Lise E Nigrovic1, Jonathan E Bennett2, Fran Balamuth3, Michael N Levas4, Rachel L Chenard5, Alexandra B Maulden5, Aris C Garro6. 1. Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; lise.nigrovic@childrens.harvard.edu. 2. Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware. 3. Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania. 4. Division of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and. 5. Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts. 6. Departments of Pediatrics and Emergency Medicine, Brown University and Rhode Island Hospital, Providence, Rhode Island.
Abstract
BACKGROUND: To make initial management decisions, clinicians must estimate the probability of Lyme disease before diagnostic test results are available. Our objective was to examine the accuracy of clinician suspicion for Lyme disease in children undergoing evaluation for Lyme disease. METHODS: We assembled a prospective cohort of children aged 1 to 21 years who were evaluated for Lyme disease at 1 of the 5 participating emergency departments. Treating physicians were asked to estimate the probability of Lyme disease (on a 10-point scale). We defined a Lyme disease case as a patient with an erythema migrans lesion or positive 2-tiered serology results in a patient with compatible symptoms. We calculated the area under the curve for the receiver operating curve as a measure of the ability of clinician suspicion to diagnose Lyme disease. RESULTS: We enrolled 1021 children with a median age of 9 years (interquartile range, 5-13 years). Of these, 238 (23%) had Lyme disease. Clinician suspicion had a minimal ability to discriminate between children with and without Lyme disease: area under the curve, 0.75 (95% confidence interval, 0.71-0.79). Of the 554 children who the treating clinicians thought were unlikely to have Lyme disease (score 1-3), 65 (12%) had Lyme disease, and of the 127 children who the treating clinicians thought were very likely to have Lyme disease (score 8-10), 39 (31%) did not have Lyme disease. CONCLUSIONS: Because clinician suspicion had only minimal accuracy for the diagnosis of Lyme disease, laboratory confirmation is required to avoid both under- and overdiagnosis.
BACKGROUND: To make initial management decisions, clinicians must estimate the probability of Lyme disease before diagnostic test results are available. Our objective was to examine the accuracy of clinician suspicion for Lyme disease in children undergoing evaluation for Lyme disease. METHODS: We assembled a prospective cohort of children aged 1 to 21 years who were evaluated for Lyme disease at 1 of the 5 participating emergency departments. Treating physicians were asked to estimate the probability of Lyme disease (on a 10-point scale). We defined a Lyme disease case as a patient with an erythema migrans lesion or positive 2-tiered serology results in a patient with compatible symptoms. We calculated the area under the curve for the receiver operating curve as a measure of the ability of clinician suspicion to diagnose Lyme disease. RESULTS: We enrolled 1021 children with a median age of 9 years (interquartile range, 5-13 years). Of these, 238 (23%) had Lyme disease. Clinician suspicion had a minimal ability to discriminate between children with and without Lyme disease: area under the curve, 0.75 (95% confidence interval, 0.71-0.79). Of the 554 children who the treating clinicians thought were unlikely to have Lyme disease (score 1-3), 65 (12%) had Lyme disease, and of the 127 children who the treating clinicians thought were very likely to have Lyme disease (score 8-10), 39 (31%) did not have Lyme disease. CONCLUSIONS: Because clinician suspicion had only minimal accuracy for the diagnosis of Lyme disease, laboratory confirmation is required to avoid both under- and overdiagnosis.
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Authors: Jason R Bobe; Brandon L Jutras; Elizabeth J Horn; Monica E Embers; Allison Bailey; Robert L Moritz; Ying Zhang; Mark J Soloski; Richard S Ostfeld; Richard T Marconi; John Aucott; Avi Ma'ayan; Felicia Keesing; Kim Lewis; Choukri Ben Mamoun; Alison W Rebman; Mecaila E McClune; Edward B Breitschwerdt; Panga Jaipal Reddy; Ricardo Maggi; Frank Yang; Bennett Nemser; Aydogan Ozcan; Omai Garner; Dino Di Carlo; Zachary Ballard; Hyou-Arm Joung; Albert Garcia-Romeu; Roland R Griffiths; Nicole Baumgarth; Brian A Fallon Journal: Front Med (Lausanne) Date: 2021-08-18