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. Author manuscript; available in PMC: 2025 Jan 1.
Published in final edited form as: J Head Trauma Rehabil. 2023 Sep 12;39(3):E132–E140. doi: 10.1097/HTR.0000000000000894

Measurement of sleep in chronic traumatic brain injury: Relationship between self-report and actigraphy

Emily L Morrow 1,2,3, Hannah Mattis-Roesch 1, Kimberly Walsh 1, Melissa C Duff 1
PMCID: PMC10927608  NIHMSID: NIHMS1919742  PMID: 37702663

Abstract

Objective:

To examine the relationship between self-report and actigraphy measurement of sleep in people with and without TBI across two aims: 1) To assess the relationship between self-report and actigraphy for sleep in people with and without TBI; and 2) To explore how self-report and actigraphy capture sleep quality in TBI.

Setting:

Participants completed the study over two weeks in their own homes. They wore activity monitors, day and night, throughout the experiment and completed morning sleep diaries while interacting with an experimenter on video conference.

Participants:

This project was embedded in a larger study on sleep and word learning in 100 adults: 50 with chronic, moderate-severe TBI and 50 demographically matched non-injured peers. Of the 100 participants who completed the larger study, 92 participants (45 with TBI and 47 non-injured peers) had sufficient actigraphy data for inclusion in the current study.

Design:

We used multilevel linear regression models and correlation analyses to assess how well participants’ self-report corresponded to actigraphy measurement of sleep.

Main Measures:

Actigraphy measures included nightly sleep duration and nighttime wakeups. Sleep diary measures included self-reported nightly sleep duration, nighttime wakeups, sleep quality, and morning fatigue.

Results:

People with and without TBI did not differ in the relationship between self-reported and actigraphy measurement of sleep. Performance on a neuropsychological memory assessment did not correlate with the difference in self-reported and actigraphy-measured sleep in the TBI group. Sleep characteristics that were measured by actigraphy did not predict subjective experiences of sleep quality or fatigue.

Conclusions:

Short-term self-report diaries capture accurate information about sleep duration in individuals with TBI and may support self-report of other daily habits. Future research is needed to identify reliable metrics of sleep quality, and how they relate to other domains like memory and mood, in the chronic phase of TBI.

Traumatic brain injury (TBI) results in a complex network of symptoms that may include physical, psycho-social, and cognitive domains1–3. Sleep disturbance is increasingly recognized as a key part of the symptom constellation and potential contributor to long-term post-injury outcomes4–6 given sleep’s well-established support of mental and physical well-being and, critically, the ability to learn in rehabilitation settings5,7–10.

While sleep disturbance is gaining recognition as a costly consequence of TBI, research regarding its prevalence, nature, and consequences is inconclusive6,11,12. Sleep health is complex and comprises multiple components that may be altered by neurological damage. TBI may change the amount of sleep (e.g., hypersomnia or insomnia), quality of that sleep (e.g., circadian rhythm disorder), or the need for sleep (e.g., increased sleep need and daytime fatigue)6,11,13,14. It is currently estimated that 50% of individuals with TBI have sleep disturbance, but estimates vary based on patient characteristics, measurement, and length of follow-up, as the nature of sleep disturbance may vary with chronicity6,11–20.

Wide-ranging prevalence estimates may be compounded by challenges in identifying the measures that best capture sleep disturbance after TBI. Both sleep quantity21 (e.g., amount or variability of sleep per night) and quality22 (e.g., subjective satisfaction with sleep experience, time spent in critical sleep phases) may be measured via self-report or objectively21,22.

Self-report measures may include short-term sleep diaries, in which individuals report on their sleep from the previous night, or longer-term questionnaires, in which individuals must characterize their sleep and fatigue over a period of weeks or months23–25. Given concerns that memory deficits may affect self-report accuracy in individuals with TBI26,27, there may be impetus to choose measures that place shorter-term demands on recall (e.g., sleep diaries) or identify measures that do not rely on recall at all.

Objective sleep measurement circumvents demands on recall by capturing sleep via diagnostic tools (e.g., actigraphy or polysomnography23,28). Each measurement technique has unique strengths. Polysomnography is considered the gold standard for comprehensive sleep evaluation and capturing movement through sleep phases, but it requires completing a sleep study in a hospital or lab. Actigraphy comprises a wrist-worn device that is considered valid for evaluating when a person is asleep and may be deployed over time in the home, increasing ecological validity. However, actigraphy may be less valuable for measuring sleep quality as it does not accurately capture movement through sleep phases23,28,29. Further, despite limiting demands on recall, objective measurement tools are high-resource and may not capture elements of the subjective sleep experience that are meaningful for post-injury outcomes and thus merit identification and intervention.

Given the complementary strengths of measurement techniques for capturing diverse elements of the sleep experience, many researchers deploy a mix of measures to capture sleep after TBI23,30–35. However, in clinical settings it is often necessary to rely on self-report given time and resource constraints. Thus, it is critical to understand how self-report relates to objective measurement of sleep for people with TBI, given co-occurring memory deficits. Unfortunately, the relationship between self-report and objective sleep measurement via actigraphy is not clear given the limited studies that have compared approaches in non-injured people33,35 or individuals with TBI30,31,34,36.

We set out to measure sleep over time, in daily settings, for a well-characterized sample of individuals with chronic, moderate-severe TBI and non-injured peers. Each participant wore an accelerometer for two weeks and completed multiple self-report sleep diaries. We had two goals:

  1. To assess the relationship between self-report and actigraphy for sleep in people with and without TBI: We examined the difference between self-report and actigraphy for sleep characteristics (sleep duration, nighttime awakenings) measured by both approaches. Our goal was to understand how people with and without TBI report basic sleep characteristics at short timescales. As actigraphy is considered valid for measuring when people are awake or asleep, examining differences from self-report for these specific characteristics may elucidate the accuracy of sleep self-report. Given that self-report places high demand on memory for previous behaviors, we predicted that both groups would exhibit a weak relationship between self-report and actigraphy. However, as memory impairment may exacerbate these demands, we predicted a weaker relationship for people with TBI. We explored whether performance on a standardized neuropsychological memory assessment was associated with the relationship between self-report and actigraphy in the TBI group.

  2. To explore how self-report and actigraphy capture sleep quality in TBI: We explored the association between objective sleep characteristics that can be measured by actigraphy (sleep duration, nighttime awakenings) and self-reported subjective experiences of sleep quality and fatigue for people with TBI. Our goal was to understand whether self-report captures distinct elements of the sleep experience from the limited characteristics captured by actigraphy. We hypothesized that actigraphy does not fully capture subjective experiences of sleep quality and fatigue and predicted a low association between the characteristics captured by actigraphy and self-reported sleep quality measures.

Methods

This study was part of a larger project examining sleep and word learning in TBI over a two-week experimental period37. The protocol was approved by the Vanderbilt University Human Research Protections Program.

Participants:

The participant pool included 50 adults in the chronic phase of moderate-severe TBI and 50 demographically matched non-injured comparison (NC) peers. Participants were recruited from the Vanderbilt Brain Injury Patient Registry and through community advertisement38. All participants were at least 18 at the time of injury to minimize developmental effects and younger than 55 at the time of the study to conservatively limit the effects of age-related cognitive decline. All participants with TBI were in the chronic phase of injury (at least 6 months post). Participants with TBI sustained a moderate-severe TBI, as determined using the Mayo Classification System39. We chose the Mayo Classification System to determine severity because it is a multi-indicator system, and the practice of classifying TBI severity with a single indicator (e.g., GCS or PTA) has been criticized39. Accordingly, to be classified as moderate-severe, participants must meet at least one of the following criteria: (1) Glasgow Coma Scale (GCS) <13 within the first 24 hours of acute care admission, (2) positive neuroimaging finding (acute CT findings, or lesions visible on chronic MRI), (3) loss of consciousness (LOC) >30 minutes, or (4) post-traumatic amnesia (PTA) >24 hours. While only one criterion must be met to be classified as moderate-severe, 37 participants met 2 or more of these criteria. Injury information was determined from available medical records and a semi-structured participant interview. All included participants with TBI were able to provide study consent on their own behalf. See Supplemental Digital Content 1 for further information about the participants with TBI. NC participants were matched to TBI participants based on sex, age (+/− 5 years), and level of education (+/− 2 years) to reduce between group demographic variability and ensure similar within-group variability. No NC participant had a history of neurological or cognitive disability.

Of the 100 participants who completed the broader study, 92 participants (45 participants with TBI (23 female) and 47 NCs (27 female)) had sufficient actigraphy data (see below) for inclusion in the current study. In the included sample, the NC and TBI groups did not differ on age (TBI mean = 38.5 years (SD: 11.5); NC mean = 37.4 years (SD: 11.6; t(90) = .468, p = .641)) or educational attainment (TBI mean = 15.0 years, (SD: 2.5); NC mean = 15.0 years (SD: 2.7; t(90) = .081, p = .934)). Participants with TBI had a mean time since injury of 5.2 (SD: 5.5) years.

Study Activities and Schedule:

Actigraphy:

Prior to the study, participants received a pre-programmed Actigraph GT9X activity monitor40. They were instructed to wear the monitor on their non-dominant wrist for 24 hours a day throughout the study. We used the GGIR package (version 2.5.0) in R for analysis. We chose GGIR rather than device-specific software because, as an open-source package with a generic algorithm, it allows for more direct comparison across studies41,42. See Supplemental Digital Content 2 for configuration information.

To be included in the analysis, participants’ actigraphy data had to meet three criteria: 1) no calibration error indicated by GGIR; 2) worn for at least 7 nights, including at least one with overlapping self-report data; and 3) no reported deviations from protocol (e.g., wearing device as a necklace) or device failure. Of the 100 eligible participants from the larger study, 8 participants (5 with TBI, 3 NCs) were excluded for insufficient data: 2 for device failure; 3 for calibration failure; 1 for concern that limited mobility impacted the monitor’s accuracy; and 2 for deviations from protocol or insufficient wear. Some of the 92 included participants did not have data at all timepoints. Six participants with TBI and four NCs did not have actigraphy data for at least one timepoint due to nonwear (e.g., due to a hospitalization requiring removal) or a broken monitor.

Sleep diaries:

Sleep diaries were closely adapted from McGregor et al. (2013)43 and administered on REDCap44. We made minor wording changes to simplify the questions for participants with TBI but kept the broader structure from McGregor et al. (2013). Participants completed the diaries in the morning, while supervised 1:1 by an experimenter via video conference. Questions captured sleep data that could be objectively measured by actigraphy (e.g., time asleep and number of nighttime awakenings) and subjective experiences of sleep (e.g., perceived sleep quality and fatigue). Sleep quality was measured on a Likert scale, and fatigue was measured on a simple ordinal rating scale. The sleep diary schedule was dictated by the larger project in which this study was embedded37. Each participant completed three or four morning sleep diaries during the two-week experiment period, depending on the larger study schedule. Three participants with TBI and eight NCs were missing a sleep diary timepoint, and those timepoints were not included in the analysis. See Supplemental Digital Content 3 for study schedule and Supplemental Digital Content 4 for sleep diary questions.

Neuropsychological Memory Assessment:

Participants completed the Rey Auditory Verbal Learning Test (AVLT) as a standardized measure of declarative memory45. Participants hear a list of 15 real words five times and attempt to recall the words after each repetition and again after a 30-minute filled delay. We used immediate (repetition of the target words after hearing the list once) and delayed (repetition of the target words after a 30-minute filled delay) recall in exploratory analyses to assess how self-report accuracy compares to a widely used standardized memory assessment in the TBI group.

Statistical Analysis:

  1. We built two mixed-effects linear regression models. In each model, the outcome was the difference between a participants’ self-report via sleep diary and the actigraphy for a given night (number of minutes difference for sleep duration, numerical difference in number of awakenings). Group membership (TBI, NC) was the predictor, and we included random intercepts to account for variability nested within participants. In the exploratory analysis, we assessed whether self-report accuracy correlates with scores on neuropsychological memory assessments for participants with TBI.

  2. We used two linear regression models (one with self-reported sleep quality as the outcome and one with self-reported morning fatigue as the outcome) in participants with TBI. Predictors were nightly sleep duration and nighttime awakenings, as measured via actigraphy. We also included random intercepts to account for variability within participants.

Results

The two groups were similar in their nighttime sleep characteristics on study nights included in the analysis. See Table 1 for information on self-reported and actigraphy-measured sleep characteristics in each group.

Table 1.

Sleep characteristics (group mean (SD)) in individuals with TBI and NC peers.

Duration
(Hours)		 Nighttime Awakenings
(# per night)		 Sleep quality
(Likert, between 1, Very Poor and 5, Very Good)		 Fatigue
(ordinal scale, between 0, Very Tired and 3, Wide Awake and Rested)
Group Self-Report Actigraphy Self-report Actigraphy Self-Report Self-Report
TBI 7.20
(SD: 1.70)		 7.10
(SD: 1.80)		 1.31 (SD: 1.27) 12.74
(SD: 5.46)		 2.43
(SD: 1.04)		 1.54
(0.96)
NC 7.55
(SD: 1.18)		 7.69
(SD: 1.32)		 1.33 (SD: 1.14) 14.60
(SD: 4.32)		 2.57
(SD: .89)		 1.64
(0.87)
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Aim 1

Duration:

On average, self-report from participants with TBI differed from actigraphy measurement of sleep duration by 1.0 hours (SD: 1.16). Self-report from NC participants differed from actigraphy measurement of sleep duration by 0.84 hours, on average (SD: 0.86). The multilevel regression model revealed that group membership (TBI, NC) did not predict the difference between self-report and objective measurement of sleep duration (estimate = .162, t = 1.098, p =.272). Both groups showed a strong correlation between self-reported sleep duration and objectively measured sleep duration (NC: r = 0.51, p < .001, TBI: r = 0.59, p < .001, see Figure 1).

Figure 1.

Figure 1.

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A) Correlation between self-reported sleep duration and sleep duration measured by actigraphy for participants with TBI. B) Correlation between self-reported sleep duration and sleep duration measured by actigraphy for NCs.

Awakenings:

When comparing self-reported number of nighttime awakenings to those measured by actigraphy, participants with TBI reported 11.43 (SD: 5.45) fewer nighttime awakenings than were captured by actigraphy, on average. NCs reported an average of 13.29 (SD: 4.50) fewer nighttime awakenings than actigraphy. The multilevel linear regression model revealed that group membership was predictive of the difference between self-report and actigraphy measurement of nighttime awakenings (estimate = 1.811, t = 2.131, p =.033), such that NCs exhibited more distance between their self-report and actigraphy measurement than participants with TBI. However, the correlation between self-report and monitor awakenings in both groups was poor (NC: r = 0.11, p = 0.62, TBI: r= 0.044, p = 0.83).

Exploratory Analysis:

Neuropsychological memory scores were available for 42 of the 45 included participants with TBI and 39 of the 47 included NCs. The two groups were significantly different in their scores on the AVLT, such that the group with TBI exhibited memory disruption relative to NCs. Participants with TBI recalled an average of 7.2 words immediately (SD: 2.1), relative to 9.4 words for NCs (SD: 2.6, t(73.6) = 4.14, p <.001). After a delay, participants with TBI recalled an average of 11.1 words (SD: 3.4), relative to 13.5 words for NCs (SD: 1.7, t(65.0) = 4.18, p < .001). In the TBI group, there was no significant correlation between the difference in self-reported and actigraphy-measured sleep duration and immediate (r = 0.024, p = 0.88)) or delayed (r = 0.027, p = 0.86) memory scores. The same was true for the difference in self-reported and actigraphy-measured nighttime awakenings when correlated with immediate (r = 0.11, p = 0.49)) and delayed (r = 0.027, p = 0.09) memory scores.

Aim 2

Sleep duration and nighttime awakenings, as measured by actigraphy, did not predict self-reported sleep quality in individuals with TBI in the multilevel regression model (duration estimate = .122, t = 1.822, p =.068, awakenings estimate = - .021, t = - 0.920, p =.357, see Figure 2). Sleep duration and nighttime awakenings also did not predict self-rated morning fatigue (duration estimate = −.055, t = −.868, p =.386, awakenings estimate = .027, t = 1.282, p =.120). Although our a priori hypothesis focused on the TBI group, we also found that sleep duration and nighttime awakenings did not predict self-reported sleep quality (duration estimate = −.008, t = −.129, p = .898, awakenings estimate = −.007, t = −.368, p = .713) or self-rated morning fatigue (duration estimate = −.097, t = −1.617, p = .105, awakenings estimate = .009, t = .533, p = .594) in the NC group.

Figure 2.

Figure 2.

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Correlation between self-reported sleep quality and sleep duration measured by actigraphy from the previous night in participants with TBI.

Discussion

Sleep disturbance is a common and costly side effect of moderate-severe TBI5,6,11,14,17. The goal of this study was to examine the relationship between self-report and actigraphy measurement of sleep. TBI diagnosis was not predictive of the relationship between self-reported and actigraphy measurement of sleep, and performance on a neuropsychological memory assessment did not correlate with the difference in self-reported and actigraphy-measured sleep in individuals with TBI. Sleep characteristics that were measured by actigraphy did not predict self-reported experiences of sleep quality or fatigue. We discuss each of these findings below.

Short-Term Sleep Diaries May Support More Accurate Reporting for Individuals with TBI

In contrast to our prediction, individuals with TBI, like their NC peers, showed a strong association between their self-report and objective measurement of sleep duration. As actigraphy is considered a valid measure of sleep duration, correspondence between self-report and actigraphy may suggest that both groups were quite accurate in their self-report of sleep duration. This finding was unexpected given well-documented memory deficits in TBI, including in the current sample, and long-standing mistrust of self-report in patients with cognitive impairment46. This finding is also in contrast to research indicating that individuals with chronic TBI may exhibit diminished accuracy in their self-report of sleep (e.g., that people with TBI report fewer hours slept than measured by actigraphy31). Interestingly, the TBI group exhibited similar variability to the group of NC peers, which stands in contrast to the expectation of increased variability due to known cognitive heterogeneity in the population of people with TBI1.

Several factors may have contributed to the accuracy of self-report and reduced variability of performance in the TBI group. First, compared to prior work, the current study asked participants about their sleep habits over a shorter time frame (the preceding 12 hours). Second, as all participants were in the chronic phase of injury, their performance was not impacted by acute effects, such as post-traumatic amnesia47. Participant sampling and severity characterization may also have played a role. Participants here were classified as moderate-severe per the Mayo Classification Scale. Like other systems for determining severity (e.g., DOD, VA, ACRM), the Mayo Classification Scale determines severity based on acute injury characteristics (e.g., GCS, PTA, abnormal neuroimaging), which may not capture or be fully predictive of cognitive heterogeneity in the chronic stage48. We suspect that current cognitive profile may be more predictive than these acute injury variables in understanding potential variability in the broader population of individuals with TBI and warrants further investigation. Particularly for behavioral domains where participants with TBI exhibit intact performance, it will be critical to fully characterize samples of participants with TBI to inform the broader literature as to which tasks and individual characteristics predict success48. In this spirit, we provide data in Supplemental Digital Content 1 in the hopes that this information may contribute to a growing literature on the heterogeneity of sleep and cognitive outcomes after TBI1,48. Finally, enabling participants to report on their daily habits in their home environment may have increased reporting accuracy for participants with more stable sleep schedules.

Self-report accuracy in the TBI group was observed even in the context of memory deficits. As a group, participants with TBI were impaired relative to NC peers on the AVLT, but they were not impaired in their self-report accuracy, and there was no correlation between AVLT scores and the accuracy of sleep self-report in the TBI group. This finding stands in contrast to the perception in clinical settings that people with TBI and memory impairment may be unreliable historians and rather suggests that self-report demands may be altered to increase self-report accuracy, at least for sleep quantity.

These preliminary results suggest that individuals with chronic TBI may be accurate in their self-report of activities of daily life at short timescales. However, many commonly used standardized sleep questionnaires (e.g., the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index) require reporting on sleep habits in the longer term (e.g, weeks, months). There is a need for standardized, well-validated, and short-term questionnaires to increase the accuracy of self-reporting for people with TBI in clinical and research settings. It is an open question if such modifications in self-report demands would increase self-report accuracy in other domains.

Objective Sleep Measurement Does Not Fully Capture Sleep Quality

Understanding the conditions that produce accurate self-report is critical given that objective sleep measurement via actigraphy does not seem to capture important aspects of sleep quality. In this study, objectively measured sleep duration and nighttime awakenings did not predict self-reported sleep quality or fatigue in individuals with TBI. This finding is consistent with prior work (e.g., El-Khatib et al., 2019) indicating that objective sleep measurement does not correspond to self-rated sleep quality for individuals with TBI. It may be difficult for individuals with TBI to report abstract information like sleep quality, relative to concrete information like sleep duration. However, the lack of overlap between objective duration and self-reported sleep quality was not confined to people with TBI in this study or other work49.

Sleep quality may have been difficult to capture because of the design of the sleep diaries. We adapted the diaries from McGregor et al. (2013) for participants with TBI, but the Likert scale used in the sleep quality question and ordinal scale used in the fatigue question have not been validated against objective data. The Likert scale is beneficial in that it differentiates abstract experiences in a concrete ordinal scale. However, the subjective experience of sleep quality may be better represented on a continuum. For example, a visual analog scale, which has a continuous, ordinal response, may be more sensitive to small but meaningful vacillations in sleep quality50,51.

It is also likely that actigraphy is unable to capture the nuances of sleep quality. Although actigraphy is considered valid for capturing when participants are asleep or awake and has increased ecological validity by measuring sleep patterns in daily settings over time28, polysomnography is regarded as the gold standard for capturing the movement through sleep phases. Sleep phases are often associated with sleep quality and critical sleep benefits like memory consolidation, so polysomnography may be more useful in capturing sleep quality. It is also possible that no objective measurement tool is a complete substitute for self-report of sleep quality52.

Indeed, self-reported sleep quality may reveal key information about the sleep experience that is not captured by any objective measures. For example, individuals with TBI may report excessive daytime sleepiness and poor sleep quality, even when actigraphy depicts a typical sleep duration. In this case, self-reported sleep quality may be more predictive of excessive daytime sleepiness than objective measurement. Individuals who experience sleep disturbance in TBI (e.g., limited movement through sleep phases) may need more sleep to reach an adequate threshold for daily functioning17. Thus, as research develops in this area, it is critical to consider multiple sources of sleep information in research and clinical settings.

One area of sleep quality that could be associated with actigraphy measurement is nighttime awakenings. Individuals with TBI and their neurotypical peers showed a very low association between actigraphy and self-reported nighttime awakenings, with actigraphy capturing many more nighttime awakenings than self-report. It is possible that actigraphy is picking up on subclinical awakenings, which occur without the conscious awareness of the individual53. Increased subclinical awakenings may contribute to sleep fragmentation, which has been tied to poor sleep quality54. Here, nighttime awakenings did not predict self-reported sleep quality. However, polysomnography could provide more nuanced information about subclinical awakenings.

Finally, it may be that specific measures of sleep are associated with different domains of daily functioning. For example, self-reported daytime sleepiness may be more closely related with some aspects of quality of life (e.g., mood, memory) than objective measures. Research in this area has been limited to the neurotypical population and confined to broad conclusions about the benefits of sleep quality for life satisfaction and mood55. Further research is warranted for people with and without TBI to determine which measures of sleep are predictive of key rehabilitation factors.

Conclusions

This study represents the first long-term exploration of the relationship between self-reported sleep quantity and quality and objective measurement via actigraphy in chronic, moderate-severe TBI. Individuals with TBI did not differ from NC peers in the relationship between actigraphy and self-reported sleep duration using short-term sleep diaries. Sleep duration and nighttime awakenings as measured by actigraphy were not predictive of self-reported sleep quality or fatigue. These findings suggest that researchers and clinicians should focus on developing and using short-term diaries to support self-report for individuals with TBI for sleep and other daily habits. These results highlight the need to identify reliable metrics of sleep quality, and how they relate to other domains like memory and mood, in the chronic phase of TBI.

Supplementary Material

Supplemental Digital Content 1

Supplemental Digital Content 1. PDF

Supplemental Digital Content 2

Supplemental Digital Content 2. PDF

Supplemental Digital Content 3

Supplemental Digital Content 3. PDF

Supplemental Digital Content 4

Supplemental Digital Content 4. PDF

Figure 3.

Figure 3.

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Correlation between self-reported fatigue and sleep duration measured by actigraphy from the previous night in participants with TBI.

Acknowledgements:

The authors sincerely thank the participants who made this work possible and Emma Montesi for her support with data collection.

Funding:

This work was made possible by NIH 1F31DC019555-01 to ELM and NIH R01 NS110661 to MCD. This work was also supported in part by the Vanderbilt CTSA grant UL1TR002243 from NCATS/NIH. ELM’s time was supported in part by grant number T32 HS026122 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

Footnotes

Conflicts of Interest: None.

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