Investing in Ex Ante Regulation: Evidence from Pharmaceutical Patent Examination.

We explore how the Patent Office may improve the quality of issued patents on "secondary" drug features by giving examiners more time to review drug-patent applications. Our findings suggest that current time allocations are causing examiners to issue low quality secondary patents on the margin. To assess the merits of expanding ex ante scrutiny of drug-patent applications at the agency, we set forth estimates of the various gains and losses associated with giving examiners more time, including reduced downstream litigation costs and added personnel expenses, along with both the static gains and dynamic innovation losses associated with earlier generic entry.

Public and Private Options in Practice: The Military Health System.

Recent debates over health care reform, including in the context of the Military Health System (MHS) and Veterans Administration, highlight the dispute between public and private provision of health care services. Using novel data on childbirth claims from the MHS and drawing on the combination of plausibly exogenous patient moves and heterogeneity across bases in the availability of base hospitals, we identify the impact of receiving obstetrical care on versus off military bases. We find evidence that off-base care is associated with slightly greater resource intensity, but also notably better outcomes, suggesting marginal efficiency gains from care privatization.

Timing of Transport of Patients with COVID-19.

Rationale: The objective of this study was to evaluate the risk of mortality or ECMO cannulation for patients with confirmed or suspected COVID-19 transferred from sending hospitals to receiving tertiary care centers as a function of the duration of time at the sending hospital.

Objective: To determine outcomes of critically ill patients with COVID-19 who were transferred to tertiary or quarternary care medical centers.

Materials And Methods: Retrospective cohort study of critical care transports of patients to one of seven consortium tertiary care centers from March 1, 2020, through September 4, 2020.

Ventilator Management in Metformin-Associated Lactic Acidosis: A Case Report.

The initiation of mechanical ventilation in the setting of profound metabolic acidosis can be a particular challenge in the transport environment. The classic teaching is that patients with severe acidemia should not be intubated, if possible, because they are often able to better maintain their own compensatory minute ventilation compared with clinician management with the mechanical ventilator. In this case, a patient had profound metformin-associated lactic acidosis with a pH of 6.

Interfacility Transport of Critically Ill Patients.

Objectives: To assess recent advances in interfacility critical care transport.

Data Sources: PubMed English language publications plus chapters and professional organization publications.

Study Selection: Manuscripts including practice manuals and standard (1990-2021) focused on interfacility transport of critically ill patients.

Postintubation Sedation After a Formulary Change From Succinylcholine to Rocuronium in a Critical Care Transport Organization.

Objective: Rocuronium is increasingly used as a first-line neuromuscular blocker (NMB) in rapid sequence intubation by transport teams. Prior work has shown that rocuronium is associated with a delay in postintubation sedation compared with intubation with succinylcholine.

Methods: Boston MedFlight is a consortium-based transport organization.

Operational Policies and Procedures for Critical Care Transport During a Respiratory Pandemic.

The severe acute respiratory syndrome coronavirus 2 pandemic of 2020 to 2021 created unprecedented challenges for health care organizations, including those in the critical care transport sector. Critical care transport services had to rapidly adjust to changing patient demographics, distribution of diagnoses, and transport utilization stratagem. To evolve with the pandemic, organizations developed new protocols and guidelines in rapid succession.

Air Versus Ground Transport Times in an Urban Center.

Purpose: Given that the benefits of helicopter transport vary with geography and healthcare systems, we assessed transport times for rotor wing versus ground transport over a 10 year period in an urban setting.

Materials And Methods: All completed transports from 153 sending hospitals in New England from 2009 through 2018 to 8 local tertiary care centers were extracted from an administrative database. The primary outcome of interest was patient-loaded transport time for rotor wing versus ground transports.

Clinical Policies and Procedures for Critical Care Transport during a Respiratory Pandemic.

The severe acute respiratory syndrome coronavirus disease-2 (SARS-CoV-2) pandemic of 2020-2021 created unprecedented challenges for clinicians in critical care transport (CCT). These CCT services had to rapidly adjust their clinical approaches to evolving patient demographics, a preponderance of respiratory failure, and transport utilization stratagem. Organizations had to develop and implement new protocols and guidelines in rapid succession, often without the education and training that would have been involved pre-coronavirus disease 2019 (COVID-19).

Critical Care Transport of Patients With COVID-19.

Purpose: Critical care transport is associated with a high rate of adverse events, and the risks and outcomes of transporting critically ill patients during the COVID-19 pandemic have not been previously described.

Materials And Methods: We performed a retrospective review of transports of subjects with suspected or confirmed COVID-19 from sending hospitals to tertiary care hospitals in Boston. Follow-up data were obtained for patients transported between March 1st and April 20th, 2020.

Is great information good enough? Evidence from physicians as patients.

We place an upper bound on the degree to which policies aimed at improving the information deficiencies of patients may lead to greater adherence to clinical guidelines and recommended practices. To do so, we compare the degree of adherence attained by a group of patients that should have the best possible information on health care practices-i.e.

Feasibility and Safety of Prone Position Transport for Severe Hypoxemic Respiratory Failure Due to Coronavirus Disease 2019.

Objectives: To assess the safety and feasibility of a new protocol for interhospital critical care transport of mechanically ventilated patients in the prone position during the coronavirus disease 2019 pandemic by nurse and paramedic critical care transport teams.

Design: Retrospective observational study.

Setting: Single critical care transport agency serving multiple centers in the greater Boston area.

ECMO Transport without Physicians or Additional Clinicians.

Background: Extracorporeal membrane oxygenation (ECMO) has accelerated rapidly for patients in severe cardiac or respiratory failure. As a result, ECMO networks are being developed across the world using a "hub and spoke" model. Current guidelines call for all patients transported on ECMO to be accompanied by a physician during transport.

Transport of a Nonintubated Prone Patient with Severe Hypoxemic Respiratory Failure Due to COVID-19.

With the COVID-19 pandemic, healthcare systems have been facing an unprecedented, large-scale respiratory disaster. Prone positioning improves mortality in severe hypoxemic respiratory failure, including COVID-19. While this is effective for intubated patients with moderate-to-severe ARDS, it has also been shown to be beneficial for non-intubated patients.

The Effect of Lights and Sirens on Critical Care Transport Time.

Background: In the prehospital setting, the use of ambulance lights and sirens (L&S) has been found to result in minor decreases in transport times, but has not been studied in interfacility transportation.

Objective: The objective of this study was to evaluate the indications for L&S and the impact of L&S on transport times in interfacility critical care transport.

Methods: We performed a retrospective analysis using administrative data from a large, urban critical care transportation organization.

Changes in Oxygen Saturation and Mean Arterial Pressure With Inhaled Epoprostenol in Transport.

Objective: Patients with hypoxemic respiratory failure have traditionally been considered one of the riskiest patient populations to transport, given the potential for desaturation with movement. We performed a retrospective cohort study to analyze our experience using inhaled epoprostenol in transport, with a primary objective of assessing change in the oxygen saturation throughout the transport.

Methods: The transport records of patients with severe hypoxemic respiratory failure or right heart failure, transported on inhaled epoprostenol, were reviewed.

Extracorporeal Membrane Oxygenation in Transport Part 2: Complications and Troubleshooting.

Factors taken for granted while the extracorporeal membrane oxygenation (ECMO) patient is maintained in a hospital setting can become critical when planning for transport. These issues include but are not limited to positioning of patients on a small transport stretcher, positioning of cannulas and equipment, ensuring adequate power sources and supply, inefficient temperature control, and a much higher risk of decannulation. It is paramount to be comfortable with the management strategies required to handle common complications of ECMO with limited resources in a relatively austere environment.

Extracorporeal Membrane Oxygenation in Transport Part 1: Extracorporeal Membrane Oxygenation Configurations and Physiology.

Extracorporeal membrane oxygenation (ECMO), a term used to describe oxygenation that occurs outside of the body, is an increasingly common means of supporting the most critically ill patients. Because of the invasiveness and high probability of serious complications during ECMO, ECMO is typically indicated only when there is a high likelihood of death with conventional treatment. With continued improvements in technology and increasing clinical experience, transport clinicians are increasingly likely to be called on to transport patients on ECMO.

Malpractice Liability and Health Care Quality: A Review.

Importance: The tort liability system is intended to serve 3 functions: compensate patients who sustain injury from negligence, provide corrective justice, and deter negligence. Deterrence, in theory, occurs because clinicians know that they may experience adverse consequences if they negligently injure patients.

Objective: To review empirical findings regarding the association between malpractice liability risk (ie, the extent to which clinicians face the threat of being sued and having to pay damages) and health care quality and safety.

ECMO and Right Ventricular Failure: Review of the Literature.

Right ventricular (RV) failure is the inability of the RV to maintain sufficient cardiac output in the setting of adequate preload, due to either intrinsic injury to the RV or increased afterload. Medical treatment of RV failure should include optimizing preload, augmenting contractility with vasopressors and inotropes, and considering inhaled pulmonary vasodilators. However, when medical therapies are insufficient, mechanical circulatory support (MCS) is needed to maintain systemic and RV perfusion.

Inhaled Epoprostenol to Facilitate Safe Transport in Legionnaires' Disease.

Hypoxemic patients often desaturate further with movement and transport. While inhaled epoprostenol does not improve mortality, improving oxygenation allows for transport of severely hypoxemic patients to tertiary care centers with a related improvement in mortality rates. Extracorporeal membrane oxygenation (ECMO) use is increasing in frequency for patients with refractory hypoxemia, and with increasing regionalization of care, safe transport of hypoxemic patients only becomes more important.

The effect of malpractice law on physician supply: Evidence from negligence-standard reforms.

We explore whether the composition of the physician workforce is impacted by the clinical standards imposed on physicians under medical liability rules. Specifically, we explore whether the proportion of non-surgeons practicing in a region decreases-and thus whether the proportion of surgeons increases-when liability standards are modified so as to expect that physicians practice more intensively. For these purposes, we draw on a quasi-experiment made possible by states shifting from local to national customs as the basis for setting liability standards.

Defensive Medicine: Evidence from Military Immunity.

We estimate the extent of defensive medicine by physicians, embracing the no-liability counterfactual made possible by the structure of liability rules in the Military Heath System. Active-duty patients seeking treatment from military facilities cannot sue for harms resulting from negligent care, while protections are provided to dependents treated at military facilities and to all patients-active-duty or not-that receive care from civilian facilities. Drawing on this variation and exploiting exogenous shocks to care location choices stemming from base-hospital closures, we find suggestive evidence that liability immunity reduces inpatient spending by 5% with no measurable negative effect on patient outcomes.

Review of Neurosurgery Medical Professional Liability Claims in the United States.

Background: Due to disparaging costs and rates of malpractice claims in neurosurgery, there has been significant interest in identifying high-risk specialties, types of malpractice claims, and characteristics of claim-prone physicians.

Objective: To characterize the malpractice claims against neurosurgeons.

Methods: This was a comprehensive analysis of all malpractice liability claims involving a neurosurgeon as the primary defendant, conducted using the Physician Insurers Association of America Data Sharing Project from January 1, 2003 and December 31, 2012.