149 Barriers to and enablers of the use of the Otology Questionnaire Amsterdam in clinical practice 7 amount of identified barriers and enablers in our study. We attempted to overcome this limitation by incorporating recommendations from previous implementation studies.15,20 The OQUA was used in research settings at Deventer Hospital, meaning that patients were guided and supported in completing the questionnaire. This may have affected the non-reporting of capability- and opportunity barriers, possibly biasing the identification of motivation barriers. Nevertheless, this does not directly impact the suggestions of the implementation strategy, given that this strategy focuses on addressing barriers from all categories of the COM-B model. In addition, the findings from Deventer Hospital may be useful for developing (successful) interventions at Amsterdam UMC and NWZ to overcome their capability- and opportunity barriers. Due to logistical and organizational constraints, we have presented only the perspective of OQUA users. Barriers and enablers may have been disregarded by not demonstrating the perspective of other stakeholders. In particular, the perspective of nurses and other professionals working in auditory rehabilitation, given their direct involvement and guidance of patients before, during and after the surgical intervention. It is plausible that this group therefore has a close understanding of what patients experience, need and would like to change in the use of PROMs in clinical practice. The inclusion of their perspective may have contributed to developing and prioritizing the interventions of the implementation strategy. Other examples include outpatient assistants, ICT technicians or non-nursing staff involved in the organization. Including their perspective would have been valuable, as it may influence the feasibility of the implementation strategy. Implications of the study The results of this study are needed for the final development of an implementation strategy in order to improve the clinical usefulness of the OQUA. Additional research may focus on the elaboration of this implementation strategy by assessing the proposed interventions in terms of Affordability, Practicality, (cost-) Effectiveness, Acceptability, Safety and Equity (APEASE criteria by Michie, Atkins.16 In addition, we recommend the use of current evidence on interventions from other implementation studies3,12,13 and the involvement of relevant stakeholders in the final selection and deployment of interventions. While executing the implementation strategy, future research may focus on re-evaluating the clinical use of the OQUA. Indeed, we
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