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The Rate and Variation of Referrals to Behavioral Medicine Services for Patients Reporting Poor Mental Health in the National Spine Network

Walsh, Thomas L., MS, PT, OCS, Dip MDT*; Hanscom, Brett, MS; Homa, Karen, MS; Abdu, William A., MD, MS*†

doi: 10.1097/01.brs.0000155558.67266.e9
Health Services Research

Study Design. Descriptive analysis of cross-sectional data collected prospectively in 20 National Spine Network (NSN) centers.

Objectives. First, to summarize clinical and demographic characteristics of patients likely to need servicesfor psychosocial concerns. Second, to determine the rate and variability of referrals for behavioral medicine interventions (BMED) across the NSN.

Summary of Background Data. The prevalence of mental distress resulting from or coexisting with spinal pain is unclear. There is evidence that psychological treatments, particularly BMED, can aid the recovery of patients with symptoms of mental distress.

Methods. From 1998 to 2001, 28,349 patients presenting to NSN centers completed the SF-36 General Health Survey. Patients were dichotomized by the mental component summary (MCS) score into two groups: 1) those scoring ≤35 on the MCS scale (patients self-reporting significant signs of mental distress) and 2) those scoring >35. Clinicians recorded a “treatment plan” comprised of a standard array of treatment options. For patients scoring ≤35 on the MCS, the rate and variation of referrals to BMED was assessed.

Results. Baseline health status scores were lower across all SF-36 scales for the patients scoring an MCS ≤ 35. For mentally distressed patients, the overall average referral rate for any BMED service for patients scoring MCS ≤ 35 was 11.8%. The rate varied across NSN sites from 0 to 41%.

Conclusion. With only 11.8% of mentally distressed NSN patients receiving a referral for any form of BMED, it appears that a large proportion of eligible patients are not receiving a potentially beneficial treatment. Wide variation across centers may indicate an inability to adequately assess mental distress via the usual clinical interview and examination for spinal conditions or a lack of consensus regarding BMED’s availability and utility.

This study of 28,349 initial patients from the National Spine Network investigated the prevalence of patients scoring 35 or below on the SF-36 mental component summary, the frequency and variation with which these patients were referred for behavioral medicine interventions. The results demonstrate significant variation in the use of behavioral medicine services across the National Spine Network.

From the *Spine Center and †Department of Orthopedics at Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; ‡Department of Community and Family Medicine, and §The Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, New Hampshire

Supported in part by the Quality Research Grant Program at Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Harmes Surgical Scholarship; The NIH, Office of Research on Women’s Health, National Institute of Occupational Safety and Health; Centers for Disease Control and Prevention, National Institute for Arthritis and Musculoskeletal and Skin Diseases Grant AR45444-01A1, and the members of the National Spine Network.

Acknowledgment date: April 8, 2003. First revision date: March 22, 2004. Second Revision date: July 27, 2004. Acceptance date: July 28, 2004.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Institutional funds were received to support this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence to Thomas L. Walsh, MS, PT, OCS, Dip. MDT, The Spine Center, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756; Email:

© 2005 Lippincott Williams & Wilkins, Inc.