An examination of individual differences in levels of processing.

The present study examined individual differences in levels of processing. Participants completed a cued recall task in which they made either rhyme or semantic judgements on pairs of items. Pupillary responses during encoding were recorded as a measure of the allocation of attentional effort and participants completed multiple measures of working and long-term memory. The results suggested levels of processing effect in both accuracy and pupillary responses with deeper levels of processing demonstrating higher accuracy and larger pupillary responses than shallower levels of processing. Most participants demonstrated levels of processing effect, but there was substantial variability in the size of the effect. Variation in levels of processing was positively related to individual differences in long-term memory and the magnitude of the pupillary levels of processing effect, but not working memory. These results suggest that some of the variation in levels of processing is likely due to individual differences in the allocation of attentional effort (particularly to items processed deeply) during encoding.

Does deep processing protect against mind wandering and other lapses of attention during learning?

Three experiments examined if deep processing would aid in reducing off-task thoughts during learning. In each experiment, participants learned words or pairs of words under deep or shallow conditions. During learning, participants were periodically presented with thought-probes to examine if they were experiencing off-task thoughts (mind wandering, external distraction, mind blanking). Levels of processing was manipulated both within (Experiment 1) and between subjects (Experiments 2 and 3) using structural, rhyme, and semantic judgements and testing memory with cued-recall (Experiments 1 and 2) or recognition (Experiment 3). All three experiments demonstrated a levels of processing effect on memory with better performance in deep compared to shallow conditions. Importantly, in all three experiments rates of off-task thinking (and mind wandering more specifically) were the same across conditions and Bayes factors suggested moderate evidence in favour of the null hypothesis. The results suggest that deep processing does not necessarily protect against mind wandering and other lapses of attention.

Predictive Value of Laryngeal Penetration to Aspiration in a Cohort of Pediatric Patients.

Videofluoroscopic swallow studies (VFSS) provide dynamic assessment of the phases of swallowing under fluoroscopic visualization and allow for identification of abnormalities in the process, such as laryngeal penetration and aspiration. While penetration and aspiration both reflect degrees of swallowing dysfunction, the predictive potential of penetration for subsequent aspiration is not fully elucidated in the pediatric population. As a result, management strategies for penetration vary widely. Some providers may interpret any depth or frequency of penetration as a proxy for aspiration and implement various therapeutic interventions (e.g., modification of liquid viscosity) to eliminate penetration episodes. Some may recommend enteral feeding given the presumed risk of aspiration with penetration, even when aspiration is not identified during the study. In contrast, other providers may advise continued oral feeding without modification even when some degree of laryngeal penetration is identified. We hypothesized that the depth of penetration is associated with the likelihood of aspiration. Identification of predictive factors for aspiration following laryngeal penetration events has significant implications for selection of appropriate interventions. We performed a retrospective cross-sectional analysis of a random sample of 97 patients who underwent VFSS in a single tertiary care center over a 6 month period. Demographic variables including primary diagnosis and comorbidities were analyzed. We examined the association between aspiration and degrees of laryngeal penetration (presence or absence, depth, frequency) across diagnostic categories. Infrequent and shallow penetration events of any type of viscosity were less likely to be associated with aspiration event(s) during the same clinical encounter regardless of diagnosis. In contrast, children with consistent deep penetration of thickened liquids invariably demonstrated aspiration during the same study. Our findings show that shallow, intermittent laryngeal penetration of any viscosity type on VFSS was not consistent with clinical aspiration. These results provide further evidence that penetration-aspiration is not a uniform clinical entity and that nuanced interpretation of videofluoroscopic swallowing findings is necessary to guide appropriate therapeutic interventions.

Effort Mobilization and Lapses of Sustained Attention.

The current study examined whether effort mobilization would enhance sustained attention and reduce lapses of attention. Participants performed a sustained attention task and were randomly assigned to either an effort condition where they were instructed to "Try Hard" on a subset of trials or were assigned to a control condition with no "Try Hard" instructions. Pupillary responses were continuously recorded, and periodically during the task participants were presented with thought probes to determine whether they were on or off task. The results suggested within the effort condition there were no behavioral differences between Try Hard and "Standard" trials. Preparatory pupil responses were increased in Try Hard trials, but there were no differences for phasic pupillary responses to stimulus onset. In contrast, examining differences between the effort and control conditions suggested that participants who received the Try Hard instructions demonstrated faster overall performance, a reduction in very long reaction times, and reported fewer off-task thoughts compared with participants in the control condition. Participants in the effort condition also demonstrated a larger ramp-up in pupillary responses during the preparatory interval and a larger phasic response to stimulus onset compared with participants in the control condition. These results are consistent with attention allocation models suggesting that participants in the effort condition mobilized more attentional effort than participants in the control condition, resulting in enhanced sustained attention and a reduction in lapses of attention. These results also are consistent with recent theories, which suggest that the locus coeruleus norepinephrine system is associated with effort mobilization.

The influence of working memory capacity and lapses of attention for variation in error monitoring.

In two experiments, individual differences in working memory capacity (WMC), lapses of attention, and error monitoring were examined. Participants completed multiple WMC tasks along with a version of the Stroop task. During the Stroop, pupil diameter was continuously monitored. In both experiments, error phasic pupillary responses were larger than phasic pupillary responses associated with correct incongruent and correct congruent trials. WMC and indicators of lapses of attention were correlated with error pupillary response, suggesting that high WMC and low lapse individuals had enhanced error monitoring abilities compared with low WMC and high lapse individuals. Furthermore, in Experiment 2 error awareness abilities were associated with WMC, lapses of attention, and the error phasic pupillary responses. Importantly, individual differences in the susceptibility to lapses of attention largely accounted for the relationship between WMC and error monitoring in both experiments. Collectively, these results suggest that WMC is related to error monitoring abilities, but this association is largely due to individual differences in the ability to consistently maintain task engagement and avoid lapses of attention.

The Utility of a Novel Definition of Health Care Regions in the United States in the Era of COVID-19: A Validation of the Pittsburgh Atlas Using Pneumonia Admissions.

STUDY OBJECTIVE: The COVID-19 pandemic in the United States has underscored the need to understand health care in a regional context. However, there are multiple definitions of health care regions available for conducting geospatial analyses. In this study, we compare the novel Pittsburgh Atlas, which defined regions for emergency care, with the existing definitions of regions, counties, and the Dartmouth Atlas, with respect to nonemergent acute medical conditions using pneumonia admissions. METHODS: We identified patients hospitalized with a primary diagnosis of pneumonia or a primary admitting diagnosis of sepsis with a secondary diagnosis of pneumonia in the Agency for Healthcare Research and Quality's State Inpatient Databases. We calculated the percentage of region concordant care, the localization index, and market share for 3 definitions of health care regions (the Pittsburgh Atlas, Dartmouth Atlas, and counties). We used logistic regression identified predictors of region concordant care. RESULTS: We identified 1,582,287 patients who met the inclusion criteria. We found that the Pittsburgh Atlas and Dartmouth Atlas definitions of regions performed similarly with respect to both localization index (92.0 [interquartile range 87.9 to 95.7] versus 90.3 [interquartile range 81.4 to 94.5]) and market share (8.5 [interquartile range 5.1 to 13.6] versus 9.4 [interquartile range 6.7 to 14.1]). Both atlases outperformed the localization index (67.5 [interquartile range 49.9 to 83.9]) and market share (20.0% [interquartile range 11.4 to 31.4]) of the counties. Within a given referral region, the demographic factors, including age, sex, race/ethnicity, insurance status, and the level of severity, affected concordance rates between residential and hospital regions. CONCLUSION: Because the Pittsburgh Atlas also has the benefit of respecting state and county boundaries, the use of this definition may have improved policy applicability without sacrificing accuracy in defining health care regions for acute medical conditions.

Encoding dynamics in free recall: Examining attention allocation with pupillometry.

In four experiments pupillary responses were used to examine attention allocation and encoding dynamics in free recall. In Experiment 1, pupillary responses increased (and then decreased) across serial position suggesting that attention was increasingly allocated to items during learning until working memory was overloaded. In Experiment 2, manipulating presentation duration resulted in larger and more sustained pupillary responses with increased presentation duration, suggesting that participants were likely engaging in more elaborative and attention-demanding processes. In Experiment 3a, manipulating list-length resulted in decreased pupillary responses across serial position suggesting that participants were prioritizing early list items and less attention was allocated to later items. In Experiment 3b, when list-length was known, pupillary responses in the long-list length condition tended to decrease across serial position whereas pupillary responses in the short list-length condition tended to increase and decrease across serial positon. These results suggest that participants flexibly allocate attention to items during encoding depending on the nature of the task and the types of processes that are engaged in. These results further suggest the potential of utilizing pupillary responses to track attention allocation during learning.

Individual differences in baseline oculometrics: Examining variation in baseline pupil diameter, spontaneous eye blink rate, and fixation stability.

Individual differences in baseline oculometrics (baseline pupil diameter, spontaneous eye blink rate, fixation stability), and their relation with cognitive abilities, personality traits, and self-report assessments were examined. Participants performed a baseline eye measure in which they were instructed to stare at a fixation point onscreen for 5 min. Following the baseline eye measure, participants completed a questionnaire asking what they were thinking about during the baseline eye measure. Participants also completed various cognitive ability measures assessing working memory capacity, attention control, and off-task thinking. Finally, participants completed a number of questionnaires assessing personality, Attention Deficit/Hyperactivity Disorder symptomology, mind wandering, and morningness-eveningness. Overall, the vast majority of correlations with the baseline eye measures were weak and nonsignificant, suggesting that these associations may not be very robust. The results also demonstrated the importance of examining what participants are thinking about during the baseline measure. These results add to the growing body of findings suggesting inconsistent relations between different baseline eye measures and various individual differences constructs.

Examining the effects of probe frequency, response options, and framing within the thought-probe method.

A recent surge of interest in the empirical measurement of mind-wandering has led to an increase in the use of thought-probing to measure attentional states, which has led to large variation in methodologies across studies (Weinstein in Behavior Research Methods, 50, 642-661, 2018). Three sources of variation in methodology include the frequency of thought probes during a task, the number of response options provided for each probe, and the way in which various attentional states are framed during the task instructions. Method variation can potentially affect behavioral performance on the tasks in which thought probes are embedded, the experience of various attentional states within those tasks, and/or response biases to the thought probes. Therefore, such variation can be problematic, both pragmatically and theoretically. Across three experiments, we examined how manipulating probe frequency, response options, and framing affected behavioral performance and responses to thought probes. Probe frequency and framing did not affect behavioral performance or probe responses. But, in light of the present results, we argue that thought probes need at least three responses, corresponding to on-task, off-task, and task-related interference. When researchers are specifically investigating mind-wandering, the probe responses should also distinguish between mind-wandering, external distraction, and mind-blanking.

Pupillary Correlates of Fluctuations in Sustained Attention.

The current study examined pupillary correlates of fluctuations and lapses of sustained attention. Participants performed a sustained attention task with either a varied ISI or a fixed ISI (fixed at 2 or 8 sec) while pupil responses were continuously recorded. The results indicated that performance was worse when the ISI was varied or fixed at 8 sec compared with when the ISI was fixed at 2 sec, suggesting that varied or long ISI conditions require greater intrinsic alertness compared with constant short ISIs. In terms of pupillary responses, the results demonstrated that slow responses (indicative of lapses) were associated with greater variability in tonic pupil diameter, smaller dilation responses during the ISI, and subsequently smaller dilation responses to stimulus onset. These results suggest that lapses of attention are associated with lower intrinsic alertness, resulting in a lowered intensity of attention to task-relevant stimuli. Following a lapse of attention, performance, tonic pupil diameter, and phasic pupillary responses, all increased, suggesting that attention was reoriented to the task. These results are consistent with the notion that pupillary responses track fluctuations in sustained attention.

Hypothyroidism and Wound Healing After Salvage Laryngectomy.

BACKGROUND: Patients undergoing salvage laryngectomy are predisposed to radiation-induced hypothyroidism and impaired wound healing secondary to the tissue effects of prior treatment. The impact of hypothyroidism on postoperative wound healing is not established. METHODS: A single-institution retrospective case series was performed. The inclusion criteria specified preoperatively euthyroid adults who underwent salvage laryngectomy with concurrent neck dissection between 1997 and 2015 for persistent or recurrent laryngeal squamous cell carcinoma after radiation or chemoradiation therapy (n = 182). The principal explanatory variable was postoperative hypothyroidism, defined as thyroid-stimulating hormone (TSH) higher than 5.5 mIU/L. The primary end points of the study were pharyngocutaneous fistulas and wounds requiring reoperation. Multivariate analysis was performed. RESULTS: The fistula rate was 47% among hypothyroid patients versus 23% among euthyroid patients. In the multivariate analysis, the patients who experienced hypothyroidism in the postoperative period had a 3.6-fold greater risk of fistula [95% confidence interval (CI) 1.8-7.1; p = 0.0002]. The hypothyroid patients had an 11.4-fold greater risk for a required reoperation (24.4 vs 5.4%) than the euthyroid patients (95% CI 2.6-49.9; p = 0.001). The risk for fistula (p = 0.003) and reoperation (p = 0.001) increased with increasing TSH. This corresponds to an approximate 12.5% incremental increase in the absolute risk for fistula and a 10% increase in the absolute risk for reoperation with each doubling of the TSH. CONCLUSION: Postoperative hypothyroidism independently predicts postoperative wound-healing complications. The association of hypothyroidism with fistula formation may yield opportunities to modulate wound healing with thyroid supplementation or to provide a biomarker of wound progression.

Individual differences in working memory capacity and search efficiency.

In two experiments, we examined how various learning conditions impact the relation between working memory capacity (WMC) and memory search abilities. Experiment 1 employed a delayed free recall task with semantically related words to induce the buildup of proactive interference (PI) and revealed that the buildup of PI differentially impacted recall accuracy and recall latency for low-WMC and high-WMC individuals. Namely, the buildup of PI impaired recall accuracy and slowed recall latency for low-WMC individuals to a greater extent than what was observed for high-WMC individuals. To provide a circumstance in which previously learned information remains relevant over the course of learning, Experiment 2 required participants to complete a multitrial delayed free recall task with unrelated words. Results revealed that with increased practice with the same word list, WMC-related differences were eventually eliminated in interresponse times (IRTs) and recall accuracy, but not recall latency. Thus, despite still accumulating larger search sets, low-WMC individuals searched LTM as efficiently as high-WMC individuals. Collectively, these results are consistent with the notion that under normal free recall conditions, low-WMC individuals search LTM less efficiently than do high-WMC individuals because of their reliance on noisy temporal-contextual cues at retrieval. However, it appears that under conditions in which previously learned items remain relevant at recall, this tendency to rely on vague self-generated retrieval cues can actually facilitate the ability to accurately and quickly recall information.

The Asfora Bullet Cage System Shows Comparable Fusion Rate Success Versus Control Cage in Posterior Lumbar Interbody Fusion in a Randomized Clinical Trial.

BACKGROUND: Low back pain and degeneration of the intervertebral disc are an integrated malady that affects millions of Americans. Cage devices used in association with posterior lumbar interbody fusion (PLIF) have been shown to be an effective approach in the treatment of a number of lower spine disorders attributed to degenerative disc disease (DDD). OBJECTIVE: This study was undertaken as part of a U.S. Food and Drug Administration (FDA) Investigational Device Exemption (IDE) study and compares the effectiveness of the Asfora Bullet Cage System (ABCS) to successfully fuse vertebra at one or two levels between L2 and S1 in patients with DDD to an FDA approved comparison device, the Medtronic-Sofamor Danek Inter Fix Threaded Fusion Device (MSDIFD). METHODS: A total of 257 randomized participants were implanted with either the ABCS device (n = 132) or the MSDIFD device (n = 125) through an open posterior approach using autogenous local bone graft without the use of pedicle screws. Patients were evaluated prior to surgery and at the 24 month (24-M) visit for fusion status, deep tendon reflex status, sensory function, motor function, straight leg raise status, pain, disability, and device safety. Radiological evaluation and statistical analysis were performed by independent professionals. RESULTS: Evaluation of device success was performed at 24-M visit. From the original group of 257 patients, 59 were lost to follow-up. Primary measures of success at the 24-M visit involved pain and function, fusion, neurological status, and device-related adverse events measures. Pain and function improved in both (MSDIFD: 75.7 percent; ABCS: 82.6 percent). Fusion success with all radiographic points at 24-M visits was 79.4 percent MSDIFD and 88.2 percent ABCS. Neurological improvement was seen in both (MSDIFD: 77.0 percent; ABCS: 87.8 percent). One device-related grade 1 adverse event was reported in the MSDIFD group. Disc height preservation was equivalent for single level fusions (MSDIFD: 16.1 percent; ABCS: 20.0 percent) and second level fusions (MSDIFD: 10.7 percent; ABCS: 14.3 percent). General health and well-being improvement was the same (MSDIFD: 37.0 percent; ABCS: 40.0 percent). Subsequent fusion, up to 10 years, was equivalent (MSDIFD: 83.8 percent; ABCS: 91.2). Results for both devices were considered to be satisfactory, with a slight non-significant superiority for the ABCS. CONCLUSION: From the ABCS device FDA IDE sanctioned study and the review of the literature, we concluded that the Asfora Bullet Cage System is safe, effective and comparable to other interbody fusion devices which are used stand-alone or in conjunction with pedicle screws, rhBMP-2, or autogenous bone harvested from the iliac crest inserted through anterior, lateral or posterior approaches.

Analytic morphomics corresponds to functional status in older patients.

BACKGROUND: Older patients account for nearly half of the United States surgical volume, and age alone is insufficient to predict surgical fitness. Various metrics exist for risk stratification, but little work has been done to describe the association between measures. We aimed to determine whether analytic morphomics, a novel objective risk assessment tool, correlates with functional measures currently recommended in the preoperative evaluation of older patients. MATERIALS AND METHODS: We retrospectively identified 184 elective general surgery patients aged >70 y with both a preoperative computed tomography scan and Vulnerable Elderly Surgical Pathways and outcomes Assessment within 90 d of surgery. We used analytic morphomics to calculate trunk muscle size (or total psoas area [TPA]) and univariate logistic regression to assess the relationship between TPA and domains of geriatric function mobility, basic and instrumental activities of daily living (ADLs), and cognitive ability. RESULTS: Greater TPA was inversely correlated with impaired mobility (odds ratio [OR] = 0.46, 95% confidence interval [CI] 0.25-0.85, P = 0.013). Greater TPA was associated with decreased odds of deficit in any basic ADLs (OR = 0.36 per standard deviation unit increase in TPA, 95% CI 0.15-0.87, P <0.03) and any instrumental ADLs (OR = 0.53, 95% CI 0.34-0.81; P <0.005). Finally, patients with larger TPA were less likely to have cognitive difficulty assessed by Mini-Cog scale (OR = 0.55, 95% CI 0.35-0.86, P <0.01). Controlling for age did not change results. CONCLUSIONS: Older surgical candidates with greater trunk muscle size, or greater TPA, are less likely to have physical impairment, cognitive difficulty, or decreased ability to perform daily self-care. Further research linking these assessments to clinical outcomes is needed.

The importance of conative factors for individual differences in attention control.

Relations between conative factors (task-specific motivation, attention self-efficacy, and self-set goals) and individual differences in attention control (AC) performance were investigated in two latent variable studies. Participants performed AC tasks along with measures of working memory and processing speed. During the AC tasks, participants self-reported their motivation, self-efficacy, and self-set goals for the tasks. Task-unrelated thoughts were also assessed. Confirmatory factor analyses demonstrated that latent factors for the constructs could be formed and the conative factors were each related to the AC factor. Structural equation modeling further suggested that the conative factors tended to account for unique variance in attention, even after accounting for shared variance with working memory and processing speed. These results provide evidence that conative factors are important for individual differences in AC and further suggest that multiple factors likely contribute to variation in performance on AC tasks. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Mind-wandering when studying valuable information: The roles of age, dispositional traits, and contextual factors.

The factors that trigger lapses of attention (e.g., mind-wandering) during new learning remain unclear. The present study investigated whether the likelihood of experiencing an attentional lapse depends on (a) the importance of the material being studied and (b) the learner's age. In two experiments, younger and older adults completed a delayed free recall task in which to-be-remembered words were paired with point values. Thought probes were embedded into the encoding phase of each list to provide an index of one's ability to maintain attention on task and prevent recurrent lapses of attention (i.e., the consistency of attention). Experiment 1 revealed all individuals better remembered high-value information at the expense of low-value information, and older adults were more frequently focused on the task than younger adults. Participants were also less likely to remember an item at test if they experienced an attentional lapse while learning said item, and they were more consistently focused on the task when studying high-value information than when studying low-value information. Age did not moderate either of these effects. Experiment 2 replicated the findings from Experiment 1 and further revealed that the positive association between age and attentional consistency was explained by age-related differences in affect, motivation, personality, and attention-deficit hyperactivity disorder symptomology. Once these factors were accounted for, older age was associated with increased attentional inconsistency (less on-task focus). While future replication of this finding is needed, implications for education and theories of both mind-wandering and aging are discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Individual differences in attention control: A meta-analysis and re-analysis of latent variable studies.

A meta-analysis and re-analysis of prior latent variable studies was conducted in order to assess whether there is evidence for individual differences in broad attention control abilities. Data from 90 independent samples and over 23,000 participants suggested that most (84.4%) prior studies find evidence for a coherent attention control factor with average factor loadings of .51. This latent attention control factor was related to other cognitive ability factors including working memory, shifting, fluid intelligence, long-term memory, reading comprehension, and processing speed, as well as to self-reports of task-unrelated thoughts and task specific motivation. Further re-analyses and meta-analyses suggest that the results remained largely unchanged when considering various possible measurement issues. Examining the factor structure of attention control suggested evidence for sub-components of attention control (restraining, constraining and sustaining attention) which could be accounted for a by a higher-order factor. Additional re-analyses suggested that attention control represents a broad ability within models of cognitive abilities. Overall, these results provide evidence for attention control abilities as an important individual differences construct.

Which Provider Specialties are Performing Diagnostic Procedures for Dysphagia in the United States?

OBJECTIVE: Care of patients with dysphagia occurs at the intersection of several different medical specialties. Otolaryngologists are uniquely equipped to diagnose dysphagia given their specialized training, yet the extent to which otolaryngologists perform diagnostic procedures for dysphagia is unknown. The objective of this study was to characterize the specialty-level variation among providers performing diagnostic assessments for dysphagia. METHODS: We performed a retrospective, cross-sectional analysis of dysphagia care utilization among Medicare beneficiaries from 2013 to 2021 using the CMS Physician & Other Practitioners by Provider and Service dataset. American Association of Medical Colleges (AAMC) data reports were used to determine the total number of providers per specialty. For each procedure and specialty, the percentage of providers performing >10 procedures annually and the average annual number of procedures per performing provider (non-radiology) were calculated. RESULTS: We analyzed nine common dysphagia diagnostic procedures, including manometry, 24-h pH testing, flexible endoscopic evaluation of swallowing (FEES), and modified barium swallow study (MBSS). Mean 3.7 (SD 1.4) otolaryngologists (0.04% of practicing) performed manometry testing annually, compared to 493 (69.3) gastroenterologists (3.3%). Less than 1% of practicing otolaryngologists (37.8 (8.0) (0.04%)) and gastroenterologists (51.6 (8.4), 0.35%) performed 24-h pH testing annually. FEES testing was most commonly performed by otolaryngologists; however, only 48 (6.3) providers (0.51% of practicing) performed these procedures annually. For MBSS, fewer otolaryngologists (5.2 (1.0), 0.05%) perform these assessments than other medical specialties. Each otolaryngologist performed 110.7 (52.5) studies annually, compared to 200.1 (68.0) per gastroenterologist. CONCLUSION: Otolaryngologists represent a small fraction of providers performing dysphagia-related diagnostic procedures despite a unique training within our specialty to comprehensively diagnose and manage this condition. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:3698-3705, 2024.

Medicare Advantage Prior Authorization Requirements for Otolaryngologic Procedures in 2021.

Little is known about the extent of prior authorization requirements in otolaryngology. We performed a secondary analysis of data comparing prior authorization (PA) policies across 5 major Medicare Advantage insurers to estimate the counterfactual proportion of 2021 Medicare Part B fee-for-service spending and utilization for commonly performed otolaryngologic procedures that would have required PA. The counterfactual proportion of spending (range: 20.4%-27.6%) and utilization (range: 1.8%-4.5%) requiring PA was relatively consistent across insurers and largely attributable to rhinologic procedures. However, PA requirements for specific services varied widely among insurers. Among the 70 (of 196; 35.7%) services subject to PA by any insurer, nearly half were subject to PA by a single insurer (n = 34; 48.6%). Only 10 (14.3%) services were subject to PA by 4 (n = 6; 8.6%) or 5 (n = 4; 5.7%) insurers. These discrepancies illustrate the challenges of navigating discordant insurer policies for otolaryngologists and raise concerns about the validity of certain PA requirements.