Perioperative Medical Optimization of Symptomatic Benign Prostatic Hyperplasia is an Economically Justified Infection Prevention Strategy in Total Joint Arthroplasty

Abstract Background 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). Methods A perioperative voiding optimization algorithm was created to represent a common approach to treating symptomatic BPH prior to 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-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 infection rate and number-needed-to-treat (NNT) necessary for cost-effectiveness. Results Pathway-1 was cost-effective if it prevented 1 infection out of 113 (ARR=0.883%) TKAs or 140 (ARR=0.714%) THAs. Pathway-2 was cost-effective if it obviated infection in 1 out 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 (NNT=71, ARR=1.406%). Cost-effectiveness for pathways 1 and 2 was maintained with varying voiding optimization costs, infection rates, and PJI costs. Conclusion Perioperative medical management of symptomatic BPH is an economically justified PJI prevention strategy, while surgical interventions appear to be financially substantiated only when considering the long-term societal costs of a PJI.