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DRAM assessment recommended for spine patients

Issue: November 2008

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TORONTO — The fact that a patient’s psychological state can not only affect his or her health, but also the ability to effectively respond to treatment, is widely known in the spine-treatment community.

However, spine surgeons could do a much better job of detecting psychological distress in their patients by routinely using a validated psychological questionnaire — the Distress Risk Assessment Method (DRAM) questionnaire — according to the top-ranked paper at the North American Spine Society’s 23rd Annual Meeting, here.

“Overall, we are poor at accurately assessing psychological distress using just our own instincts and clinical skills,” said Michael D. Daubs, MD, from the University of Utah in Salt Lake City.

“Surgeon experience is definitely not a factor” related to better psychological assessment skills, which is contradictory to what one might expect, Daubs noted in discussing the study’s findings. The most senior of the eight physicians involved in his study did no better than their less-skilled counterparts in categorizing patients into four key psychological stress categories after evaluation, he said.

The prospective study involved 400 new patients undergoing an initial spine disorder evaluation at the university’s spine center. Patients completed the validated DRAM questionnaire and were evaluated by one of eight spine doctors (four surgeons, four physiatrists) who were blinded to the DRAM scores, Daubs said.

Using their usual methods of clinical evaluation, the physicians were asked to categorize patients they examined into one of four DRAM categories: normal (N), at-risk (AR), distressed depressive (DD) or distressed somatic (DS).

DRAM vs. instinct

Based on DRAM results, 37% of patients were categorized as N, 42% as AR, 13% as DD and 9% as DS. However, as a group only 44% of the physicians’ assessments matched these results, according to Daubs. Nonsurgical specialists did slightly better than the surgeons, accurately classifying patients’ psychological distress 49% of the time vs. 40% of the time for the surgeons.

Nonoperative spine specialists were more accurate in detecting AR patients and DS patients.

Most doctors rely on their clinical instincts, but they would be wise to instead start relying more on results of the DRAM and other validated psychological questionnaires, Daubs said. “Psychological stress is a risk factor for poor surgical and nonsurgical outcomes,” he added.

Daubs stated in a press release, “We need more studies to define the impact of psychosocial factors on patient outcomes.”

For more information:

• Michael D. Daubs, MD, can be reached at 590 Wakara Way, Salt Lake City, UT 84108; 801-587-5450; e-mail: michael.daubs@hsc.utah.edu. He has no direct financial relationship with any companies or products mentioned in this article.

Reference:

• Daubs MD, Patel A, Willick S, et al. Clinical instinct vs. standardized questionnaire: The spine specialists’ ability to detect psychological distress. Paper #1. Presented at the North American Spine Society 23rd Annual Meeting. Oct. 15-18, 2008. Toronto.