Millions of Migraine Attacks, Many Answers, More Questions.

In the landscape of migraine treatment, many unanswered questions remain-particularly, which medications are most effective as acute agents and for which patients? Given the heterogeneity of patients, clinicians' practice, and the integration of new agents into migraine care, this is an ambitious question to address.1 At the same time, this question is crucial both because proper acute treatment is an important metric of quality of care and such treatments are woefully underused in the general population.2,3.

A cohort-based nutrition ECHO for community health workers.

Project Extension for Community Healthcare Outcomes (ECHO) Nevada applied the ECHO virtual hub-and-spoke telementoring model over nine 6-week cohorts (between November 2019 and November 2021) supporting community health workers (CHWs) who advise clients with diabetes or pre-diabetes. This study describes the program implementation, including evaluation data collection efforts. Didactic topics included 'Intro to Healthy Eating and Easy Wins' to 'Grocery Shopping, Cooking Tips, Reading Labels, Meal Plans' and 'Reducing Bias and Being a Good Role Model'. Spoke participants signed up to review cases. Seventy-three of the enrolled participants (n = 100) attended three or more of the six sessions. Spoke participants completed 42 case presentations. The average self-efficacy increased from 2.7 [standard deviation (SD): 1.1] before completing the program to 4.1 (SD: 0.8) after completing the program. Average knowledge scores increased from 71 (SD: 16) before completing the program to 83 (SD: 14) after completing the program. Five group interviews drew actionable feedback that was incorporated into the program. Key elements of the ECHO model were successfully incorporated to support educational goals of a cohort of CHWs in nutritional coaching. Our program evaluation data tracking system shows non-significant but encouraging results regarding self-efficacy improvement and knowledge retention.

Secondary Headache Disorders: Approach, Workup, and Special Considerations for Select Populations.

Headache is one of the most common diagnoses in neurology. A thorough understanding of the clinical presentation of secondary headache, which can be life-threatening, is critical. This review provides an overview of the diagnostic approach to a patient with headache, including discussion of "red," "orange," and "green" flags. We emphasize particular scenarios to help tailor the clinical workup to individual circumstances such as in pregnant women, when particular attention must be paid to the effects of blood pressure and hypercoagulability, as well as in older adults, where there is a need for higher suspicion for an intracranial mass lesion or giant cell arteritis. Patients with risk factors for headache secondary to alterations in intracranial pressure, whether elevated (e.g., idiopathic intracranial hypertension) or decreased (e.g., cerebrospinal fluid leak), may require more specific diagnostic testing and treatment. Finally, headache in patients with COVID-19 or long COVID-19 is increasingly recognized and may have multiple etiologies.

Skeletal Muscle Manifestations and Creatine Kinase in COVID-19.

Background and Purpose: Skeletal muscle symptoms and elevated creatine kinase (CK) levels have been consistently reported as part of the COVID-19 disease process. Previous studies have yet to show a consistent relationship between CK levels and skeletal muscle symptoms, disease severity, and death from COVID-19. The purpose of this study is to determine whether elevated CK is associated with a COVID-19 course requiring intubation, intensive care, and/or causing death. Secondary objectives: To determine if there is a relationship between elevated CK and (1) skeletal muscle symptoms/signs (2) complications of COVID-19 and (3) other diagnostic laboratory values. Methods: This is a retrospective, single center cohort study. Data were collected from March 13, 2020, to May 13, 2020. This study included 289 hospitalized patients with laboratory-confirmed SARS-CoV-2 and measured CK levels during admission. Results: Of 289 patients (mean age 68.5 [SD 13.8] years, 145 [50.2%] were men, 262 [90.7%] were African American) with COVID-19, 52 (18.0%) reported myalgia, 92 (31.8%) reported subjective weakness, and 132 (45.7%) had elevated CK levels (defined as greater than 220 U/L). Elevated CK was found to be associated with severity of disease, even when adjusting for inflammatory marker C-reactive protein (initial CK: OR 1.006 [95% CI: 1.002-1.011]; peak CK: OR 1.006 [95% CI: 1.002-1.01]; last CK: 1.009 [95% CI: 1.002-1.016]; q = .04). Creatine kinase was not found to be associated with skeletal muscle symptoms/signs or with other laboratory markers. Conclusions: Creatine kinase is of possible clinical significance and may be used as an additional data point in predicting the trajectory of the COVID-19 disease process.

Quantifying Balance Billing for Out-of-Network Behavioral Health Care in Employer-Sponsored Insurance.

OBJECTIVE: The study estimated balance billing for out-of-network behavioral health claims and described subscriber characteristics associated with higher billing. METHODS: Claims data (2011-2014) from a national managed behavioral health organization's employer-sponsored insurance (N=196,034 family-years with out-of-network behavioral health claims) were used to calculate inflation-adjusted annual balance billing-the submitted amount (charged by provider) minus the allowed amount (insurer agreed to pay plus patient cost-sharing) and any discounts offered by the provider. Among family-years with complete sociodemographic data (N=68,659), regressions modeled balance billing as a function of plan and provider supply, subscriber and family-year, and employer characteristics. A two-part model accounted for family-years without balance billing. RESULTS: Among the 50% of family-years with balance billing, mean±SD balance billing was $861±$3,500 (median, $175; 90th percentile, $1,684). Adjusted analysis found balance billing was higher ($523 higher, 95% confidence interval [CI]=$340, $705) for carve-out versus carve-in plans and for health maintenance organization (HMO) enrollees versus non-HMO enrollees ($156, 95% CI=$75, $237); for subscribers with a bachelor's degree, compared with an associate's degree or with a high school diploma or lower (between $172 [95% CI=$228, $116] and $224 [95% CI=$284, $163] higher, respectively); and for subscribers ages 45-54, compared with those ages 35-44 and 18-24 (between $57 [95% CI=$103, $10] and $290 [95% CI=$398, $183] higher, respectively). Balance billing was lower in states with more in-network providers per capita (-$8, 95% CI=-$10, -$5). CONCLUSIONS: Balance billing for out-of-network behavioral health claims may be burdensome. Expanded behavioral health networks may improve access.

Comparing Gold-standard Copayment and Coinsurance Values From Claims Processing Engines to Values Derived From Behavioral Health Claims Databases.

BACKGROUND: While researchers use patient expenditures in claims data to estimate insurance benefit features, little evidence exists to indicate whether the resulting measures are accurate. OBJECTIVE: To develop and test an algorithm for deriving copayment and coinsurance values from behavioral health claims data. SUBJECTS: Employer-sponsored insurance plans from 2011 to 2013 for a national managed behavioral health organization (MBHO). MEASURES: Twelve benefit features, distinguishing between carve-in and carve-out, in-network and out-of-network, inpatient and outpatient, and copayment and coinsurance, were created. Measures drew from claims (claims-derived measures), and benefit feature data from a claims processing engine database (true measures). STUDY DESIGN: We calculate sensitivity and specificity of the claims-derived measures' ability to accurately determine if a benefit feature was required and for plan-years requiring the benefit feature, the accuracy of the claims-derived measures. Accuracy rates using the minimum, 25th, 50th, 75th, and maximum claims value for a plan-year were compared. PRINCIPAL FINDINGS: Sensitivity (82% or higher for all but 3 benefit features) and specificity (95% or higher for all but 2 benefit features) were relatively high. Accuracy rates were highest using the 75th or maximum claims value, depending on the benefit feature, and ranged from 69% to 99% for all benefit features except for out-of-network inpatient coinsurance. CONCLUSIONS: For most plan-years, claims-derived measures correctly identify required specialty mental health copayments and coinsurance, although the claims-derived measures' accuracy varies across benefit design features. This information should be considered when creating claims-derived benefit features to use for policy analysis.

The Effects of Three Kinds of Insurance Benefit Design Features on Specialty Mental Health Care Use in Managed Care.

BACKGROUND: Insurance benefit features play a role in determining access to specialty mental health care. Previous research, primarily examining the effects of copayments, coinsurance, and deductibles in a fee-for-service setting, has concluded that specialty mental health use is highly sensitive to changes in financial requirements. Less is known about the effects of other benefit features and the effects of all of these features in a managed care environment. AIMS OF THE STUDY: Determine whether increased generosity of three types of benefit features was associated with increases in specialty mental health use and expenditures in a managed care setting. Secondary analyses investigated whether these associations varied by income level. METHODS: A first-differences design used linked claims, enrollment, and benefit data for 1,242,949 non-elderly adults (aged 18-64) with employer-sponsored insurance, before (2009) and after (2011) national behavioral health parity implementation. The data were provided by a large national managed behavioral health organization. Benefit design features included combined cost sharing from copayment and coinsurance, deductibles, the presence of annual use limits, cost sharing penalties associated with services used without getting required prior-authorization, and provider network. Outcomes included visits/days, total expenditures and patient out-of-pocket expenditures for individual psychotherapy and inpatient use, with separate values for in-network and out-of-network (OON) service use. Ordinary least squares regression was performed on change scores (2011 minus 2009 values) of all outcomes to implement the first-differences study design and normalize distributions of otherwise heavily skewed (towards zero) variables. Regressions stratified by higher income (>=USD75,000) and net worth (>=USD100,000) and lower income/net worth were also conducted. RESULTS: For in-network individual psychotherapy, larger increases in cost sharing from copayment and coinsurance were modestly associated with larger decreases in use and total expenditures (beta_visits=--0.00008, p-value=0.030; beta_total expenditures=USD--0.00629, p-value=0.011), and elimination of treatment limits was associated with larger increases in use (beta=0.09637, p-value=0.002) and total expenditures (beta=USD6.57506, p-value=0.001). These results were observed among all enrollees of plans that covered in-network and out-of-network plans and among a sub-set of these enrollees who did not change plans between 2009 and 2011. Benefit features had fewer associations with inpatient care and OON services. DISCUSSION: Elimination of limits was associated with small average increases in in-network individual psychotherapy utilization and expenditures. Cost sharing sensitivities of individual psychotherapy visits to financial requirements reported here were small, and resembled previous findings based in a managed care setting, which were smaller than findings based on the fee-for-service settings. Cost sharing may not pose a practical barrier to specialty behavioral health for non-elderly adults with employer-sponsored managed care plans. However, the influence of cost sharing may vary by specific healthcare needs, something that should be explored in further research.

The Mental Health Parity and Addiction Equity Act (MHPAEA) evaluation study: Did parity differentially affect substance use disorder and mental health benefits offered by behavioral healthcare carve-out and carve-in plans?

BACKGROUND: To assess whether implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA) was associated with: 1. Reduced differences in financial requirements (i.e., copayments and coinsurance) for substance use disorder (SUD) versus specialty mental health (MH) care and 2. Reductions in the level of cost-sharing for SUD-specific services. METHODS: MH and SUD copayments and coinsurance, 2008-2013, were obtained from benefits databases for carve-in and carve-out plans from Optum®. Linear regression was used to estimate the association of MHPAEA with differences between MH and SUD care financial requirements among carve-in and carve-out plans. A two-part regression model investigated whether MHPAEA was associated with changes in the use or level of financial requirements for SUD-specific services among carve-out plans. RESULTS: MHPAEA was not associated with significant changes in the difference between SUD and MH copayments or coinsurance levels among either carve-in or carve-out plans. MHPAEA was associated with decreases in the levels of inpatient (in-network: -$51.17; out-of-network: -$34.39) and outpatient (in-network: -$10.26) detox copayments, but increases in the levels of in-network outpatient detox coinsurance (6 percentage points) among all carve-out plans. CONCLUSION: Even if SUD benefits had been historically less generous than MH benefits, SUD financial requirements were already at parity with MH financial requirements by the time MHPAEA was passed, among Optum® plans. MHPAEA's SUD parity mandate reduced cost-sharing for detox services via copayments, but, for outpatient detox, the law simultaneously increased cost-sharing via coinsurance.

The Mental Health Parity and Addiction Equity Act Evaluation Study: Impact on Mental Health Financial Requirements among Commercial "Carve-In" Plans.

OBJECTIVE: Did mental health cost-sharing decrease following implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA)? DATA SOURCE: Specialty mental health copayments, coinsurance, and deductibles, 2008-2013, were obtained from benefits databases for "carve-in" plans from a national commercial managed behavioral health organization. STUDY DESIGN: Bivariate and regression-adjusted analyses compare the probability of use and (conditional) level of cost-sharing pre- and postparity. An interaction term is added to compare differential levels of pre- and postparity cost-sharing changes for plans that were and were not already at parity pre-MHPAEA. FINDINGS: Controlling for employer/plan characteristics, MHPAEA is associated with higher intermediate care copayments ($15.9) but lower outpatient ($2.6) copayments among in-network-only plans. Among plans with in- and out-of-network benefits, MHPAEA is associated with lower inpatient ($23.2) and outpatient ($2.5) copayments, but increases in inpatient and intermediate in-network and out-of-network coinsurance (about 1 percentage point). Among the few plans not at parity pre-MHPAEA, changes in use and level of cost-sharing associated with MHPAEA were more dramatic. CONCLUSION: Mixed evidence that MHPAEA led to more generous mental health benefits may stem from the finding that many plans were already at parity pre-MHPAEA. Future policy focus in mental health may shift to slowing growth in cost-sharing for all health services.

The Mental Health Parity and Addiction Equity Act (MHPAEA) Evaluation Study: Impact on Quantitative Treatment Limits.

OBJECTIVE: The Mental Health Parity and Addiction Equity Act (MHPAEA) significantly changed regulations governing behavioral health benefits for large, commercially insured employers. Pre-MHPAEA, many plans covered only a specific number of behavioral health treatment days or visits; post-MHPAEA, such quantitative treatment limits (QTLs) were allowed only if they were "at parity" with medical-surgical limits. This study assessed MHPAEA's effect on the prevalence of behavioral health QTLs. METHODS: Analyses used 2008-2013 specialty behavioral health benefit design data for Optum large-group plans, both carve-outs (N=2,257 plan-years, corresponding to 1,527 plans and 40 employers) and carve-ins (N=11,644 plan-years, 3,569 plans, and 340 employers). Descriptive statistics were calculated for limits existing at parity implementation, distinguished by accumulation period (annual or lifetime), level of care (inpatient, intermediate, or outpatient), unit (days, visits, or courses), condition, and network level. Proportions of plans using specific limits during the preparity (2008-2009), transition (2010), and postparity (2011-2013) periods were compared with Fisher's exact tests. RESULTS: Preparity, the most common QTLs were annual visit or day limits. Accounting for overlap in limit types, 89% of regular carve-out plans, 90% of in-network-only carve-outs, and 77% of carve-in plans limited outpatient visits; 66% of regular carve-out plans, 74% of in-network-only carve-outs, and 73% of carve-ins limited inpatient or intermediate days. Postparity, QTLs almost entirely disappeared (p<.001). CONCLUSIONS: Before MHPAEA, QTLs were common. Postimplementation, virtually all plans dropped such limits, suggesting that MHPAEA was effective at eliminating QTLs. However, increasing access to behavioral health care will mean going beyond such QTL changes and looking at other areas of benefit management.

Travel time and attrition from VHA care among women veterans: how far is too far?

BACKGROUND: Travel time, an access barrier, may contribute to attrition of women veterans from Veterans Health Administration (VHA) care. OBJECTIVE: We examined whether travel time influences attrition: (a) among women veterans overall, (b) among new versus established patients, and (c) among rural versus urban patients. RESEARCH DESIGN: This retrospective cohort study used logistic regression to estimate the association between drive time and attrition, overall and for new/established and rural/urban patients. SUBJECTS: In total, 266,301 women veteran VHA outpatients in the Fiscal year 2009. MEASURES: An "attriter" did not return for VHA care during the second through third years after her first 2009 visit (T0). Drive time (log minutes) was between the patient's residence and her regular source of VHA care. "New" patients had no VHA visits within 3 years before T0. Models included age, service-connected disability, health status, and utilization as covariates. RESULTS: Overall, longer drive times were associated with higher odds of attrition: drive time adjusted odds ratio=1.11 (99% confidence interval, 1.09-1.14). The relationship between drive time and attrition was stronger among new patients but was not modified by rurality. CONCLUSIONS: Attrition among women veterans is sensitive to longer drive time. Linking new patients to VHA services designed to reduce distance barriers (telemedicine, community-based clinics, mobile clinics) may reduce attrition among women new to VHA.

Anticoagulation in atrial fibrillation: impact of mental illness.

OBJECTIVES: To characterize warfarin eligibility and receipt among Veterans Health Administration (VHA) patients with and without mental health conditions (MHCs). STUDY DESIGN: Retrospective cohort study. METHODS: This observational study identified VHA atrial fibrillation (AF) patients with and without MHCs in 2004. We examined unadjusted MHC-related differences in warfarin eligibility and warfarin receipt among warfarin-eligible patients, using logistic regression for any MHC and for specific MHCs (adjusting for sociodemographic and clinical characteristics). RESULTS: Of 125,670 patients with AF, most (96.8%) were warfarin-eligible based on a CHADS2 stroke risk score. High stroke risk and contraindications to anticoagulation were both more common in patients with MHC. Warfarin-eligible patients with MHC were less likely to receive warfarin than those without MHC (adjusted odds ratio [AOR], 0.90; 95% CI, 0.87-0.94). The association between MHC and warfarin receipt among warfarin-eligible patients varied by specific MHC. Patients with anxiety disorders (AOR, 0.86; 95% CI, 0.80-0.93), psychotic disorders (AOR, 0.77; 95% CI, 0.65-0.90), and alcohol use disorders (AOR 0.62, 95% CI 0.54-0.72) were less likely to receive warfarin than patients without these conditions, whereas patients with depressive disorders and posttraumatic stress disorder were no less likely to receive warfarin than patients without these conditions. CONCLUSIONS: Compared with patients with AF without MHCs, those with MHCs are less likely to be eligible for warfarin receipt and, among those eligible, are less likely to receive such treatment. Although patients with AF with MHC need careful assessment of bleeding risk, this finding suggests potential missed opportunities for more intensive therapy among some individuals with MHCs.

Primitive layered gabbros from fast-spreading lower oceanic crust.

Three-quarters of the oceanic crust formed at fast-spreading ridges is composed of plutonic rocks whose mineral assemblages, textures and compositions record the history of melt transport and crystallization between the mantle and the sea floor. Despite the importance of these rocks, sampling them in situ is extremely challenging owing to the overlying dykes and lavas. This means that models for understanding the formation of the lower crust are based largely on geophysical studies and ancient analogues (ophiolites) that did not form at typical mid-ocean ridges. Here we describe cored intervals of primitive, modally layered gabbroic rocks from the lower plutonic crust formed at a fast-spreading ridge, sampled by the Integrated Ocean Drilling Program at the Hess Deep rift. Centimetre-scale, modally layered rocks, some of which have a strong layering-parallel foliation, confirm a long-held belief that such rocks are a key constituent of the lower oceanic crust formed at fast-spreading ridges. Geochemical analysis of these primitive lower plutonic rocks--in combination with previous geochemical data for shallow-level plutonic rocks, sheeted dykes and lavas--provides the most completely constrained estimate of the bulk composition of fast-spreading oceanic crust so far. Simple crystallization models using this bulk crustal composition as the parental melt accurately predict the bulk composition of both the lavas and the plutonic rocks. However, the recovered plutonic rocks show early crystallization of orthopyroxene, which is not predicted by current models of melt extraction from the mantle and mid-ocean-ridge basalt differentiation. The simplest explanation of this observation is that compositionally diverse melts are extracted from the mantle and partly crystallize before mixing to produce the more homogeneous magmas that erupt.

The financial performance of rural hospitals and implications for elimination of the Critical Access Hospital program.

PURPOSE: To compare the financial performance of rural hospitals with Medicare payment provisions to those paid under prospective payment and to estimate the financial consequences of elimination of the Critical Access Hospital (CAH) program. METHODS: Financial data for 2004-2010 were collected from the Healthcare Cost Reporting Information System (HCRIS) for rural hospitals. HCRIS data were used to calculate measures of the profitability, liquidity, capital structure, and financial strength of rural hospitals. Linear mixed models accounted for the method of Medicare reimbursement, time trends, hospital, and market characteristics. Simulations were used to estimate profitability of CAHs if they reverted to prospective payment. FINDINGS: CAHs generally had lower unadjusted financial performance than other types of rural hospitals, but after adjustment for hospital characteristics, CAHs had generally higher financial performance. CONCLUSIONS: Special payment provisions by Medicare to rural hospitals are important determinants of financial performance. In particular, the financial condition of CAHs would be worse if they were paid under prospective payment.

New women veterans in the VHA: a longitudinal profile.

OBJECTIVE: The number of women veterans using Veterans Health Administration (VHA) services has increased rapidly, but the characteristics of women joining VHA are not well understood. We sought to describe sociodemographic characteristics, utilization, and retention of new and returning women VHA patients over a 7-year period. METHODS: We identified women veterans who used VHA outpatient services from VHA Enrollment and Utilization files for fiscal years 2003 through 2009. "New" patients in a given year had no outpatient use within the prior 3 years. Patients were "retained" if they continued to use VHA in subsequent years. MAIN FINDINGS: Of the 287,447 women veteran VHA outpatients in 2009, 40,000 (14%) were new to VHA in that year and over half had joined VHA since 2003. Nearly two thirds of these new patients were younger than 45, and 43% carried a service-connected disability status. Most new patients (88%) received primary care services in 2008, and 40% used mental health services. Repeated use of mental health services (at least three visits per year) nearly doubled among new patients (from 11% in 2003 to 20% in 2008). Among those using VHA primary care in 2006, 68% of new patients versus 91% of returning patients were retained in either of the subsequent 2 years. CONCLUSION: The influx of new women veterans seeking VHA services in recent years, combined with their high rate of retention within VHA, contribute to the marked increase in numbers of women veterans using VHA. Many require fairly intensive VHA services.

Recognition of rapid speech by blind and sighted older adults.

PURPOSE: To determine whether older blind participants recognize time-compressed speech better than older sighted participants. METHOD: Three groups of adults with normal hearing participated (n = 10/group): (a) older sighted, (b) older blind, and (c) younger sighted listeners. Low-predictability sentences that were uncompressed (0% time compression ratio [TCR]) and compressed at 3 rates (40%, 50%, and 60% TCR) were presented to listeners in quiet and noise. RESULTS: Older blind listeners recognized all time-compressed speech stimuli significantly better than did older sighted listeners in quiet. In noise, the older blind adults recognized the uncompressed and 40% TCR speech stimuli better than did the older sighted adults. Performance differences between the younger sighted adults and older blind adults were not observed. CONCLUSIONS: The findings support the notion that older blind adults recognize time-compressed speech considerably better than older sighted adults in quiet and noise. Their performance levels are similar to those of younger adults, suggesting that age-related difficulty in understanding time-compressed speech is not an inevitable consequence of aging. Instead, frequent listening to speech at rapid rates, which was highly correlated with performance of the older blind adults, may be a useful technique to minimize age-related slowing in speech understanding.

Recognition of time-compressed and natural speech with selective temporal enhancements by young and elderly listeners.

PURPOSE: The goal of this experiment was to determine whether selective slowing of speech segments improves recognition performance by young and elderly listeners. The hypotheses were (a) the benefits of time expansion occur for rapid speech but not for natural-rate speech, (b) selective time expansion of consonants produces greater score increments than other forms of selective time expansion, and (c) older listeners benefit from time expansion of speech METHOD: Participants (n=10-16 per group) were younger and older adults with normal hearing or with hearing loss. A repeated-measures design was used to assess recognition of sentence-length stimuli presented in 2 baseline speech rates: natural and 50% time compression. Selective time expansion of consonants, vowels, or pauses was applied to the natural-rate and time-compressed sentence-length stimuli. RESULTS: Listeners showed excellent performance for natural-rate speech, regardless of time-expansion method. Recognition was significantly poorer for the time-compressed sentences, but performance by elderly listeners and listeners with hearing loss improved with selective time expansion, particularly when applied to consonant segments. CONCLUSION: The findings support the hypothesis that older listeners and listeners with hearing impairment benefit from selective time expansion of consonants applied to rapid speech, without a corresponding decrement when applied to normal-rate speech.

Effects of age and sequence presentation rate on temporal order recognition.

The experiments examined the ability of younger and older listeners to identify the temporal order of sounds presented in tonal sequences. The stimuli were three-tone sequences that spanned two-octave frequency range, and listeners identified random permutations of tone order using labels of relative pitch. Some of the sequences featured uniform timing characteristics, and the sequence duty cycle was varied across conditions to examine the relative influence of tonal durations and intertone interval on recognition performance across a range of sequence presentation rates. Other stimulus sequences featured nonuniform timing with unequal tone durations and intertone intervals. The listeners were groups of younger and older persons with or without hearing loss. Results indicated that temporal order recognition was influenced primarily by sequence presentation rate, independent of tonal duration, tonal interval spacing, or sequence timing characteristics. The performance of older listeners was poorer than younger listeners, but the age-related recognition differences were independent of sequence presentation rate. There were no consistent effects of hearing loss on temporal ordering performance.