12 Chapter 1 There is a difference between success and quality when looking at ear surgery. Success is often presented as the number of patients in which the primary goal is achieved. Quality has a wider definition though and depends on the degree of achieving all goals with avoidance of side effects or complications. Success depends on the primary goal; it can be defined as absence of residual or recurrent disease in case of cholesteatoma or in case of conductive hearing loss it can be defined as hearing improvement. In case of chronic otorrhea (“running ear”) the quality / success is defined as reduction of otorrhea. These are all success measures and clinical objective outcomes. To assess quality of care it is necessary to redefine success and take not only objective measures into account but also incorporate the patient’s perspective. For example, improving a patient’s ability to hear can objectively be successful (audiometry), though it can be experienced as a failure subjectively at the same time, for example when other complaints like dizziness or tinnitus appear as a side effect of the treatment. Furthermore, improving a patient’s ability to hear will probably compensate for the small risks of complications of surgery. In general, risks of ear surgery include bleeding, infection, dizziness, (increase of) tinnitus, loss of- or diminished taste or severe hearing loss. But all these risks can be invalidating and require prolonged hospital admission, revision surgery or permanent disability. Although the complication rate of (often elective) ear surgery is low, careful decision making and setting the right indication for this patient is important. It is therefore necessary to have objective as well as subjective measures in the quality assessment of ear surgery. Data from PROMs can be very valuable and be added to the objective clinical data to assess quality of care. PROMs PROMs are increasingly being used for gathering patient data to support clinical decision making and to produce valuable data on the overall impact of an intervention or treatment. The SNOT-22 questionnaire is a good example of a PROM used in clinical decision making.5 The SNOT-22 is being used to evaluate nose-related complains with or without surgery. It is expected that the use of PROMs for clinical decision making will grow in the near future.6 However, at this moment, integration of PROMs into routine practice specifically in otology is limited. A PROM can be designed as a generic, domain-, complaint- or disease specific measurement. For example, a generic PROM might measure quality of life using tools like the EQ-5D, SF-367-9, or HUI-310. These generic PROMs allow comparisons across different diseases but may not be sensitive enough to detect changes within a single
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