Source: International Lyme and Associated Diseases Society
HealthDayNews
By Steven Reinberg, HealthDay Reporter
6 Aug 2004
August 6, 2004 - The debate over how
much testing for Lyme disease is too much has turned up
in the pages of a medical journal.
A study in the July/August issue of the Annals of Family
Medicine claimed that doctors order too many inappropriate
tests for Lyme disease, often just giving in to the demands
of worried patients.
But a letter just published on the journal's Web site
questions the validity of the study, saying that the researchers
used too narrow a definition of Lyme disease, downplayed
the fact that the test itself is flawed, and didn't treat
the illness as a serious enough one to merit a certain
percentage of negative test results.
Study author Dr. Alan H. Ramsey, an assistant clinical
professor of family medicine from the University of Wisconsin,
said his team concluded "a good number of Lyme disease
blood tests are ordered inappropriately, primarily for
patients who come in without symptoms."
But a Lyme disease expert said Ramsey's group focused
only on the early, easily recognizable symptoms, such
as a bull's-eye red rash and joint pain, and ignored the
less tangible symptoms of the disease that can follow
a missed diagnosis. These include cognitive problems,
generalized pain and chronic fatigue.
"They [Ramsey's group] used a very narrow definition
for Lyme disease, so narrow that you would be guaranteed
to get a significant number of inappropriate tests,"
said Dr. Raphael B. Stricker, a co-author of the rebuttal
letter and president-elect of the International Lyme Associated
Disease Society.
"All they were looking at is the acute manifestations,
which you don't see that much," he said. "They
are excluding the majority of patients with Lyme disease
for whom testing would be appropriate. But according to
their parameters, it's not."
However, Ramsey stands by the results.
"Dr. Stricker fails to acknowledge in his letter
that we found the majority of tests to be discretionary,
that is, of indeterminate appropriateness using existing
guidelines," he said. In the study, Ramsey's team
found 27 percent of the tests were possibly inappropriate.
"It was only 27 percent," Stricker replied.
"If you consider Lyme disease a trivial illness,
then 27 percent of inappropriate tests is probably a big
number."
However, Stricker said he considers Lyme disease a significant
illness, akin to syphilis or AIDS. "In AIDS, if you
do voluntary testing, the positive rate is about 2 percent
or less, so you could argue that 98 percent of those tests
are inappropriate," Stricker said. "Does that
mean we shouldn't be doing those tests? I don't think
anyone would argue that."
The same is true for syphilis, Stricker noted, where you
have to test a lot of people to find one positive case.
There is a double standard, Stricker added: "A trivial
illness like Lyme disease, it's not important to test.
But syphilis or AIDS, oh boy, you better test people because
it's a really serious illness."
"Their data suggests that they did the study the
wrong way, and that the data is meaningless," Stricker
said.
"Dr. Stricker puts words in our collective mouths,"
Ramsey said. "We never declared Lyme disease to be
a trivial illness that is Ôhard to catch and easy
to cure.' These are his words. Nonetheless, in outlining
our second major error, Dr. Stricker confuses test appropriateness
with validity."
Stricker said that most of the so-called inappropriate
tests were done in emergency rooms. "You don't go
to an emergency room because you're asymptomatic,"
he said.
"As a practicing emergency physician, I can assure
Dr. Stricker that asymptomatic patients are often evaluated
in the emergency department," Ramsey said. "For
example, we found that a known or suspected tick bite
was strongly associated with inappropriate Lyme disease
testing."
"Anyone who thinks they may have Lyme disease should
be tested. They need to be tested," Stricker said.
Stricker and Ramsey agree there are problems with the
current Lyme disease test. According to Stricker, unless
the test is done at a very good lab, 50 percent of the
cases of Lyme disease can be missed.
"We agree with Dr. Stricker that Lyme disease serologic
tests remain flawed," Ramsey said. "Indeed,
this fact forms the foundation of our study. It is our
hope that clinicians find the results of this study helpful
in using existing Lyme disease serologic tests more effectively."
Roughly 2.8 million tests for Lyme disease are given each
year, carrying a price tag of $100 million annually. Antibiotics
are the standard treatment for the disease.
