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This study explores the relationship between text-to-speech (TTS) usage and item-by-item performance. Findings indicate that TTS usage is associated with longer and more difficult math items, as well as multiple-choice or short response formats for students with disabilities (SWDs), English language learners (ELLs), and general education (GE) peers. Among SWDs and GE students, lower proficiency and higher perceived time pressure contribute to TTS usage, while factors like gender, minority status, math persistence, interests, and effort during testing influence TTS usage among GE students. Propensity score weighting reveals a positive association between TTS usage and item performance for SWDs and ELLs with extended time accommodations, but not for those without accommodations or general education students.