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: '9139bbd2fc74fd0a',cH: 'xg0Pp87K41AGEpQtFNPIW3FGEjT7ulNL0e.PkwnRvPE-1739836792-1.2.1.1-xRlGoj6a1cCH56jwahK1FhUfRzclEcx9rra9DCZnYrtqc.a.sSKXB0SH2hR9.0m3',cUPMDTk: "\/journals\/jama\/fullarticle\/2762688?__cf_chl_tk=MUMSM55OLBURqmwrcm6HbUv5z20HTlkh3sMVESDK2kw-1739836792-1.0.1.1-Z0oAkH849pBW.DrQp..si14HGyCrYCfjz7zL35kIZsU",cFPWv: 'g',cITimeS: '1739836792',cTTimeMs: '1000',cMTimeMs: '390000',cTplC: 0,cTplV: 5,cTplB: 'cf',cK: "",fa: "\/journals\/jama\/fullarticle\/2762688?__cf_chl_f_tk=MUMSM55OLBURqmwrcm6HbUv5z20HTlkh3sMVESDK2kw-1739836792-1.0.1.1-Z0oAkH849pBW.DrQp..si14HGyCrYCfjz7zL35kIZsU",md: "RzkflvSJRF0BawlKwrM3vzTDQSK8k8.jnAIFT0krrhk-1739836792-1.2.1.1-oDtS9Z4H1X5HxazOCQ7rB9YYQejzyUxjdpb4WNQ9hvs8TRS5yjoN7OYtUjak_vsD6FKVvYIb1eNunJ83nBL0tpECp7yth4YPgV1WVGY_sxAsNzhX8K5sgbFyQ.u.jYVxeE7ZUhdEiqYD_bfa6CNp8F6W_sZKBvTzFXyV_VW.ScraS0ypVa5X0aWzA24EK9lzLsgrFqSEvU8_TQ94rLWISZeM9IMBZNjQ6SErhw54Pq7AkiT6q4wdSrqWAoRXuESt5_9rF1pdqBM3.MaHetvd3XYeMbP3X25mtp.OIKhhKy9rlY8CeaJ5yglo0lWMlXEcNmR4qTBZUAiQa36aI6QRIFLMax9xWwNaI3gvTT2PmuPllCkofc_M9gBSS8jrx2MerGb1FGCJ8fTFIWRZqfD8IlOPQPy5wl14NKxWDUqovxEGdAt_DFVqxrft19fBSGNBREacgBeKXZFWnhAtUNOOsg6jS70hZdvhUEUG18uyECJa0364b7ITUD45HCJ5vgr502VpOXwpTA.4APsQgU5_KH_2M4oOdjp8KPUapNF52c5IawTuTyNsNoYjvAR2T6lx1xHX3WxnDYxJevM3RPFJWGuD5Ii2jA8ncrB9O4CMXvhLT_LBVyr3wMxNbwa1qRExGOJ65nrKN9gU9GUZ9HsUlUWILJlDvTRMshZ.aMnqz2nmzqft618gX930RyoSWguW_QHLgAEjuA3zMnL6hQt2C58RGUywbXhn6FFvzjqLocZ2qNyJ5rEf4MYLnvONi4NLvxe3rF9DZ5ZcGpqQaJgfIxtnfn0ToUVkabKB5v0S9BYO.MsD3SPN0nxEnUGKHOJyOPA8WrHtXerpmoULI.PWSY1qr9QB5mGDyzHiy43O4S7eyDrdwC.v_jaiWoZREM9_AyjOGYU.Ds8yfPMCss64ChA3ph3CanzQGIH.xgzuG4hqbk5iG5N7tO8byLQNaukaW4Juj9d4tw.wKr8sPo.Nyy0JuVzG7emmquIdRq7PUV4BpvHyfOUMQW39ZBsLam9uO6.vbBwKmYPVEp_6zP37Te4nc6izf0gNO03EFY0GL0WQpzllgLYMwQp87I.ACbhbDMEhCxNYivLBccjUeDuldyPjD09_TAliEsuKiZ43yPAvon9_PJIkvtAaUumG1WLAYXzfo06x62TA9.8iUriH9npkg4vK_D8Nq7SSvDZOeQY9AaVNRAt6._Iw0mxUdLqA9XKSFV7xvT0PMWQ8Upz8nDiEa8qrGr77_gkprV_LwlNHxEZsgxxIDYUt9UyJS_0pPxMxwQJFgFZwStgk6M7u.l2oZJbwKQ9V8otnOBJDpSY5YwmwY40J1MOcMiiBTyxVNDCupfDLYyWQMxeTQIoH_dd8yHg6.PZckuQAUY5BMcr01d.b2Gv8XVkkCQ3KdAU5HZky4Y3W8uNhelgV5uWxX_3thenKfxkrmdAAgnNjB2hiJ7v6ngb0VQN3We9tJKlPvuNsSqhGk5nJm9yz0B30h0ojWNL_SfRipI5.EForFQQd254JguY.iMtkEgBBkigDPnU8181_iNJyAlII.VPaRxsK95HVoyA7b3BWhtdbEc0O9KVtVJdelkwbjuuEW86U1pVLwc47X7Ck6jPhQtONcNY08XDOZICLBmUTDhNIqV3hKbPkuOUf4caupljanIm9kGLeos2UbU6dh04lMJqtbDOwh8y1NQ2ZStmkMAjMr9Oy0Bj3P.SH7Na_XUfhXhFVoOhNRs4mRFbmKnbVTESDxindrnnfUrHMOuEeLc6ihAq6Dq5EpnZJSOafk8bEO9vjteGv9CRq8m7q_PKGfBSO1HUx6k3oBzW714MaYLpgB2biWwsBaN8RihiJORYWwLO0fOlAQeuZ9xu7alEUVLuUCGFj28Dfyj3po1kkZpEpH.LbmCPU86jh8NaoDTpfTXAvMH_IXnD.SmSi8w0mmvoV4oNzWp.123vK88yPkw66naKQfRj7iqnYkDCKjul8c9kGe6Ep6L00IeagvF934w8KsuiqAG76Bh5Hfppl5IOu0oZc.RJ.L9rHW07CAe9_d7jWitNkNEQBxwFjCMyiroCzY_xQFm7kX3gWyXN9B8.9aWeVNQq41udq41OgzMG21UWoqBNZ_ZcKKVhjKdSy2Fe.lFEiZ0H.eevJgNaYDyUvJ.FmuLBcI6NGDDSiihpegH5Q6UH2I0XVuYrzhWtgS88iSDxa6yHQjamq.zDbykEoyd1e64Ep_hkBhgzTXmgfReAc2JDSirqcIsGgqnkgOSAk_bp1mWBCs3_Eef7cVWJahRsHlRlc2aoj_J3WSnFPQJiim5ja4.6jG.Vfkl1G32uvflCXE0ZS7DqwWn0k1B30pWSWaAwKwxdNIi8IPLadM2wSQzCgoL_aA9a9uh2vu.3va2m1SQ9779Q2uq2VHjSjxBMZG4t6_r6nvqPaULpTy3a1EhSf996ag2vmZQO4Yq7xnZ5CSgeBq.9U5I8iOKl0DhEC_Kg2NDB9Duz993Zt5Y8dnDcrMbOi4tOpk1HQPFoaw6mMBHUMRUYiBpn5Gt4lJH6O85E8oqC0dpiAkb9FcRXAHAUqYSU5aTPxcVqPpayezsK4K1l3psPE7r2V2zGerjI",mdrd: "l0r7k1LMzX84uANYD3pb5wCyGYviblHjREN7trPJl9E-1739836792-1.2.1.1-7AibJgCwZ0BUfDgmk9IK4Dg2Il4PpnJ.zuUikAhpNa6Z4Y7GujBF5uzIcF7gk_IDkJFSeq.SO45n_eSh9wLeIscP4HWkDgdQnXz8IISlfCBnJZgUDbdVCrGyvGvuSqITw8WhyZNybMpCJBZuPwrygMTZ6_CFUlEUIsDfvbOkpsNSJF.pjq0yX3mWjXRAOt9XiFbzlgFC1kYQbGRxHBm4QexN7JwSXrTZZnVN3j9EPfEXLiMcmriv3bqiqG0kuvGiUXoZqWfVEtBngWF5pUSE5Gee.Bv9DgEcPZHrHyiZC3MY3Ax8p7xeyFEcwOeDPhWfMFDDcanWtn6fXY6sMKZt0Jp774VRHRyWe6sdMxD7HBErRrCYw2tijgVKrBdpjrNUn541dH50sRk8mvVrXSpEwZoRYYykNF._lkoc3bwQlfmNHJQEq0hnqA2FvaG651jgybeaJwTsV_TfrB5w1XuEfXHRYMUFD8tG2wSCwuC_CCq7S1u0gpWuhe30U0H_Z_3p41waPzQY9j3LiRmqrOsBRpr0AYLUZCKZWZS6y3gbvhLr_tjMWttOSV71rnmtfgnNfa1r4Q1YxpRavs9bSsG4GFIgc2HN88IJ55vA2bijcmt.D8X_DBRh3aFhUNtFUrMN_55HiLBxwcDknQ1VdEqCdUkkxIqYbcrDbrc0BgUmqdgUyDB_nh34lCWbApMkkuRhx1cYFhZQOqwSa.5_e8MV2ztFM2syGwLKdqbb0Ns_PumkFm7NPHrX_to_SwNPgsYx1xnLM4d9BgCi0YhrN2r9dtlEB9PcN8oyLk1xMw.aQM83D.ChnO1Q6TjKBNG3N.HgaQqcequFrdxQUvlxnJ14cLXjgF_iVaC1cvyfc7koLNzoZe7eN6Z.avBBLBtkjGHqtj_kASg_tkzeY00VlT1NLCJuF2PK2_q8FnZ8LR.7gBsjAcrTe5MJMFNzLK6Cv6uYLDWpJ4gAEPK9xDjAjiwESa.dqebgumEe4T3HTY3D6IU2oqqq16NbzSTkZVAZ.QKvbDWEqAczwtoSf4cHKpO.rf4D.u8D98o9og0WeTPtVP_S4MRBnGq_NEDvf0s2iqfWP6mNGZUk2BbgQL.7EbpZTbtiC_3CtcGpFpJUu1OVC_6ECOMO0ZktY.dBBRtGxetvmeoujvHkceVBAmT2Xy.ku_i_bw5c0Nx6ne.uqE.fykUpkssaRlPL5jf.Uf0SzEyiWHfaZpZhnjvu4LNkBemcg.RBn5Hz.pzMSzpmELg2ayHGnHNF7P1S6pBJei__4gWeUxme3BPUTb8Nk2Rjn.JqK5gHGJaWp_OgnyfJLtmiqnXGNid2gUfc3it8MQL45k8DtW_u0Rw4cucSFrkWdeitNMNAyK_0sjGpUSHQSa5FqDxd1Qj3axg3DSsfQlRQpnE.qCr8QqggBazAuy0jtxRVzzEGsbcb5evNtfwoZQ3eg8n9B49au6lG0xRAo_h0I4vnjF.b.Qe6aXjyxuEgNMvoXWo_tmqKDEsGoPoLWXSssc3EkaP3ZXwb2.fTv96DgPsxMdAOO5TvBrPcTHMWEgsmaernP1xxZHUFPhqzpoEdeMBwtMA0UmXglFydUgMH0LMuvJGWAibTagcSdy3ATHzdHTrrmXNIlH5XawM7N.kM8oR76Couu1hIJs6ONM7p2yIvfnEADn_Ne6mx0mQ751SjGt1VBwEoMgmTTnwGn.MYK3aU7.cIfLuquWHhYHFK.HOaN48bIer5dIvwac46BLXxBTyd.NeKxWUKf5JFOjZgKch55D8Muu9dUCNZbh.fs95xVgzqjHfw8TJwbcBzEQSR9cGDHEtWkMbpqKYpG.klOpJiAuW8KWtoWn0CThw.fmzyRTcrO3_ErifTve4jUF7r71I9wLTzOVhJ7sFtrMNFpE9m1X5W7z7BZ9yLpL97WW_avqgQI2yqAAKCXoBCJc5nToXDthNO32Er8IxC1d310Uyr8uhwzADd2Z5t9HqNm_es"};var cpo = document.createElement('script');cpo.src = '/cdn-cgi/challenge-platform/h/g/orchestrate/chl_page/v1?ray=9139bbd2fc74fd0a';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\/2762688?__cf_chl_rt_tk=MUMSM55OLBURqmwrcm6HbUv5z20HTlkh3sMVESDK2kw-1739836792-1.0.1.1-Z0oAkH849pBW.DrQp..si14HGyCrYCfjz7zL35kIZsU" + window._cf_chl_opt.cOgUHash);cpo.onload = function() {history.replaceState(null, null, ogU);}}document.getElementsByTagName('head')[0].appendChild(cpo);}());</script></body></html>