Health care resource use is a complicated phenomenon that is influenced by a myriad of factors. Interest and acceptance is critical to the delivery of health care. This study focused on the perception of potential patients about upper-extremity reconstructive surgery. We chose this question because there appeared to be a discrepancy between what people with Tetraplegia want and the treatments they are receiving. Previous studies have suggested that upper-extremity function is a high priority for people with tetraplegia;15 however, there appears to be a profound underuse of procedures to enhance upper-extremity function in this population." The reasons for the un\deruse must be better understood because improving access to care for people with disabilities is a national health priority.23

Before looking into patient perceptions of upper-extremity reconstruction, it was important to establish whether people with tetraplegia were aware of upper-extremity reconstructive options. The Acute rehabilitation after spinal cord injury focuses on a variety of life-saving interventions, such as pressure relief and urinary function care. In addition, the initial rehabilitative plan often is designed by physiatrists, who have little formal training in upper-extremity surgery. Therefore, patients may not be informed about the surgical options. We found that a large percentage of our participants 13 (26%) had not heard about upper-extremity surgery. This is particularly surprising when one considers that many of the patients had been injured for many years. For example, one surveyed individual commented, "All you ever hear about is technology to help people walk again. You never hear anything about improving hand use." The lack of awareness of upperextremity surgery clearly contributes to the underuse of these procedures. Of the people with tetraplegia who had heard of these procedures, the largest percentage learned about upper-extremity surgery from physicians. Other reported sources included support groups and the Internet. Ensuring that accurate information about these procedures is obtainable to potential patients should be a first step to improving access to this care.

People with tetraplegia face many challenges in their Rehabilitation. Therefore, our second question examined whether improving upper-extremity function is a high priority for this population. Although patient perception is underrepresented in the literature, preliminary research has suggested that people with tetraplegia would be most interested in improving upper-extremity function.14 Our study confirmed that people with tetraplegia placed a high value on upper-extremity function. The largest percentage of individuals surveyed ranked upper-extremity function as their top restoration desire, far greater than bowel function, bladder function, lower-extremity function, and sexual function. Despite the many competing issues in the care of people with tetraplegia, upper- extremity function is of paramount interest to this population.

We hypothesized that current patient education discourages people with tetraplegia from pursuing upper-extremity surgery. Even a slight negative bias to the information received by patients about upperextremity surgery would influence their opinions because it is known that even subtle changes in the way medical information is presented can drastically affect patient perceptions.24 To assess if a negative bias was being propagated, we focused on our respondents' first impression of upper-extremity surgery. This is a critical question because first impressions remain surprisingly persistent.25'26 Our data showed that more than a third of our participants had a negative first impression of upper-extremity surgery. Receiving information about upper-extremity surgery from physicians was more likely to result in a negative attitude when compared with other informational sources.

Physiatrists coordinate injury rehabilitation programs and should be the main source of information about upper-extremity surgery for patients with spinal cord injury. We know that physiatrists have some reservations about these procedures, with 37% not wanting to have these procedures themselves.13 Physiatrists' concerns with these procedures do not appear to be overwhelming, but their hesitation appears to have a profound effect on using these procedures.11 These data suggest that to improve use of upper- extremity reconstructive procedures, the physiatrists are the important link. It is not surprising that even minor physician hesitation could take precedence over a patient's clear desire to improve upper-extremity function. This is because patients' medical decision-making processes are not always rational and physician recommendations are profoundly influential.27'28 The hand surgery community must participate actively in the educational programs of the physiatry organizations to promote our interest in serving this patient population.

We hypothesized that people with tetraplegia may have a negative impression of upper-extremity surgery because of surgical risk or cost. Before choosing surgical procedures, patients consider factors such as risk, cost, recovery time, and the availability of nonsurgical alternatives.29 We found that although all of these issues were prominent in the minds of people with tetraplegia, none of them were predictive of desire for upper-extremity reconstruction. A rehabilitative plan for tetraplegia patients, however, must include a realistic assessment of risks and benefits of these procedures to involve patients in the decisionmaking process.30"32

We do acknowledge the limitations of this project. This study was a limited geographic representation of the study sample. It is possible that local culture may affect the responses of the survey participants. Furthermore, we did not screen survey participants for Spasticity, contractures, mental health issues such as Depression, or other relative contraindications to surgery such as poor caregiver support. If a disproportionate number of survey participants were poor surgical candidates, some may conceivably have been given a realistically negative impression by their physiatrists. It is possible that a potential patient may place high priority on restoring upper-extremity function but choose not to have the surgical procedure after considering the risks and inconvenience of the surgical option. Overall, however, the findings from this survey support our prior published studies that the physician factor is the dominant reason for the national underuse of upper-extremity procedures for this group.

We began this study in an attempt to understand the underuse of upper-extremity surgery in the United States. We found that people with tetraplegia want to improve their upper-extremity function; however, many people have not heard of surgical procedures to improve function, and many of those who knew of these procedures had a negative impression. As the providers of upper-extremity reconstructive surgery, hand surgeons must take a leadership role both in a push for policy change and in the education of their fellow physicians. If hand surgeons are unwilling or unable to take this role, it is unlikely that the decrease in upper-extremity reconstruction will be reversed. We believe a constructive collaboration with Physiatrist societies is the first step to jointly care for this population. In addition, patient education programs and ongoing discussions between physicians and patients about these procedures will empower people with tetraplegia to make rational decisions about upper-extremity surgery that can markedly affect their recovery.