Unfortunately, research suggests that patients are ill-informed when faced with understanding the risks, benefits, and downstream burdens of their ICDs. Patients with an ICD tend to overes- timate the benefit of this therapy and underes- timate its risks.S15-1 S15-3 Likewise, patients who decline an ICD also frequently underestimate their personal risk of VA and SCD.S15-4,S15-5 Stud- ies of clinician decision-making demonstrate that clinicians often overestimate the benefits while downplaying the potential harms.S15-3 In kind, ICD replacement is also an important point in time where patients and clinicians should discuss whether replacing an ICD is still consistent with the patients goals. What made sense at 70 years of age may not make sense at 80 years of age. Patients may have had progressive disease or developed poor QoL. These factors can all change the risk/benefit ratio of the ICD and the patients preferences. 16. COST AND VALUE CONSIDERATIONS The key principles of value assessment as part of clini- cal practice guidelines have been discussed in detail.S16-1 Economic outcomes of clinical management strategies can be documented empirically using the same re- search designs as used in establishing clinical outcomes, including RCTs and observational comparisons. In ad- dition, simulation models are often used to assess the value of management strategies, because the standard for cost-effectiveness studies is to compare life-time outcomes, and clinical studies usually have follow-up of a few years at most. Standards for economic model- ing in health care have been published by an expert Economic assessments of alternative management strategies for VA and prevention of SCD have primarily andobser- In all studies, patients who received ICDs had higher long-term costs. The high initial cost of the ICD device and the implantation procedure leads to higher long- term costs, because there are few, if any, subsequent cost-savings from implanting an ICD. 