My $0.02, Inserts that sit out on the hearth slightly will fit in more fireplaces as already mentioned. In my opinion, they are slightly more efficient than those flush but trust me not that much more as mentioned the blowers are probably like 95% of what gets the heat out and distributed. With it slightly out means you can use what they call the "cooking" surface for food. Those "cooking" surfaces are usually insulated so they're more like warming surfaces. My insert has a 5" cooking surface as it sticks out slightly on the hearth and it's insulated so I'm lucky if it ever reaches much over 200-300F, I don't have a thermometer to say the exacts but did put a frozen thin-crust pizza on it and after an hour the cheese was slightly melted. I know the Osburns "cooking" surface has air blowing underneath it so it's unlikely to get too hot either. The Pacific Energy Summit inserts have their cooking surface insulated as well.
Now, as for those that sit out need more clearance to mantel, I believe it's the opposite. Those that sit flush need more clearance to mantel than those that stick out. Any flames that are coming out the insert, if it's installed flush the flames will have a chance of hitting your mantel directly, or the hottest air in direct contact. If your insert is sticking out 6" if flames are coming out the front your mantel above is likely to be behind the direct contact or hottest part of said flames. To back up my idea, Jotul Kennebec insert manual page 8 shows if your mantel sticks out only 3 1/2", you need 37 1/2" from floor to make clearance. If your mantel sticks out 12" you need more clearnace 43 1/2" from floor. It's a stepped picture. That would imply, if your insert sticks out 6" and your mantel sticks out 9 1/2" with an insert that sticks out 6" you only need 37 1/2" from floor. If your insert is flush the mantel needs to be 42" above. But, as mentioned although one that sticks out may reduce your clearances to combustibles above it increases how big your hearth has to be as you need 16" or 18" usually in front of the loading door and, having it out 6" will mean your hearth needs to be 6" longer than one installed flush.