Graham Nichol, MD; David T. Dennis, MD; Allen C. Steere, MD; Robert Lightfoot, MD; George Wells, PhD; Beverley Shea, BScN; Peter Tugwell, MD
Nichol G., Dennis D., Steere A., Lightfoot R., Wells G., Shea B., Tugwell P.; Test-Treatment Strategies for Patients Suspected of Having Lyme Disease: A Cost-Effectiveness Analysis. Ann Intern Med. 1998;128:37-48. doi: 10.7326/0003-4819-128-1-199801010-00007
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Published: Ann Intern Med. 1998;128(1):37-48.
To examine the cost-effectiveness of test-treatment strategies for patients suspected of having Lyme disease.
The medical literature was searched for information on outcomes and costs. Expert opinion was sought for information on utilities.
Articles that described patient population, diagnostic criteria, dose and duration of therapy, and criteria for assessment of outcomes.
The decision analysis evaluated the following strategies: 1) no testing-no treatment; 2) testing with enzyme-linked immunosorbent assay [ELISA] followed by antibiotic treatment of patients with positive results; 3) two-step testing with ELISA followed by Western blot and antibiotic treatment for patients with positive results on either test; and 4) empirical antibiotic therapy. Three patient scenarios were considered: myalgic symptoms, rash resembling erythema migrans, and recurrent oligoarticular inflammatory arthritis. Results were calculated as costs per quality-adjusted life-year and were subjected to sensitivity analysis. Adjustment was made for the diagnostic value of common clinical features of Lyme disease.
For myalgic symptoms without other features suggestive of Lyme disease, the no testing-no treatment strategy was most economically attractive (that is, had the most favorable cost-effectiveness ratio). For rash, empirical antibiotic therapy was less costly and more effective than other strategies. For oligoarticular arthritis with a history of rash and tick bite, two-step testing was associated with the lowest cost-effectiveness ratio. Testing with ELISA and empirical antibiotic therapy cost an additional $880 000 and $34 000 per quality-adjusted life-year, respectively. For oligoarticular arthritis with one or no other features suggestive of Lyme disease, two-step testing was most economically attractive.
Neither testing nor antibiotic treatment is cost-effective if the pretest probability of Lyme disease is low. Empirical antibiotic therapy is recommended if the pretest probability is high, and two-step testing is recommended if the pretest probability is intermediate.
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