Algorithm Criteria and Descriptive Analyses
Lyme disease was defined by >1 diagnosis code (ICD-9-CM code 088.81; ICD-10-CM codes A69.20, A69.21, A69.22, A69.23, and A69.29) and >1 outpatient dispensing of an antimicrobial drug used to treat Lyme disease according to Infectious Diseases Society of America guidelines (13). We defined antimicrobial drugs by using the US Food and Drug Administration National Drug Codes for doxycycline, amoxicillin, cefuroxime axetil, azithromycin, penicillin G, ceftriaxone, and cefotaxime; we included oral and nonoral formulations. We required a minimum 7-day supply of the antimicrobial drug and for it to be dispensed within 30 days of the Lyme disease diagnosis. We evaluated the use of doxycycline, amoxicillin, cefuroxime axetil, azithromycin, penicillin G, ceftriaxone, and cefotaxime to treat Lyme disease.
To identify Lyme disease episodes, we required that HPHC members did not have a Lyme disease diagnosis code documented within 180 days before meeting the Lyme disease definition (i.e., if someone had a Lyme disease diagnosis code but no antimicrobial drug dispensed and then had another Lyme disease diagnosis code <180 days later with a qualifying antimicrobial drug dispensed, we did not include the second episode). For members who had multiple Lyme disease episodes, we used recurrence intervals to exclude episodes in which the diagnosis code and antimicrobial drug were likely used for treating Lyme disease-related sequelae from the first infection; we used intervals according to those used by others for ICD-9-CM (9) and ICD-10-CM (10) codes. During the ICD-9-CM era (before October 1, 2015), the recurrence interval was 365 days. During the ICD-10 era (beginning October 1, 2015), if a member met the algorithm definition with code A69.2 (Lyme disease) or A69.20 (Lyme disease, unspecified) on or after October 1, 2015, the recurrence interval was 180 days, as long as the second Lyme disease case date was in the next calendar year. If the second Lyme disease case date was in the same calendar year, then the second episode was not included. If a member met the algorithm definition with code A69.21 (meningitis), A69.22 (other neurologic disorders), A69.23 (arthritis), or A69.29 (other conditions) on or after October 1, 2015, the recurrence interval was 365 days.
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We summarized characteristics of HPHC members with algorithm-defined Lyme disease during the full study period by using descriptive statistics. We examined the frequencies and percentages of patient demographic and clinical characteristics associated with Lyme disease episodes that were available in the administrative claims data. Acute signs and symptoms were rash, fever, chills, fatigue, headache, joint and muscle pain, radiculopathy, and paresthesia, and those were identified by ICD-9-CM and ICD-10-CM diagnosis codes reported within 14 days before or after meeting the Lyme disease algorithm definition (Appendix Table). Musculoskeletal, nervous system, cardiovascular, and ocular manifestations of Lyme disease were examined up to 1 year after Lyme disease diagnosis and were also identified by diagnosis codes (Appendix Table). Among those patients with obtainable MGB medical records that were reviewed and adjudicated, we evaluated demographic and clinical characteristics and summarized acute symptoms and disseminated manifestations by using the same criteria described previously. We also assessed laboratory data captured in the medical records to determine how many cases were laboratory-confirmed.
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