CINXE.COM

<!DOCTYPE html><html lang="en-US"><head><title>Just a moment...</title><meta http-equiv="Content-Type" content="text/html; charset=UTF-8"><meta http-equiv="X-UA-Compatible" content="IE=Edge"><meta name="robots" content="noindex,nofollow"><meta name="viewport" content="width=device-width,initial-scale=1"><style>*{box-sizing:border-box;margin:0;padding:0}html{line-height:1.15;-webkit-text-size-adjust:100%;color:#313131;font-family:system-ui,-apple-system,BlinkMacSystemFont,Segoe UI,Roboto,Helvetica Neue,Arial,Noto Sans,sans-serif,Apple Color Emoji,Segoe UI Emoji,Segoe UI Symbol,Noto Color Emoji}body{display:flex;flex-direction:column;height:100vh;min-height:100vh}.main-content{margin:8rem auto;max-width:60rem;padding-left:1.5rem}@media (width <= 720px){.main-content{margin-top:4rem}}.h2{font-size:1.5rem;font-weight:500;line-height:2.25rem}@media (width <= 720px){.h2{font-size:1.25rem;line-height:1.5rem}}#challenge-error-text{background-image:url(data:image/svg+xml;base64,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);background-repeat:no-repeat;background-size:contain;padding-left:34px}@media (prefers-color-scheme:dark){body{background-color:#222;color:#d9d9d9}}</style><meta http-equiv="refresh" content="390"></head><body class="no-js"><div class="main-wrapper" role="main"><div class="main-content"><noscript><div class="h2"><span id="challenge-error-text">Enable JavaScript and cookies to continue</span></div></noscript></div></div><script>(function(){window._cf_chl_opt={cvId: '3',cZone: "jamanetwork.com",cType: 'managed',cRay: '91e9ef1bbca39f6e',cH: '4CUabHj.X5WLsNiiFAq3ykHHwnW0r.4fGR4ry32yhIo-1741684387-1.2.1.1-hR7UwzRP3Ya_qIz5CAihRI6eoYDUv.er4G6Hr2Jke4tx03O17kSyRXxspoIaj6f7',cUPMDTk: "\/journals\/jama\/fullarticle\/2793446?__cf_chl_tk=MTsKvGACa4KsgUg7dME4zxbFICNWxUHTHIXZojiXqKk-1741684387-1.0.1.1-VS3b5tNd2647jbm5rtzDKLWmXaGWq2rv1yv9zm.U4wE",cFPWv: 'g',cITimeS: '1741684387',cTTimeMs: '1000',cMTimeMs: '390000',cTplC: 0,cTplV: 5,cTplB: 'cf',cK: "",fa: "\/journals\/jama\/fullarticle\/2793446?__cf_chl_f_tk=MTsKvGACa4KsgUg7dME4zxbFICNWxUHTHIXZojiXqKk-1741684387-1.0.1.1-VS3b5tNd2647jbm5rtzDKLWmXaGWq2rv1yv9zm.U4wE",md: "wvSaVgjJvbUpdAkjjKWmMkI._ZxiwlAHEGdz.nx3p_w-1741684387-1.2.1.1-E9d1MdBZ9Q03PKxoVRoskNrFKW.vs3MWCWcszEZTrMNW5Bq1q8ZTVyV9xqmPTjNUrdn7yAcbzKZkYJxZ6GinmYg99Bu6IuHR9E..fytoQmNhNHHDqXHMYIUTVDLaxdfG1IRWH4oXv9.6H9yCoghj1W.mfLAHsKWFFGI7VgeVed82IsZiIabZlW5jlSrxMLv52mXD1dEYKnSk_EmOr.mfoOe_jyLUlI.7HCHecrmLadS9hcH.SoWeAu55KogdOvurmtcPwa2J2VcMT.o2SiGR9GOBPQhUHpvnQNivaUwesrC94luWi7kKSu3nF6YNTFLztz35PqTfYPC08utWfJRDWGigKlkLlSZR8MXine8hmvNg98I9uq1lVr6xgh2raqooJzDJA1SgWa.mQUwBkaAnkoPf_Uki3ThcSLBIZjGLHI0eNbxqPOuVj4jrwWpwYoR5b2nQrCOLrDu._LjWPqMVadhl8gEqCgF5LgIG4.QEE_zZk8hxOahuchvCWCBdfgYVhI1NJ03C9r0578h_kJ8FdgLDh3.EqteUU4eT_ASKkOymZFD8PGGNdqSO3ABwp3kyziwHqJTMQWoS2udoB4y0IluNlOoA_.qMAijHO7l96gaYRSPeiBHPZgxDfDP.b0GWePriXLD5FW7N.5l6nCaTHejTONy.bC3qHYlv.SyMmJc_hZ5Mw5yRPDatXFxyHZyJe4hApqpFv7MkIZ3gl5VJusR0tUl2t140jRVXykxxwJM2gw1UFHqHI6_2WgqWmnMZy7GgZLCEnOqybp5bqlgxiQDhfDdmbfglULUk03NktFZiFFKntNMvgGzTuLN8_kqOEfiQik1sbi9sPMcAhqP1Ok_If2MaeSrDksjSuGGsXdhwTX7I7F9BjgT4FSOLiRUXqdUgktc5WGnm8FkgDbczk781NXURCwZpFY0VqUOXnTC2LgSsye4JWXJS7v0lffE_dH__EA.OiDOfuMzzjXx4gcEzVpSh9CgOQ6cVol4GAzlkdX9VvaC6pad211Oy9CuGlClDHGZ2lGxyEZD7F_RSb0qZ3XOWzlb5sBoxaxq5XahIVr5mXAkgcAtuzU8CYLIw4lfQDtQvaAeKn5DZCe7WELTQoVuZaXV.AJtISV9nW9fqCrA_Kr79hmQU5fz_I.XnT3_SqcD4F4hBUMMUvAQ_h3lzJorUbaUxUySKXbnbvnKWVuSzbE4ifwn7QY.YKOyvAkHv5xCbz1cP0d5DULPMAGXHtzFp5o4LW3ak_Cr1VEXLN3sjRNxxD0ujMo7fOrX.JlAOzqg9ux574asS0ImqR5I6m4XRvrBIcAiY4yTmgqg",mdrd: "RkEI1bQp2xHnpqejNZO9bK52Vqg5Qr9mqXpzNj2NjHY-1741684387-1.2.1.1-0RJZQclUevJinWxdMyujAj8A7HpaOb_YItFA56ilg0TgUmS.TI4E6L1XV6dKPDwU3lyQTqf9xR.9dKtbnF5VexEWvnUncaDmjECDDO1EFMtiGmkMbbPiqGl_4IzgHLqTr4t.ksrnz43ueGOW3LdKdslrseiYiPorVHt4OhVPPpAkqBHk1RK56kMH6y_UdwrEciem4jQVpi9H8_8Ts7rGQlLfRmi6D5ozVo3Y7e0aO38NRk4Kh_.213EYrJTxHkDEjLNhoEkVor_B.mJg4d73_Trhn31fqXzXjhUm5Pon.Yv52vJpn_2YnWbOKT5JEuejoXnNLazlDvGfxx.4H.oDTEs1wcZ8177.62WQz7cQTnKjsUL3oGSwHpGyVRTDofoMsc32zD29GHFLNWMu.v_azoH2EyeZBxPgh.rZJZSjOzmOuWHic2gin7kITNZK3iZOyZT7gtElS9BL_tHZDwLQSEUqXA8qjhAO82VYmF26FP3b6.u.POzbYYnBFGPPFd1vU1BouNemE6ldZDOciGHlSbR5kOaBKWFHFHqMcsbq_R2I8.L8aqTKHqazQ5UD_oZ8O1AyiFjq3Ubtwx_qkh0KRRmGyj0Xdnj7_ogD45qi02bf1apga8vVd95A0dZ19hSmn_tODXattoqQpAOjoop_CGUSrsxf.l5lPjmY14tqJQfRvzvwthgfmsnv3WnKxChoUjOoth__OQ_oKK.okusX._Y9F.HIqbULEIGxePu6VUzNIgV6uU8g2gZXhLYsnf9doKS5aKOLb6tM2VOMvau5zH8I3o9yw2ybBM2WOrNUZ3.SaZFoTGFU4WttZFec00HnI8eWhQMii6n1kfof57aXFloa_pbQVeVuCMkBzCoYWArhzhjjlpLweHujZJLJTbp5V9bsE7HOvAKRAqxScQG0TVk9uy4VokDNUPhixsLBA_qMgrRHe7HM1DoiWiA3eWN5UQcFeRJquxjHfDxzQV7WYuzEzfs_0QxEjs95uvz.9I.VMN2KK5gQi1XyNs.L44cbOgsjrZW.rL6eDY_eBRnECCTAV9l8gHQ8nWRi5Rbj0.uYwmICgZ6y.o4JKUZXwhWTlo2xY8nRBexfA32V93hBWK54RcB1howkhR4JafdgUsKEgy9zbTF1xaQXbhQ6PIVNomtXOuFDRgDyPjW3OyKhKvpe0R7qRXU7WnqHwAH3Pm9VUproCvirkseizjemylzOf6Ealtvw7AZre1wS1AwD6m32e_CAbiQQBkfHyXUV1S9xApL4sdGKCX0U4_qf6B8moa1642Bw63jIXwD05ApnG4ndqktyvlBcT639E08.ysxpIAwbkGIQmCLG_W.S9WD46j0RIWVQ0QGuH2BpkJ7AAm8eaDnBmofe7lc0k3DK9naDifZhYWUrMvYLI_3WH_y2yxdd_dIP_Q9obdUAk544B1SYbsmntZOSnOjNwO3cuSS31epFkJLGd4d7M9QuoRny0AaOeZydZ8J.MysAXpt28nNQv_IlT5o_SGyL851lDtNscug1w3G_kUorkv8PBAA7bFY3M3XRjHmdOcyuUYFucIBZCZJaFYIiCSyjMDQKYhOhdoQzw9tJOmoYOVtXNct6bNEAr9jRLK6bhhPDnuDd21HG7xA33WRdOloOB_D5CxYMoJsFgbNBMy_V3ovHkfI59mqU2Tf5EHgInMX_0g88VN.KArDAZxFXYvF2RR4nRjO__Y9KYwlm7SEMHZt1tuy8_0P1Z63jbPHTEVpOPuP9lzCAoBZWhGXOHGH2N.lZczkAeuaGjAuMPPlZAPopggLhVs1qm6I9sRuVrPNbuRb4WQiSb9bOgarJlEp1GUWAy3Vl0ADF5D97HXSiL5J0bEA8d6yv2hoSkSzUDb6tS3USzjHLmrdS2dnq7eU6BjsD2WKUSGoQ_9p31JlO_5XVyJJMyT5TNpTCWZDNSFGf4pbg0Bla0oN8jq.WYqY_NXqTtnSLHlOZt.LmoJjruJaV3.edjzWy13J5B4U2yV37Ac8DZA"};var cpo = document.createElement('script');cpo.src = '/cdn-cgi/challenge-platform/h/g/orchestrate/chl_page/v1?ray=91e9ef1bbca39f6e';window._cf_chl_opt.cOgUHash = location.hash === '' && location.href.indexOf('#') !== -1 ? '#' : location.hash;window._cf_chl_opt.cOgUQuery = location.search === '' && location.href.slice(0, location.href.length - window._cf_chl_opt.cOgUHash.length).indexOf('?') !== -1 ? '?' : location.search;if (window.history && window.history.replaceState) {var ogU = location.pathname + window._cf_chl_opt.cOgUQuery + window._cf_chl_opt.cOgUHash;history.replaceState(null, null, "\/journals\/jama\/fullarticle\/2793446?__cf_chl_rt_tk=MTsKvGACa4KsgUg7dME4zxbFICNWxUHTHIXZojiXqKk-1741684387-1.0.1.1-VS3b5tNd2647jbm5rtzDKLWmXaGWq2rv1yv9zm.U4wE" + window._cf_chl_opt.cOgUHash);cpo.onload = function() {history.replaceState(null, null, ogU);}}document.getElementsByTagName('head')[0].appendChild(cpo);}());</script></body></html>