165 General discussion & future perspectives 8 pain or depression).32 Though standardization of PROs in otology is challenging using existing disease specific questionnaires, the OQUA might be able to address this issue. By using one ear-domain specific otologic PROM across patient groups with different ear diseases, we can better compare these groups with one another. Some efforts have been made to compare and pool data across different PROMs in otology. Mlynski and his colleagues compared the COMOT-1511 and ZCMEI-2133 PROM psychometric properties and PROM results.34 They concluded that the COMOT-15 focusses on hearing with a redundant content of the hearing sub-score and probably is more suited for hearing-focused research questions. The ZCMEI-21 provides a comprehensive assessment of the COM symptom complex and may therefore also be used in research settings, where ear discharge, vertigo or pain should be assessed 34. The results show that the differences in design make it hard to compare outcomes. Other challenges faced when comparing different PROMs are the different items used within the similar complaint subscale that ask for different aspects or define subtle changes of these aspects. For example, in the hearing scale one could ask ‘If I am with a group of more than 3 people, I find it hard to follow the conversation. (COQOL). Or ‘Can you follow a conversation between a few people during dinner?’ (OQUA). Furthermore subtle language nuances and sentence structure can lead to different interpretations. Cross cultural differences have a role in this aspect as well. The perception of symptoms and their impact on quality of life can vary across different cultures or countries. Translation, adaptation and validation of instruments or scales for cross-cultural research is very time-consuming and requires careful planning and the adoption of rigorous methodological approaches to derive a reliable and valid measure of the concept of interest in the target population3,5. Normative data realized in a general Dutch population of the OQUA cannot simply be used in a different country or culture for the same reason. The OQUA is officially translated into the English language, though it is not cross-culturally validated. Cross-cultural validation of an Australian, UK or American English OQUA version even might not be the same. Cross cultural validation in other languages of the OQUA is in progress. Strength and weakness and what do we expect (& wish) for the future? To better interpret and use individual and group data from the OQUA for shared decision making, it is essential to establish Minimal Important Change (MIC) scores. MIC defines a difference in the score that is clinically relevant for the patient. For
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