Variation in Inpatient Croup Management and Outcomes

Abstract

Background and objectives: Croup is a clinical diagnosis, and the available evidence suggests that, except in rare cases, ancillary testing, such as radiologic imaging, is not helpful. Given the paucity of inpatient-specific evidence for croup care, we hypothesized that there would be marked variability in the use of not routinely indicated resources (NRIRs). Our primary study objective was to describe the variation and predictors of variation in the use of NRIRs.

Methods: This was a retrospective cohort study that used the Pediatric Health Information System database of generally healthy inpatients with croup aged 6 months to 15 years who were admitted between January 1, 2012 and September 30, 2014. We measured variability in the use of NRIRs: chest and lateral neck radiographs, viral testing, parenteral steroids, and antibiotics. Risk-adjusted analysis was used to compare resource utilization adjusted for hospital-specific effects and average case mix.

Results: The cohort included 26 hospitals and 6236 patients with a median age of 18 months. Nine percent of patients required intensive care services, and 3% had a 30-day readmission for croup. We found marked variability in adjusted and unadjusted utilization across hospitals for all resources. In the risk-adjusted analysis, hospital-specific effects rather than patient characteristics were the main predictor of variability in the use of NRIRs.

Conclusions: We observed an up to fivefold difference in NRIR utilization attributable to hospital-level practice variability in inpatient croup care. This study highlights a need for inpatient-specific evidence and quality-improvement interventions to reduce unnecessary utilization and to improve patient outcomes.

FIGURE 1

Variation in inpatient croup management and outcomes.

FIGURE 2

Risk-adjusted comparison of the use of parenteral steroids (A) and antibiotics (B). Observed rates (+ = observed) of utilization of parenteral steroids and antibiotics for each hospital A through Z were compared with risk-adjusted rates. The analysis adjusted for hospital-specific effects (o = predicted] and average case mix (x = expected). Hospital-specific effects were the main determinant of variability in the use of parenteral steroids. The main determinants of variability in antibiotic use were likely unmeasured patient characteristics.

FIGURE 3

Risk-standardized resource use by hospital. With the use of risk-standardized rates of utilization, each hospital (A–Z) was given a quartile rank of 1 through 4 for each resource on row 1. Hospitals were ordered by their rank sum for all resources. Shading corresponds to rank for each outcome. White shading represents the lowest quartile of utilization and black represents the highest quartile of utilization. Hospitals with the lowest-quartile risk-standardized rates of utilization are underlined in bold in column 1. IM, intramuscular; IV, intravenous.

FIGURE 4

Range across hospitals for patient outcomes. From top to bottom, the bar graphs labeled I through VII show the proportion of patients at each hospital with each outcome. Hospitals are ordered A through Z across the x axis. I, proportion of patients at each hospital with nonminor severity; II, LOS >1 day; III, intubation; IV, ICU admission; V, ICU admission without intubation; VI, readmission within 30 days for croup; VII, return to ED within 7 days for croup.