But here is the highly suspect Canadian research.

Ann Intern Med 1998 Jan 1;128(1):37-48
Test-treatment strategies for patients suspected of having Lyme disease: a
cost-effectiveness analysis.

Nichol G, Dennis DT, Steere AC, Lightfoot R, Wells G, Shea B, Tugwell P.

Ottawa Civic Hospital, Ontario, Canada.

PURPOSE: To examine the cost-effectiveness of test-treatment strategies for
patients suspected of having Lyme disease. DATA SOURCES: The medical
literature was searched for information on outcomes and costs. Expert
opinion was sought for information on utilities. STUDY SELECTION: Articles
that described patient population, diagnostic criteria, dose and duration of
therapy, and criteria for assessment of outcomes. DATA EXTRACTION: 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. DATA SYNTHESIS: 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. CONCLUSIONS: 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.


Ann Intern Med 1997 Dec 15;127(12):1109-23
Laboratory evaluation in the diagnosis of Lyme disease.

Tugwell P, Dennis DT, Weinstein A, Wells G, Shea B, Nichol G, Hayward R,
Lightfoot R, Baker P, Steere AC.

University of Ottawa, Ontario, Canada.

PURPOSE: To provide a qualitative evaluation of the predictive value of the
laboratory diagnosis of Lyme disease and to use the resultant data to
formulate guidelines for clinical diagnosis. DATA SOURCES: A MEDLINE search
of English-language articles or articles with English-language abstracts
published from 1982 to 1996. DATA EXTRACTION: Sensitivity, specificity, and
likelihood ratios were calculated, and a random-effects model was used to
combine the proportions from the eligible studies. Prespecified criteria
were used to determine which studies were eligible for analysis. DATA
SYNTHESIS: Laboratory testing in general is not clinically useful if the
pretest probability of Lyme disease is less than 0.20 or greater than 0.80.
When the pretest probability is 0.20 to 0.80, sequential testing with
enzyme-linked immunosorbent assay and Western blot is the most accurate
method for ruling in or ruling out the possibility of Lyme disease.
CONCLUSIONS: Laboratory testing is recommended only in patients whose
pretest probability of Lyme disease is 0.20 to 0.80. If the pretest
probability is less than 0.20, testing will result in more false-positive
results than true-positive results; a negative test result in this situation
effectively rules out the disease.
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