Checkpoints to Progression: Qualitative Analysis of the Personal and Contextual Factors That Influence Selection of Upper Extremity Reconstruction Among Patients With Tetraplegia

Assessing an Online Patient Decision Aid about Upper Extremity Reconstructive Surgery for Cervical Spinal Cord Injury: Pilot Testing Knowledge, Decisional Conflict, and Acceptability

Background. While nerve and tendon transfer surgery can restore upper extremity function and independence after midcervical spinal cord injury, few individuals (∼14%) undergo surgery. There is limited information regarding these complex and time-sensitive treatment options. Patient decision aids (PtDAs) convey complex health information and help individuals make informed, preference-consistent choices. The purpose of this study is to evaluate a newly created PtDA for people with spinal cord injury who are considering options to optimize upper extremity function. Methods. The PtDA was developed by our multidisciplinary group based on clinical evidence and the Ottawa Decision Support Framework. A prospective pilot study enrolled adults with midcervical spinal cord injury to evaluate the PtDA. Participants completed surveys about knowledge and decisional conflict before and after viewing the PtDA. Acceptability measures and suggestions for further improvement were also solicited. Results. Forty-two individuals were enrolled and completed study procedures. Participants had a 20% increase in knowledge after using the PtDA (P < 0.001). The number of participants experiencing decisional conflict decreased after viewing the PtDA (33 v. 18, P = 0.001). Acceptability was high. To improve the PtDA, participants suggested adding details about specific surgeries and outcomes. Limitations. Due to the COVID-19 pandemic, we used an entirely virtual study methodology and recruited participants from national networks and organizations. Most participants were older than the general population with a new spinal cord injury and may have different injury causes than typical surgical candidates. Conclusions. A de novo PtDA improved knowledge of treatment options and reduced decisional conflict about reconstructive surgery among people with cervical spinal cord injury. Future work should explore PtDA use for improving knowledge and decisional conflict in the nonresearch, clinical setting.

Highlights

People with cervical spinal cord injury prioritize gaining upper extremity function after injury, but few individuals receive information about treatment options.A newly created patient decision aid (PtDA) provides information about recovery after spinal cord injury and the role of traditional tendon and newer nerve transfer surgery to improve upper extremity upper extremity function.The PtDA improved knowledge and decreased decisional conflict in this pilot study.Future work should focus on studying dissemination and implementation of the ptDA into clinical practice.

Surgery to Restore Upper Extremity Function in Tetraplegia-Preferences for Early and Frequent Access to Information

INTRODUCTION

People with cervical spinal cord injury (SCI) identify improving upper extremity (UE) function as a top priority. In addition to comprehensive rehabilitation, UE surgeries, including nerve and tendon transfers, enhance function. However, barriers exist to disseminating information about surgical options to enhance UE function.

OBJECTIVE

To assess the experiences and preferences of people with cervical SCI and their caregivers in accessing information about surgery to enhance UE function.

DESIGN

Prospective cohort study. Participants were followed for 24 months and completed up to three interviews.

SETTING

Tertiary care at academic and affiliated Veterans Administration Health Care Centers.

PARTICIPANTS

Adults with cervical SCI (n=35) ages 18 to 80 years with mid-cervical SCI American Spinal Injury Association Impairment Scale A, B, or C (at least six months post-injury) and their caregivers (n=23) were eligible to participate. Participants were enrolled in three groups: nerve transfer, tendon transfer, or no UE reconstructive surgery.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Semi-structured interviews about surgical knowledge and experiences.

RESULTS

Data were analyzed and three themes were identified. First, providing information about UE surgical options early post-injury was recommended. The acute or inpatient rehabilitation phases of recovery were the preferred times to receive surgical information. Second, challenges with information dissemination were identified. Participants learned about UE surgery through independent research, medical provider interactions, or peers. Third, peers were identified as valuable resources for SCI needs and surgical information.

CONCLUSIONS

Following cervical SCI, information about UE reconstructive surgeries should be a standard component of education during rehabilitation. An increased understanding of the reconstructive options available to improve UE function is necessary to educate stakeholders. Future research is needed to support the development of strategies to effectively present surgical information to individuals with SCI and healthcare providers. This article is protected by copyright. All rights reserved.

Patterns of Upper Extremity Reconstruction for Patients With Tetraplegia Across the United States: A Retrospective Study

PURPOSE

The rates of upper extremity reconstruction for patients with tetraplegia remain low. We performed a retrospective study to assess recent reconstruction rates and delineate factors associated with the occurrence of reconstruction.

METHODS

We examined the National Inpatient Sample database (2012-2017) for the rate of reconstruction for patients with tetraplegia. The details of provider distribution characteristics and neighborhood attributes were obtained from the American Medical Association Physician Masterfile and based on the area deprivation index, respectively. We calculated the mean reconstruction rate per year and generated multivariable logistic regression models to examine the influence of patient factors, hospital characteristics, and provider distribution on the odds of undergoing functional reconstruction for tetraplegia patients.

RESULTS

Among 404,660 encounters with patients with tetraplegia, only 1,430 (0.4%) patients underwent upper extremity reconstruction from 2012 to 2017, with a mean rate of 238 procedures per year. We identified 5,450 hand surgeons, 12,751 physiatrists, and 444 spinal cord injury specialists, with variation in their national distribution. A greater number of surgeons near SCIS was associated with increased probability of reconstruction (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.03-1.12). The odds of surgery were greater for patients receiving care at urban teaching (OR 5.00, 95% CI 3.35-7.47) or urban nonteaching (OR 1.71, 95% CI 1.11-2.63) hospitals, whereas those at private nonprofit (OR 0.67, 95% CI 0.58-0.78) or investor-owned (OR 0.65, 95% CI 0.52-0.82) hospitals had lower odds. Although most patients had insurance coverage, patients with a higher income or those who received subsidized care had greater odds of undergoing reconstruction.

CONCLUSIONS

Reconstruction rates remain low and are correlated with the environment of care, financial factors, and provider availability. Policies that focus on reducing these factors in addition to increasing interspecialty collaboration could improve access to surgery for patients with tetraplegia.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

Identifying barriers to upper extremity reconstruction in tetraplegia: a systematic scoping review

STUDY DESIGN

Systematic scoping review OBJECTIVES: The purpose of this study was to understand the barriers to accessing upper extremity (UE) reconstructive surgery among those living with tetraplegia, and to identify gaps in knowledge.

METHODS

Using standardized scoping review methods, a literature search was conducted using four databases and 1069 articles were procured. Two independent reviewers systematically screened the articles in two phases. Retrieved articles underwent thematic analysis using a constructivist grounded theory methodology.

RESULTS

The reviewed articles (n = 25) were published between 2002 and 2019, and study designs included: cross-sectional (64%), retrospective (16%), and review articles (8%). Common barriers to UE reconstruction were categorized into factors related to patients, providers, and systems. These general domains included lack of awareness of UE reconstruction and its benefits among people with tetraplegia and providers, poor interdisciplinary working relationships, and a lack of specialized centers that provide these reconstructive surgeries. Specific patient-related barriers related to intrinsic (coping skills, trust, fear) and extrinsic (support network, finances, postoperative course) factors that influenced decision-making.

CONCLUSIONS

There are many barriers that prevent individuals with tetraplegia from accessing surgery at different levels of the healthcare system. Establishing specialized centers with strong interdisciplinary working relationships and raising awareness about the advantages and disadvantages of UE reconstruction through peer networks may help to improve accessibility. Using a value-based, patient-centered approach by exploring how individuals with SCI weigh each decision factor when considering surgery may help providers develop treatment options that better align with their goals.

Defining Quality in Hand Surgery From the Patient's Perspective: A Qualitative Analysis

PURPOSE

Quality measures are used to evaluate health care delivery. They are traditionally developed from the physician and health system viewpoint. This approach can lead to quality measures that promote care that may be misaligned with patient values and preferences. We completed an exploratory, qualitative study to identify how patients with hand problems define high-quality care. Our purpose was to develop a better understanding of the surgery and recovery experience of hand surgery patients, specifically focusing on knowledge gaps, experience, and the surgical process.

METHODS

A steering committee (n = 10) of patients who had previously undergone hand surgery reviewed and revised an open-ended survey. Ninety-nine patients who had undergone hand surgery at 2 tertiary care institutions completed the open-ended, structured questionnaire during their 6- to 8-week postoperative clinic visit. Two reviewers completed a thematic analysis to generate subcodes and codes to identify themes in high-quality care from the patient's perspective.

RESULTS

We identified 4 themes of high-quality care: (1) Being prepared and informed for the process of surgery, (2) Regaining hand function without pain or complication, (3) Patients and caregivers negotiating the physical and psychological challenges of recovery, and (4) Financial and logistical burdens of undergoing hand surgery.

CONCLUSIONS

Multiple areas that patients identify as representing high-quality care are not reflected in current quality measures for hand surgery. The patient-derived themes of high-quality care can inform future patient-centered quality measure development.

CLINICAL RELEVANCE

Efforts to improve health care delivery may have the greatest impact by addressing areas of care that are most valued by patients. Such areas include patient education, system navigation, the recovery process, and cost.

The golden year: How functional recovery sets the stage for tendon transfer surgery among patients with tetraplegia-a qualitative analysis

BACKGROUND

Tendon transfer surgery can effectively improve hand function for patients with tetraplegia but remains poorly utilized. Little is known regarding how patients' rehabilitation experiences influence their perception of function, identity, and coping to shape their reconstructive context.

METHODS

We performed a cross-sectional qualitative analysis of 19 participants with C4-C7 cervical spinal injuries: 9 patients had undergone reconstruction; 10 had not. Semistructured interviews were conducted using an interview guide focusing on rehabilitation experience, the relationship between function and identity, and how patient experience evolved. Interview transcripts were analyzed using grounded theory.

RESULTS

The study sample was predominantly male (79%), white (89%), and American Spinal Injury Association grades A-D (grade A: 42%; grade B: 32%; grade C: 16%; grade D: 10%). Recognizing rehabilitation's necessity, functional gains, and constructive patient-therapist relationships promoted engagement in therapy. Poor insurance coverage and financial constraints decreased rehabilitation access. Function affected identity through the degree to which it tied participants to a "patient" role. Early in recovery, patients' function, roles, and attitudes were fluid but solidified over time; how satisfied patients were with these final positions influenced how they coped.

CONCLUSION

The balance of patients' positive and negative coping has been found to influence patients' progression to surgery. This study describes how function and identity contribute to coping. Participants' function and identity evolved during a finite period we call "the golden year," before reaching a fixed point around which they built their lives. The norms patients establish during this time may affect receptiveness to surgery.

Leveraging the Medical Context to Increase Upper Extremity Reconstruction Among Patients With Tetraplegia: A Qualitative Analysis

OBJECTIVES

To (1) characterize patients' medical experiences from initial injury until they become candidates for upper extremity reconstruction (UER); and (2) identify points in this medical context that may be most amenable to interventions designed to increase UER utilization.

DESIGN

A qualitative cross-sectional study using grounded theory methodology and constant comparative analysis of data collected through semistructured individual interviews.

SETTING

Community.

PARTICIPANTS

A sample of individuals with C4 to C8 cervical spinal injuries (N=19) who sustained injuries at least 1 year before interview. Nine patients had undergone reconstruction, and 10 had not. The study sample was predominantly male (79%) and white (89%), and American Spinal Injury Association grades A through D were represented (A, 42%; B, 32%; C, 16%; D, 10%).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants' self-report of their medical experiences from the time of injury through the early recovery period.

RESULTS

We identified 3 domains that formed patients' medical context before UER candidacy: (1) their ability to achieve and maintain health; (2) their relationship with health care providers; and (3) their expectations regarding clinicians' tetraplegia-specific expertise. Trust emerged as a major theme driving potential intervention targets. Patients transferred to referral centers had higher trust in tertiary providers relative to local physicians. In the outpatient setting, patients' trust correlated with the tetraplegia-specific expertise level they perceived the specialty to have (high for physical medicine and rehabilitation, intermediate for urology, low for primary care).

CONCLUSIONS

In appropriate candidates, UER produces substantial functional gains, but reconstruction remains underused in the tetraplegic population. By analyzing how patients achieve health and build trust in early recovery/injury, our study provides strategies to improve UER access. We propose that interventions targeting highly trusted points of care (transfer hospitals) and avoiding low-trust points (primary care physicians, home health) will be most effective. Urology may represent a novel entry point for UER interventions.