Hospital mergers have proliferated across the United States, yet a comprehensive understanding of how mergers affect nurses and patients is lacking. Determine the known associations between US hospital mergers and hospital-level factors that influence nursing, nurse well-being, and nurse-sensitive patient safety and quality-of-care outcomes. A scoping review of systematically searching 10 databases comprised of business and health care literature up to January 2025. We found 1775 articles; 10 met our inclusion criteria and were included in the analysis: 5 quantitative, 3 qualitative, 2 multimethods. Only 3 studies analyzed data from 2003 or later. Although data were sparse and older, we found that hospital mergers introduced organizational changes in nursing-nurse staffing, leadership, and operations. Whether nurse-sensitive patient safety and quality-of-care outcomes improved post-merger was equivocal. Qualitatively, nurses described poor communication, a perceived lack of trust in leadership, a loss of identity and unity, decreased morale, increased fear or uncertainty, and issues with equal and/or respectful treatment. Employed study methods and designs, as well as a dearth of recent studies, influenced the ability to draw strong causal and/or detailed conclusions, especially about newly emerging issues in today's health care system. Our findings suggest that hospital mergers may impact nurses and the nursing workforce. As hospital mergers continue to increase, future research with recent data and rigorous methods is needed to develop timely and applicable policy to mitigate any potential harms and leverage potential benefits of hospital mergers for nurses and patients.
Gravitational waves from binary black hole mergers provide a glimpse of gravitational dynamics in its most extreme observable regime, potentially enabling precision tests of general relativity (GR) and of the Kerr description of black holes. However, until recently, numerical simulations of black hole mergers have not been possible in theories beyond GR. While recent breakthroughs have overcome that obstacle, simulations covering the full, interesting range of binary parameters remain unfeasible. Here we present a new first-principles approach to this problem. We show how self-force theory can be used to model the merger and ringdown of black holes in a broad class of gravitational theories, assuming one object is much smaller than the other. We calculate self-force effects on the merger waveform for the first time, and we demonstrate how our formulation allows us to modularly compute beyond-GR effects and readily incorporate them into a fast merger-ringdown waveform model.
Existing studies have emphasized the important effect of native phonotactic experience and cross-language perceptual similarity on non-native speech perception, but have seldom considered this issue when the targeted non-native segments are undergoing a phonological merger. To supplement this discussion, this study investigated Mandarin Chinese (MC) speakers' perception of syllable-final segments (⁄-р⁄, ⁄-t⁄, ⁄-k⁄, ⁄-m⁄, ⁄-n⁄, ⁄-ŋ⁄, ⁄-Ø⁄) that are undergoing a coronal-dorsal merger (⁄-t⁄↔⁄-k⁄, ⁄-n⁄↔/-ŋ/) in Hong Kong Cantonese (HKC). The HKC speakers completed an Identification Test, which confirmed the documented merger of Cantonese syllable-final segments in previous research. A Perceptual Assimilation Test and an Identification Test were prepared for MC speakers to assess their perceptual mapping and perception performance of HKC syllable-final segments. As observed, the MC speakers failed to map the merging HKC ⁄-n⁄-⁄-ŋ⁄ onto the contrastive MC ⁄-n⁄-⁄-ŋ⁄. Moreover, they perceptually collapsed the merging HKC ⁄-t⁄ and ⁄-k⁄ into one category via an illicit alteration of the place of articulation. However, neither native Mandarin phonotactic experience nor cross-MC-HKC perceptual similarity can sufficiently explain the MC speakers' perceptual mapping and rendering of the merging HKC targets. Accordingly, the current study proposes that the non-native phonological merger has a supplemental mediating effect on non-native speech perception.
The taxonomic status of Chamaemyces as a genus separate from Lepiota has recently been questioned, as its type species has been transferred to Lepiota, implicitly rendering the merger of Chamaemyces as a synonym without a resolved sectional assignment or morphological validation. Multilocus (ITS, LSU, rpb2, mtSSU) phylogenetic analyses robustly place this transferred species within L. sect. Cristatae, and detailed morphological re-evaluation further supports the merger. The recently proposed seven-section classification of Lepiota is largely supported by the phylogenetic framework, which also clarifies the phylogenetic position of L. angusticystidiata. Furthermore, two novel species are described and illustrated: L. pallidovelata (sect. Lepiota), which is characterized by whitish squamules on the pileus with veil remnants, and L. stillispora (sect. Helveolae), distinguished by its droplet-shaped basidiospores. Both the sectional assignment and the proposal of novel species were further independently confirmed by a comprehensive ITS phylogeny of the genus. This study provides conclusive phylogenetic and morphological evidence for the prior merger and expands the known diversity of Lepiota in East Asia with two new taxa.
This study extends the Montefiore Einstein Robust Geriatric (MERGER) norms by developing and validating standardized regression-based (SRB) change formulas for a co-normed neuropsychological battery in a robust sample of older adults. We also examine their clinical utility for differentiating mild cognitive impairment (MCI) and dementia and provide multivariate base rates of decline. Standardized regression-based equations were derived from a subsample of MERGER participants (n = 320) using backward regression to predict Time 2 scores from Time 1 performance and relevant demographic factors. Equations were validated in an independent subset (n = 100) and applied to 63 individuals with MCI and 32 with dementia who completed at least two study visits but were excluded from normative analyses. Clinical utility was examined by comparing predicted and observed performance across diagnostic groups. Categorical and multivariate base-rate analyses were used to establish clinically meaningful thresholds. Baseline performance was the strongest predictor of follow-up scores, with demographic factors adding measure-specific variance. SRB equations performed well in the validation sample. Exploratory clinical validation analyses indicated that decline was uncommon in cognitively unimpaired (CU) participants but more frequent in MCI and dementia, particularly on memory and executive tasks. Multivariate analyses showed that decline on ≥3 measures was rare in CU participants but observed in nearly half of participants with MCI and most individuals with dementia. MERGER SRB change formulas offer a practical, individualized method for tracking cognitive change in older adults. Incorporating multivariate base rates of decline further improves differentiation between normal aging, MCI, and dementia, supporting more accurate longitudinal interpretation and clinical decision-making.
The horizon of a black hole, the 'surface of no return', is characterized by its rotation frequency ΩH and surface gravity κ. A striking signature is that any infalling object appears to orbit at ΩH owing to frame dragging, while its emitted signals decay exponentially at a rate set by κ as a consequence of gravitational redshift. Recent theoretical work1 predicts that gravitational waves from binary black-hole mergers carry direct imprints of the properties of the merger remnant in the form of a 'direct wave'. This gravitational-wave component oscillates near 2ΩH, reflecting the horizon's frame dragging, and decays at an increasing rate characterized by κ, with additional screening from the black hole's spacetime. Here we report observational evidence of a direct wave in GW2501142, with a 90% credible matched-filter signal-to-noise ratio of 15.8 - 0.5 + 0.1 ( 17.1 - 0.4 + 0.1 ) in the LIGO Hanford (Livingston) detector. The measured properties are in full agreement with theoretical predictions for a Kerr black hole. These findings establish an observational channel to directly measure frame-dragging effects in black-hole ergospheres and explore (near-)horizon physics in dynamical, strong-gravity regimes.
Rhesus macaques play a valuable role in biomedical research, and their genetic characterization is critical for effective colony management. Levels of genetic diversity, genomic admixture, and genetic substructure can all impact the suitability of macaques for biomedical research. The Southwest National Primate Research Center (SNPRC) houses one of the largest rhesus macaque colonies in the United States. Their genetic management includes the ongoing assessment of genetic diversity, ancestral origin (India or China), and deep sequencing of the major histocompatibility complex (MHC). A goal of the SNPRC has been the reduction of levels of admixture between Indian- and Chinese-origin macaques and the prevalence of simian immunodeficiency virus (SIV) refractory MHC haplotypes while maintaining overall genetic and MHC haplotype diversity. This has been achieved by targeted sequencing of the MHC and removing animals with haplotypes more prevalent in Chinese-origin macaques from breeding. We investigated the impact of management strategies on admixture, population genetic structure, genetic diversity, and inbreeding using whole exome sequencing of founding and colony-born animals (n = 488). Admixture analysis of founders showed one animal to be of Chinese origin and an additional 37 considered admixed (> 15% Chinese ancestry; range 16.3-84.5%) with population substructure closely reflecting primate research center source. The levels of Chinese ancestry in the colony declined over time, though genetic diversity remains high (heterozygosity = 0.320). We characterized the MHC through targeted sequencing of 1,069 SNPRC macaques born over a twelve-year period. MHC management strategies reduced the prevalence of SIV-refractory MHC haplotypes, with Mamu-B*008 reaching significance (p = 0.027), while overall haplotype diversity was maintained (Mamu-A, h = 0.907; Mamu-B, h = 0.952). Finally, we performed genome-wide scans for genetic selection over time. We identify numerous genomic regions where allele frequencies have shifted significantly, supporting the presence of short-term adaptation under colony management. We show that colony management strategies have been successful without reducing genetic diversity of the MHC or exonic regions. We also show that colony genetic substructure is related to animal colony source and that mergers and migrations have reduced inbreeding and increased overall genetic diversity.
Membrane fusion is an important process for the survival of eukaryotes. Moreover, enveloped viruses enter the host cell utilizing membrane fusion. Therefore, it is essential to comprehend the mechanistic details of this intrinsic and crucial process. In this chapter, we will discuss several aspects of membrane fusion, including intermediate states and their energetics. We will further discuss the role of lipids in the stabilization of intermediate structures that lead to fusion pore opening. We will elaborate on the different existing models of membrane merger or fusion, with a major focus on the importance of lipid-peptide interplay for the completion of the process.
The pharmaceutical industry is experiencing significant transformations driven by mergers and acquisitions (M&A), leading to complex debates regarding their impact on innovation. This study examines the intricate relationship between M&A activities and innovation within the sector, analysing whether the traded firms have received public funding and revealing diverse scholarly perspectives on the balance of benefits and drawbacks. We conducted a targeted literature search for a narrative review using a combination of various terms in academic databases (PubMed), complemented by grey literature to find studies that analysed the impact of M&A on R&D. For the case study on the European pharmaceutical M&A landscape of 2023, we used the proprietary database Orbis to find such deals. We then combined information from company websites, investor news, governmental funding agencies, academic news, and academic publications to find public spending for the companies that were acquired in 2023 and used a category system we developed for public contributions. Existing literature suggests that M&A in pharmaceuticals is primarily motivated by technological and geopolitical shifts. However, concerns about market concentration during the drug discovery-to-development pathway highlight potential regulatory challenges. Our analysis of 2023 M&A deals shows that four out of 29 firms traded originated from academic spin-outs, with almost all small and medium enterprises (SMEs) involved having received public funding at some point (18 out of 21). The lack of a comprehensive, publicly accessible register for such contributions complicates analysis. We advocate for mandatory reporting of all publicly funded projects to a single agency, enhancing transparency. The study concludes that while M&A activities can foster innovation, they also pose risks that must be carefully managed through informed policy and regulatory frameworks, particularly concerning publicly funded biotech firms and academic spin-outs.
With U.S. health systems increasingly entering partnership, acquisition, and merger agreements, the usual stated goals are improvement in quality of care and patient experience, along with improved financial performance. But attainment of these goals has been inconsistent at best. After its April 2023 acquisition of Sparrow Health, Michigan Medicine and its five-hospital system, University of Michigan Health, launched a major effort to advance business, clinical, and cultural integration across the new 11-hospital enterprise. The goal was to achieve a coordinated, integrated statewide system of care that delivered improved quality and better experience, while providing academic hospital-caliber care closer to home for patients across the state. Those efforts have led to improved financial performance. The adjusted operating margin at the former Sparrow hospitals, renamed University of Michigan Health-Sparrow (UM Health-Sparrow), increased from negative US$158 million in 2022 to positive US$28 million in 2024. Employees' response to a survey question about their level of satisfaction with UM Health-Sparrow as a place to work, measured on a 1 to 5 scale, increased from 3.54 in 2022 to 3.87 in 2024. Annual turnover of registered nurses at UM Health-Sparrow dropped from 17.4% in 2022 to 7.7% in 2024. Clinical integration, driven by the development of local clinical programs, initiatives to coordinate statewide care, and innovative technology solutions, has resulted in a higher quality of care delivered closer to home. A new neurosurgical program at UM Health-Sparrow has improved local access for patients with more complex diagnoses while also delivering higher-quality care. In the Michigan Spine Surgery Improvement Collaborative, the overall quality score increased from 63% in 2022 to 91% in 2024. For cultural integration, the keys to success have been leadership alignment, a clear vision and goals, a supportive infrastructure, strong systemwide communication, and achieving and celebrating early wins. Although the journey is ongoing, progress to date demonstrates that a carefully planned and executed strategy for system integration can yield greater operational efficiency, meaningful improvements in patient care, and progressive cultural alignment.
In the present manuscript, we describe the development of a protocol for the alkylpyridylation of styrenes, enabled by the synergistic combination of triplet ketone catalysis and an aminyl radical transfer (ART) strategy. A wide variety of alkylboronic acids or boronates and substituted 4-cyanopyridines act as the alkyl and pyridyl sources, respectively, and react with styrenes to deliver the corresponding dicarbofunctionalized products in good yields. Mechanistic studies indicate the generation of alkyl radicals under the reaction conditions, and the activation of alkylboronic acids or boronates occurs through the ART pathway.
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Exocytosis releases vesicular cargo to the extracellular space and adds membrane to the cell surface, whereas endocytosis retrieves membrane and internalizes extracellular material; together, they maintain membrane homeostasis and enable rapid intercellular signaling. Super-resolution imaging has revealed that these processes are far richer than the classical "kiss-and-run vs. full-collapse" or flat-to-round schemes. Exocytosis now encompasses at least seven fusion modes with reversible pores, vesicle shrinking or enlargement, and compound or sequential compound fusion, while endocytosis proceeds mainly via modular flat→Λ→Ω→O transitions and rapid closure of preformed Ω-profiles. These dynamic transformations are orchestrated by Soluble N-ethylmaleimide-sensitive factor Attachment protein REceptors, Ca2+/synaptotagmin, dynamin, clathrin, and the actomyosin cortex, and their dysregulation underlies neurological, metabolic, and oncogenic disorders.
Costing nearly three quarters of a trillion dollars annually, the funding for pain research pales in comparison to that spent on cancer, diabetes, and heart disease despite consuming more resources than the three aforementioned summed together. Decentralized science (DeSci) supported by decentralized finance (DeFi) provides a complementary framework for funding and conducting pain research by addressing longstanding limitations in traditional grant systems. Reliance on federal funding often results in structural bottlenecks, transparency gaps, and restricted access to early stage or high-risk scientific ideas. DeSci-DeFi systems employ decentralized ledgers, tokenized utility for governance, and smart contracts to enhance transparent research funding allocations, verifiable workflows, and tamper resistant data management. Decentralized Autonomous Organizations (DAOs) enable community-driven participation in scientific research, can help support milestone-based resource distribution, and facilitate open data dissemination through interoperable infrastructure. Case studies, including longevity focused initiatives, demonstrate the ability of DAOs to support projects that face constraints in conventional channels. Despite technical, regulatory, and governance challenges, DeSci-DeFi represents a practical complement to legacy models and may broaden participation, strengthen reproducibility, and expand the scope of fundable pain research.
Membrane nanotubes, including tunneling nanotubes (TNTs), tumor microtubes (TMs), cytonemes, and related structures, constitute open-ended conduits that directly connect cells. They enable the directed exchange of organelles, nucleic acids, proteins, and ions across tens to hundreds of micrometers while preserving cellular identities. Specifically, this chapter synthesizes the current understanding of mechanisms, delineates cargo selectivity and transfer modes, and integrates cancer-relevant functions, such as mitochondrial transfer, calcium-wave propagation, and therapy adaptation. We emphasize rigorous criteria and multimodal workflows to distinguish conduit-mediated exchange from gap junction coupling, extracellular vesicles (EVs), trogocytosis, entosis, and bona fide cell-cell fusion. Across carcinomas and malignancies, tubes organize multicellular networks that distribute stress, shape metabolic plasticity, and seed resistant subclones. We outline vulnerabilities in tube biogenesis and coupling, propose a communication-fusion continuum, and set near-term priorities for in vivo quantification and translational targeting.
Even though the merger of two (or more) cells appears simple, the whole process is rather complex and not yet fully understood. While it is clear that cell-cell fusion and virus-cell fusion depends on the expression and presence of specific fusion-relevant proteins and molecules, such as fusogens in general and their receptors, cell-cell adhesion molecules, proteases, and phospholipids like phosphatidylserine (PS), the underlying mechanisms that regulate and control cell-cell fusion still remains to be elucidated. In this regard, it is necessary to discriminate between physiological and pathophysiological cell-cell fusion processes. In physiological cell-cell merger, the fusion machinery, which is composed of all fusion-relevant proteins and molecules, is initiated in individual cells in an inherent and even evolutionarily conserved time- and development-dependent manner. The sperm and the oocyte have to fuse during fertilization, the merger of trophoblasts into multinucleated syncytiotrophoblasts is important for proper placenta formation and function, and multinucleated myofibers cannot originate without the fusion of single-nucleated myoblasts. In contrast, cell-cell fusion events that occur in adult organisms in a rather non-evolutionarily conserved manner, such as the merger of cells in tissue regeneration processes or in tumor tissues, remain ambiguous. While it is clear that the fusion machinery must be active, it is not completely understood how the merger machinery is ultimately initiated and controlled in these cells, which particularly applies to tumor cells. In fact, it is well-known that tumor cells can fuse with other normal cells, such as macrophages, fibroblasts, and stem cells, but it is completely unclear why tumor cells and normal cells do this. Is this the reactivation of probably evolutionarily conserved mechanisms that have occurred in cancer cells and normal cells, or is this purely random? And if so, does the merging of cancer cells and normal cells have any benefits for the organism, for example, by enabling the immune system to better recognize and eliminate the fused tumor cells? Or, on the other hand, does illicit tumor cell fusion compound tumor growth and evolution via genomic rewiring/reprogramming and the inheritance of genomic instability to the next generation?Thus, the aim of this book is to bring more light into the complex, tightly regulated, and fascinating process of cell-cell fusion.
The academic identity of clinician-educators is critical to supporting the broader mission of health care organizations. Mergers are increasingly common, but when private and academic institutions merge, they may threaten clinician-educator academic identity and negatively impact their work as educators. The effect of these mergers on academic identity-specifically for clinical educators-has not been systematically investigated. We aim to understand the effect of a merger between our academic institution and a not-for-profit regional health care system on the academic identity of clinician-educators. Two theories of organizational change framed our qualitative interview study. A semistructured interview guide was designed following the theoretical framework elements. Fifteen academic clinician-educators who experienced the merger were invited to a Zoom interview. Selected candidates were at the academic rank of Professor or Associate Professor, were noted to have leadership roles within the academic institution and represented varied clinical specialties including surgical, medical, hospital-based, and clinic-based disciplines. Data were coded using deductive directed content analysis to identify professional identity-related response patterns that would illuminate potential change in identity, consideration of alternative employment, shift in motivation, or reduced organizational loyalty. The data coalesced into the four theoretical framework elements. Clinician-educators articulated their transition reactions, detailed how they define their identity, noted varying degrees of continuity perceptions, and articulated resistance considerations and actions. The initial uncertainty and workplace changes were distracting and may weaken clinician-educator academic identity. Supporting clinician-educator academic identity is core to fostering a culture of academic and educational excellence during mergers.
The authors explore how large pharmaceutical corporations may integrate emerging decentralized technologies-such as blockchain and decentralized autonomous organizations (DAOs)-within their merger, acquisition and partnership frameworks, and how these strategies intersect with broader innovation and external sourcing models. In this context, blockchain is considered primarily as an enabling infrastructure for decentralized governance and programmable coordination-supporting mechanisms such as tokenized incentives, auditable decision trails, and new forms of intellectual property (IP) and collaboration structures. This study employed a qualitative case study methodology, combining document analysis and semi-structured interviews with internal stakeholders from a leading large-cap pharmaceutical company (herein after "Company"). Participants included executives and professionals from corporate development, scientific research, external innovation, and digital strategy units.The analysis examined how a large-cap "Company" approaches mergers, acquisitions, and partnerships, and how emerging technologies may influence these frameworks. The study focused on strategy alignment, organisational attitudes towards decentralisation, integration constraints, and perceptions of innovation value along the external sourcing continuum. Acquisition and innovation strategy by the "Company" is driven by long-term alignment between external opportunities and internal priorities. Over time, the "Company" increasingly turned to external sources of innovation, leveraging technologies to improve innovation scouting, target identification, and operational forecasting. While decentralisation technologies such as DAOs are viewed as promising for early-stage innovation and collaboration, their integration is hindered by legal ambiguity, internal governance rigidity, and unfamiliarity with token-based economics. The "Company" views mergers and acquisitions (M&As) and licensing as critical to sustaining its pipeline, and sees potential for emerging technologies to accelerate preclinical decision-making and improve visibility into academic and biotech ecosystems. This study contributes insights into how large-cap pharmaceutical firms might adapt their innovation models in response to technological change and external pressures. While established mechanisms such as M&A and partnerships remain dominant, digital and decentralized technologies offer complementary tools for scouting, collaboration, and portfolio expansion. The authors examine how a top-tier large-cap pharmaceutical company’s external innovation framework (spanning mergers and acquisitions (M&A), licensing, and partnerships) interacts with emerging decentralized approaches, particularly blockchain and decentralized autonomous organizations. Using a qualitative case study design, we combine document analysis with semi-structured interviews with seven senior stakeholders across corporate development, R&D, external innovation, and digital strategy. We analyze how strategic alignment is assessed, how decentralization is perceived internally, which constraints shape adoption, and where decentralized approaches are viewed as potentially value-adding along the external sourcing and partnering process. Findings indicate that acquisition and partnering decisions are primarily guided by long-term fit between external opportunities and internal priorities, with a growing reliance on external innovation supported by digital tools for scouting, evaluation, and forecasting. Decentralized approaches are seen as most relevant for upstream activities, such as early-stage sourcing, distributed evaluation, and ecosystem building, but their adoption is constrained by legal and regulatory ambiguity, entrenched internal governance requirements, and limited familiarity with token-based economic models. Overall, decentralized technologies are perceived as complementary enablers that may strengthen early innovation discovery and ecosystem visibility, rather than substitutes for traditional M&A, licensing, and partnership models that remain central to late-stage development, integration, and market access.
Vision-language models (VLMs) have recently shown strong potential for multimodal scientific applications, yet their direct application to molecular structure images remains challenging due to the need for precise visual-textual alignment. In this study, we investigate efficient fine-tuning strategies for adapting a large-scale VLM to molecular image captioning tasks. Our approach is built upon the Qwen3.5-9B architecture and focuses on lightweight parameter-efficient adaptation.Specifically, we apply Low-Rank Adaptation (LoRA) to the language-side MLP layers and explore selective tuning of the visual merger module that bridges the vision encoder and the language model. This module compresses visual features and projects them into the language embedding space, making it a critical component for cross-modal alignment. Experimental results on molecular image captioning tasks show that the combined L-MLP + Visual Merger tuning strategy achieves the best performance while maintaining low computational overhead.In addition, we evaluate multiple decoding strategies, including greedy decoding and stochastic sampling methods, to identify the most suitable inference configuration for molecular image captioning. The results demonstrate that selective fine-tuning of the visual-language interface significantly improves caption accuracy while preserving efficiency. These findings highlight the importance of adapting cross-modal projection modules when deploying general-purpose VLMs in specialized scientific domains such as cheminformatics.Scientific contributionWe provide a systematic analysis of layer-wise fine-tuning strategies in large-scale vision-language models(VLMs), identifying which components are most critical for adapting general-purpose models to molecular image captioning tasks.We identify the cross-modal projection module (visual merger) as a key factor in visual-textual alignment, demonstrating that its selective adaptation plays a central role in improving caption quality.We propose a parameter-efficient fine-tuning strategy that combines light weight language-side adaptation with targeted tuning of the visual-language interface, achieving an effective balance between performance and computational cost.We provide practical insights into efficient adaptation of VLMs in scientific domains, highlighting key considerations for achieving performance under computational constraints.
We examined associations between hospital system market share, merger activity, 340B participation and operating margins using data for 2,226 U.S. hospitals. We calculated Metropolitan Statistical Area (MSA)-level health system market share, tracked merger activity from 2017 to 2022, and constructed a commercial price index for 1,336 hospitals with available prices. Hospitals with a greater share were significantly more likely to participate in the 340B Program. Among larger hospitals, a 20 percentage-point increase in MSA-level health system share was associated with a 7.6 percentage-point increase in the likelihood of participation. Recent mergers were linked to an 8.6 percentage-point higher likelihood of 340B participation; 340B participation was associated with 1.1-3.0 percentage-point higher margins for non-merged hospitals and 5.2-7.0 percentage-point higher margins for merged hospitals. Greater market share and outpatient revenues were associated with larger estimated 340B margin effects, consistent with the outpatient-focused design of the program.