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Increasing Access To Upper Limb Reconstruction In Cervical Spinal Cord Injury: A Qualitative Study of Provider Level Barriers
Jana Dengler, MD1, Maytal Perlman, BKI2 and Michelle Jennett, HBA2, (1)University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada, (2)University of Toronto, Toronto, ON, Canada

Introduction: Cervical spinal cord injury (SCI) is a devastating event resulting in upper limb paralysis, loss of independence, and disability. People living with cervical SCI have identified improvement of upper limb function as a top priority. Nerve and tendon transfer surgery have successfully restored upper limb function in cervical SCI, but is not universally used or available to all eligible individuals. Using an implementation science approach, the purpose of this exploratory mixed-methods study was to better understand the factors that impact access to upper limb surgery in people with SCI.

Materials and Methods: Semi-structured interviews informed by the Consolidated Framework for Implementation Research were used to explore healthcare provider knowledge and practices regarding nerve and tendon transfer surgery to improve upper limb function in cervical SCI. An inductive, iterative constant comparative process involving descriptive and interpretive analyses was used to identify themes that emerged from the data.

Results: Thirty-two interviews with healthcare providers in Ontario, Canada (n=10 upper extremity surgeons, n=10 SCI physiatrists, n=12 physical/occupational therapists) were conducted. Nine major themes were identified as barriers to accessing care: (1) lack of awareness of nerve and tendon transfers as an option; (2) lack of knowledge about the procedures which leads to a lack of confidence and willingness to initiate conversations about patient options; (3) lack of buy-in from providers that upper limb surgical intervention is a priority; (4) lack of collaboration among surgeons and rehabilitation specialists; (5) healthcare provider misperceptions of one another, which leads to bias and prevents collaboration; (6) lack of resources available for post-operative rehabilitation and support; (7) lack of available 'evidence' due to differences in the language used between healthcare providers; (8) lack of ownership amongst rehabilitation specialists over upper limb surgical options; and (9) a sense of protectiveness amongst rehabilitation providers due to the vulnerability of this patient population.

Conclusions: Although healthcare providers expressed enthusiasm around nerve and tendon transfer surgery to improve upper limb function in eligible individuals, this study identified specific barriers that limit equitable access to care. Addressing the barriers that emerged from this study requires a multi-modal approach to address individual-, provider- and system-level barriers. Future studies will focus on addressing healthcare provider knowledge and awareness of nerve and tendon transfer surgery using user-centered design methods.

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