Application of Time-Driven Activity-Based Costing for Protocol-Driven Adult Open Airway Reconstruction

To describe a protocol-driven approach to adult open airway reconstruction for benign airway stenosis and apply time-driven activity-based costing (TDABC) methodology to characterize resource utilization and cost drivers.

Retrospective cohort study.

Tertiary academic medical center.

Adult patients undergoing tracheal or cricotracheal resection (TR/CTR) between 2022 and 2024 were reviewed. Multidisciplinary process mapping was performed using a modified Delphi technique. Validated TDABC methodology was applied across the operative admission. Univariate and generalized linear mixed models were used to examine associations between patient and hospital characteristics and the cost of care delivery.

Twenty patients (70% female, mean age 41 [±14.8] years, and mean Charlson Comorbidity Index 1 ± 1.1) underwent airway reconstruction. TR was most common (n = 13), followed by CTR (n = 5) and revision CTR (n = 2). Protocol-driven management included clinic evaluation, direct laryngoscopy/bronchoscopy, operative reconstruction, and postoperative intensive care unit (ICU)/floor management. Complications included seroma, tracheitis, and hematoma in one patient. Ten patients required a single post-reconstruction procedure, six required multiple, and four required none. One patient remained tracheostomy dependent at follow-up. Total cost of care delivery across admission was $135,598.08 ± 25,100, with ICU care accounting for 60.5% of costs. ICU length of stay and nursing labor were significant cost drivers (P < .05), while operating room, supplies, and physician effort accounted for only 10% of total costs.

Protocol-driven open airway reconstruction is resource-intensive, with postoperative ICU care representing the primary cost driver. TDABC provides a granular framework for understanding cost structure and identifying opportunities for future value-based optimization in complex airway surgery.