United States

Background:
Patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction are at elevated risk for venous thromboembolism (VTE) due to prolonged operative times, cancer-associated hypercoagulability, and postoperative immobility. Despite the prevalence of VTE risk, there is limited consensus on standardized prophylaxis regimens in this high-risk population.
Methods:
A retrospective chart review was conducted of all patients who underwent DIEP flap breast reconstruction performed by the senior author between October 2021 and July 2024. A standardized VTE prophylaxis protocol was applied to all patients, including preoperative education, subcutaneous heparin, intraoperative efficiency techniques, and a postoperative regimen consisting of early ambulation (physical therapy initiated at 8:00 AM on postoperative day one), sequential compression devices, compressive garments, and two weeks of enoxaparin. Patient demographics, operative details, and VTE outcomes were recorded.
Results:
A total of 187 DIEP flaps were performed on 110 patients. The average age was 49.3 years, and the mean BMI was 29.7 kg/m². All flaps were performed by a single surgeon. There was one reported VTE event—an upper extremity deep vein thrombosis (DVT) 119 days after surgery, associated with intravenous access during a revision procedure. No lower extremity DVTs or pulmonary embolisms were reported. Therefore, the VTE rate attributable directly to DIEP flap reconstruction was 0.0%.
Conclusions:
A standardized, multimodal VTE prophylaxis protocol integrating pre-, intra-, and postoperative measures—including structured early ambulation—can result in a remarkably low VTE rate in DIEP flap patients. Our findings support that such a regimen is safe, effective, and may obviate the need for risk-based pharmacologic stratification using tools such as the Caprini Risk Assessment Model in this population.

AMA Research Challenge 2025 

Optimizing Venous Thromboembolism (VTE) Prophylaxis Following Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction

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AMA Research Challenge 2022

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Abstract Title
Population Genomic Analysis Identifies MDN1 Variant Linked to Endocrine Resistance in Breast Cancer
Background 
Endocrine resistance remains a critical challenge in the treatment of hormone receptor-positive breast cancer. The overexpression of MDN1 (midasin AAA ATPase 1), a nuclear chaperone involved in 60s ribosomal biogenesis, was previously linked to aggressive tumor behavior. Ongoing studies implicate alterations in MDN1 and estrogen receptor (ESR1) mutations that co-occur and are associated with endocrine resistance. 
This study investigates whether germline single nucleotide polymorphisms (SNPs) in MDN1 are associated with endocrine therapy resistance and explores plausible molecular links using multi-platform bioinformatics and biological studies. 
Methods
Using data from the All of Us Research Program, women aged ≥51 with a diagnosis of breast cancer were stratified as endocrine-sensitive or endocrine-resistant based on medication history. Genotypes for the MDN1 region were extracted using the Hail framework. Fisher’s exact test assessed the significance of the genotype-phenotype associations between SNPs and treatment status. The variant effect predictor (VEP) defined the functional protein impact of these variations. cBioportal, a multi-omics cancer platform, provided MDN1-ESR1 mutation co-occurrence data, while immunoblot analysis provided protein expression data. 
Results
Of the 236 variants identified, 133 were analyzed to assess genotype-phenotype associations. Two MDN1 SNPs were found to be significantly associated with endocrine therapy response: genotype IDs gt_GT_89702058 (p = 0.04879) and gt_GT_89707365 (p = 0.003311). The heterozygous genotype (0/1) of gt_GT_89707365 was observed in 20 endocrine-resistant cases and four endocrine-sensitive cases. The odds ratio 4.35 (95% CI: 1.47–16.67) suggests that individuals carrying the variant allele had a significantly higher likelihood of being resistant to endocrine therapy. VEP analysis revealed gt_GT_89707365 to be a missense variant with moderate impact, confirming an amino acid substitution suggesting a possible functional protein consequence. 
Data from cBioportal demonstrated that MDN1 alterations are associated with known estrogen receptor alterations (log2 odds ratio 1.5928, p-value= 0.027). In vitro studies revealed a 3-fold and 1.5-fold increase (p-value<0.05) in the expression of MDN1 in endocrine-resistant breast cancer cells with estrogen receptor point mutations Y537S and D538G, respectively. 

Conclusion
This study is the first to identify germline MDN1 variants potentially associated with endocrine therapy resistance. The significant enrichment of a missense SNP and evidence linking MDN1 to estrogen receptor mutations in treatment highlight a novel association with clinical relevance. These findings suggest MDN1 variation may influence endocrine therapy response. While there was a low variant frequency, ongoing studies in independent cohorts may support clinical implementation of MDN1 genotyping as a biomarker for therapy stratification.


Population Genomic Analysis Identifies MDN1 Variant Linked to Endocrine Resistance in Breast Cancer

Evaluating SiamMask and XMem for Real-Time Tumor Tracking in MR-Guided Radiotherapy

Swati Rampalli, Wookjin Choi, Karen Mooney, Nicole Simone, and Hamidreza Nourzadeh

Background
Magnetic Resonance Linear Accelerator (MRLinac) marks a major advancement in radiation therapy by enabling real-time tumor tracking. To improve tracking accuracy, there is growing interest in high-performance algorithms. General-purpose object-tracking algorithms have shown promising speed and adaptability in visual environments (e.g., driving, surveillance), but have not been extensively validated in medical imaging applications. Prior efforts developed AI models specifically trained on medical datasets, but these often require extensive expert-labeled annotations and lack generalizability across broader medical data. In this study, we evaluate the performance of SiamMask and XMem, two general purpose object tracking algorithms, initially developed from natural video data, now applied to cine MRI data. We explore the application of two off-the-shelf computer vision models in anatomical tracking without domain-specific training.

Methods
Both SiamMask and XMem models were tested on the publicly available TrackRad2025 Challenge Dataset. Our study consisted of a subset of 50 patients in two MRLinac systems 0.35 T (Institution A: 25 patients) and 1.5 T (Institution B: 15 patients, Institution C: 10 patients). Each patient had 2D+t MRI sequences with expert-drawn contours of a target structure. Both models were shown the labeled target in the first frame, tracked it across subsequent frames, and generated a bounding box around it. Tracking performance was assessed by comparing predicted bounding boxes with expert contours using the Dice Similarity Coefficient, Intersection over Union (IoU), and Hausdorff Distance, all standard image segmentation metrics.

Results
While threshold values for strong tracking performance vary depending on anatomy and imaging modality, higher scores reflect better overlap. DICE scores greater than 0.95 are often used as a threshold in clinical applications. Across all subgroups, XMem consistently achieved higher tracking accuracy than SiamMask, with an average DICE score of 0.861 ± 0.168, IoU of 0.783 ± 0.183, and Hausdorff Distance 95 (HD95) of 5.51 ± 7.02 mm. In comparison, SiamMask averaged a DICE score of 0.773 ± 0.232, IoU of 0.710 ± 0.244, and HD95 of 9.62 ± 8.30 mm.

Conclusion
Our findings show that XMem outperformed SiamMask across all patients, indicating greater overlap with initially drawn contoursstronger alignment with expert contours. However, overlap metrics like DICE and IoU alone do not guarantee clinical readiness viability as performance must also account for target complexity and proximity to critical structures. Clinically acceptable tracking performance varies with target size, proximity to critical structures, and steep dose gradients. HD95, a boundary-based metric capturing worst-case segmentation error, is especially critical in high-precision tracking. When broken down by subgroup, XMem exhibited variable Hausdorff distances in Institution B, driven by a small number of outlier frames with poor segmentation quality. Further investigation is needed to assess clinical applicability in high-risk anatomical regions. Both models also showed reduced performance on the 0.35 T system (Institution A), highlighting the impact of field strength and image quality, and underscoring the need for further statistical evaluation (e.g., ANOVA) across MR-Linac systems. Nonetheless, improved automated tracking can enable shorter treatments, more precise radiation delivery, and safer dose escalation. Off-the-shelf computer vision models such as SiamMask and XMem offer a strong foundation for enhancing MR-guided radiotherapy workflows. Future efforts will focus on integrating statistical comparisons across systems and refining these models for broader clinical implementation, with the potential to enable safer dose escalation and more efficient, personalized treatment delivery.


Evaluating SiamMask for Real-Time Tumor Tracking in MR-Guided Radiotherapy Without Domain Training

Background: Ibrutinib, a Bruton's tyrosine kinase (BTK) inhibitor, is a cornerstone therapy for Chronic Lymphocytic Leukemia (CLL). However, its use is linked to significant cardiotoxicity, including atrial fibrillation, hypertension, and a rare but critical risk of ventricular arrhythmias and sudden cardiac death.

Objective: To highlight the importance of recognizing Ibrutinib-associated sudden cardiac death through a case of a CLL patient with a complex pre-existing cardiac history.

CASE PRESENTATION
Patient Profile
A 67-year-old African American male was diagnosed with Stage 4 Chronic Lymphocytic Leukemia (CLL) in August 2022.
Cytogenetic analysis revealed a 13q14.2 deletion, indicating a favorable prognosis for his CLL.
His significant past medical history included chronic atrial fibrillation, hypertension, and a prior surgical repair of an atrial septal defect (ASD).

Treatment and Clinical Course
The patient was started on the standard-dose Ibrutinib (a Bruton's tyrosine kinase inhibitor) at 420 mg once daily.
Throughout his treatment, he reported experiencing chronic palpitations, which were clinically attributed to his known history of atrial fibrillation.
In April 2023, approximately eight months after treatment initiation, he developed worsening thrombocytopenia. As a result, his Ibrutinib dose was reduced to 280 mg daily. The patient tolerated this lower dose well with stabilization of his CLL.

Outcome
In 2025, despite his CLL remaining stable, the patient suffered a sudden and unwitnessed cardiac arrest at home and was pronounced deceased. The presentation was consistent with sudden cardiac death.

CONCLUSION
Ibrutinib is a potential contributor to sudden cardiac death, even in patients with stabilized CLL.
A high-risk cardiac history is a critical factor; fatal cardiotoxicity can occur despite a favorable hematologic prognosis.
This case underscores that vigilant cardiovascular surveillance is non-negotiable for all patients on Ibrutinib.

Clinical Recommendations
Baseline Evaluation: Perform a thorough cardiac risk assessment, including an EKG, before initiating Ibrutinib.
Active Monitoring: Implement routine monitoring during treatment to detect early signs of cardiotoxicity.
Collaborative Care: Utilize a Cardio-Oncology team approach for proactive management of high-risk patients.
Future Directions: Further research is needed to identify biomarkers that can risk-stratify patients and guide the selection of safer, newer BTK inhibitors.


The Unseen Risk: A Case of Sudden Cardiac Death in Ibrutinib-Treated CLL

Background
Aspergillus species are molds which cause infection via conidia inhalation. Invasive aspergillosis (IA) typically affects immunocompromised individuals and presents with fever unresponsive to antibiotics, thrombosis, and pulmonary infarction. However, IA can occur in immunocompetent patients due to contamination during vascular and cardiac surgeries. Early recognition of aspergillus aortitis and endocarditis is important given the high mortality rate (92.7%). We describe an immunocompetent patient with a remote history of coronary artery bypass graft (CABG) who presented with progressive strokes and was found to have an infected aortic thrombus caused by Aspergillus flavus.

Case Presentation
A 69-year-old man presented five hours after onset of dysarthria and confusion. Medical history was significant for well-controlled diabetes mellitus and history of CABG ten months prior to presentation. The patient was seen by Neurology due to concern for stroke. Computed tomography (CT) of the head and CT angiography of the brain and neck were unremarkable. However, a filling defect of the ascending aorta showed a thrombus and possible dissection. Given the concern for aortic dissection, thrombolytics were not given. Magnetic resonance imaging (MRI) of the brain showed multiple acute infarcts concerning for a stroke of cardioembolic origin.
On hospital day two, the patient developed fever and bilateral lower extremity weakness. Repeat MRI showed further stroke burden. Chest radiograph and urinalysis were unremarkable. Blood cultures were obtained. Due to concern for endocarditis, vancomycin and meropenem were started. By day five, he was responsive only to pain. On day seven, blood cultures grew aerobic fungal elements and caspofungin and isavuconazonium were initiated. On day eight, Aspergillus flavus was identified from the blood culture. Due to poor neurologic status, surgical repair of the aorta was not advised. Comfort measures were initiated, and the patient died with family at the bedside on day ten.

Discussion
While IA primarily occurs in immunocompromised patients, immunocompetent patients can develop IA after cardiac or vascular surgeries due to intraoperative contamination. Symptoms can develop up to two years after surgery. Aspergillus aortitis proximal to the brachiocephalic arch mimics endocarditis given the proximity to the carotid arteries. Aspergillus flavus shows reduced susceptibility to amphotericin B; therefore, concomitant antifungals such as caspofungin or voriconazole should be used. Emergent surgical intervention and resection is
the preferred treatment for IA involving the aorta given the potential for emboli and rupture.

Invasive Aspergillosis following CABG in an Immunocompetent Patient

Background: Autoimmune encephalitis (AE) comprises a group of inflammatory central nervous system disorders characterized by neuronal autoantibodies targeting intracellular or cell-surface proteins, often associated with distinct clinical phenotypes and underlying malignancy. Anti-ZIC4 antibodies, which target a cerebellar zinc-finger transcription factor involved in neuronal development, are rare and classically associated with paraneoplastic cerebellar degeneration, particularly in small-cell lung cancer. Their significance may be underrecognized, especially when co-occurring with more common antibodies such as anti-Hu.
Case Presentation: We report a case of a 70-year-old woman who presented with rapidly progressive encephalopathy and was found to have isolated anti-ZIC4 antibody positivity. Brain magnetic resonance imaging (MRI) revealed bilateral temporal lobe involvement, and continuous electroencephalogram (EEG) monitoring demonstrated refractory focal status epilepticus originating from the left posterior quadrant, evolving into an ictal–interictal continuum with brief recurrent seizures. No evidence of malignancy or cerebellar dysfunction was found, and infectious etiologies were thoroughly excluded. The patient received immunomodulatory treatment with high-dose methylprednisolone and intravenous immunoglobulin (IVIG) for suspected AE. Despite aggressive therapy, she passed away four weeks after admission.
Discussion: To our knowledge, this is the first reported case of isolated anti-ZIC4–associated encephalitis with temporal lobe predominance and no detectable malignancy, expanding the clinical and radiological spectrum of ZIC4 autoimmunity beyond its classical cerebellar phenotype. While ZIC4 antibodies often coexist with anti-Hu or CRMP5 antibodies, this case supports the notion that ZIC4 alone may have pathogenic relevance. It underscores the importance of paraneoplastic antibody testing even in atypical presentations and highlights the need for early recognition given the potential for rapid clinical deterioration despite treatment.

Isolated Anti-Zic4 Autoimmune Encephalitis with Temporal Lobe Involvement in the Absence of Malignancy

Background
Temporal crescent syndrome is a rare monocular visual field defect characterized by the loss of peripheral vision in the temporal field of one eye, typically caused by a contralateral retrochiasmal lesion on the visual pathway. Visual defects from retrochiasmal lesions are usually homonymous field defects, except for temporal crescent syndrome. Temporal crescent syndrome is an overall rare occurrence with few documented cases, especially when attributed to brain tumors, as more common etiologies include ischemic and hemorrhagic infarcts. Patients with temporal crescent syndrome often report visual disturbances such as blurred vision in the peripheral temporal field, and the condition is generally determined via visual field test.  
Case Presentation
A 40-year-old female presented with a history of grade II astrocytoma presented with a new onset of visual disturbances, specifically reporting of recent flashes of light in the right eye and blurriness. Her initial complaints were of headaches, fever, and seizures, though a meningitis workup proved negative. The patient’s medical history is significant for a left parietal astrocytoma that grew to affect the anteromedial occipital lobe, which was diagnosed in 2014. Over the past ten years, the tumor grew slowly, eventually leading to a loss of peripheral vision in the contralateral eye. 
  During initial evaluation, a formal visual field test revealed a loss of temporal vision in the right eye, initially corresponding with the tumor’s location on the left hemisphere. A neuro-ophthalmology consultation was conducted and concluded that the astrocytoma likely contributed to her visual symptoms. Despite ongoing symptoms, neurosurgery determined that surgical intervention was not warranted, as outpatient monitoring was deemed appropriate. The patient was started on steroid therapy to manage symptoms, which improved her condition but also induced hypoglycemia for which she has received counseling. During follow-up visits over the next decade, the patient reported persistent visual disturbances but no significant pain or further loss of vision.
Discussion
This case report highlights a rare manifestation of temporal crescent syndrome secondary to a grade II parietal astrocytoma. This case underscores the importance of considering CNS tumors in patients with peripheral visual field defects, particularly temporal crescent syndrome. Differential Diagnoses regarding this case include Creutzfeldt-Jacob disease, hemorrhagic infarction, and anterior striate cortex ischemia. Other ocular manifestations of parietal astrocytomas include sensory dysfunction, difficulty with spatial awareness, and issues with motor coordination. The unusual presentation of temporal crescent syndrome in this context underscores the need for interdisciplinary management and careful monitoring to address complex neurological conditions. 


Temporal Crescent Syndrome Secondary to Parietal Astrocytoma

Background 

Health access in Puerto Rico varies across regions and populations, with ongoing gaps in available services. Extensive literature highlights long-standing differences in health status among people with limited access to health or social services.¹,² Differences on the island continue to affect populations including people experiencing homelessness, people born outside the United States, older adults in geographically isolated regions, and communities affected by trauma.² These populations face barriers to care such as shortages of culturally and linguistically appropriate providers, stigma within service environments, fragmented systems, and restrictive eligibility requirements. Without the implementation of targeted and sustainable interventions, these health differences will persist. To address these gaps, we aimed to develop an evidence-based policy framework to strengthen access to care to care across four priority populations by proposing universal solutions and group-specific strategies. 

Methods 

Community forums were conducted with key stakeholders from each of the four priority populations (n=223). Participants shared experiences and challenges related to service access, trust in systems, and basic infrastructure needs. Responses were analyzed using thematic coding to identify common and distinct access barriers. Recommendations were then developed using a needs-centered lens grounded in public health best practices, emphasizing system-level accountability and community-defined priorities. 

Results 
Common themes across all groups included: a lack of trauma-informed and culturally competent providers, transportation barriers, restricted eligibility due to ID or insurance requirements, and underfunded community-based care.   

Universal recommendations include:   
- Expand mobile and telehealth units, particularly in remote and rural regions.   

- Train and deploy community-based case managers across all municipalities.  

- Remove documentation barriers for service access.   

- Improve health data systems to track equity metrics in vulnerable populations.   

Group-specific recommendations include:   

- People experiencing homelessness: Fund street medicine teams and prohibit care denial based on housing status.  

- Communities experiencing trauma: Mandate trauma-informed care training for all frontline health workers.  

- Elderly in isolated areas: Subsidize transport and repair post-disaster infrastructure (road, ferry systems, etc).   

- Foreign-born persons: Eliminate the five-year residency requirements for health benefits and expand protections for undocumented individuals.   

Conclusion 

Addressing health service gaps in Puerto Rico requires both system-wide reforms and population-tailored solutions. Each recommendation addresses barriers identified by affected populations and aligns with equity-focused best practices. Implementation can inform legislative reform, drive health system redesign, and guide public health leaders toward a more just and accessible model of care in Puerto Rico. This work directly contributes to filling long-standing policy gaps by centering the voices of those most impacted.

From the Margins to the Map: Rewriting Health Policy in Puerto Rico for the Invisible  


Cardiac arrest remains to be a leading cause of mortality in the United States, with the majority of events happening outside of the hospital. Although prior studies have demonstrated that compression-only CPR leads to improved survival rates, less than half of out-of-hospital cardiac arrests receive bystander CPR. This study aimed to assess participants' perceptions and baseline knowledge of CPR, deliver a concise hands-only CPR course, and evaluate the efficacy of the training through a post-survey. Results demonstrated a statistically significant increase in self-reported confidence after the training session. These findings suggest that brief, community-based CPR training can increase bystander confidence and may increase the likelihood of CPR participation, ultimately improving outcomes for patients with community cardiac arrests.

Improving Bystander Confidence in CPR Through a Hands-on Training

BACKGROUND

Approximately 68 million people—21% of the U.S. population—prefer to speak a language other than English. Patients with limited English proficiency and unrecognized cultural differences often struggle to communicate effectively in healthcare settings. Even well-educated, fluent speakers of conversational English can find medical terminology and clinical communication challenging. Language barriers profoundly affect healthcare quality and equity across a wide spectrum of patients—from those with little everyday English to those proficient in occupational English as a second language outside medicine. 

Federal law mandates that healthcare interpretation be provided at no cost. Yet, patients’ insights into the access, quality, and efficiency of interpretation services remain underexplored. Most studies have examined how patient communication and health outcomes are influenced by interpretation (with vs. without, or professional vs. ad hoc), rather than evaluating the language services themselves. Furthermore, research has largely relied on surveys, with limited use of in-depth qualitative methods such as semi-structured interviews or focus groups. As a result, patients’ lived experiences and unique voices are seldom captured or systematically analyzed.

METHODS

This study explores the lived experiences of Mandarin speakers who use English as a second language in healthcare settings, with the aim of identifying barriers in patient communication, issues in healthcare interpretation, and gaps in policy delivery. Recruitment was conducted in the San Francisco Bay Area through poster advertising and snowball sampling. Twelve Mandarin-speaking participants were selected after screening. Each participant completed a demographic survey and took part in a one-on-one, semi-structured virtual interview in Mandarin. Interviews were audio-recorded and transcribed directly into English. Thematic analysis was then applied to code transcripts in an inductive, bottom-up approach. Codes were iteratively grouped into categories, from which themes were constructed to provide a cohesive and salient account of participants’ lived experiences.

RESULTS

All participants, regardless of English proficiency or professional background, reported negative experiences when receiving healthcare in their second language, English. Confusion surrounding medical terminology was universal—even among well-educated, fluent speakers—who often struggled to fully express symptoms. Most prior studies have focused on oral communication, but participants emphasized that all four skills—listening, speaking, reading, and writing—shape healthcare encounters. Beyond language, cultural differences further complicated the situation. Strikingly, there is a gap between patients’ actual needs and the current all-or-nothing approach to healthcare interpretation. Five themes emerged as follows: (1) Common Patient Confusion,(2) Task-Dependent English Proficiency, (3) Difficulty Expressing Oneself, (4) Cultural Barriers in Care, (5) Gaps in Interpretation Services.

CONCLUSION 

Language barriers in healthcare are not all-or-nothing and affect far more people than studies or policies often acknowledge. “Limited English proficiency” also includes fluent second-language speakers who lack medical vocabulary or struggle to express themselves fully. These challenges go beyond speech—listening, reading, and writing all shape care experiences. Providers should use multiple forms of communication, such as written materials, visual aids, and body language, while fostering a supportive environment for patients to share concerns. To advance equity, healthcare systems must move beyond rigid interpretation models toward flexible, context-sensitive strategies that deliver the right support at the right moment for all.

Language Barriers And Inequities In Healthcare: a qualitative study of mandarin-speaking patients who use English as a second language when communicating with healthcare professionals

Background
Price transparency initiatives have gained traction among health reform efforts over the past decade. Almost exclusively targeting patients, existing efforts have produced underwhelming results, mostly failing to encourage meaningful price shopping. What remains underexplored, however, is whether making prices more transparent to physicians can change prescription behavior and ultimately lower health care spending.

Methods
Leveraging detailed electronic health record (HER) order entry data from 5 hospitals associated with a large health system in 2018–19, we conducted an interrupted time series analysis to estimate the extent to which the introduction of a novel EHR-based price transparency intervention was associated with a decrease in the proportion of high-price medications ordered by physicians when therapeutically similar lower-price medications existed. Our study spanned the 12 months immediately pre- and post-intervention, and we estimated effects separately for patients with pneumonia and sepsis, 2 common conditions that range in severity and have multiple treatment options. We grouped medications into high- and low-price categories based on acquisition data, and adjusted analyses for hospital, seasonality, and patient characteristics (age, sex, race, education, language, comorbidities). We performed falsification analyses using placebo intervention months.

Results
Across 12,863 patients with pneumonia and sepsis in 2018–19, patient characteristics were balanced across pre- and post-intervention periods (SMD <0.07 for all). Physicians prescribed significantly fewer high-price medications post- vs pre-intervention, with an estimated 4.8
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percentage point (pp) absolute reduction (32% relative reduction; P<0.01) in high-price medications following the intervention for patients with pneumonia and a 5.8 pp reduction (23%; P=0.029) for patients with sepsis. These effects were almost entirely driven by less severe cases (P<0.01) and were not replicated in placebo analyses (P>0.05). Reductions in length-of- stay and total admission cost were non-statistically significant (P>0.05).

Conclusion
Driven by less complicated cases with multiple close therapeutic substitutes, our results suggest that making medication prices transparent to physicians leads physicians to order medications of similar efficacy but lower cost to their patients when acuity allows. Price transparency efforts may be more productively targeted at providers than patients, with the potential to lower health care spending.

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