Introduction
Materials and methods
Design
Phase 1: preparation
Focus group script
No. | Question | Question logic | |
---|---|---|---|
Free discussion | 1 | What did you expect of the treatment for your broken collar bone? | Contrasting expectations to actual level of care |
2 | Looking back at your own treatment, how satisfied are you with the treatment? -What went well? -What might need to be improved? | ||
3 | Would you accept having the other treatment (e.g. sling instead of surgery)? | Compare beliefs for the other treatment to actual level of care | |
Facilitator-guided discussion | 4 | What did you think of the treatment at the E&A department? | Dimension: Process of care Hypothesis: no difference between treatment groups |
5 | What did you think of your visits to the outpatient clinic? -Involvement in treatment decision -Guidance throughout process | Dimension: Process of care Hypothesis: interpersonal factors important | |
6 | What do you think of the result of the treatment? -Recovery of function -Pain -Cosmetic result -Complications | Dimension: Outcome of care | |
7 | What do you think of the facilities where the treatment was given? -Travel time -Waiting times | Dimension: Structure of care Hypothetical waiting times important to overall satisfaction | |
Summary | 8 | Are there any relevant topics missing in our summary? | Data saturation |
Treatment groups
Phase 2: data collection
Participants
Data collection
Phase 3
Data analysis
Results
Sample description
Nonoperative (n = 14) | Operative (n = 10) | |
---|---|---|
Age (years) | 45.8 years | 40.7 years |
Male gender | 11 (78%) | 6 (60%) |
Relevant comorbidities (e.g. malignancy, cardiovascular disease, pulmonary disease) | 2 (14%) - aortic aneurism - COPD | None |
Employment physical labour (%) | 4 (28%) | 6 (60%) |
Fracture dominant side (%) | 1 (7%) | 4 (40%) |
Length of time since injury (days) | 574 days | 545 days |
Operative treatment (%) | 2 (14%)* | 10 (100%) |
Full return to function (%) | 12 (86%) | 8 (80%) |
Current pain levels > 3/10 (%) | 4/10 | 2/10 |
Overall satisfaction with treatment (NRS) | 6.5/10 | 7/10 |
Any complication (%) | 7 (50%) | 4 (40%) |
• Type of complication | Frozen shoulder 4x impaired union (delayed union or nonunion) | Frozen shoulder Sensibility loss Brachial plexus irritation Delayed union |
Analysis of qualitative data
Themes | Subthemes | |
---|---|---|
Main themes | Information | Pros and cons of treatment options Being heard X-ray explanation Rehabilitation advise |
Recovery from injury | Range of motion Strength Return to function Pain Irritation from surgical hardware Cosmetic result | |
Speed of recovery | Speed of diagnosis Delay to surgery Duration of follow-up Time to return to function | |
Doctor-patient interaction | Empathy Trust Kindness | |
Minor themes | Parking facilities Travel distance/time Waiting times at the outpatient department |
Information
25M-O: The surgeon gave a confident and competent impression, and the pros and cons were discussed […] what I could expect and how long it would be before I could do everything again was clear [… ] we made a joint decision to have the surgery, and I’ve never regretted it.9M-N: I understand that I’m responsible for my own choices […] let’s just look at percentages: 60 percent have it, it’s 40, most are in that corner, and I choose that too […]. I think, just give me the information, I’m asking for it
Some even requested the X-rays to ascertain a progression of consolidation.61F-N: I didn’t see any X-rays either, they didn’t show me what the fracture looked like, so I’ve been making a fuss about it.
Preferences for treatment were also very much based on the radiological findings. Some participants thought that nonoperative treatment can only result in good outcomes if the X-ray shows bony apposition.50F-N: […] when I asked a day later for the X-ray to see if that was really the case […] is it really attached.
Likewise, participants found it especially difficult to accept nonoperative management when they considered the fracture to be severe.43M-N: If conservative treatment gives good results, I wouldn’t really have to or want to be operated, as long as they could clearly confirm whether the sling would be enough […] if the parts of the collarbone touch against it.
Strikingly, several patients in the nonoperative group did not regard a sling or collar-and-cuff as a treatment at all – rather, they felt dismissed and felt like nothing was being done about the fracture.49M-O […] if you see that it’s split and is broken and split in three places, and you think to yourself, you can see even as a layperson that it is not going to heal by itself.22M-N: I myself don’t understand how it can be expected to turn out all right if you have multiple fractures and the bones are out of place.
Delayed union after nonoperative management was common and often resulted in surgery. Although initially patients were relieved that they did not need surgery, choosing nonoperative management and switching to the operative group caused a feeling of regret.50F-N: They told me what I had and didn’t do anything more with it […] to me that’s not a real treatment.
More information was also needed regarding rehabilitation after injury. Some would have liked advice on how to perform daily activities in the acute phase, others stated that they would have liked focused exercises or a referral to a physical therapist to aid their recovery.37M-N 3: Well maybe at that moment you like the idea of not having an operation […] Later on you will see it differently, but at that moment you think it is the better option.
Likewise, all participants who did receive a referral to a physical therapist reported a benefit to their perceived recovery.22M-N: You have no tips on how to climb out of bed or anything like that […] You don’t know that, nobody tells you.49M-O: […] You’re on your own, make an appointment with the physiotherapist, who will help you. Then you do some research on the Internet and then, then you figure it out, but I mean, in the end you have to sort it out yourself.
60M-O: Yes, indeed with physiotherapy […] If you do the home exercises, because you don’t have that much to do anyway, you do improve really quickly.
Recovery from injury
Functional recovery
60M-O: I expected to recover fully. I had assumed that. A year-and-a-half and two operations further, yes it still bothers me […] I also can’t do the work I used to anymore, I can’t do my hobbies.49M-N: And actually it took about two weeks, I could do almost everything again, I could do it. If you think about it, it’s fast […] Imagine, two weeks and it’s 100 percent good again. But it never recovered completely […]
Pain relief
54M-N: That pain, you see […]. I can do everything again. But if I stay a bit longer in one position then it does become painful. The pain is a 3 or 4 on a scale of 10, I think.31F-N: Sometimes it pulls to the shoulder, but also when I have something around it, like the car seat belt, it feels piercing, as if someone had stuck a knife in it. I feel it for a moment and then it’s gone […] a handbag, that is also uncomfortable.
Cosmetic result
61F-N: I’m very satisfied, I can do everything again. Only that bulge doesn’t look that nice, but okay.38M-O: yeah, beautiful is something else. You can see the scar tissue but it doesn’t bother me.
Speed of recovery
Especially participants in the nonoperative group had negative associations with treatment, as they felt it took too long.33M-O: I thought they would put a plate, then take it out. Done. But things went differently. I thought that with all the advances nowadays, they operate and you’re done with it, […] everything will work like it used to. But it isn’t working.
The feeling of decisional regret was reinforced by a feeling of seemingly quick recovery after surgery.28M-O: What gets me is that first they said that it can heal naturally and then they said nah we’ll have to operate. Thinking back, I probably would’ve preferred them to put a plate there immediately, because now I am ten or eleven weeks further.
Especially semi-professional athletes had a clear preference for operative management, based on experiences among team members, friends or relatives of faster return to function.24M-N: One day after the operation I could do as much as nine weeks without the operation.
One participant experiencing delayed union would have liked earlier advanced imaging (MRI, CT-scan) to have extra certainty about choosing the right treatment.29F-O: I made a rather quick decision to let them operate, even though it was probably a no-brainer, as in other people’s experiences it heals more quickly.
Even patients from the operative group indicated feeling disappointed with the delay to surgery.43M-N: Maybe when in doubt […] do an MRI immediately anyway […] so they can assess more quickly whether a sling is the first choice or they should operate.
55M-O: I am quite satisfied with the treatment, only the operation should have been done sooner than two weeks after the accident […] those are two lost weeks.
Doctor-patient interaction
38M-O: The first doctor that treated me was rather distant and didn’t seem to have a lot of time. The second doctor was exceptionally good and really took the time.