A flowchart indicating steps of scale development. To the left of the flowchart, overall purpose for each step of development is presented. To the right of the flowchart, the actions taken at each step are specified.
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Links AR, Tunkel DE, Boss EF. Stakeholder-Engaged Measure Development for Pediatric Obstructive Sleep-Disordered Breathing: The Obstructive Sleep-Disordered Breathing and Adenotonsillectomy Knowledge Scale for Parents. JAMA Otolaryngol Head Neck Surg. 2017;143(1):46–54. doi:https://doi.org/10.1001/jamaoto.2016.2681
Is a questionnaire on adenotonsillectomy (AT) performed for obstructive sleep-disordered breathing (oSDB) appropriate for measuring parental knowledge of oSDB symptoms and treatment with AT?
The oSDB and AT Knowledge Scale for Parents scale was designed using a sequential development process incorporating key content themes highlighted by parents and clinicians. When administered to 19 clinicians and 13 laymen, the measure showed high reliability, and comparisons of laymen and clinician scores showed significant differences, demonstrating the measure’s validity.
The oSDB and AT Knowledge Scale for Parents is a stakeholder-developed, psychometrically sound measure that may be used to enhance clinical decision making and patient-centered outcomes research for pediatric oSDB.
Parental decision making about adenotonsillectomy (AT) for obstructive sleep-disordered breathing (oSDB) is associated with decisional conflict that may be alleviated with improved knowledge about symptoms and treatments.
To develop a measure of parental knowledge about oSDB and AT.
Design, Setting, and Participants
A sequential design was used for scale development. A prototype measure containing 9 oSDB and AT themes and 85 items was administered in survey format via an online platform. Participants included 19 clinician experts (otolaryngologists and pediatricians) and 13 laymen (parents of children who snore or do not snore, and other adults). Quantitative and qualitative responses were used to modify the measure and create the knowledge scale. Content validity of the scale was established through expert feedback and evaluation. Criterion validity was established with t test comparisons of experts with laymen. Reliability of the responses was assessed with Cronbach α testing.
Main Outcomes and Measures
An 85-item prototype measure and 39-item modified measure were evaluated for consensus/approval and psychometric integrity.
Of 45 potential participants, 32 individuals (71%) responded to the prototype scale. Respondents included 19 clinician experts (59%) (otolaryngologists and pediatricians) and 13 laymen (41%) (parents of children who snore [n = 8] or do not snore [n = 2] and other adults [n = 3]); demographic data were not collected. Content analysis and qualitative feedback were largely rated positively: 27 respondents (84%) stated that the measure was a good evaluation of knowledge, 30 respondents (94%) commented that the items were clear, and 31 individuals (97%) approved of its organization, although there were several suggestions for rewording and/or addition of response options. Experts identified themes most important for assessing oSDB (symptoms) and AT (experiences: risks and benefits) knowledge. These qualitative comments were used to modify the scale, and items were eliminated if more than 2 were reported as misleading or less than 85% of clinicians provided correct responses. Five themes (oSDB symptoms, treatment options, AT risks, anesthesia, and AT benefits) and 39 items composed the final scale. Experts scored higher than laymen on the oSDB and AT Knowledge Scale for Parents overall (17 [94%] vs 12 [67%]; Cohen d = 1.96; 95% CI, 1.05-2.86) and within all themes, including experiences of children with oSDB (19 [88%] vs 13 [62%]; Cohen d = 1.53; 95% CI, 0.71-2.32), treatment options (19 [97%] vs 12 [68%]; Cohen d = 1.74; 95% CI, 0.88-2.57), AT risks (17 [97%] vs 12 [59%]; Cohen d = 1.94; 95% CI, 1.03-2.83), anesthesia (17 [97%] vs 12 [79%]; Cohen d = 1.09; 95% CI, 0.29-1.88), and AT benefits (17 [95%] vs 12 [67%]; Cohen d = 1.28; 95% CI, 0.46-2.09), demonstrating criterion validity. All responses demonstrated high reliability (Cronbach α = 0.94).
Conclusions and Relevance
The oSDB and AT Knowledge Scale for Parents is psychometrically sound for use in the assessment of parental knowledge.
In recent years, there has been a focus on improving the quality and impact of patient and family decisions about diagnosis and treatment. Decision quality, “the extent to which treatments reflect the considered preferences of well-informed patients and are implemented,”1[p58] includes specific facets of decision making, such as patient information and knowledge, concordance with patient goals and preferences, and patient engagement by providers in the decision process.2 Measurement of knowledge or “the extent to which patients are informed”2[p1] of health conditions and the risks and benefits of treatment options is being increasingly implemented into patient-centered outcomes research to ensure that patients, parents, and families are able to make high-quality decisions about their care.2 Patient knowledge measures for conditions, including human immunodeficiency virus (HIV),3 diabetes,4 cancer,5 nutrition,6 cardiovascular,7 smoking,8 and lifestyle/activity,9 have been developed and validated, but few exist for conditions in pediatric surgical care.
The emphasis on enhancing patient and family decision quality is particularly significant in areas with clinical equipoise or insufficient evidence to support the superiority of 2 or more treatment alternatives, which is often seen with elective surgical procedures. Obstructive sleep-disordered breathing (oSDB) occurs in 6% to 12% of children10,11 and may have significant physical, behavioral, and neurocognitive sequelae.11-13 The most common treatment for pediatric oSDB is adenotonsillectomy (AT) surgery.13 Although it is often effective for improving the quality of life and sleep habits,14 AT may also be equivalent to watchful waiting with supportive care in reducing symptoms (ie, behavioral and neurocognitive)14,15 for patients with mild to moderate oSDB. With more than 500 000 operations performed annually on children in the United States, AT is considered by some to be potentially overused.16-19 Moreover, the AT operation bears inherent risks for the child, including painful recovery, dehydration, or postoperative hemorrhage. Parental decisions for AT have been associated with significant conflict or uncertainty about the choice of treatment20-22; likewise, parents have been shown23 to have little understanding of potential consequences of adenotonsillar hypertrophy and oSDB. Despite the high prevalence of this condition, frequency of surgery, and effect on patients and families, to our knowledge, no measure exists to assess parental knowledge of oSDB or AT.
Because assessment of parental knowledge may increase our ability to provide health care consistent with family preferences and values, thereby yielding high-quality treatment decisions and reducing overuse of elective surgeries, we engaged oSDB stakeholders, including physicians, parents, and other laymen, to develop a measure to assess parent knowledge about oSDB and preparation for AT surgery, titled the oSDB and AT Knowledge for Parents scale.
The scale was developed based on a sequential development process,24 which included steps of construct definition, scale construction, administration, content evaluation, psychometric evaluation, and scale modification (Figure).24 This project was approved by the Johns Hopkins Institutional Review Board. To maintain the anonymity of participants in this small sample and waive written consent through the Internet-based testing platform, demographic information was not collected.
Initial scale construction was informed by established techniques for knowledge scale development surrounding other conditions and procedures.3,6,25 First, we conducted a comprehensive literature review for key studies and research evidence on oSDB, AT, and development of knowledge scales for use in patient-centered outcomes research.3,26 We synthesized findings from the literature review with key themes identified during previously conducted parent and clinician stakeholder analyses on decision making for parents of children with oSDB.21 We created a comprehensive pool of potential items related to key elements of parent oSDB and AT questions about treatment of oSDB. These items were categorized into the principal themes of (1) causes of oSDB,21,27 (2) symptoms of oSDB,21,27,28 (3) diagnosis,29 (4) treatment options,14,15,21,30 (5) consequences of not treating oSDB,14,31 (6) anesthesia,21,28 (7) experiences after AT,14,15,32 (8) risks of AT,21,32,33 and (9) benefits of AT14,15,21,34 (Table 1).
We subsequently developed a prototype measure containing 85 items in 9 themes in a format based on the Ottawa Hospital Research Institute framework.35 This framework was selected as a model based on its clear organization and accordance with the purpose and scope of the oSDB and AT Knowledge Scale for Parents. According to this framework, a knowledge questionnaire should measure “cognizance of a clinical problem, its alternatives, main benefits, risks and side effects.”35[p1] Based on a categorical format dividing true/false statements into overarching themes, the framework specifies a focus on factors important for patient and family decision making.
Purposive and snowball sampling was used. Participants were recruited through professional and parent networks, and additional physicians and laymen were subsequently invited to participate.36 Feedback was solicited from physician oSDB experts (including both community and academic otolaryngologists in the American Society of Pediatric Otolaryngology’s oSDB interest group), pediatricians, pediatric anesthesiologists, and laymen parents and other adults. The scale was posted online via Qualtrics software37 containing (1) the knowledge measure; (2) open-ended, qualitative evaluation questions; and (3) a brief postsurvey assessment.
Qualitative evaluation questions asked participants to provide “comments or suggestions about the questions asked above” after responding to items on each theme. Participants who did not elaborate or suggest modifications were considered to have found items in applicable themes to be satisfactory.
Quantitative postsurvey evaluations contained multiple-choice questions about content (eg, “Which categories do you believe to be necessary for measuring knowledge?”) and quality (eg, clarity of items and organization). Quantitative postsurvey evaluations were analyzed using frequency analysis to verify a majority agreement. Pile-sorting methods were used to thematically analyze qualitative feedback for individual items. Responses from laymen participants were evaluated for usability and readability, and expert qualitative evaluation was considered for content modification. Changes proposed by more than 1 participant led to appropriate editing. Revisions suggested by only 1 participant were evaluated by investigators well versed in the content matter who reached a consensus on implementing changes. Percentage of agreement (percentage of experts who answered a knowledge item correctly) was used to identify problematic items, and items with less than 85% agreement were eliminated.7
Content validity was established based on results from the content evaluation, as described above. Criterion validity was established through unpaired, 2-tailed t test comparisons of expert and laymen scores on the knowledge measure, testing the hypothesis that experts would yield significantly higher scores. Cohen d effect sizes were computed to assess the magnitude of the differences between expert and laymen scores. Typically, 0.2 is considered a small effect size, 0.5 a medium effect size, and 0.8 or greater a large effect size.38 Cronbach α was used to assess the reliability of responses.
Analyses were first computed for the prototype measure (ie, all 85 items) and subsequently for the final modified measure (ie, the 33 original items from the prototype present in the modified oSDB and AT Knowledge Scale for Parents) to ensure that psychometric properties would remain consistent after the measure was modified. The score for the final, modified scale included all items of the oSDB and AT Knowledge Scale for Parents except for 6 false responses (ie, untrue statements added to the scale to provide variety in correct responses and improve accurate assessment of knowledge) that had been added following content evaluation to improve on previous items (eg, ringing in ears, heat/cold tolerance, and heartburn). Participants received scores for both the cumulative measure (overall knowledge score) and the individual themes (eg, treatment options). Theme scores were computed for all participants who answered each item in a given category (eg, causes of oSDB [n = 32]), and full knowledge scores were computed for participants who answered at least 90% of the items and responded to each theme in the cumulative measure (n = 29). Mean substitution was used for missing data when participants met the criteria (ie, ≤10% items left unanswered), such that the mean group (eg, clinician) response would be substituted for a missing value.
We abbreviated the final oSDB and AT Knowledge Scale for Parents based on expert evaluation. The scale contains items considered to be most important for evaluating knowledge of oSDB and AT divided into 5 major themes (Table 1). The Flesch-Kincaid test39 confirmed that the measure is less than an eighth-grade reading level (level, 7.7) and applicable to parents of diverse educational level backgrounds.
Of 45 identified potential participants, 32 responded to the electronically distributed scale, yielding an estimated response rate of 71% and a final sample of 19 clinician experts (59%) and 13 laymen (41%) (8 parents of children who snore, 2 parents of children who do not snore, and 3 other laymen, such as adults without children) overall, and 17 experts and 12 laymen who addressed all 9 themes on the knowledge measure, with a minimum rate of 90%. Because participants who did not answer every item tended to leave the last 3 themes unanswered, attrition may have resulted from a scale that seemed too long (85 items subsequently condensed to 39 items). Given the relatively small number of participants, a post hoc sensitivity analysis was conducted to show that the sample size was sufficient and results were valid and reliable to evaluate the oSDB and AT Knowledge Scale for Parents. Results demonstrated that a Cohen d effect size of a minimum of 1.1 would be necessary for a sample of 17 experts and 12 laymen (α = .05; power = 0.9).
The prototype measure included the categories of (1) causes of oSDB (n = 9 items), (2) symptoms of oSDB (n = 13), (3) diagnosis options (n = 6), (4) treatment options (n = 11), (5) outcomes of not treating oSDB (n = 7), (6) experiences after surgery (n = 13), (7) anesthesia (n = 9), (8) risks of AT (n = 8), and (9) benefits of AT (n = 9 items). After content evaluation and modification, the final oSDB and AT Knowledge scale now includes the 5 categories of symptoms of oSDB (n = 9), treatment options (n = 6), experiences with anesthesia (n = 5), risks of AT (n = 10), and benefits of AT (n = 9). The quality of the measure was rated positively: 27 participants (84%) stated that it was a good evaluation of knowledge, 30 participants (94%) commented that the items were clear, and 31 individuals (97%) approved of its organization. Overall, the 19 experts believed that the identified themes were important for defining oSDB and AT, illustrating construct validity. The categories valued most highly were outcomes of not treating oSDB (18 [95%]), experiences after AT (18 [95%]), benefits of AT (18 [95%]), and possible risks of AT (19 [100%]). Causes of oSDB were also emphasized (16 [84%]), with adequate ratings on symptoms of oSDB (15 [79%]). Fewer experts emphasized the risks of anesthesia (14 [74%]), which was retained and justified according to laymen ratings (12 [92%]), previous stakeholder analysis emphasizing the role of anesthesia in decision making,21 and investigator experience. Themes such as experiences after AT and risks of AT were combined to create a shorter measure.
When asked for suggestions, experts and laymen were satisfied with the content within each theme, with some suggested modifications. Participants who did not indicate a need for revisions to the measure were considered to approve of all content. The number of participants who provided comments or suggestions for at least 1 item within each theme ranged from 8 participants (25%) (anesthesia) to 15 (47%) (causes of snoring). Primary changes indicated by 6 participants (19%) included rewording the construct (eg, distinguishing between snoring and oSDB) and removing unnecessary or unrepresentative items (eg, changes in personality or temperament). Eight participants (25%) suggested removing at least 1 item in the prototype measure, and 3 individuals (9%) suggested the addition of items. Six participants (19%) raised concerns about the readability or usability of at least 1 item with suggestions for modification, and 12 individuals (38%) provided some suggestions and clarifications of the content of at least 1 response (eg, “Is nasal tone of voice short- or long-term?”).
A small sample of items (22 [26%]) fell below the 85% expert agreement threshold, including weight gain as a symptom, personality change as an experience after surgery, and monitoring daytime activity as a diagnostic strategy. Most of the items that experts disagreed on were intended to be false (18 [82%]), which had been implemented to provide contrast and accurately assess knowledge (eg, chest pain and genetics). All items with less than 85% consensus were eliminated.
Criterion validity was established through a comparison of knowledge scores of experts and laymen. Experts were hypothesized to have significantly higher knowledge levels on (1) the full prototype, (2) each of the 9 original categories, (3) the full modified oSDB and AT Knowledge Scale for Parents, and (4) each of the 5 themes of the modified scale. All hypotheses were supported.
Analyses were performed with t tests using a .05 α level. Experts scored significantly higher on the prototype knowledge measure than laymen (17 [86%] vs 12 [57%]; Cohen d = 2.16; 95% CI, 1.21-3.09) and within all themes, including causes (19 [78%] vs 13 [49%]; Cohen d = 1.45; 95% CI, 0.65-2.24), symptoms (19 [85%] vs 13 [52%]; Cohen d = 2.05; 95% CI, 1.17-2.91), treatment options (19 [86%] vs 12 [57%]; Cohen d = 1.63; 95% CI, 0.79-2.46), diagnosis (19 [75%] vs 12 [46%]; Cohen d = 1.64; 95% CI, 0.79-2.46), outcomes without treatment (18 [79%] vs 12 [58%]; Cohen d = 1.69; 95% CI, 0.82-2.53), experiences after AT (17 [86%] vs 12 [58%]; Cohen d = 1.37; 95% CI, 0.54-2.18), AT risks (18 [90%] vs 12 [53%]; Cohen d = 1.71; 95% CI, 0.84-2.55), anesthesia (17 [98%] vs 12 [82%]; Cohen d = 1.10; 95% CI, 0.31-1.88), and AT benefits (17 [90%] vs 12 [53%]; Cohen d = 1.93; 95% CI, 1.02-2.82). These differences were repeated and confirmed in the final 39-item oSDB and AT Knowledge Scale for Parents, with experts scoring higher on the knowledge measure than laymen (17 [94%] vs 12 [67%]; Cohen d = 1.96; 95% CI, 1.05-2.86) and within all themes, including experiences of children with oSDB (19 [88%] vs 13 [62%]; Cohen d = 1.53; 95% CI, 0.71-2.32), treatment options (19 [97%] vs 12 [68%]; Cohen d = 1.74; 95% CI, 0.88-2.57), AT risks (17 [97%] vs 12 [59%]; Cohen d = 1.94; 95% CI, 1.03-2.83), anesthesia (17 [97%] vs 12 [79%]; Cohen d = 1.09; 95% CI, 0.29-1.88), and AT benefits (17 [95%] vs 12 [67%]; Cohen d = 1.28; 95% CI, 0.46-2.09). Analysis results for both the prototype and final measure are presented in Table 2.
Reliability was assessed to determine the consistency of responses via Cronbach α coefficients. Responses from this sample yielded high reliability on both the prototype measure (α = 0.96) and the modified oSDB and AT Knowledge Scale for Parents (α = 0.94). Reliability was adequate across themes as well (symptoms, α = 0.82; treatment options, α = 0.74; risks, α = 0.82; and benefits, α = 0.84). The sole exception was anesthesia (α = 0.66). The individual themes were expected to have somewhat lowered α values because they each had 5 to 9 items, as distinct from the 39-item oSDB and AT Knowledge Scale for Parents. Typically, a measure with a greater number of items is more likely to have a higher Cronbach α value.40
The oSDB and AT Knowledge Scale for Parents is composed of 39 items classified into 5 themes (symptoms of oSDB, treatment, risks of AT, anesthesia, and benefits of AT) (Table 3). Correct answers are summed to attain an overall percentage score representing the degree of parent knowledge level. Parents require evidence-based knowledge about the consequences of their child’s condition, the risks and benefits of treatment options inclusive of surgery, and the conditions under which surgery is performed, to make a high-quality decision.41,42 As such, researchers have supported the practicality of measures to assess knowledge of health conditions and have stressed the importance of promoting patient knowledge overall.5 These measures have been noted for their capability to (1) help the patient understand both the condition and the risks and benefits of treatment options and (2) provide the patients with tools to participate in decision making with a full understanding of that decision.5 Guidelines such as the Ottawa Hospital Research Institute framework35 have been established to support the availability of these knowledge assessments, allowing for development of knowledge questionnaires for any condition (eg, tamoxifen treatment for breast cancer43 and hormone replacement therapy44).
To achieve high-quality care, clinicians must provide adequate information and ensure parental retention and understanding before decisions are made. To that end, the oSDB and AT Knowledge Scale for Parents was developed through a combination of current literature and stakeholder (clinician and parent) analysis. This scale will assist parents in decision making for children with oSDB and will be a useful tool for patient-centered outcomes research on AT and oSDB. Several measures have been created to assess the experience and status of children with oSDB, such as tools to evaluate the quality of life in children with oSDB (Obstructive Sleep Apnea-1845) and assist in the diagnosis of pediatric oSDB (Clinical Assessment Score-1546). Another prior measure, the Obstructive Sleep Apnea Knowledge and Attitudes scale,47 assesses physicians’ knowledge about obstructive sleep apnea. Likewise, measures such as the Epworth Sleepiness Scale,48 Sleep Disorders Questionnaire,49 and Pediatric Sleep Questionnaire50 evaluate and screen oSDB symptoms and sequelae. To our knowledge, no measure has been developed to inclusively measure parental knowledge of oSDB and AT surgery.
The oSDB and AT Knowledge Scale for Parents may therefore be used in both research and practice to engage parents. Components will further support the development and implementation of a decision aid (ie, material containing scientific information about oSDB and AT to use during medical decision making) that might assist parents in decision making for AT. To our knowledge, this scale presents the first validated measure to test the users’ knowledge of oSDB and AT for these purposes.
Prior research3,4,20,21 has demonstrated the importance of patient and family knowledge and preparation in improving satisfaction and care experience and reducing anxiety before surgery. Measures that assess knowledge about a specific condition or procedure aid in the development and evaluation of family-centered educational materials, identify gaps in parent or patient knowledge, and guide communication strategies for physicians.51 Patient knowledge measures, such as the HIV Treatment Knowledge Scale3 or a tool to assess knowledge of stroke for high-risk patients,25 have asserted their use both as an outcome measure and as a clinical teaching tool.25 Several multimodal informational programs about general anesthesia for children, including materials that test parents to apply knowledge provided by their physicians, such as a drawMD app or the ADVANCE (ie, anxiety-reduction, distraction, video-modeling and education, adding parents, no excessive reassurance, coaching, and exposure) behavioral modification program,52 have been described.53-55
In considering validity evaluation, the theme of anesthesia in the oSDB and AT Knowledge Scale for Parents contained some discrepancy in expert evaluation and reliability analysis. We retained anesthesia in the scale because a prior parent stakeholder analysis21 indicated that anesthesia risks were significant issues in parental decision making. It is possible that less reliability was attained for this theme given that the clinician group was composed primarily of otolaryngologists rather than anesthesiologists, who would therefore have more consistent and well-rounded knowledge of oSDB and AT outcomes. Furthermore, reliability analysis for a measure such as the oSDB and AT Knowledge Scale for Parents may have some nuances since correct responses are reliant on select information provided by physicians or other sources, which may not be consistent for each item. Indeed, the reliability of anesthesia themes suggests that individuals’ knowledge and information about anesthesia is more variable than for other aspects of oSDB (eg, symptoms). Reliability analysis of this measure is helpful in supporting the consistency of included items, but validation of the measure was more reliant on content and criterion validity to establish its purpose and use for further studies and contexts. All content evaluations performed for this study are considered to support the integrity and further use of the oSDB and AT Knowledge for Parents Scale.
Although our sample size was adequate for the present analysis, a larger, more heterogeneous sample may have aided in quantitative evaluation. Furthermore, the distribution of the laymen subsamples (parents of children who snore [n = 8] or do not snore [n = 2] and other adults [n = 3]) might be improved: a sample that was better distributed across groups would have been useful for determining between-group differences. In addition, the laymen subsample did not wholly represent the target population of parents of children with oSDB deciding on treatment. Because of the sampling strategy and size, demographic and background information were not collected from participants. Although we recognize this lack of information as a limitation in assessing educational and multicultural differentiations, it was considered pertinent to ethically protect participant privacy of the small, nonrandom sample. As such, it is possible that personal characteristics, including ethnicity, educational level, or practice setting, may have affected the responses. We are presently conducting a prospective study that includes parents and children of a wide demographic spectrum in which the knowledge scale is used as 1 outcome measure. The primary purpose of the present study was to develop and evaluate a usable tool to assess knowledge of oSDB and AT. Staged user testing and analysis that adjusts for specific demographics of parent participants is forthcoming for further validation. In addition, evaluation of the psychometric properties of the modified oSDB and AT Knowledge Scale for Parents was performed through a rescoring of responses to the prototype measure, taking only items present in the final scale into account. In the future, the modified scale should be administered to a new population in isolation and results should be verified.
The oSDB and AT Knowledge Scale for Parents is an operational measure of parental knowledge about oSDB and treatment with AT. It will be a useful tool in otolaryngic practice and research. Ultimately, the scale will be used to aid patient-centered outcomes research investigating parental perceptions of decision making in pediatric oSDB and associated treatment. Some or all of the scale could also be incorporated into decision support tools for parents of children with oSDB when considering treatment options.
Corresponding Author: Emily F. Boss, MD, MPH, 601 N. Caroline St, Baltimore, MD 21287 (email@example.com).
Accepted for Publication: July 20, 2016.
Published Online: September 15, 2016. doi:10.1001/jamaoto.2016.2681
Author Contributions: Ms Links and Dr Boss had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Links, Boss.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Links.
Obtaining funding: Boss.
Study supervision: Boss.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: Dr Boss is supported by grant K08HS022932 from the Agency for Healthcare Research and Quality. Dr Boss is also supported by the Johns Hopkins Clinician-Scientist Award and the American Society of Pediatric Otolaryngology Career Development Award.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: 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.
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