ACR Appropriateness Criteria® Headache: 2022 Update.

Headache is an ancient problem plaguing a large proportion of the population. At present, headache disorders rank third among the global causes of disability, accounting for over $78 billion per year in direct and indirect costs in the United States. Given the prevalence of headache and the wide range of possible etiologies, the goal of this document is to help clarify the most appropriate initial imaging guidelines for headache for eight clinical scenarios/variants, which range from acute onset, life-threatening etiologies to chronic benign scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Embracing telemedicine into your otolaryngology practice amid the COVID-19 crisis: An invited commentary.

The COVID-19 pandemic has quickly and radically altered how Otolaryngologists provide patient care in the outpatient setting. Continuity of care with established patients as well as establishment of a professional relationship with new patients is challenging during this Public Health Emergency (PHE). Many geographic areas are under "stay at home" or "shelter in place" directives from state and local governments to avoid COVID-19 exposure risks. Medicare has recently allowed "broad flexibilities to furnish services using remote communications technology to avoid exposure risks to health care providers, patients, and the community." [1] The implementation of telemedicine, or virtual, services, will help the Otolaryngologists provide needed care to patients while mitigating the clinical and financial impact of the pandemic. The significant coding and billing issues related to implementing telemedicine services are discussed to promote acceptance of this technology by the practicing Otolaryngologist. Of particular importance, outpatient visit Current Procedural Terminology® codes (99201-99215) may be used for telehealth visits performed in real-time audio and video.

Are industry financial ties associated with greater scholarly impact among academic otolaryngologists?

OBJECTIVES/HYPOTHESIS: In response to concerns regarding physician-industry relationships, the Physician Sunshine Act of 2010 was passed in an effort to increase transparency and accountability. Our objective was to determine whether there is an association between industry support and scholarly impact among academic otolaryngologists. METHODS: Faculty listings, academic rank, and fellowship training of academic otolaryngologists were accessed from departmental websites. H-indices, number of publications, and publication range (years) of each individual were calculated using the Scopus database. The Center for Medicare and Medicaid Services Open Payments database was used to determine industry payments during 2014 to each otolaryngologist. RESULTS: Of 1,515 otolaryngologists, 65.4% received industry support and 15.8% received support > $1,000. No difference in impact, as measured by the h-index, was noted upon comparison of those receiving support and those who did not (P > 0.05). Individuals receiving > $1,000 had higher h-indices and total publications than those receiving < $1,000 or receiving no support (H = 17.8 vs. 10.9, P < 0.0001), even upon controlling for academic seniority. Upon organization by subspecialty, individuals receiving > $1,000 had greater scholarly impact among most subspecialties. Industry contributions increased with advancing experience. CONCLUSION: Receiving industry contributions greater than $1,000 is associated with greater scholarly impact among academic otolaryngologists. In a smaller surgical specialty, such as otolaryngology-head and neck surgery, direct industry research support-as well as indirect contributions through the support of educational programs, consulting, and other expenses-potentially impacts scholarly discourse; these findings do not reflect a causal relationship and may require further characterization. LEVEL OF EVIDENCE: NA Laryngoscope, 127:87-94, 2017.

Voicing an impact: who does the National Institutes of Health support for voice disorder research?

PURPOSE: Interest in a variety of neoplastic, functional, neurological, and age-related laryngeal disorders has contributed to the development of laryngology as an established subspecialty. Funding support plays a critical role in facilitating scholarship within the field. Our objectives were to evaluate who is receiving funding from the NIH for topics relevant to voice disorders, and further describe temporal trends in grants awarded. METHODS: The NIH RePORTER database was searched for grants relevant to voice disorders. Data were further organized by PI specialty, academic department, and funding totals. Furthermore, PI scholarly impact, as measured by the h-index, was calculated. RESULTS: A total of 830 funded fiscal years (for 232 unique projects) totaling $203 million have supported projects examining voice disorders. A plurality of projects (32.8%) was awarded to PIs in otolaryngology departments, followed by 17.2% to speech pathology/communication sciences departments. Although year-to-year variation was noted, otolaryngology departments received approximately 15% of funding annually. Funded otolaryngologists had similar scholarly impact values to individuals in other specialties. CONCLUSIONS: The study of voice disorders involves an interdisciplinary approach, as PIs in numerous specialties receive NIH funding support. As they receive a considerable proportion of this funding and had similar h-indices compared to other specialties involved, otolaryngologists have just as much scholarly impact despite being a smaller specialty. As speech and language pathologists also comprised a significant proportion of individuals in this analysis, enhanced cooperation and encouragement of interdisciplinary scholarly initiatives may be beneficial.

Geographic and temporal trends in frontal sinus surgery.

BACKGROUND: The purpose of this study was to evaluate geographic and temporal trends in frontal sinus surgery procedures. METHODS: Medicare Part B data files from 2000 to 2011 were examined for temporal trends in various frontal sinus procedures, and the most recent year containing geographic information (2010) was evaluated for Current Procedural Terminology (CPT) code use. Additionally, nationwide charges per procedure were recorded. Regional populations of individuals ≥ 65 years old were obtained from the 2010 U.S. Census, and surgical society websites were used to determine the number of practicing rhinologists and otolaryngologists in each region. RESULTS: The use of open approaches declined by one third, while endoscopic procedures went from 6463 to 19262 annually, with the most marked increases occurring from 2006 through 2011. Geographic variation was noted, with practitioners in the South Atlantic states performing the greatest number of endoscopic procedures in 2010, whereas the East South Central states had the greatest number when controlling for population. There was an inverse relationship between endoscopic procedures performed and number of fellowship-trained rhinologists (controlling for regional populations) (R(2) = 0.66). The first year frontal sinus ballooning had a unique CPT code illustrated decreased reimbursements for non-balloon endoscopic surgery ($609) relative to balloon approaches ($2635). CONCLUSION: Declines in open frontal sinus surgery and marked increases in endoscopic approaches have potential implications for residency training. Potential reasons for marked increases in endoscopic approaches include the rising popularity of balloon technologies, although this is speculative. Geographic variation exists in frontal sinus surgery patterns, including an inverse relationship between endoscopic approaches and the number of fellowship-trained rhinologists.

Do AAO-HNSF CORE Grants Predict Future NIH Funding Success?

OBJECTIVE: To determine (1) whether academic otolaryngologists who have received an American Academy of Otolaryngology- Head and Neck Surgery Foundation (AAO-HNSF) Centralized Otolaryngology Research Efforts (CORE) grant are more likely to procure future National Institutes of Health (NIH) funding; (2) whether CORE grants or NIH Career Development (K) awards have a stronger association with scholarly impact. STUDY DESIGN AND SETTING: Historical cohort. METHODS: Scholarly impact, as measured by the h-index, publication experience, and prior grant history, were determined for CORE-funded and non-CORE-funded academic otolaryngologists. All individuals were assessed for NIH funding history. RESULTS: Of 192 academic otolaryngologists with a CORE funding history, 39.6% had active or prior NIH awards versus 15.1% of 1002 non-CORE-funded faculty (P < .0001). Higher proportions of CORE-funded otolaryngologists have received K-series and R-series grants from the NIH (P-values < .05). K-grant recipients had higher h-indices than CORE recipients (12.6 vs 7.1, P < .01). Upon controlling for rank and experience, this difference remained significant among junior faculty. CONCLUSIONS: A higher proportion of academic otolaryngologists with prior AAO-HNSF CORE funding have received NIH funding relative to their non-CORE-funded peers, suggesting that the CORE program may be successful in its stated goals of preparing individuals for the NIH peer review process, although further prospective study is needed to evaluate a "cause and effect" relationship. Individuals with current or prior NIH K-grants had greater research productivity than those with CORE funding history. Both cohorts had higher scholarly impact values than previously published figures among academic otolaryngologists, highlighting that both CORE grants and NIH K-grants awards are effective career development resources.

Scientific inquiry into rhinosinusitis: who is receiving funding from the National Institutes of Health?

OBJECTIVES/HYPOTHESIS: To evaluate National Institutes of Health (NIH) support for rhinosinusitis research and characterize the proportion of funding awarded to otolaryngologists. STUDY DESIGN: Analysis of the NIH RePORTER database. METHODS: Specialty and terminal-degree of primary investigators (PIs) for 131 projects spanning 364 fiscal years (1989 to present) were determined. Awards for projects examining rhinosinusitis were organized by size, academic department, and PI scholarly impact (using h-indices). Analysis of geographic and temporal funding trends was performed and organized by PI specialty. RESULTS: A total of 62.6% of projects were awarded to physicians, one-third of whom were otolaryngologists. Allergists/immunologists had greater median awards than otolaryngologist PIs (P = .02), and pediatric-trained PIs had a greater h-index than otolaryngologist PIs (P = .04). Although year-to-year fluctuation was noted, otolaryngologists have received approximately a quarter of total rhinosinusitis funding since 2000. PIs practicing in the south-Atlantic, east-north-central, and west-north-central states had the greatest funding totals, whereas otolaryngologists had a greater proportion of regional funding in the Pacific and east-south-central states than other regions. CONCLUSIONS: Inquiry into the mechanisms underlying rhinosinusitis and optimal therapeutic strategies represents an interdisciplinary venture. PIs in medicine and pediatric departments had greater funding for rhinosinusitis projects than individuals in otolaryngology departments, partly because of greater utilization of PhD faculty. Otolaryngology departments may consider increased recruitment of basic scientists interested in rhinosinusitis as a means to facilitate increased scholarship in this area. Encouraging pursuit of funding opportunities is critical for otolaryngologists, as well-funded practitioners may have greater opportunities to shape advances and serve as an advocate for their approaches. LEVEL OF EVIDENCE: NA.

Epistaxis: the factors involved in determining medicolegal liability.

BACKGROUND: The purpose of this study was to examine litigation involving epistaxis and analyze factors that determine liability. METHODS: Jury verdicts and settlements regarding cases involving epistaxis were gathered utilizing the Westlaw database. Factors involved in litigation gathered included demographics, defendant specialty, procedure, alleged cause of malpractice, outcome, monetary award, and other variables. RESULTS: A total of 26 cases were analyzed. The majority of cases (57.7%) were decided in favor of the plaintiff or settled out of court. Total awards amounted to $24,501,252. Average awards for cases decided in favor of the plaintiff were $2,260,893 and ranged from $499,845 to $9,022,643. Settlements averaged $1,084,375 and ranged from $300,000 to $3,800,000. Common causes of malpractice encountered included delay in diagnosis, complications from medical procedures, and failure to recognize complications in a timely manner. CONCLUSION: Contrary to previous reports analyzing malpractice for varying medical procedures and complications, litigation in epistaxis is more commonly resolved in favor of the plaintiff or resolved through out-of-court settlements. Substantial financial awards and therapeutic complications from blindness to death make epistaxis a candidate for litigation. Of importance from a medicolegal stand is the fact that 30.8% (8) of the patients involved in epistaxis litigation died, either from complications of therapy or from experiencing epistaxis as a complication of another procedure/pathology. Using necessary diagnostic imaging, ensuring proper management techniques, and recognizing complications in a timely manner can serve to limit legal liability and enhance patient safety.

AAO-HNSF CORE grant acquisition is associated with greater scholarly impact.

OBJECTIVE: To determine whether receiving funding from the American Academy of Otolaryngology--Head and Neck Surgery Foundation (AAO-HNSF) Centralized Otolaryngology Research Efforts (CORE) grant program is associated with career choice (in terms of practice setting) and scholarly impact. STUDY DESIGN AND SETTING: Examination of bibliometrics among academic otolaryngologists, including CORE grants funding history. METHODS: An Internet search was conducted to determine the current practice setting and, for academic otolaryngologists, academic rank of individuals receiving CORE grants since 1985. The Scopus database was used to determine scholarly impact, as measured by the h-index, and publication experience (in years) of these practitioners along with a "control" cohort of nonfunded academic otolaryngologists. RESULTS: Of 432 unique individuals receiving CORE grant funding since 1985, 44.4% are currently academicians. This cohort had a higher h-index (mean, 11.9; median, 10; interquartile range [IQR], 6-18) than their non-CORE grant-funded academic peers (mean, 9.2; median, 7; IQR, 3-13; P = .002) and colleagues who are not currently in academic practice (mean, 4.4; median, 3; IQR, 0-6; P < .001). CORE grant-funded academic otolaryngologists had a statistically higher scholarly impact on controlling for academic rank and among practitioners with greater than 10 years of publication experience. No statistical differences in academic promotion patterns were noted between those with and those without a CORE grant funding history. CONCLUSIONS: Procurement of an AAO-HNSF CORE grant is associated with greater scholarly impact, as measured by the h-index. This relationship persists among practitioners with more than 10 years of publication experience, as well as upon comparison of CORE grant-funded and non-CORE grant-funded otolaryngologists at all academic ranks. Practitioners awarded these grants may be more likely to go into and remain in academic practice.

Does receiving an American Academy of Otolaryngology-Head and Neck Surgery Foundation Centralized Otolaryngology Research Efforts grant influence career path and scholarly impact among fellowship-trained rhinologists?

BACKGROUND: To determine whether American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) Centralized Otolaryngology Research Efforts (CORE) grants influence career paths and scholarly impact of fellowship-trained rhinologists, and whether funding from the National Institutes of Health (NIH) and CORE programs is associated with increased scholarly impact among rhinologists. Another aim was to explore whether obtaining CORE grant funding is associated with NIH award acquisition. METHODS: Practice setting, academic rank, and fellowship-training status were determined for individuals in the CORE grant database. The h-index and publication experience of practitioners was calculated using the Scopus database. Faculty listings were used to determine this data for a non-CORE-grants-funded "control" group of academic rhinologists. Active and past NIH funding was obtained using the NIH RePORTER database. RESULTS: Fifteen of 26 (57.7%) fellowship-trained rhinologists receiving CORE grants were funded for rhinologic projects. Five of 6 rhinologists receiving NIH funding had a CORE-grants-funding history. Twenty-two of 26 (84.6%) rhinologists receiving CORE funding are currently in academic practice. Academic rhinologists receiving CORE or NIH funding had higher h-indices, a result reaching significance among promoted faculty and those with greater than 10 years of publication experience. CONCLUSION: Encouraging the pursuit of CORE grants among junior faculty as well as trainees interested in rhinology may be a strategy for developing highly effective research habits that pay dividends after the first few years of one's career. Fellowship-trained rhinologists with a CORE funding history predominantly pursue careers in academic medicine, although their CORE projects are not necessarily related to rhinologic topics.

Rhinology fellowship training and its scholarly impact.

BACKGROUND: Previous examination of the impact of fellowship training on scholarly productivity among otolaryngologists found that head and neck surgeons and otologists had a higher mean h-index than fellowship-trained rhinologists. Because fellowship training in rhinology is a historically newer trend, the objectives of the present analysis were to further characterize research productivity among fellowship-trained academic rhinologists, including geographic and temporal trends, to gain insight into the future direction of scholarly pursuits within the field. METHODS: Fellowship-trained rhinologists in academic practices were identified from the American Rhinologic Society online listings and organized by academic rank, number of years in practice, location, and h-index, as calculated using the Scopus database. RESULTS: Mean h-index rose with increasing years in practice after fellowship. The h-index, number of publications, and the E-factor (a newly described bibliometric) increased with successive academic rank. The E-factor for rhinologists in this current analysis was not statistically different from the values calculated for other otolaryngology subspecialties (p > 0.05). CONCLUSION: Fellowship-training in rhinology is a relatively recent development, with half of the academic rhinologists included in this analysis having completed fellowship training within the past 5 years. Scholarly productivity among academic rhinologists increases with academic seniority. As the current cohort of fellowship-trained rhinologists progress in their academic careers, previously described deficits in scholarly productivity relative to other subspecialties are expected to diminish.

Geographic differences in academic promotion practices, fellowship training, and scholarly impact.

PURPOSE: Previous literature described how clinical fellowship training impacts scholarly production among academic otolaryngologists, finding that fellowship-trained practitioners had higher research productivity than their non-fellowship-trained peers, and head and neck (H&N) surgeons and otologists had the highest scholarly impact. In this analysis we investigate whether geographic differences in academic promotion and scholarly impact exist, and whether such differences are associated with emphasis on regional fellowship training patterns. METHODS: The Scopus database was used to determine scholarly impact (as measured by the h-index) of 1109 academic otolaryngologists from 97 departments. Online faculty listings were organized by fellowship training, academic rank, and location. RESULTS: Fellowship-trained practitioners had greater research productivity than non-fellowship-trained otolaryngologists (H=9.5 ± 0.26 SEM vs. 6.5 ± 0.43, p<0.001), a finding that persisted throughout except in the Mountain and East South Central Regions. H&N surgeons and otologists had the highest h-indices. Practitioners in the West had the highest h-index, with differences persisting upon examination of junior faculty. The West (62.1%) and Midwest (60.5%) had the highest proportions of senior faculty. Regional differences in scholarly impact and academic promotion were further noted upon organizing faculty by subspecialty fellowship training. CONCLUSIONS: Geographic differences in academic promotion and scholarly impact exist, most markedly among junior faculty. Practitioners in the West had high impact and were more represented at senior ranks. Upon examination by fellowship training status, fellowship-trained otolaryngologists had higher impact in most, but not all, geographic regions. Regional variations in promotion were noted upon organizing faculty by subspecialty, although association with scholarly impact differs by region.

Determining legal responsibility in otolaryngology: a review of 44 trials since 2008.

PURPOSE: Medicolegal factors contribute to increasing healthcare costs through the direct costs of malpractice litigation, malpractice insurance premiums, and defensive medicine. Malpractice litigation trends are constantly changing as a result of technological innovations and changes in laws. In this study, we examine the most recent legal decisions related to Otolaryngology and characterize the factors responsible for determining legal responsibility. METHODS: The Westlaw legal database (Thomson Reuters, New York, NY) was used to search for jury verdicts since 2008 in Otolaryngology malpractice cases. The 44 cases included in this analysis were studied to determine the procedures most commonly litigated and progressing to trial, as well as the year, location, alleged cause of malpractice, specialty of co-defendants, and case outcomes. RESULTS: Out of the 44 cases included in this analysis, physicians were not found liable in 36 (81.8%) cases. Rhinologic procedures comprised 38.6% of cases litigated, and rulings were in physicians' favor in 66.7% of endoscopic sinus surgery (ESS) cases and all non-ESS rhinologic cases. A perceived lack of informed consent was noted in 34.1% of cases. The 8 jury awards averaged $940,000 (range, $148,000-$3,600,000). CONCLUSION: Otolaryngologists were not found liable in the majority of cases reviewed. Rhinologic surgeries were the most common procedures resulting in litigation. Adenotonsillectomies, thyroidectomies, and airway management are also well-represented. Perceived deficits in informed consent and misdiagnosis were noted in a considerable proportion of otolaryngologic malpractice cases resulting in jury decisions.

Is NIH funding predictive of greater research productivity and impact among academic otolaryngologists?

OBJECTIVES/HYPOTHESIS: The h-index is an accurate and reliable indicator of scholarly productivity that takes into account relevance, significance, and influence of research contributions. As such, it is an effective, objective bibliometric that can be used to evaluate academic otolaryngologists for decisions regarding appointment and advancement. In this study, we evaluate the impact of NIH funding on scholarly productivity in otolaryngology. STUDY DESIGN: Analysis of bibliometric data of academic otolaryngologists. METHODS: Funding data for the 20 otolaryngology departments with the largest aggregate total of NIH grants for the fiscal years (FY) 2011 and 2012 was obtained using the National Institutes of Health Research Portfolio Online Reporting Tools Expenditures and Reports (RePORTER) Database. H-indices were calculated using the Scopus online database, and then compared to funding data at both the departmental and individual level. RESULTS: Faculty members in otolaryngology departments who received NIH funding had significantly greater research productivity and impact, as measured by the h-index, than their nonfunded peers. H-indices increased with greater NIH funding levels, and investigators with MD degrees tended to have higher mean NIH funding levels than those with PhDs. While there was no correlation between average h-index and NIH funding totals at the level of departments, there was greater correlation upon examination of NIH funding levels of individual investigators. CONCLUSIONS: The h-index has a strong relationship with, and may be predictive of, grant awards of NIH-funded faculty members in otolaryngology departments. This bibliometric may be useful in decisions regarding appointment and advancement of faculty members within academic otolaryngology departments.

Readability assessment of the American Rhinologic Society patient education materials.

BACKGROUND: The extensive amount of medical literature available on the Internet is frequently accessed by patients. To effectively contribute to healthcare decision-making, these online resources should be worded at a level that is readable by any patient seeking information. The American Medical Association and National Institutes of Health recommend the readability of patient information material should be between a 4th to 6th grade level. In this study, we evaluate the readability of online patient education information available from the American Rhinologic Society (ARS) website using 9 different assessment tools that analyze the materials for reading ease and grade level of the target audience. METHODS: Online patient education material from the ARS was downloaded in February 2012 and assessed for level of readability using the Flesch Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook (SMOG) Grading, Coleman-Liau Index, Gunning-Fog Index, FORCAST formula, Raygor Readability Estimate, the Fry Graph, and the New Dale-Chall Readability Formula. Each article was pasted as plain text into a Microsoft® Word® document and each subsection was analyzed using the software package Readability Studio Professional Edition Version 2012.1. RESULTS: All healthcare education materials assessed were written between a 9th grade and graduate reading level and were considered "difficult" to read by the assessment scales. CONCLUSION: Online patient education materials on the ARS website are written above the recommended 6th grade level and may require revision to make them easily understood by a broader audience.

Gender disparities in scholarly productivity within academic otolaryngology departments.

OBJECTIVE: To examine whether there are gender disparities in scholarly productivity within academic otolaryngology departments, as measured by academic rank and the h-index, a published, objective measure of research contributions that quantifies the number and significance of papers published by a given author. STUDY DESIGN AND SETTING: Analysis of bibliometric data of academic otolaryngologists. METHODS: Faculty listings from academic otolaryngology departments were used to determine academic rank and gender. The Scopus database was used to determine h-index and publication range (in years) of these faculty members. In addition, 20 randomly chosen institutions were used to compare academic otolaryngologists to faculty members in other surgical specialties. RESULTS: Mean h-indices increased through the rank of professor. Among academic otolaryngologists, men had significantly higher h-indices than women, a finding also noted on examination of faculty members from other specialties. Men had higher research productivity rates at earlier points in their career than women did. The productivity rates of women increased and equaled or surpassed those of men later in their careers. Men had higher absolute h-index values at junior academic ranks. Women academic otolaryngologists of senior rank had higher absolute h-indices than their male counterparts. CONCLUSIONS: The h-index measures research significance in an objective manner and indicates that although men have higher overall research productivity in academic otolaryngology, women demonstrate a different productivity curve. Women produce less research output earlier in their careers than men do, but at senior levels, they equal or exceed the research productivity of men.

Readability assessment of patient education materials on major otolaryngology association websites.

OBJECTIVE: Various otolaryngology associations provide Internet-based patient education material (IPEM) to the general public. However, this information may be written above the fourth- to sixth-grade reading level recommended by the American Medical Association (AMA) and National Institutes of Health (NIH). The purpose of this study was to assess the readability of otolaryngology-related IPEMs on various otolaryngology association websites and to determine whether they are above the recommended reading level for patient education materials. STUDY DESIGN AND SETTING: Analysis of patient education materials from 9 major otolaryngology association websites. METHODS: The readability of 262 otolaryngology-related IPEMs was assessed with 8 numerical and 2 graphical readability tools. Averages were evaluated against national recommendations and between each source using analysis of variance (ANOVA) with post hoc Tukey's honestly significant difference (HSD) analysis. Mean readability scores for each otolaryngology association website were compared. RESULTS: Mean website readability scores using Flesch Reading Ease test, Flesch-Kincaid Grade Level, Coleman-Liau Index, SMOG grading, Gunning Fog Index, New Dale-Chall Readability Formula, FORCAST Formula, New Fog Count Test, Raygor Readability Estimate, and the Fry Readability Graph ranged from 20.0 to 57.8, 9.7 to 17.1, 10.7 to 15.9, 11.6 to 18.2, 10.9 to 15.0, 8.6 to 16.0, 10.4 to 12.1, 8.5 to 11.8, 10.5 to 17.0, and 10.0 to 17.0, respectively. ANOVA results indicate a significant difference (P < .05) between the websites for each individual assessment. CONCLUSION: The IPEMs found on all otolaryngology association websites exceed the recommended fourth- to sixth-grade reading level.