title: Medical treatment decision making after total avulsion brachial plexus injury: a qualitative study.
abstract: OBJECTIVE
  Complete avulsion traumatic brachial plexus injuries (BPIs) can be treated using nerve and musculoskeletal reconstruction procedures. However, these interventions are most viable within certain timeframes, and even then they cannot restore all lost function. Little is known about how patients make decisions regarding surgical treatment or what impediments they face during the decision-making process. Using qualitative methodology, the authors aimed to describe how and why patients elect to pursue or forego surgical reconstruction, identify the barriers precluding adequate information transfer, and determine whether these patients are satisfied with their treatment choices over time.
  
  
  METHODS
  Twelve patients with total avulsion BPIs were interviewed according to a semi-structured guide. The interview transcripts were qualitatively analyzed using the systematic inductive techniques of grounded theory to identify key themes related to the decision-making process and long-term satisfaction with decisions.
  
  
  RESULTS
  Four decision factors emerged from our analysis: desire to restore function, perceived value of functional gains, weighing the risks and costs of surgery, and having concomitant injuries. Lack of insurance coverage (4 patients), delayed diagnosis (3 patients), and insufficient information regarding treatment (4 patients) prevented patients from making informed decisions and accessing care. Three individuals, all of whom had decided against reconstruction, had regrets about their treatment choices.
  
  
  CONCLUSIONS
  Patients with panplexus avulsion injuries are missing opportunities for reconstruction and often not considering the long-term outcomes of surgery. As more Americans gain health insurance coverage, it is very likely that the number of patients able to pursue reconstruction will increase. The authors recommend implementing clinical pathways to help patients meet critical points in care within the ideal timeframe and using a patient- and family-centered care approach combined with patient decision aids to foster shared decision making, increase access to information, and improve patient satisfaction with decisions. These measures could greatly benefit patients with BPI while reducing costs, improving efficiency, and generating better outcomes.
authors.affiliation: 1Section of Plastic Surgery, Department of Surgery; and.
authors.forename: Lauren E
authors.initials: LE
authors.lastname: Franzblau
authors.affiliation: 1Section of Plastic Surgery, Department of Surgery; and.
authors.forename: Mallory
authors.initials: M
authors.lastname: Maynard
authors.affiliation: 1Section of Plastic Surgery, Department of Surgery; and.
authors.forename: Kevin C
authors.initials: KC
authors.lastname: Chung
authors.affiliation: 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
authors.forename: Lynda J-S
authors.initials: LJ
authors.lastname: Yang
mesh_terms: D000328:Adult; D000368:Aged; D001917:Brachial Plexus / Q000293:injuries* / Q000601:surgery*; D020516:Brachial Plexus Neuropathies / Q000601:surgery*; D003657:Decision Making; D006801:Humans; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D036301:Qualitative Research; D019651:Plastic Surgery Procedures
keywords: BPI = brachial plexus injury; FFMT = functioning free-muscle transfer; PFCC = patient- and family-centered care; brachial plexus injury; medical treatment decision making; patient education; peripheral nerve