{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,29]],"date-time":"2026-10-29T16:01:40Z","timestamp":1793289700141,"version":"4.5.0"},"reference-count":45,"publisher":"American Medical Association (AMA)","issue":"3","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"Importance<\/jats:title>The Centers for Medicare &amp;amp; Medicaid Services Severe Sepsis and Septic Shock Management Bundle (SEP-1) is supported by observational studies that report SEP-1 compliance is associated with lower mortality. Most studies, however, adjusted for limited confounders and provided little insight into why bundle-compliant care was not provided.<\/jats:p><\/jats:sec>Objectives<\/jats:title>To identify the clinical factors that complicate the diagnosis and management of sepsis and assess their association with SEP-1 compliance and mortality.<\/jats:p><\/jats:sec>Design, Setting, and Participants<\/jats:title>This retrospective cohort study was conducted among 590 adults with sepsis in the emergency department of 4 academic hospitals from January 1, 2019, to December 31, 2022. Patients\u2019 medical records were reviewed between September 2022 and December 2023.<\/jats:p><\/jats:sec>Main Outcomes and Measures<\/jats:title>Study outcomes were (1) characteristics of patients who received SEP-1\u2013compliant care vs characteristics of patients who received noncompliant care and (2) association between SEP-1 compliance and hospital mortality using multivariable models to adjust for successively more potential confounders (first demographics and comorbidities, then infection source, then severity of illness, and then clinical markers of complexity).<\/jats:p><\/jats:sec>Results<\/jats:title>Of 590 patients with sepsis (median age, 65 years [IQR, 53-77 years]; 329 men [55.8%]), 335 (56.8%) received SEP-1\u2013compliant care, and 225 (43.2%) received noncompliant care. Compared with patients in the compliant group, patients in the noncompliant group were more likely to be 65 years or older (142 [55.7%] vs 158 [47.2%]; odds ratio [OR], 1.41 [95% CI, 1.01-1.95]), to have multiple comorbidities (Elixhauser score &amp;gt;20: 99 [38.8%] vs 99 [29.6%]; OR, 1.51 [95% CI, 1.07-2.13]), and to have a higher incidence of septic shock (107 [42.0%] vs 107 [31.9%]; OR, 1.54 [95% CI, 1.10-2.16]), kidney dysfunction (87 [34.1%] vs 80 [23.9%]; OR, 1.65 [95% CI, 1.15-2.37]), and thrombocytopenia (43 [16.9%] vs 37 [11.0%]; OR, 1.16 [95% CI, 1.02-2.62]) on presentation. Compared with patients in the compliant group, those in the noncompliant group also had more nonfebrile presentations (136 [53.3%] vs 121 [36.1%]; OR, 2.02 [95% CI, 1.45-2.82]), impaired mental status (92 [36.1%] vs 94 [28.1%]; OR, 1.45 [95% CI, 1.02-2.05]), need for bedside procedures (57 [22.4%] vs 41 [12.2%]; OR, 2.06 [95% CI, 1.33-3.21]), acute concurrent noninfectious illnesses (140 [54.9%] vs 151 [45.1%]; OR, 1.48 [95% CI, 1.07-2.06]), and noninfectious illness as the primary factor associated with their presentation (84 [32.9%] vs 71 [21.2%]; OR, 1.82 [95% CI, 1.08-3.08]). SEP-1 compliance was associated with lower crude mortality rates compared with noncompliance (40 [11.9%] vs 41 [16.1%]; unadjusted OR, 0.60 [95% CI, 0.37-0.98]), but there was no statistically significant difference between groups after successively adjusting for demographics and comorbidities (adjusted OR [AOR], 0.71 [95% CI, 0.42-1.18]), infection source (AOR, 0.71 [95% CI, 0.43-1.20]), severity of illness (AOR, 0.86 [95% CI, 0.50-1.49]), and clinical markers of complexity (AOR, 1.08 [95% CI, 0.61-1.91]).<\/jats:p><\/jats:sec>Conclusions and Relevance<\/jats:title>In this cohort study of adults with sepsis, complex clinical presentations were more common among patients whose treatment was noncompliant with SEP-1. These nuances are poorly captured in most observational studies but confound the association between SEP-1 compliance and mortality.<\/jats:p><\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2025.1100","type":"journal-article","created":{"date-parts":[[2025,3,19]],"date-time":"2025-03-19T15:23:10Z","timestamp":1742397790000},"page":"e251100","source":"Crossref","is-referenced-by-count":22,"title":["Complex Sepsis Presentations, SEP-1 Compliance, and Outcomes"],"prefix":"10.1001","volume":"8","author":[{"given":"Chanu","family":"Rhee","sequence":"first","affiliation":[{"name":"Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts"},{"name":"Division of Infectious Diseases, Department of Medicine, Brigham and Women\u2019s Hospital, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah E.","family":"Train","sequence":"additional","affiliation":[{"name":"Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women\u2019s Hospital, Boston, Massachusetts"},{"name":"Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Wisconsin\u2013Madison School of Medicine and Public Health, Madison"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael R.","family":"Filbin","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Massachusetts General Hospital, Boston"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steven T.","family":"Park","sequence":"additional","affiliation":[{"name":"Division of Infectious Diseases, Department of Medicine, University of California, Irvine, School of Medicine, Orange"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicholas M.","family":"Mohr","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Iowa Health Care, Iowa City"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anne","family":"Zepeski","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Iowa Health Care, Iowa City"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brett A.","family":"Faine","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of Iowa Health Care, Iowa City"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David J.","family":"Roach","sequence":"additional","affiliation":[{"name":"Division of Infectious Diseases, Department of Medicine, Brigham and Women\u2019s Hospital, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emily","family":"Porter","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Massachusetts General Hospital, Boston"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claire N.","family":"Shappell","sequence":"additional","affiliation":[{"name":"Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women\u2019s Hospital, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kamryn","family":"Plechot","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, University of California Medical Center, Orange"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura","family":"DelloStritto","sequence":"additional","affiliation":[{"name":"Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tingting","family":"Yu","sequence":"additional","affiliation":[{"name":"Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Klompas","sequence":"additional","affiliation":[{"name":"Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts"},{"name":"Division of Infectious Diseases, Department of Medicine, Brigham and Women\u2019s Hospital, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2025,3,19]]},"reference":[{"issue":"2","key":"zoi250081r1","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2018.7571","article-title":"Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals.","volume":"2","author":"Rhee","year":"2019","journal-title":"JAMA Netw Open"},{"issue":"3","key":"zoi250081r2","doi-asserted-by":"publisher","first-page":"276","DOI":"10.1097\/CCM.0000000000004224","article-title":"Sepsis among Medicare beneficiaries, 1: the burdens of sepsis, 2012-2018.","volume":"48","author":"Buchman","year":"2020","journal-title":"Crit Care Med"},{"issue":"5","key":"zoi250081r3","doi-asserted-by":"publisher","first-page":"955","DOI":"10.1016\/j.chest.2017.01.011","article-title":"Accountability for sepsis treatment: the SEP-1 core measure.","volume":"151","author":"Motzkus","year":"2017","journal-title":"Chest"},{"issue":"1","key":"zoi250081r4","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1097\/CCM.0000000000000723","article-title":"Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study.","volume":"43","author":"Levy","year":"2015","journal-title":"Crit Care Med"},{"issue":"23","key":"zoi250081r5","doi-asserted-by":"publisher","first-page":"2235","DOI":"10.1056\/NEJMoa1703058","article-title":"Time to treatment and mortality during mandated emergency care for sepsis.","volume":"376","author":"Seymour","year":"2017","journal-title":"N Engl J Med"},{"issue":"7","key":"zoi250081r6","doi-asserted-by":"publisher","first-page":"856","DOI":"10.1164\/rccm.201609-1848OC","article-title":"The timing of early antibiotics and hospital mortality in sepsis.","volume":"196","author":"Liu","year":"2017","journal-title":"Am J Respir Crit Care Med"},{"issue":"11","key":"zoi250081r7","doi-asserted-by":"publisher","first-page":"1406","DOI":"10.1164\/rccm.201712-2545OC","article-title":"Mortality changes associated with mandated public reporting for sepsis: the results of the New York State Initiative.","volume":"198","author":"Levy","year":"2018","journal-title":"Am J Respir Crit Care Med"},{"issue":"1","key":"zoi250081r8","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1164\/rccm.201212-2199OC","article-title":"Multicenter implementation of a severe sepsis and septic shock treatment bundle.","volume":"188","author":"Miller","year":"2013","journal-title":"Am J Respir Crit Care Med"},{"issue":"11","key":"zoi250081r9","doi-asserted-by":"publisher","first-page":"1264","DOI":"10.1164\/rccm.201507-1489OC","article-title":"Multicenter implementation of a treatment bundle for patients with sepsis and intermediate lactate values.","volume":"193","author":"Liu","year":"2016","journal-title":"Am J Respir Crit Care Med"},{"issue":"2","key":"zoi250081r10","doi-asserted-by":"publisher","first-page":"392","DOI":"10.1016\/j.chest.2021.07.2167","article-title":"Effects of compliance with the early management bundle (SEP-1) on mortality changes among Medicare beneficiaries with sepsis: a propensity score matched cohort study.","volume":"161","author":"Townsend","year":"2022","journal-title":"Chest"},{"issue":"3","key":"zoi250081r11","doi-asserted-by":"publisher","first-page":"505","DOI":"10.1093\/cid\/ciad447","article-title":"Improving sepsis outcomes in the era of pay-for-performance and electronic quality measures: a joint IDSA\/ACEP\/PIDS\/SHEA\/SHM\/SIDP position paper.","volume":"78","author":"Rhee","year":"2024","journal-title":"Clin Infect Dis"},{"issue":"4","key":"zoi250081r12","doi-asserted-by":"publisher","first-page":"541","DOI":"10.1093\/cid\/ciaa059","article-title":"Infectious Diseases Society of America position paper: recommended revisions to the national Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) sepsis quality measure.","volume":"72","author":"Rhee","year":"2021","journal-title":"Clin Infect Dis"},{"issue":"6","key":"zoi250081r13","doi-asserted-by":"publisher","first-page":"779","DOI":"10.1097\/CCM.0000000000004305","article-title":"SEP-1 has brought much needed attention to improving sepsis care\u2026 but now is the time to improve SEP-1.","volume":"48","author":"Rhee","year":"2020","journal-title":"Crit Care Med"},{"key":"zoi250081r14","doi-asserted-by":"publisher","first-page":"S22","DOI":"10.21037\/jtd.2019.12.100","article-title":"Driving blind: instituting SEP-1 without high quality outcomes data.","volume":"12","author":"Wang","year":"2020","journal-title":"J Thorac Dis"},{"key":"zoi250081r15","doi-asserted-by":"publisher","first-page":"S166","DOI":"10.1093\/infdis\/jiaa133","article-title":"Impact of sepsis mandates on sepsis care: unintended consequences.","volume":"222","author":"Swenson","year":"2020","journal-title":"J Infect Dis"},{"issue":"10","key":"zoi250081r16","doi-asserted-by":"publisher","first-page":"1585","DOI":"10.1097\/CCM.0000000000003261","article-title":"Compliance with the national SEP-1 quality measure and association with sepsis outcomes: a multicenter retrospective cohort study.","volume":"46","author":"Rhee","year":"2018","journal-title":"Crit Care Med"},{"issue":"10","key":"zoi250081r17","doi-asserted-by":"publisher","first-page":"1592","DOI":"10.1097\/CCM.0000000000003260","article-title":"Presenting symptoms independently predict mortality in septic shock: importance of a previously unmeasured confounder.","volume":"46","author":"Filbin","year":"2018","journal-title":"Crit Care Med"},{"issue":"4","key":"zoi250081r18","doi-asserted-by":"publisher","first-page":"1153","DOI":"10.1007\/s11606-020-05653-0","article-title":"Adherence to the SEP-1 sepsis bundle in hospital-onset v. community-onset sepsis: a multicenter retrospective cohort study.","volume":"35","author":"Baghdadi","year":"2020","journal-title":"J Gen Intern Med"},{"issue":"9","key":"zoi250081r19","doi-asserted-by":"publisher","first-page":"1169","DOI":"10.1097\/CCM.0000000000003817","article-title":"Epidemiology of hospital-onset versus community-onset sepsis in U.S. hospitals and association with mortality: a retrospective analysis using electronic clinical data.","volume":"47","author":"Rhee","year":"2019","journal-title":"Crit Care Med"},{"issue":"4","key":"zoi250081r20","doi-asserted-by":"publisher","first-page":"466","DOI":"10.1513\/AnnalsATS.201909-655OC","article-title":"Improvements in sepsis-associated mortality in hospitalized patients with cancer versus those without cancer: a 12-year analysis using clinical data.","volume":"17","author":"Cooper","year":"2020","journal-title":"Ann Am Thorac Soc"},{"issue":"10","key":"zoi250081r21","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2022.35331","article-title":"Association between preexisting heart failure with reduced ejection fraction and fluid administration among patients with sepsis.","volume":"5","author":"Powell","year":"2022","journal-title":"JAMA Netw Open"},{"issue":"11","key":"zoi250081r22","doi-asserted-by":"publisher","first-page":"1582","DOI":"10.1097\/CCM.0000000000003960","article-title":"Evaluation and predictors of fluid resuscitation in patients with severe sepsis and septic shock.","volume":"47","author":"Kuttab","year":"2019","journal-title":"Crit Care Med"},{"issue":"7","key":"zoi250081r23","doi-asserted-by":"publisher","first-page":"985","DOI":"10.7326\/M24-0400","article-title":"Heterogeneity of sepsis presentations and mortality rates.","volume":"177","author":"Biebelberg","year":"2024","journal-title":"Ann Intern Med"},{"issue":"10","key":"zoi250081r24","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pmed.0040297","article-title":"Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration.","volume":"4","author":"Vandenbroucke","year":"2007","journal-title":"PLoS Med"},{"issue":"2","key":"zoi250081r25","doi-asserted-by":"publisher","first-page":"377","DOI":"10.1016\/j.jbi.2008.08.010","article-title":"Research electronic data capture (REDCap)\u2014a metadata-driven methodology and workflow process for providing translational research informatics support.","volume":"42","author":"Harris","year":"2009","journal-title":"J Biomed Inform"},{"issue":"3","key":"zoi250081r26","doi-asserted-by":"publisher","first-page":"763","DOI":"10.1097\/01.CCM.0000256726.80998.BF","article-title":"Occurrence and outcomes of sepsis: influence of race.","volume":"35","author":"Dombrovskiy","year":"2007","journal-title":"Crit Care Med"},{"issue":"3","key":"zoi250081r27","doi-asserted-by":"publisher","first-page":"279","DOI":"10.1164\/rccm.200703-480OC","article-title":"Racial variation in the incidence, care, and outcomes of severe sepsis: analysis of population, patient, and hospital characteristics.","volume":"177","author":"Barnato","year":"2008","journal-title":"Am J Respir Crit Care Med"},{"issue":"4","key":"zoi250081r29","doi-asserted-by":"publisher","first-page":"591","DOI":"10.1097\/CCM.0000000000002249","article-title":"Fever in the emergency department predicts survival of patients with severe sepsis and septic shock admitted to the ICU.","volume":"45","author":"Sund\u00e9n-Cullberg","year":"2017","journal-title":"Crit Care Med"},{"issue":"6","key":"zoi250081r30","doi-asserted-by":"publisher","first-page":"e575","DOI":"10.1097\/CCM.0000000000002311","article-title":"The absence of fever is associated with higher mortality and decreased antibiotic and IV fluid administration in emergency department patients with suspected septic shock.","volume":"45","author":"Henning","year":"2017","journal-title":"Crit Care Med"},{"issue":"1","key":"zoi250081r31","doi-asserted-by":"publisher","first-page":"101","DOI":"10.1016\/j.chest.2022.01.016","article-title":"Prevalence and outcomes of previously healthy adults among patients hospitalized with community-onset sepsis.","volume":"162","author":"Alrawashdeh","year":"2022","journal-title":"Chest"},{"issue":"2","key":"zoi250081r32","doi-asserted-by":"publisher","DOI":"10.1097\/CCE.0000000000000637","article-title":"Concomitant sepsis diagnoses in acute myocardial infarction\u2013cardiogenic shock: 15-year national temporal trends, management, and outcomes.","volume":"4","author":"Jentzer","year":"2022","journal-title":"Crit Care Explor"},{"issue":"20","key":"zoi250081r33","doi-asserted-by":"publisher","first-page":"2248","DOI":"10.1001\/jama.2011.1615","article-title":"Incident stroke and mortality associated with new-onset atrial fibrillation in patients hospitalized with severe sepsis.","volume":"306","author":"Walkey","year":"2011","journal-title":"JAMA"},{"issue":"8","key":"zoi250081r34","doi-asserted-by":"publisher","first-page":"762","DOI":"10.1001\/jama.2016.0288","article-title":"Assessment of clinical criteria for sepsis: for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).","volume":"315","author":"Seymour","year":"2016","journal-title":"JAMA"},{"issue":"2","key":"zoi250081r35","doi-asserted-by":"publisher","first-page":"289","DOI":"10.1016\/j.chest.2019.03.032","article-title":"Epidemiology of quick sequential organ failure assessment criteria in undifferentiated patients and association with suspected infection and sepsis.","volume":"156","author":"Anand","year":"2019","journal-title":"Chest"},{"issue":"11","key":"zoi250081r36","doi-asserted-by":"publisher","first-page":"1534","DOI":"10.1093\/cid\/ciad450","article-title":"Risk of misleading conclusions in observational studies of time-to-antibiotics and mortality in suspected sepsis.","volume":"77","author":"Pak","year":"2023","journal-title":"Clin Infect Dis"},{"issue":"4","key":"zoi250081r37","doi-asserted-by":"publisher","first-page":"607","DOI":"10.1097\/CCM.0000000000002235","article-title":"Early goal-directed therapy for sepsis: a novel solution for discordant survival outcomes in clinical trials.","volume":"45","author":"Kalil","year":"2017","journal-title":"Crit Care Med"},{"issue":"12","key":"zoi250081r38","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2021.38596","article-title":"Association between implementation of the Severe Sepsis and Septic Shock Early Management Bundle performance measure and outcomes in patients with suspected sepsis in US hospitals.","volume":"4","author":"Rhee","year":"2021","journal-title":"JAMA Netw Open"},{"issue":"7","key":"zoi250081r39","doi-asserted-by":"publisher","first-page":"927","DOI":"10.7326\/M20-5043","article-title":"Treatment patterns and clinical outcomes after the introduction of the Medicare sepsis performance measure (SEP-1).","volume":"174","author":"Barbash","year":"2021","journal-title":"Ann Intern Med"},{"issue":"3","key":"zoi250081r40","doi-asserted-by":"publisher","first-page":"503","DOI":"10.1093\/cid\/ciab937","article-title":"The impact of Centers for Medicare & Medicaid Services SEP-1 core measure implementation on antibacterial utilization: a retrospective multicenter longitudinal cohort study with interrupted time-series analysis.","volume":"75","author":"Anderson","year":"2022","journal-title":"Clin Infect Dis"},{"issue":"4","key":"zoi250081r41","doi-asserted-by":"publisher","first-page":"556","DOI":"10.1093\/cid\/ciaa456","article-title":"Impact of the Centers for Medicare and Medicaid Services sepsis core measure on antibiotic use.","volume":"72","author":"Pakyz","year":"2021","journal-title":"Clin Infect Dis"},{"issue":"7","key":"zoi250081r43","doi-asserted-by":"publisher","first-page":"535","DOI":"10.1001\/jama.2023.0340","article-title":"The importance of shifting sepsis quality measures from processes to outcomes.","volume":"329","author":"Klompas","year":"2023","journal-title":"JAMA"},{"issue":"10","key":"zoi250081r44","doi-asserted-by":"publisher","DOI":"10.1097\/CCE.0000000000000049","article-title":"Risk adjustment for sepsis mortality to facilitate hospital comparisons using Centers for Disease Control and Prevention\u2019s Adult Sepsis Event criteria and routine electronic clinical data.","volume":"1","author":"Rhee","year":"2019","journal-title":"Crit Care Explor"},{"issue":"11","key":"zoi250081r45","doi-asserted-by":"publisher","first-page":"2342","DOI":"10.1097\/CCM.0000000000000516","article-title":"Using the number needed to treat to assess appropriate antimicrobial therapy as a determinant of outcome in severe sepsis and septic shock.","volume":"42","author":"Vazquez-Guillamet","year":"2014","journal-title":"Crit Care Med"},{"key":"zoi250081r28","unstructured":"Elixhauser comorbidity software refined for ICD-10-CM (V2024.1). Agency for Healthcare Research and Quality. Accessed June 10, 2024. https:\/\/hcup-us.ahrq.gov\/toolssoftware\/comorbidityicd10\/comorbidity_icd10.jsp"},{"key":"zoi250081r42","unstructured":"Medicare hospital compare. Medicare.gov. Accessed June 14, 2024. https:\/\/www.medicare.gov\/care-compare\/?providerType=Hospital"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2831700\/rhee_2025_oi_250081_1741798607.07308.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,3,19]],"date-time":"2025-03-19T15:23:13Z","timestamp":1742397793000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2831700"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,3,19]]},"references-count":45,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2025,3,3]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2025.1100","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,3,19]]}}}