The Otology Questionnaire Amsterdam: a generic patient reported outcome measure about the severity and impact of ear complaints. A cross-sectional study on the development of this questionnaire

Barriers to and enablers of the use of the Otology Questionnaire Amsterdam in clinical practice-a qualitative post-implementation study

BACKGROUND

The Otology Questionnaire Amsterdam (OQUA) is developed to evaluate multiple ear complaints and their impact on patients' daily lives. The current clinical use of this questionnaire is below the potential utilization.

AIM

To identify the barriers and enablers of using the OQUA as perceived by ENT surgeons and patients and provide recommendations for an implementation strategy.

METHODS

Prospective and qualitative analysis was performed using focus groups and interviews with ENT professionals (n = 15) and patients (n = 25) with ear complaints of one tertiary referral hospital and two regional hospitals. Barriers and enablers were identified and classified by using the Capability-Opportunity-Motivation-Behavior model and the Theoretical Domains Framework. Suggestions for an implementation strategy will be made accordingly.

RESULTS

ENT professionals' barriers included lack of knowledge and skills to use the OQUA, inadequate technological support and perceived time constraints during consultation, uncertainty about the clinical relevance and lack of feedback on the outcomes of the OQUA. Enablers included beneficial consequences of the OQUA for the professional, organization and science. Patients' barriers included lack of knowledge about the objective and usefulness of the OQUA, perceived burden, difficulties in completing the questionnaire and insufficient feedback during consultation. Patient enablers included beliefs about beneficial consequences of the OQUA for the patient, health care and society. Suggested interventions involved education, training, environmental restructuring and incentivisation.

CONCLUSION

Based on the findings, we propose an implementation strategy should focus on education and training about the objective, outcomes and relevance of the OQUA, environmental restructuring regarding the optimal use of the OQUA, and incentivisation with feedback on the valuable outcomes of the OQUA for the patient, professional and healthcare. Future research is needed to determine the feasibility of the implementation strategy.

Quality assessment of patient-reported outcome measures for patients with multiple ear complaints

INTRODUCTION

There is an increased demand for well-validated PROMs in otology. This study will systematically assess the methodological quality of all published patient-reported outcome measures (PROMS) for patients with multiple ear complaints and to identify the best suitable PROM for use by clinicians treating patients with multiple ear complaints.

METHODS

An extensive systematic mapping review of all otology questionnaires was performed to identify questionnaires measuring multiple ear complaints. The 'Consensus-based standards for the selection of health measurement Instruments' (COSMIN) checklists were used to evaluate the quality of the questionnaire by two researchers. The worst item score per aspect of the methodological assessment counted.

RESULTS

Twelve multiple-complaint questionnaires were included in the study for quality assessment. Ten questionnaires were disease-specific (COMQ-12, CES, ZCMEI-21, MD-POSI, PAN-QOL, ETDQ-7, MDOQ, GYSSCDQ, COMOT-15 and DEU-MDDS). Two questionnaires were ear domain-specific (OQUA and COQOL). The majority of multiple complaint questionnaires lacked good design with concept elicitation and patient involvement.

CONCLUSION

For the majority of questionnaires, the quality assessment was inadequate as only a few authors consulted with patients affected by the complaints in the development. Modifications of earlier versions of PROMS or combinations of multiple questionnaires lead to ongoing (cross-cultural) validation of these questionnaires albeit mediocre design and validation. The two domain-specific questionnaires are the COQOL and OQUA, both with adequate quality but different focus. COQOL to quantify the quality of life and OQUA to measure and evaluate the severity and impact of ear complaints. [Correction added on 26 January 2024, after first online publication: In the preceding sentence, the spelling of the abbreviation COQOL has been corrected in this version.].

Surgical results and quality of life after subtotal petrosectomy

PURPOSE

Few data are available regarding subjective complaints and quality of life (QoL) after subtotal petrosectomy (STP). The purpose of our study was to assess long-term surgical results after STP, and to evaluate disease-specific, patient-reported outcomes including QoL and subjective hearing.

METHODS

A retrospective cohort study, including a postal survey, was performed in the Amsterdam University Medical Centers (Amsterdam UMC) location Academic Medical Centre (AMC). All patients who underwent a STP between 1990 and 2018 were included. Patient characteristics, indication for surgery, adverse events, disease recidivism, and patient-reported health outcomes were evaluated.

RESULTS

181 patients (183 ears) underwent a STP for several indications. The main indication was chronic otitis media (COM) with or without cholesteatoma (69%). In the total cohort, 8 residual cholesteatoma (5%) and 6 inclusion cholesteatoma 4% were detected. Postoperative (functional) health outcomes showed a significant negative impact on QoL in the STP cohort compared to normative data. Compared to patients without ear problems, the postoperative STP patients scored worse on almost all domains of the Chronic Ear Survey (CES) (p < 0.001). SF-36 scores of postoperative STP data showed negative Z-scores in almost all subscales, indicating lower levels of QoL compared to Dutch reference values. Most subscales of the Amsterdam Inventory for Auditory Disability and Handicap (AIADH) demonstrate a large-effect size in disadvantage of the STP cohort when compared to Dutch reference values.

CONCLUSION

STP is a suitable technique to tackle severe ear disease. Despite its favourable surgical results, STP has a negative impact on several domains of patient's QoL.

The development of a Self-Rated ICF-based questionnaire (HEAR-COMMAND Tool) to evaluate Hearing, Communication, and Conversation disability: Multinational experts' and patients' perspectives

Objective

An instrument that facilitates the advancement of hearing healthcare delivery from a biomedical model to a biopsychosocial one that underpins the International Classification of Functioning, Disability, and Health framework (ICF) brief and comprehensive Core Sets for Hearing Loss (CSHL) is currently unavailable. The objective is to describe the process of developing and validating a new questionnaire named the HEAR-COMMAND Tool created by transferring the ICF CSHL into a theory-supported, practically manageable concept.

Design

A team from Germany, the USA, the Netherlands, and Egypt collaborated on development. The following ICF domains were considered; "Body Functions" (BF), "Activities and Participation" (AP), and "Environmental Factors" (EF). The development yielded English, German, and Arabic versions. A pilot validation study with a total of 109 respondents across three countries, Germany, Egypt, and the USA was conducted to revise the item terminology according to the feedback provided by the respondents.

Results

The questionnaire included a total of 120 items. Ninety items were designed to collect information on the functioning and 30 items inquiring about demographic information, hearing status, and Personal Factors. Except for the "Body Structures" (BS) domain, all the categories of the brief ICF CSHL were covered (a total of 85% of the categories). Moreover, the items covered 44% of the comprehensive ICF CSHL categories including 73% of BF, 55% of AP, and 27% of EF domains. Overall, the terminology of 24 ICF-based items was revised based on the qualitative analysis of the respondents' feedback to further clarify the items that were found tod be unclear or misleading. The tool highlighted the broad connection of HL with bodily health and contextual factors.

Conclusions

The HEAR-COMMAND Tool was developed based on the ICF CSHL and from multinational experts' and patients' perspectives with the aim to improve the execution of audiological services, treatment, and rehabilitation for adult patients with HL. Additional validation of the tool is ongoing. The next step would be to pair the tool with BS categories since it was excluded from the tool and determine its effectiveness in guiding hearing health care practitioners to holistically classify categories influencing hearing, communication, and conversation disability.

Postoperative Patient Reported Outcomes After Cholesteatoma Surgery

BACKGROUND

Results and success measures of cholesteatoma surgery are generally described using objective data whereas subjective data are mostly lacking. Patients experiences and complaints are becoming more important alongside clinical and audiometric outcome measures in cholesteatoma care.

OBJECTIVE

To investigate the course of patient-reported complaints, the impact of complaints, audiometric measures and the stability of audiometric measures, and complaints over time after primary and recurrent/residual cholesteatoma surgery.

METHODS

Postoperative patients were prospectively included and divided into primary acquired and recurrent/residual cholesteatoma. The EuroQol 5D (EQ-5D-3L), Otology Questionnaire Amsterdam (OQUA), and the Speech Spatial Questionnaire (SSQ) were completed by 144 patients up to 2 years postoperative. Patient-reported complaints divided in eight separate domains, postoperative hearing and impact on daily life were longitudinally assessed by means of linear mixed models.

RESULTS

Hearing loss and tinnitus are the most reported postoperative complaints over time. Patient-reported loss of taste and the impact of all complaints decline over time. All other patient-reported complaints remain stable over time, only itch complaints fluctuate. Primary cholesteatoma patients score significantly higher on hearing loss complaints compared with recurrent/residual patients although they have comparable mean audiometric hearing loss. Furthermore, pure-tone hearing threshold, instead of asymmetric hearing loss, is correlated with the localization domain of the SSQ.

CONCLUSION

This study provides important insights in the course of complaints and its impact on daily life after cholesteatoma surgery. Overall, the postoperative patient-reported complaints after cholesteatoma surgery are generally low in the studied population.

Operationalization of the Brief ICF Core Set for Hearing Loss: An ICF-Based e-Intake Tool in Clinical Otology and Audiology Practice

OBJECTIVES

According to the International Classification of Functioning, Disability and Health (ICF), functioning reflects the interplay between an individual's body structures and functions, activities, participation, environmental, and personal factors. To be useful in clinical practice, these concepts need to be operationalized into a practical and integral instrument. The Brief ICF Core Set for Hearing Loss (CSHL) provides a minimum standard for the assessment of functioning in adults with hearing loss. The objective of the present study was to operationalize the Brief CSHL into a digital intake tool that could be used in the otology-audiology practice for adults with ear and hearing problems as part of their intake assessment.

DESIGN

A three-step approach was followed: (1) Selecting and formulating questionnaire items and response formats, using the 27 categories of the Brief CSHL as a basis. Additional categories were selected based on relevant literature and clinical expertise. Items were selected from existing, commonly used disease-specific questionnaires, generic questionnaires, or the WHO's official descriptions of ICF categories. The response format was based on the existing item's response categories or on the ICF qualifiers. (2) Carrying out an expert survey and a pilot study (using the three-step test interview. Relevant stakeholders and patients were asked to comment on the relevance, comprehensiveness, and comprehensibility of the items. Results were discussed in the project group, and items were modified based on consensus. (3) Integration of the intake tool into a computer-based system for use in clinical routine.

RESULTS

The Brief CSHL was operationalized into 62 items, clustered into six domains: (1) general information, including reason for visit, sociodemographic, and medical background; (2) general body functions; (3) ear and hearing structures and functions; (4) activities and participation (A&P); (5) environmental factors (EF); and (6) personal factors (mastery and coping). Based on stakeholders' responses, the instructions of the items on A&P and EF were adapted. The three-step test interview showed that the tool had sufficient content validity but that some items on EF were redundant. Overall, the stakeholders and patients indicated that the intake tool was relevant and had a logical and clear structure. The tool was integrated in an online portal.

CONCLUSIONS

In the current study, an ICF-based e-intake tool was developed that aims to screen self-reported functioning problems in adults with an ear/hearing problem. The relevance, comprehensiveness, and comprehensibility of the originally proposed item list was supported, although the stakeholder and patient feedback resulted into some changes of the tool on item-level. Ultimately, the functioning information obtained with the tool could be used to promote patient-centered ear and hearing care taking a biopsychosocial perspective into account.

Questionnaires in otology: a systematic mapping review

BACKGROUND

Patient-reported outcome measures (PROMs) are valuable tools in assessing the quality of health care from a patient perspective and are increasingly used by otologists. However, selecting the right questionnaire has proven to be a difficult and time-consuming task. To facilitate this process, we will provide a comprehensive overview of existing questionnaires.

METHODS

A systematic literature search has been conducted on August 26, 2019, using the EMBASE and PubMed medical databases. 13,345 unique records were extracted. Questionnaires addressing any otologic complaint (tinnitus, hearing loss, earache, otorrhoea, and ear-related pressure sensation, vertigo, itch, or dysgeusia) were identified. All questionnaires were evaluated for eligibility by two independent researchers. Inclusion criteria were adult population, closed-ended questions, English language of the questionnaire, and the availability of the original article describing the development of the instrument or a validation paper describing the validation process written in English.

OBJECTIVE

Create a comprehensive overview of all validated closed-ended otology questionnaires for adults and demonstrate their basic characteristics.

MAIN OUTCOME MEASURE

The number of questionnaires in English literature for the adult population, subdivided per symptom and target population.

RESULTS

A total of 155 unique questionnaires were selected: 33 tinnitus questionnaires, 23 vertigo questionnaires, 84 hearing loss questionnaires, and 15 multiple complaint questionnaires. A protocol for further questionnaire comparison is presented.

DISCUSSION

Two separate sequential searches were needed to identify unique questionnaires and to identify their development/validation paper. Although many ear diseases create multiple symptoms, the majority of the questionnaires were symptom specific.

CONCLUSION

Many questionnaires concerning ear-related symptoms exist and predominantly concern hearing loss, vertigo, or tinnitus. Only a few questionnaires cover the multiple complaints that ear diseases can create. The presented overview is the most comprehensive overview of otology questionnaires in literature to date. It will serve as a basis for questionnaire selection by professionals and could serve as a protocol for questionnaire selection in other fields.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017058155.

Uniform Registration Agreements on Cholesteatoma Care: A Nationwide Consensus Procedure

Background:

To coordinate and align the content for registration of cholesteatoma care.

Methods:

Systematic Delphi consensus procedure, consisting three rounds: two written sessions followed by a face-to-face meeting. Before this procedure, input on important patient outcomes was obtained. Consensus was defined as at least 80% agreement by participants. Hundred-thirty-six adult patients who had undergone cholesteatoma surgery and all ENT surgeons of the Dutch ENT Society were invited. The consensus rounds were attended by ENT surgeons with cholesteatoma surgery experience. Feasibility and acceptability of outcome measures and reporting agreements were assessed in round 1 by 150 ENT surgeons. In round 2 definitions were narrowed and context information to interpret outcome measure were questioned. In round 3, the results, amendments, and the open-ended points were discussed to reach agreement.

Results:

Most important outcome measures are: 1) the presence or absence of a cholesteatoma in the first 5 years after surgical removal of cholesteatoma, 2) hearing level after surgical removal of cholesteatoma, and 3) the documented assessment of patient's complaints with a validated patient reported outcome measures questionnaire (PROM). Furthermore, consensus was reached on the registration of cholesteatoma type (residual/recurrent), localization of cholesteatoma, and reporting of the presence of cholesteatoma in the follow-up.

Conclusion:

Consensus was reached on the content and method of registration of cholesteatoma care based on patient's and ENT surgeons input. Three outcome measures were defined. National agreements on the method and content of registration will facilitate monitoring and feedback to the ENT surgeon about the cholesteatoma care.

Practical applicability of the STAMCO and ChOLE classification in cholesteatoma care

Background

To compare cholesteatoma care internationally and to evaluate outcomes, ear surgeons must use the same terminology. However, a clear universal definition on how to describe the extension, destruction and accompanying morbidity caused by the cholesteatoma is lacking. The practical applicability by means of interrater agreement is assessed for the STAMCO and the ChOLE classification.

Methods

A total of 134 adult patients derived from the nationwide multicentre study in the Netherlands, entitled Dutch Cholesteatoma Data (DCD) were included. Retrospective analysis of 134 surgical reports according to the STAMCO and ChOLE classification for localisation/extension of the cholesteatoma, complication status and ossicular chain status. Both the percentage agreement and the interrater agreement were determined for each item of the classifications and interrater agreement was compared between the classifications as a whole.

Results

Differences in interrater agreement were found for both the localisation/extension of the cholesteatoma and ossicular chain status. STAMCO classification derived from the surgical report scored better on the localisation/extension of the cholesteatoma, whereas the ChOLE classification derived from the surgical report scored better on the status of the ossicular chain. In both classifications, complication status had a low agreement level but was also poorly registered in the surgical reports.

Conclusion

Both STAMCO and ChOLE will be beneficial in uniform registration of cholesteatoma pathology in practice. Modifications proposed for both classifications may make them even more practical applicable in the future. A common denominator obtained from these two classifications may be incorporated in a standardised surgical report to facilitate evaluation which make outcomes transferable towards both classifications.

Electronic supplementary material

The online version of this article (10.1007/s00405-020-06478-7) contains supplementary material, which is available to authorized users.

The Otology Questionnaire Amsterdam: A generic patient-reported outcome measure about the severity and impact of ear complaints. Validation, reliability and responsiveness

Objective

To examine the construct validity, reliability and responsiveness of the Otology Questionnaire Amsterdam (OQUA).

Design

Multicentre, longitudinal study in 2 separate cohorts of patients visiting an ENT surgeon via an online survey programme.

Setting

Tertiary ENT clinics.

Participants

Cohort 1 consisted of patients at their first visit at an ENT outpatient clinic with an ear complaint. Cohort 2 consisted of patients who underwent surgery, with a 3‐month follow‐up post‐surgery.

Main outcome measures

Construct validity: Hypothesis testing, internal consistency and inter‐item correlation. Reliability: Test‐retest reliability. The construct approach was used for assessing responsiveness. Hypotheses were formulated based on the association between the OQUA and Glasgow Health Status Inventory (GHSI) or Global Rating Scale (GRS).

Results

Construct validity: The correlation between the individual items in the impact domain ranged from 0.424 to 0.737. Confirmatory factor analysis showed a good fit. As expected, the OQUA impact showed strong relationships with GHSI total and general scale.

Reliability: The test‐retest reliability coefficient ranged from 0.541 to 0.838.

Responsiveness: All hypotheses were conformed. As expected, the change score of the OQUA showed good correlation between OQUA impact and GHSI and moderate correlation between the GRS and OQUA complaints.

Conclusion

The OQUA has 8 complaint domains (earache, pressure sensation, itching, tinnitus, hearing loss, ear discharge, loss of taste and dizziness) and 1 impact domain. Each domain results in one score of 0‐100. The OQUA shows good results for construct validity, (test‐retest) reliability and responsiveness, supporting the potential benefit for the patient with an ear complaint visiting the ENT surgeon. The extensive validation furthermore confirms a certified generic otology PROM with an impact and a complaints' part, to be used in different types of otologic interventions and patient groups.

Clinimetric evaluation and clinical outcomes of the Dutch version of the Chronic Ear Survey

BACKGROUND

To validate and evaluate the reliability of the Dutch version of the Chronic Ear Survey (CES) in patients suffering from Chronic Suppurative Otitis Media (CSOM) and to evaluate clinical outcomes of surgery using this questionnaire.

METHODS

We developed the Dutch version of the CES (D-CES) using forward-backward translation of the original CES into the Dutch language. Next, patients with CSOM and controls completed the D-CES pre- and postoperatively. Internal consistency, test-retest reliability, known-group validity and convergent validity were evaluated. In addition to the D-CES, the Short Form 36 (SF-36) was administered to all participants to correlate D-CES data to quality of life.

RESULTS

A total of 29 patients with CSOM scheduled for ear surgery were included. Our control group consisted of 26 patients scheduled for eye surgery, all without signs and symptoms of CSOM. Cronbachs' α of the complete questionnaire was 0.69. The Intraclass Correlation Coefficients (ICCs), reflecting test-retest reliability, ranged between 0.69 and 0.82. Scores differed significantly between CSOM patients and controls with substantial lower (more impaired) D-CES scores in the CSOM group. Duration of complaints preoperatively and the presence of a dry ear and/or improvement of hearing postoperatively all had a significant impact on D-CES improvement scores. Small to moderate correlations were found between D-CES subscales and matching subscales of the SF-36.

CONCLUSION

The D-CES is an appropriate disease specific questionnaire to assess a patient's perceived functional health in CSOM.