Appropriateness of Lime Disease Testing

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Appropriateness of Lime Disease Testing

  1. 1. Appropriateness of Lime Disease Testing Article by Alan H. Ramsey, MD Edward A. Belongia, MD Po-Huang Chyou, PhD Jeffrey P. Davis Presented by
  2. 2. Summary of Introduction <ul><li>Lyme Disease is a multisystem tick-borne infection caused by the spirochete Brrelia burgdorferi. One infected a person can experience Erythematic migran, or expanding rashes. </li></ul><ul><li>Some other symptoms of Lyme Disease include joint, neurological, cardiac and other manifestations(Wikipedia,2006). </li></ul><ul><li>One way of diagnosing Lyme Disease is when there is an absence of antibodies to combat Lyme Disease </li></ul><ul><li>2.8 million Lyme Disease serological tests are performed each year in the United States, with a cost of $40 per test </li></ul><ul><li>“ Any of several laboratory procedures carried out on a sample of blood serum, the clear liquid that separates from the blood when it is allowed to clot. The purpose of such a test is to detect serum antibodies or antibody-like substances that appear specifically in association with certain diseases.”(Enyclopedia Brittanica,2007) </li></ul>
  3. 3. Summary of Introduction II <ul><li>There is a concern that these serological tests are used inappropriately by clinicians. </li></ul><ul><li>Early testing based on only tick bites or potential exposure to ticks has low sensitivity and specificity. (NOT RECOMMENDED) </li></ul><ul><li>For patients that live in areas where Lyme Disease is a growing problem, and have patients with erythma migrans, serologic testing is not recommended, because the likelihood that these patients have Lyme disease goes past the positive predictive value of serologic testing, and the negative predictive value of serological testing is really low. </li></ul><ul><li>To find out the factors that contribute to appropriate and inappropriate use of Lime Disease Serological Testing, doctors conduct a cross sectional survey of clinicians that carry out Lime Disease serological testing </li></ul>
  4. 4. Summary of the Methods <ul><li>The Doctors carried out a survey, by surveying the clinicians who submitted specimens for an LDST to 2 large laboratories in Wisconsin. </li></ul><ul><li>Up to 30 tests per month were selected from each laboratory during October 1999 to September 2000. </li></ul><ul><li>Only 2 tests per clinicians were sampled during each study </li></ul><ul><li>Then each clinician was given access to medical records and told to complete a standardized survey by phone. </li></ul><ul><li>The data collected pertained to the clinician characteristics and clinical circumstances related to each of the tests </li></ul><ul><li>Each test was then classified into appropriate, inappropriate or discretionary using clinical principles </li></ul><ul><li>A test was defined Appropriate if the patient had any objective findings consistent with various symptoms that include joint, neurological, or cardiac symptoms. Such as arthritis, lymphocytic meningitis, cranial neuritis, or atrioventricular conduction defects. </li></ul>
  5. 5. Summary of Methods II <ul><li>A test was innapropriate if the patient was showing no signs of disease, was treated experimentally with antibiotics, or the test was ordered as a test of cure. </li></ul><ul><li>Because evidence based practice guidelines do not address Lyme Disease testing for other symptoms like fatigue or malaise, the test was defined as discretionary if it met none of the criteria </li></ul>“ E nzyme- L inked I mmuno S orbent A ssay a serological test in which the sensitivity of the reaction is increased by attaching an enzyme that produces a colored product to one of the reactants (multi-well ELISA plate; wells showing yellow color are positive)”(Apsnet,2006)
  6. 6. Table of Appropriate and Inappropriate Indications for an LDST, Lyme-Endemic Region Patient with carditis Serologic test ordered as a test of cure Patient with atrioventricular block Patient treated experimentally with antibiotics Patient with lymphocytic meningitis Patient with clinician-diagnosed erythma migrans Patient with cranial neuritis Patient is asymptomatic Patient with arthritis Inappropriate Appropriate
  7. 7. Summary of Results <ul><li>The Doctor’s sampled 408 LDST requests and 356 surveys were completed, 250 clinicians completed only 1 questionnaire, and forty clinicians refused to participate, and 12 could not be reached </li></ul><ul><li>Of the 356 LDST requests, 20% were classified as appropriate, 27% appropriate and 53% discreinary. </li></ul><ul><li>The reasons for classifying tests as inappropriate included absence of symptoms(55%), empirical antibiotic treatment(27%), test of cure(27%), and diagnosis of erythma migrans(24%) </li></ul>
  8. 8. Summary of Results II <ul><li>Patient-initiated tests were more likely to be inappropriate than tests initiated by clinicians </li></ul><ul><li>Two factors were independently associated with inappropriate testing: Known or suspected tick bite within 30 days of illness onset, and test ordered by an emergency or urgent care clinician. </li></ul><ul><li>In this study more than 50% of the inappropriate tests were for asymptomatic patients. </li></ul><ul><li>Compared with family physicians, and internists, physcians in emergency or urgent care were more likely to order inappropriate tests. The Doctors speculated that the people that ordered the tests were not educated enough. </li></ul><ul><li>Interventions should be focused on educating providers about indications for Lyme disease testing, mainly about the absence of symptoms with or without a tick bite to eliminate the need for testing </li></ul>
  9. 9. Summary of Results III <ul><li>The Doctors also found out that patients requested a lot of number of tests, that turned out to be innappropriate(40%), although most of the inappropriate tests were carried out by physicians. </li></ul><ul><li>A limitation of the study was that clinical information was provided by clinicans without validation of medical record review </li></ul>
  10. 10. Conclusion <ul><li>The Doctors concluded that inappropriate Lyme Disease serologic testing was common in Wisconsin, and patients initiated many of these tests. </li></ul><ul><li>Expanded Education for clinicians and patients about testing indications may reduce the number of inappropriate LDST requests. </li></ul>
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