant procedure and 
implementation of the other mitigation strategies will be effective.  
CONCLUSIONS 
This study is characterized by a significant degree of risk and a high level of uncertainty 
regarding the anticipated benefits. However, given the lack of effective alternative treatments, 
the risks associated with those treatments, the consequences of ineffective treatment, and that the 
benefits and risks of the device have been reasonably characterized in non-clinical and feasibility 
clinical studies, FDA is likely to approve the pivotal IDE study.  
If current treatments were more effective at controlling or curing the disease process, or if the 
disease process were more benign, the benefit-risk assessment might be unfavorable. If 
feasibility clinical study data were not available, there would be a significantly higher degree of 
uncertainty regarding anticipated benefits. 
  30  Contains Nonbinding Recommendations 
 
Example 2  Feasibility study proposal for a device to treat an activity limiting condition 
with reasonable alternative treatments  
CONTEXT OF THE PROPOSED INVESTIGATION  
A company has developed an absorbable device to treat a condition associated with modest pain 
and functional limitations, but not increased mortality. Several reasonably effective permanently 
implantable device alternatives exist, although they are associated with chronic adverse events 
that in some patients require surgical revision, device removal, or replacement.  
The sponsor proposes a prospective non-randomized feasibility study to provide a preliminary 
assessment of the safety and potential for benefit of an absorbable device. 
ASSESSMENT OF RISKS OF THE PROPOSED INVESTIGATION 
Compared to the currently available alternatives there are two primary unaddressed risks 
associated with this device.   
The first risk is that the device is comprised of new materials that have not been fully 
characterized and may have significant toxicities. While the materials are similar to those used in 
other devices, the differences in formulation and processing for this device have the potential to 
lead to an unacceptable safety profile. The biocompatibility of the device can be addressed with 
additional nonclinical testing that was not provided by the sponsor.  
The effectiveness of the device is dependent on the concept that preservation of structural 
integrity is only needed during the acute healing phase of the condition and that the device 
degradation profile is consistent with the healing timeline. However, there is a risk that 
premature device degradation will result in the loss of structural integrity prior to complete 
healing and subsequent reoccurrence of the condition. Assessment of the chronic performance of 
the device will likely require clinical evaluation.  
The sponsor has not specified any clinical mitigation strategies for the study. To address the 
biocompatibility concern, the sponsor states that the similarity in materials to other absorbable 
devices is sufficient mitigation.  
ASSESSMENT OF BENEFITS OF THE PROPOSED INVESTIGATION 
There is theoretical support for the concept that an absorbable device could reduce the chronic 
adverse events associated with the currently available devices while maintaining effectiveness.  
CONSIDERATION OF PATIENT PREFERENCE INFORMATION 
The sponsor has provided a small survey regarding patient preference. The survey indicates that 
some patients are satisfied with the currently available devices. However, there is a modest level 
of interest in novel technologies that could reduce the potential need for future surgery for device 
removal or replacement. 
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ASSESSMENT OF UNCERTAINTY 
There is considerable uncertainty regarding whether this absorbable device provides sufficient 
structural integrity over an appropriate timeframe to support chronic healing of the condition.  
There is also considerable uncertainty regarding the potential toxicity of degradants.  
CONCLUSIONS 
This device is intended to treat a condition associated with modest pain and discomfort for which 
there are reasonable alternatives currently available. The new materials raise biocompatibility 
concerns which may result in unacceptable risks for subjects which can and should be addressed 
with nonclinical testing that the sponsor has not provided. There does not appear to be a strong 
basis for allowing the clinical study to proceed until the biocompatibility data are provided, as 
FDA does not concur that the claim of similarity in materials is adequate to address this concern. 
Therefore, FDA would likely not approve this study until these data are provided and found to be 
supportive of an acceptable biocompatibility profile.   
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Example 3  Early feasibility study proposal for a device to treat a life-threatening 
condition without an alternative treatment option  
CONTEXT OF THE PROPOSED INVESTIGATION  
The condition affects adults and is associated with a high risk of morbidity and mortality.  
No effective treatment alternative exists for patients with the advanced form of the disease. 
Treatments that are successful for patients with less severe forms of the disease have failed in 
patients with advanced disease. 
The sponsor proposes an early feasibility study to provide proof of principle and initial clinical 
safety data for the use of a device to treat the condition.   
ASSESSMENT OF RISKS OF THE PROPOSED INVESTIGATION 
This intervention has risks associated with both the procedure as well as the potential for long-
term adverse effects. The procedural risks have been evaluated in an animal study. In addition, 
information can be leveraged from the clinical experience with a similar device for a different 
intended use. With available leveraged information and an understanding of the device design 
concept, the types of risks are known, but the frequency and severity are unknown. In cases 
where patient characteristics (e.g., age, gender, or other key variables) are not comparable for the 
new intended use, the extent to which this previous clinical experience can be leveraged may be 
more limited. 
The sponsor has proposed several strategies to minimize the frequency and severity of risks to 
study subjects including the following:   
  use of study sites that have sufficient expertise and resources to manage adverse events and 
provide appropriate additional therapies if needed;  
  identification of qualified investigators with adequate training to conduct the early feasibility 
study;  
  implementation of an informed consent process which adequately conveys to potential 
subjects the high degree and seriousness of both known and unknown risks and the low 
likelihood of direct benefits; a plan to capture human factors information during the course of 
the study to modify the procedures or device as necessary based on the information obtained 
prior to the treatment of additional participants; 
  limiting the sample size to a reasonable number for an early feasibility study (e.g., 5-10 
initial subjects); 
  frequent follow-up assessments to monitor subject safety and device effectiveness; 
  timely reporting of serious adverse events (i.e., after each occurrence rather than only in a 
periodic progress report); 
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  timely reporting of device performance parameters, which help determine whether the device 
functions as intended;  
  refine study eligibility criteria to subjects with favorable anatomical characteristics to avoid 
subjects with anatomic features thought likely to increase difficulty of device use; and 
  a pre-specified plan for periodic participant outcome assessments and reporting prior to 
enrollment of additional participants (i.e., after each use of the device). 
ASSESSMENT OF BENEFITS OF THE PROPOSED INVESTIGATION 
Initial data from the previous nonclinical studies, with the available leveraged information, 
suggest the potential for clinically relevant reductions in morbidity and mortality from the 
condition, despite the potential for procedure-related and long-term adverse effects.   
CONSIDERATION OF PATIENT PREFERENCE INFORMATION 
Given the lack of an effective alternative treatment and the morbidity and mortality associated 
with the condition, patients are expected to have a high risk tolerance for considering potential 
new treatments. However, no definitive data have been provided by the sponsor to support this 
expectation. 
ASSESSMENT OF UNCERTAINTY 
Due to the novelty of the device and procedure and the lack of a nonclinical model to predict the 
clinical safety and effectiveness of the device, there is a high degree of uncertainty regarding the 
device, including the initial safety, the long-term adverse effects of the treatment, and the 
anticipated benefits.   
CONCLUSIONS 
Potential study subjects have failed conventional treatments that can be beneficial to patients 
with less severe cases. The proposed study is characterized by a significant degree of 
uncertainty, given the early phase of device development and the novelty of the proposed device 
and procedure. Information available on a similar device from a different intended use and from 
an animal study provide some assurance that catastrophic failures would not be anticipated 
during the early feasibility study. Conducting additional nonclinical testing is unlikely to provide 
information to decrease the level of uncertainty.   
Considering that: (1) the proposed device treats a severe disease for which there is no alternative 
treatment; (2) information is available from the clinical experience with a similar device for a 
different intended use to suggest that catastrophic failures will not occur; (3) there is reason to 
believe that patients may benefit from treatment with the device; and (4) additional nonclinical 
testing will not provide the information needed to advance the device design, FDA is likely to 
approve the early feasibility study IDE. 
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APPENDIX C  REFERENCE GUIDE: DESCRIPTION OF INVESTIGATIONAL 
DEVICE 
Fundamental to an assessment of benefits and risks associated with investigational device use is 
an understanding of the investigational device itself. 21 CFR 812.25(d) requires that the 
investigational plan include a: 
description of this device (a description of each important component, ingredient, 
property, and principle of operation of the device and any anticipated changes in the 
device during the investigation). 
Deficiencies related to an incomplete or inadequate investigational device description 
are the single most common type of non-protocol related deficiency in IDE applications 
that fail to attain full approval. This Appendix lists the device attributes that CDRH 
recommends be included in the IDE device description. 
The investigational device description should include an explanation of how the device 
functions, the scientific concepts that form the basis for the device, and the significant physical 
and performance characteristics of the device, such as device design, material used, and physical 
properties. A complete description of the device may be facilitated by the submission of 
engineering schematics or other figures. If the device consists of multiple components, a diagram 
identifying how the different components of the device system work together may be beneficial. 
The device description should also include a discussion of the physical specifications, 
dimensions and mechanical tolerances of the investigational device. Of note, the Device 
Evaluation Strategy worksheet recommended in FDAs Early Feasibility Guidance provides 
similar information and can also be used to address the recommendations provided here. 
In general, it is recommended that the investigational device description include the 
following details or provide a rationale for why information concerning the specified 
element is not needed or does not apply:    
  Device Identification:  
o  List all device components (e.g., catheter, cable wire, leads, sizing tools, 
delivery system, etc.)  
o  List all models to be used in the investigation and briefly explain the 
differences among models 
  Brief Written Description of the Device:  
o  Explanation of how the device works/principle of operation  
o  Mechanism of action, if known  
o  Key performance specifications and manufacturing tolerances of the device, if 
known 
o  Key device features/characteristics (address all that apply)  
  Software  
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  Electrical properties 
  Mechanical properties 
  Biologics  
  Drugs  
  Coating(s) and surface modifications (e.g., an abraded material surface 
to encourage implant retention) 
  Single-use or multi-use 
  Single patient or multi-patient  
  Defined User Type  Patient, Caregiver, Healthcare Professional or 
combination. 
  Sterile or sterilization method [specify] 
  Energy source (if applicable)  
  This not only includes energy delivery to the device, including the 
use of batteries, but also energy delivery that is part of the 
functional aspect of the device (e.g., laser, radiofrequency, 
ultrasound, etc.).  
  Materials of use  
  Chemical formulation used in the materials of construction, 
especially for those materials that come into contact with the 
patient, should be provided if available.  
  Duration and type of contact 
  Procedure for use 
  For in vitro diagnostic devices, a step-by-step outline of 
recommended pre-analytical and analytical procedures from 
receipt of specimens to obtaining results. 
  Other critical device features 
  These may include, but are not limited to, software/ hardware 
features, density, porosity, degradation characteristics, nature 
of reagents (recombinant, plasma derived, etc.), principle of the 
assay method, manufacturing-related aspects, etc., that are not 
explicitly included as part of the materials, design or energy 
source characteristics.   
  If modifications are made to the device during the course of a 
study or between different stages of investigation (e.g., early 
feasibility to pivotal), a detailed comparison of the original and 
modified device should be provided. 
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APPENDIX D  GLOSSARY OF RISK MANAGEMENT TERMS  
Terminology/Definitions  Risk Assessment  
The following risk management terms are consistent with ISO 14971. For the purposes of this 
guidance, terms are defined as follows: 
  Harm  physical injury or damage to the health of people, or damage to property or the 
environment. 
  Hazard  potential source of harm 
  Risk  a combination of the probability of occurrence of harm and the severity of that 
harm. Note that in earlier stages of development a relative sense of likelihood may be 
used instead of probability of occurrence, which is difficult or impossible to estimate 
when little evidence is available. 
  Risk estimation  process used to assign values to the probability of occurrence of harm 
and the severity of harm 
  Risk analysis  systematic use of available information to identify hazards and to 
estimate the risk 
  Risk control  process in which decisions are made and measures implemented (e.g..; 
risk mitigations) by which risks are reduced to, or maintained within, specified levels. 
[Please note, the term risk mitigation is not used in ISO 14971.] 
  Residual risk  risk remaining after risk control measures have been taken 
  Risk Assessment  overall process comprising a risk analysis and a risk evaluation 
  Risk Evaluation  process of comparing the estimated risk against given risk criteria to 
determine the acceptability of the risk 
  Risk Management  systematic application of management policies, procedures and 
practices to the tasks of analyzing, evaluating, controlling and monitoring risk 
 
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