AMIA 2016 S59: Podium Presentations Using Data Science to address Clinical Problems Full-length paper: YJ Tseng, et al. Claims-based Diagnostic Patterns of Patients Evaluated for Lyme Disease and Given Extended Antibiotic Therapy. Vector-Borne and Zoonotic Diseases. 2016 (In Press)

1. Diagnostic Journeys of Patients
Evaluated for Lyme Disease and
Given Extended Antibiotic Therapy
Yi-Ju Tseng, PhD
Computational Health Informatics Program (CHIP)
Boston Children’s Hospital, MA, USA
Dept. of Information Management, Chang Gung University, Taiwan
Co-authors:
Alfred DeMaria Jr, Donald Goldmann, Kenneth Mandl*
AMIA 2016
S59: Podium Presentations
Using Data Science to address Clinical Problems

2. Research Target
2
Nelson CA. et al (2015). Incidence of Clinician-Diagnosed Lyme Disease,
United States, 2005–2010. Emerging Infectious Diseases, 21(9), 1625–1631

3. Research Target
2
Nelson CA. et al (2015). Incidence of Clinician-Diagnosed Lyme Disease,
United States, 2005–2010. Emerging Infectious Diseases, 21(9), 1625–1631
Only 25,000 reported cases in 2014

4. 3

5. Standard treatment:
2-4w antibiotic
↓
Persistent Symptom
↓
Post-treatment LD Syndrome
10~20%
4

6. Standard treatment:
2-4w antibiotic
↓
Persistent Symptom
↓
Post-treatment LD Syndrome
10~20%
4

7. Narrative Matte
DOI: 10.1377/HLTHAFF.2011.0792
Chronic Lyme Disease:
It’s Time To Solve The
Medical Mystery Inside
An Enigma
Scientists and doctors disagree about whether there is such a condition
as “chronic” Lyme disease or “post–Lyme disease syndrome.” Americans
need the National Institutes of Health and basic science research to
help determine the answer.
BY LAURIE MCCLELLAN
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Standard treatment:
2-4w antibiotic
↓
Persistent Symptom
↓
Post-treatment LD Syndrome
10~20%
4

9. What Happens before Lyme?
• Standard vs. extended courses of antibiotics for Lyme
• Hypothesis -
Patients receiving extended treatment for Lyme:
• Symptomatic
• Seeking diagnosis for symptoms
Prior to the first Lyme diagnosis….
• To know the diagnostic journey towards a diagnosis of
Lyme disease
6

10. LD Case Definition
7
Claims data
2011-2012

11. LD Case Definition
7
Lyme 1
<30d
Lyme 2
ICD-9: 088.81 Lyme Disease
Diagnosis
Claims data
2011-2012

12. LD Case Definition
7
Lyme 1
<30d
Lyme 2
ICD-9: 088.81 Lyme Disease
Diagnosis
30d 30d
1 Drug Era
NDC, from IDSA, 9 antibiotics,
LD recorded date ± 30 d
+ Treatment
Claims data
2011-2012

13. LD Case Definition
7
Lyme 1
<30d
Lyme 2
ICD-9: 088.81 Lyme Disease
Diagnosis
30d 30d
1 Drug Era
NDC, from IDSA, 9 antibiotics,
LD recorded date ± 30 d
+ Treatment
CPT codes,
LD recorded date ± 90 d
+ Lab orders
Claims data
2011-2012

14. LD Case Definition
8
Lyme 1
<30d
Lyme 2
ICD-9: 088.81 Lyme Disease
Diagnosis
30d 30d
1 Drug Era
NDC, from IDSA, 9 antibiotics,
LD recorded date ± 30 d
+ Treatment
CPT codes,
LD recorded date ± 90 d
+ Lab orders
Claims data
2011-2012
Patients diagnosed with LD
and given extended
antibiotic therapy
(PLDEA, Abx ≥5w)
Patients diagnosed with LD
and given standard
antibiotic therapy
(PLDSA, Abx ≥2w and <5w)

15. The Diagnosis Journey
Before LD - 1/2
Claims data
2011-2012
9

16. The Diagnosis Journey
Before LD - 1/2
Claims data
2011-2012
First Lyme
Diagnosis
Continuously enrolled for ≥180d
9

17. The Diagnosis Journey
Before LD - 1/2
Claims data
2011-2012
First Lyme
Diagnosis
Continuously enrolled for ≥180d
Days before
LD diagnosis
9
151-180 121-150 91-120 61-90 31-60 1-30

18. The Diagnosis Journey
Before LD - 1/2
Claims data
2011-2012
First Lyme
Diagnosis
Continuously enrolled for ≥180d
Days before
LD diagnosis
Diagnosis categories
(grouped by CCS)
Malaise
Joint pain
…
…
9
151-180 121-150 91-120 61-90 31-60 1-30

19. The Diagnosis Journey
Before LD - 1/2
Claims data
2011-2012
First Lyme
Diagnosis
Continuously enrolled for ≥180d
151-180 121-150 91-120 61-90 31-60 1-30
1 0 1 0 0 0
0 1 0 0 0 1
0 0 0 0 0 0
1 1 0 0 1 0
Days before
LD diagnosis
Diagnosis categories
(grouped by CCS)
Malaise
Joint pain
…
…
1: diagnosed with at least 1 ICD-9 code in the group
9

20. The Diagnosis Journey
Before LD - 1/2
Claims data
2011-2012
First Lyme
Diagnosis
Continuously enrolled for ≥180d
151-180 121-15- 91-120 61-90 31-60 1-30
151-180 121-15- 91-120 61-90 31-60 1-30
151-180 121-150 91-120 61-90 31-60 1-30
1 0 1 0 0 0
0 1 0 0 0 1
0 0 0 0 0 0
1 1 0 0 1 0
Every patients with LD
Days before
LD diagnosis
Diagnosis categories
(grouped by CCS)
Malaise
Joint pain
…
…
1: diagnosed with at least 1 ICD-9 code in the group
9

21. The Diagnosis Journey
Before LD - 2/2
10
151-18
0
121-15
-
91-120 61-90 31-60 1-30
151-18
0
121-15
-
91-120 61-90 31-60 1-30
151-180 121-150 91-120 61-90 31-60 1-30
1 0 1 0 0 0
0 1 0 0 0 1
0 0 0 0 0 0
1 1 0 0 1 0
Days before
LD diagnosis
Every patients with PLDEA
Malaise
Joint pain
…
…
Patients diagnosed with LD and
given extended antibiotic therapy
(PLDEA, Abx ≥5w)

22. The Diagnosis Journey
Before LD - 2/2
10
151-18
0
121-15
-
91-120 61-90 31-60 1-30
151-18
0
121-15
-
91-120 61-90 31-60 1-30
151-180 121-150 91-120 61-90 31-60 1-30
1 0 1 0 0 0
0 1 0 0 0 1
0 0 0 0 0 0
1 1 0 0 1 0
Days before
LD diagnosis
Every patients with PLDEA
Malaise
Joint pain
…
…
151-18
0
121-15
-
91-120 61-90 31-60 1-30
151-18
0
121-15
-
91-120 61-90 31-60 1-30
151-180 121-150 91-120 61-90 31-60 1-30
1 0 1 0 0 0
0 1 0 0 0 1
0 0 0 0 0 0
1 1 0 0 1 0
Days before
LD diagnosis
Every patients with PLDSA
Malaise
Joint pain
…
…
Patients diagnosed with LD and
given extended antibiotic therapy
(PLDEA, Abx ≥5w)
Patients diagnosed with LD and
given standard antibiotic therapy
(PLDSA, Abx ≥2w and <5w)
compared
with

23. The Diagnosis Journey
Before LD - 2/2
10
151-18
0
121-15
-
91-120 61-90 31-60 1-30
151-18
0
121-15
-
91-120 61-90 31-60 1-30
151-180 121-150 91-120 61-90 31-60 1-30
1 0 1 0 0 0
0 1 0 0 0 1
0 0 0 0 0 0
1 1 0 0 1 0
Days before
LD diagnosis
Every patients with PLDEA
Malaise
Joint pain
…
…
151-18
0
121-15
-
91-120 61-90 31-60 1-30
151-18
0
121-15
-
91-120 61-90 31-60 1-30
151-180 121-150 91-120 61-90 31-60 1-30
1 0 1 0 0 0
0 1 0 0 0 1
0 0 0 0 0 0
1 1 0 0 1 0
Days before
LD diagnosis
Every patients with PLDSA
Malaise
Joint pain
…
…
Patients diagnosed with LD and
given extended antibiotic therapy
(PLDEA, Abx ≥5w)
Patients diagnosed with LD and
given standard antibiotic therapy
(PLDSA, Abx ≥2w and <5w)
compared
with
Logistic Regression
ORs

24. Demographic Characteristics and
Antibiotic Therapy of PLDSA & PLDEA
N (%)
Characteristic PLDEA PLDSA P value
Patients 600 3,207
Female 367 (61.2) 1,556 (48.5) <0.001
Age (years) 42.5 (17.9) 40.7 (19.9) <0.05
Diagnosed outside of
summer months
302 (50.3) 1,284 (40.0) <0.001
Most common antibiotic
Doxycycline
367 (61.2)
Doxycycline
2497 (77.9)
Exposure days of antibiotic
Mean (SD) 73.9 (38.3) 23.0 (5.5)
Range (Min–Max) 35-315 14-34
Number of refills 2.7 (1.2) 1.2 (0.4) <0.001
11

25. Diagnostic Journeys of
PLDEA
8.5
7.8
9.7
9
11
9
5.2
9
5.5
9.2
6.7
14
10.2
10.2
13
10.8
13.8
20.8
18.8
13.5
10.3
23.7
9.5
Spondylosis, intervertebral disc disorders,
and other back problems
Other connective tissue disease
Other nervous system disorders
Malaise and fatigue
Non−traumatic joint disorders
Mental Illness
Headache, including migraine
Diseases of the skin and subcutaneous tissue
151−180
121−150
91−120
61−90
31−60
1−30
Before Lyme disease diagnosis, days
Diagnosticlabels
1.0
1.5
2.0
Adjusted
OR
12

26. Diagnostic Journeys of
PLDEA
8.5
7.8
9.7
9
11
9
5.2
9
5.5
9.2
6.7
14
10.2
10.2
13
10.8
13.8
20.8
18.8
13.5
10.3
23.7
9.5
Spondylosis, intervertebral disc disorders,
and other back problems
Other connective tissue disease
Other nervous system disorders
Malaise and fatigue
Non−traumatic joint disorders
Mental Illness
Headache, including migraine
Diseases of the skin and subcutaneous tissue
151−180
121−150
91−120
61−90
31−60
1−30
Before Lyme disease diagnosis, days
Diagnosticlabels
1.0
1.5
2.0
Adjusted
OR
12
Odds of mental illness in
PLDEA compared with PLDSA

27. Diagnostic Journeys of
PLDEA
8.5
7.8
9.7
9
11
9
5.2
9
5.5
9.2
6.7
14
10.2
10.2
13
10.8
13.8
20.8
18.8
13.5
10.3
23.7
9.5
Spondylosis, intervertebral disc disorders,
and other back problems
Other connective tissue disease
Other nervous system disorders
Malaise and fatigue
Non−traumatic joint disorders
Mental Illness
Headache, including migraine
Diseases of the skin and subcutaneous tissue
151−180
121−150
91−120
61−90
31−60
1−30
Before Lyme disease diagnosis, days
Diagnosticlabels
1.0
1.5
2.0
Adjusted
OR
12
% of PLDEA patients
with mental illness

28. Diagnostic Journeys of
PLDEA
8.5
7.8
9.7
9
11
9
5.2
9
5.5
9.2
6.7
14
10.2
10.2
13
10.8
13.8
20.8
18.8
13.5
10.3
23.7
9.5
Spondylosis, intervertebral disc disorders,
and other back problems
Other connective tissue disease
Other nervous system disorders
Malaise and fatigue
Non−traumatic joint disorders
Mental Illness
Headache, including migraine
Diseases of the skin and subcutaneous tissue
151−180
121−150
91−120
61−90
31−60
1−30
Before Lyme disease diagnosis, days
Diagnosticlabels
1.0
1.5
2.0
Adjusted
OR
13

29. Diagnostic Journeys of
PLDEA
8.5
7.8
9.7
9
11
9
5.2
9
5.5
9.2
6.7
14
10.2
10.2
13
10.8
13.8
20.8
18.8
13.5
10.3
23.7
9.5
Spondylosis, intervertebral disc disorders,
and other back problems
Other connective tissue disease
Other nervous system disorders
Malaise and fatigue
Non−traumatic joint disorders
Mental Illness
Headache, including migraine
Diseases of the skin and subcutaneous tissue
151−180
121−150
91−120
61−90
31−60
1−30
Before Lyme disease diagnosis, days
Diagnosticlabels
1.0
1.5
2.0
Adjusted
OR
13

30. Diagnostic Journeys of
PLDEA
8.5
7.8
9.7
9
11
9
5.2
9
5.5
9.2
6.7
14
10.2
10.2
13
10.8
13.8
20.8
18.8
13.5
10.3
23.7
9.5
Spondylosis, intervertebral disc disorders,
and other back problems
Other connective tissue disease
Other nervous system disorders
Malaise and fatigue
Non−traumatic joint disorders
Mental Illness
Headache, including migraine
Diseases of the skin and subcutaneous tissue
151−180
121−150
91−120
61−90
31−60
1−30
Before Lyme disease diagnosis, days
Diagnosticlabels
1.0
1.5
2.0
Adjusted
OR
13

31. Diagnostic Journeys of
PLDEA
8.5
7.8
9.7
9
11
9
5.2
9
5.5
9.2
6.7
14
10.2
10.2
13
10.8
13.8
20.8
18.8
13.5
10.3
23.7
9.5
Spondylosis, intervertebral disc disorders,
and other back problems
Other connective tissue disease
Other nervous system disorders
Malaise and fatigue
Non−traumatic joint disorders
Mental Illness
Headache, including migraine
Diseases of the skin and subcutaneous tissue
151−180
121−150
91−120
61−90
31−60
1−30
Before Lyme disease diagnosis, days
Diagnosticlabels
1.0
1.5
2.0
Adjusted
OR
14

32. Summary
• Among PLDEA, 15.8% of them were symptomatic
and seeking care for several months prior to their
first LD diagnosis.
• These findings could be used to prospectively
identify and target patients likely to receive a LD
diagnosis several months hence.
15

33. @YiJuTseng http://yijutseng.github.io/
yjtseng@mail.cgu.edu.tw
YJ Tseng, et al. Claims-based Diagnostic Patterns of Patients Evaluated for
Lyme Disease and Given Extended Antibiotic Therapy. Vector-Borne and
Zoonotic Diseases. 2016 (In Press)