Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA.
Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, NY.
J Arthroplasty. 2021 Jul;36(7):2551-2557. doi: 10.1016/j.arth.2021.02.059. Epub 2021 Feb 27.
Abnormal voiding dynamics may be a modifiable risk factor for prosthetic joint infection (PJI) after total joint arthroplasty (TJA), but the cost-effectiveness of their optimization in the perioperative setting is unknown. Using a break-even analysis, we calculated the economic viability of perioperative voiding optimization for infection prevention after TJA in patients with symptomatic benign prostatic hyperplasia (BPH).
A perioperative voiding optimization algorithm was created to represent a common approach to treating symptomatic BPH before TJA. Treatment is initiated with a 6-week trial of tamsulosin (pathway 1), followed by 6 months of combination tamsulosin/finasteride therapy (pathway 2) if symptoms persist. Patients with unremitting symptoms after medical management undergo surgical correction with transurethral resection of the prostate (pathway 3). Costs associated with each pathway were derived from the literature and institutional purchasing records. A break-even economic model was constructed to calculate the absolute risk reduction (ARR) in the infection rate and number needed to treat necessary for cost-effectiveness.
Pathway 1 was cost-effective if it prevented 1 infection of 113 (ARR = 0.883%) TKAs or 140 (ARR = 0.714%) THAs. Pathway 2 was cost-effective if it obviated infection in 1 of 69 TKAs (ARR = 1.445%) or 86 THAs (ARR = 1.169%). Pathway 3 was only deemed cost-effective assuming a cost of $400,000 to treat a PJI (number needed to treat = 71, ARR = 1.406%). Cost-effectiveness for pathways 1 and 2 was maintained with varying voiding optimization costs, infection rates, and PJI costs.
Perioperative medical management of symptomatic BPH is an economically justified PJI prevention strategy, whereas surgical interventions appear to be financially substantiated only when considering the long-term societal costs of a PJI.
异常的排空动力学可能是全膝关节置换术（TJA）后人工关节感染（PJI）的可改变危险因素，但围手术期优化其功能的成本效益尚不清楚。本研究采用盈亏平衡分析，计算了对 TJA 前有症状的良性前列腺增生（BPH）患者进行围手术期排尿优化以预防感染的经济可行性。
创建了围手术期排尿优化算法来代表 TJA 前治疗有症状 BPH 的常见方法。治疗首先进行为期 6 周的坦索罗辛（途径 1）试验，如果症状持续，则进行 6 个月的坦索罗辛/非那雄胺联合治疗（途径 2）。如果药物治疗后症状持续，患者则进行经尿道前列腺切除术（途径 3）。每个途径的相关成本均来源于文献和机构采购记录。构建了盈亏平衡经济模型，以计算感染率和治疗需要的人数的绝对风险降低（ARR），以评估成本效益。
如果途径 1 预防了 113 例 TKA 中的 1 例感染（ARR=0.883%）或 140 例 THR 中的 1 例感染（ARR=0.714%），则该途径具有成本效益。如果途径 2 避免了 69 例 TKA 中的 1 例感染（ARR=1.445%）或 86 例 THR 中的 1 例感染（ARR=1.169%），则该途径具有成本效益。只有在假设治疗 PJI 的费用为 400000 美元时，途径 3 才被认为具有成本效益（需要治疗的人数=71，ARR=1.406%）。当优化排尿的成本、感染率和 PJI 成本存在差异时，途径 1 和 2 的成本效益仍然成立。
围手术期对有症状 BPH 的药物治疗是一种具有成本效益的 PJI 预防策略，而只有当考虑到 PJI 的长期社会成本时，手术干预才具有经济意义。
