98 Chapter 5 precision and reliability. Few studies focus on the individual patients and report group level. Multiple factors should be taken into consideration when assessing the outcome of the PROM.28,29 Group-averaged comparisons cancel out measurement error, but individual PROMS do not.30 The issue of applying PROMs initially developed and validated in selected populations to more diverse or mixed populations, is a critical concern in healthcare research and clinical practice. PROMs validated in highly selected populations, may not be generalizable to broader or mixed populations. Mixed populations can be highly heterogeneous in terms of disease severity, comorbidities, and patient demographics. In cases where a PROM developed in a highly selected population needs to be applied to a mixed population, it may be necessary to adapt and revalidate the instrument to ensure its suitability and reliability across diverse groups. Researchers and healthcare providers should continuously assess the performance of PROMs in mixed populations. Strengths and limitations While it’s acknowledged that the assessment inherently involves a degree of subjectivity, the authors made diligent efforts to safeguard against any form of bias. This was accomplished by adhering to well-defined criteria, specifically the COSMIN criteria, which had been collectively agreed upon prior to the initiation of the assessment process. This rigorous approach underscores the authors’ commitment to maintaining the integrity and impartiality of the evaluation. Given that the Otology Questionnaire Amsterdam (OQUA) was developed collaboratively by the first and second authors (JK, PM), a conscious effort was made to mitigate any potential conflicts of interest during the assessment process. To achieve this, the evaluation of the OQUA was entrusted to the last author (DP). It’s important to note that the inclusion of the last author (DP) on the research team occurred prior to the commencement of the questionnaire assessments. This strategic decision was taken to minimize the risk of bias that might have arisen. Recommendations & future work Assessment of additional otological questionnaires on tinnitus, hearing loss e.g. can be provided using the mapping review as a backbone.9 This will help to further untangle the puzzling collection of different disease- and symptom specific questionnaires. The two identified domain specific questionnaires are the COQOL and OQUA, both with adequate quality but different focus. COOQL to quantify the quality of life and
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