Leveraging the Medical Context to Increase Upper Extremity Reconstruction among Patients with Tetraplegia: A Qualitative Analysis

Publication date: Available online 3 August 2017
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Chelsea A. Harris, John-Michael Muller, Melissa J. Shauver, Kevin C. Chung
Objectives(1) To characterize patients' medical experiences from initial injury until they become candidates for Upper Extremity Reconstruction (UER). (2) To identify points in this medical context that may be most amenable to interventions designed to increase UER utilization.DesignA qualitative cross-sectional study using grounded theory methodology and constant comparative analysis of data collected through semi-structured individual interviews.SettingCommunityParticipantsA sample of individuals with C4-C8 cervical spinal injuries (N=19) who sustained injuries at least one year prior to interview. Nine patients had undergone reconstruction, ten had not. The study sample was predominantly male (79%), white (89%), and ASIA Grade A-D were represented (Grade A: 42%; Grade B: 32%; Grade C 16%; Grade D 10%).InterventionsnoneMain Outcome MeasuresParticipant self-report of their medical experiences from the time of injury through the early recovery period.ResultsWe identified three domains that formed patients' medical context prior to 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 PM&R, intermediate for urology, low for primary care).ConclusionsIn appropriate candidates, UER produces substantial functional gains, but reconstruction remains underutilized 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 (PCPs, home health) will be most effective. Urology may represent a novel entry point for UER interventions.



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