variation in inpatient croup management and outcomes · croup affects >1.4 million children...

ARTICLEPEDIATRICS Volume 139 , number 4 , April 2017 :e 20163582

Variation in Inpatient Croup Management and OutcomesAmy Tyler, MD, MSCS, a, b Lisa McLeod, MD, MPH, a, b, c Brenda Beaty, MSPH, c Elizabeth Juarez-Colunga, PhD, b, c Meghan Birkholz, MSPH, a Daniel Hyman, MD, MMM, a, b Allison Kempe, MD, MPH, a, b, c James Todd, MD, a, b Amanda F. Dempsey, MD, PhD, MPHa, b, c

abstractBACKGROUND 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.

aChildren's Hospital Colorado, Aurora, Colorado; bDepartment of Pediatrics, University of Colorado School of

Medicine, Aurora, Colorado; and cAdult and Child Center for Health Outcomes Research and Delivery Science,

Aurora, Colorado

Dr Tyler conceptualized and designed the study, participated in data collection, assisted in data

analysis, drafted the initial manuscript, and critically reviewed and revised the manuscript;

Drs McLeod, Kempe, and Juarez-Colunga conceptualized and designed the study, participated in

data analysis, and critically reviewed and revised the manuscript; Ms Beaty conceptualized and

designed the study, participated in data collection, analyzed the data, and critically reviewed

and revised the manuscript; Ms Birkholz and Dr Todd conceptualized and designed the study,

participated in data collection, and critically reviewed and revised the manuscript; Dr Hyman

conceptualized and designed the study and critically reviewed and revised the manuscript;

Dr Dempsey conceptualized and designed the study, participated in data collection, participated

in data analysis, and critically reviewed and revised the manuscript; and all authors approved the

fi nal manuscript as submitted.

The contents are the authors’ sole responsibility and do not necessarily represent the offi cial

views of the National Institutes of Health.

DOI: 10.1542/peds.2016-3582

NIH

To cite: Tyler A, McLeod L, Beaty B, et al. Variation in Inpatient

Croup Management and Outcomes. Pediatrics. 2017;139(4):

e20163582

WHAT’S KNOWN ON THIS SUBJECT: Croup is a

clinical diagnosis, and the available evidence

suggests that, except in rare cases where

alternative diagnoses are being considered,

resources such as radiologic imaging and viral

testing are not routinely indicated.

WHAT THIS STUDY ADDS: There is marked variation

across free-standing children’s hospitals in the use

of not routinely indicated resources in croup that

is not explained by average patient case mix. This

study highlights a need for quality-improvement

interventions to reduce unnecessary utilization.

by guest on June 6, 2020www.aappublications.org/newsDownloaded from

TYLER et al

Croup affects >1.4 million children

under 6 years of age in the United

States annually. 1, 2 In most patients,

it is a mild, self-limited disease

characterized by rhinorrhea, a hoarse

voice, a barky cough, and stridor. The

majority of patients with croup are

cared for in the outpatient setting,

but croup can be a life-threatening

disease. Overall, 1.5% to 6% of

patients with croup are hospitalized

at an estimated cost of $56 million

annually in the United States. 1, 3– 5

Despite the potential severity and

cost associated with hospitalization,

there is a paucity of inpatient-

specific research on the diagnosis,

optimal treatment, and outcomes

for inpatients with croup. As such,

many hospitals use evidence from

outpatient studies for the inpatient

management of croup.

Croup is a clinical diagnosis, and the

available evidence suggests that,

except in rare patients with atypical

presentations in whom alternative

diagnoses such as bacterial tracheitis

or retropharyngeal abscess are

being considered, ancillary testing

such as radiologic imaging and viral

testing is not helpful. 6, 7 Systemic

corticosteroids are the main

treatment in croup, and there is

strong evidence to support a single

dose of dexamethasone (0.15–0.6

mg/kg) in all patients with croup

regardless of the care setting. 6, 8 Given

equal efficacy, except in severe cases

or when oral intake is not tolerated,

the oral route is preferred to the

parenteral route for corticosteroid

administration.9 – 11 Because croup

is a viral illness, antibiotics are

not indicated except in cases of

concomitant bacterial infection.

This study aimed to analyze variation

in the use of not routinely indicated

resources (NRIRs) in the inpatient

management of croup, including

the following: the use of chest and

neck radiographs, viral testing,

antibiotics, and parenteral rather

than enteral corticosteroids. The

study had 3 primary objectives: (1)

to describe unadjusted hospital-level

variation in inpatient management,

patient outcomes, and utilization of

NRIRs, (2) to identify patient factors

associated with the utilization of

NRIRs, and (3) to determine the

predictors of NRIR utilization. We

hypothesized that, given the lack

of inpatient-specific evidence and

practice guidelines, there would be

significant variation in the evaluation

and management of generally healthy

patients hospitalized with croup.

We further hypothesized that the

main predictor of variation in the

use of NRIRs would be the hospital

of admission. To test our hypothesis

and compare utilization across

hospitals that may admit different

patient populations, we used risk-

adjustment methods for our analysis.

Our secondary aim was to describe

the relationship between resource

utilization and patient outcomes

including the following: readmission

for croup within 30 days, return to

the emergency department (ED) for

croup within 7 days, ICU admission,

and intubation. We hypothesized that

patient outcomes would not vary

significantly between hospitals or by

the number of NRIRs used.

METHODS

Data Source

For this retrospective cohort

study, we used the Pediatric Health

Information System (PHIS) database

(Children’s Hospital Association,

Overland Park, KS). PHIS contains

de-identified administrative data

on demographic characteristics,

diagnoses, procedures, imaging,

medications (including route of

administration), and readmissions

from 47 children’s hospitals in the

United States. The data include

International Classification of Diseases, Ninth Revision, Clinical Modification, codes and Clinical

Transaction Classification codes for

each procedure and clinical services,

for each patient by hospital day. This

study was approved as exempt by

the Colorado Multiple Institutional

Review Board because it did not

involve human subjects.

Study Population

Patients aged >6 months and <14

years were eligible for inclusion

if they were discharged from an

inpatient unit or observation

status between January 1, 2012,

and September 30, 2014 with

an International Classification of

Diseases, Ninth Revision (ICD-9),

code representing viral croup

(see Appendix 1). We excluded

patients with complex chronic

conditions as defined by Feudtner

et al 12 because these patients may

warrant nonstandard evaluation

and management. We also excluded

patients with diagnoses for which

parenteral steroids, viral testing,

radiographs, or antibiotics may

be indicated, such as asthma,

pneumonia, and otitis media. In

addition, we excluded patients

with diagnoses for which the croup

diagnosis had a high likelihood of

being secondary, such as congenital

anomalies of the larynx/trachea,

burns, foreign body ingestion/

aspiration, trauma, a surgical

diagnosis, and motor vehicle

accidents.

Study Defi nitions

Study variables were defined a priori,

and complete data were available

for 26 PHIS- participating hospitals

representing all regions of the

country. Patient-level characteristics

included the following: demographic

characteristics (sex, age in months,

race/ethnicity, and public versus

private insurance status), season

of discharge, All Patient Refined

Diagnosis Related Group (APR-DRG)

severity classification (3M APR-DRG

Classification System), length of stay

(LOS) in days, number of hospital

days patient received inhaled

racemic epinephrine treatments,

and number of hospital days patient

2 by guest on June 6, 2020www.aappublications.org/newsDownloaded from

PEDIATRICS Volume 139 , number 4 , April 2017

received steroids (oral or parenteral).

Steroid use was measured in days,

because individual doses could not be

differentiated in PHIS data. Hospital-

level variables included number

of admissions for croup per year,

hospital region (Midwest, Northeast,

South, West), mean annual patient

census, and admission rate for croup

from the ED, which was calculated

as the number of patients admitted

through the ED with croup over the

total number of patients seen in the

ED with croup.

Outcomes

For our primary outcomes, we

examined the following resources

utilization variables during the index

croup admission by using associated

billing codes: parenteral steroids,

viral studies, chest radiographs

(CXRs), lateral neck radiographs,

and antibiotics. For our secondary

outcomes, we examined data on

readmission for croup within 30

days, return to the ED within 7

days, ICU admission, and intubation.

Although most readmissions for

croup occur within 7 days, we

examined 30-day readmissions

because a common rationale for

ordering NRIRs is to avoid a missed

diagnosis that may result in a delayed

readmission.

Statistical Analysis

Descriptive statistics were used to

describe the cohort. Variance across

hospitals was analyzed with medians

and ranges. Univariate associations

between independent variables and

NRIR utilization were determined.

The final multivariable logistic

regression model assessing the

outcome of 0 to 1 versus ≥2 NRIRs

was adjusted for all patient-level

variables (age, sex, race, insurance

status, season of discharge, APR-DRG

severity, and LOS) and controlled for

hospital variability through random

effects.

Risk-Adjusted Analysis

In a secondary analysis, we

compared outcomes adjusted

for (1) patient effects based on

average case mix, defined here

as “expected rates” of utilization,

and (2) hospital-specific effects,

defined here as “predicted rates”

of utilization. First, for each NRIR

we estimated the expected rates

of utilization by hospital on the

basis of their average case mix

by using multivariable logistic

regression with patient factors as

fixed effects. 13 Patient factors in the

model included the following: age,

sex, race, insurance status, season

of discharge, APR-DRG severity, and

LOS. We then calculated predicted

rates of utilization of each NRIR

3

FIGURE 1Variation in inpatient croup management and outcomes.

TABLE 1 Patient and Hospital Characteristics

Value

Patients (N = 6236)

Median (IQR) age, mo 18 (12–29)

Male sex, % (n) 68 (4263)

Race, % (n)

White 66 (4088)

Black 11 (699)

Asian/other/missing 23 (1449)

Hispanic ethnicity 24 (1474)

Public insurance, % (n) 45 (2801)

Season at discharge, % (n)

Winter 24 (1505)

Spring 17 (1079)

Summer 22 (1351)

Fall 37 (2301)

Severity, % (n)

Extreme/major/moderate 30 (1874)

Minor 70 (4362)

Hospitals (N = 26), median (SD)

Croup admissions/year 69 (53)

Annual patient census 200 (77)

Admission rate for croup from ED, % 9.1 (4.6)

IQR, interquartile range.


TYLER et al

by hospital by using hierarchical

multivariable logistic regression

with hospital as a random effect

and patient characteristics as fixed

effects. We calculated predicted/

expected (p/e) ratios for each

hospital for each NRIR. Finally,

for each NRIR we multiplied the

p/e ratio for each hospital by the

average observed rates of utilization

across all hospitals to calculate risk

standardized utilization outcomes.

To allow for comparison of what we

observed to what would be expected

given each hospital’s average

case mix, observed, expected, and

predicted outcomes rates for the use

of NRIRs were depicted graphically.

To analyze potential patterns of

resource use across hospitals, for

each risk-standardized outcome,

hospitals were ranked from the

lowest quartile for utilization to

the highest quartile for utilization.

We also analyzed hospital-level

characteristics of the highest-quartile

utilizers and lowest-quartile utilizers.

Finally, to explore associations

between resource utilization and

patient outcomes, we depicted

the proportion of patients at each

hospital with each outcome (LOS

>1 day, intubation, ICU admission,

30-day readmission, and return

to ED within 7 days) stratified by

3 categories of utilization at the

hospital level: (1) lowest-quartile

rank sum utilization for all resources,

(2) hospitals in quartiles 2 and 3, and

(3) hospitals with highest-quartile

rank sum utilization. For all hospital-

level comparisons, hospitals were

labeled A through Z, with consistent

labeling across Figs 2 – 4.

RESULTS

Description of Cohort

Twenty-six hospitals with complete

study data matching our study

definitions were selected before

data extraction from PHIS. Only

the first croup admission for each

patient during the study period was

included in our cohort. Subsequent

hospitalizations within 30 days

counted as readmissions. There

were 11 210 unique patients aged 6

months to 14 years with a primary

or secondary diagnosis of croup

(see Appendix 2). We excluded

patients with complex chronic

conditions, diagnoses for which

utilization of measured resources

may be indicated, and diagnoses for

which croup was likely secondary

as described in the Methods section

( Fig 1).

Our final cohort included 6236

unique patients with a median age

of 18 months ( Table 1). The majority

of patients were admitted through

the ED (80%; n = 5010) and were

classified as an APR-DRG of minor

severity. Across the 26 hospitals in

our cohort, the median (SD) croup

admissions per year was 69 (53) and

the median admission rate for croup

from the ED was 9.1% (4.6%).

Patient-Level and Hospital-Level Variation in Management and Outcomes

Table 2 shows unadjusted

patient- and hospital-level data

on management and outcomes.

Depending on the hospital

of admission, 10% to 58% of

hospitalized patients received

≥2 days of corticosteroids. The

majority of patients received 1 day of

steroids (51%; n = 3195) and 1 day

of racemic epinephrine (55%; n =

3443). However, 19% (n = 1197) of

patients did not receive any steroids

and 31% (n = 1941) did not receive

any racemic epinephrine. Although

30% of patients received ≥2 days

of steroids, only 14% received ≥2

days of racemic epinephrine. On the

4

TABLE 2 Patient- and Hospital-Level Variations in Management and Outcomes

Patients (N = 6236),

% (n)

% Patients by Hospital, Median

(Range)

Days of steroids

None 19 (1197) 17 (4–45)

1 51 (3195) 50 (33–66)

≥2 30 (1870) 27 (10–58)

Days of racemic epinephrine

None 31 (1941) 24 (7–79)

1 55 (3443) 62 (15–72)

≥2 14 (873) 14 (0–35)

ICU admission 9 (567) 7 (1–27)

Intubation 3 (165) 3 (0–6)

ICU without intubation 7 (413) 5 (0–24)

LOS, in days

1 82 (5096) 81 (66–92)

2 12 (736) 12 (6–24)

≥3 6 (404) 8 (2–11)

Readmission rate within 30 days for

croup

3 (166) 2 (1–5)

Return to ED with 7 days (croup only) 2 (105) 1 (0–3)

TABLE 3 Hospital-Level Unadjusted Resource Utilization

Range Median Interquartile Range

CXR 9–44 24 19–27

Lateral neck radiograph 8–51 21 17–26

Viral studies 1–40 10 4–16

Parenteral steroid use 16–88 41 28–63

Antibiotic use 4–15 9 7–12

Use of ≥2 of above resources 16–61 29 23–39

N = 6236. Data are presented as ranges, medians, and interquartile ranges for the percentage of patients across all

hospitals who received the resources in column 1.



final day of hospitalization,

24% of patients received steroids

and 8% received racemic

epinephrine.

Although the majority of patients

had an LOS of 1 day, at the hospital

level the proportion of patients

staying 2 days ranged from 6%

to 24%. Overall, 9% (n = 567) of

patients required intensive care

services. At the hospital level, the

proportion of patients admitted to

the ICU but not intubated ranged

from 0% to 24%. Three percent

(n = 166) of patients were

readmitted within 30 days for croup.

Mortality was rare (1 in 6236;

0.02%).

Unadjusted Hospital-Level Variation in Resource Utilization

Table 3 shows the basic distribution

of NRIR utilization across hospitals.

The widest variation was seen in the

use of parenteral rather than oral

steroids and viral studies.

Patient Factors Associated With Resource Utilization

Table 4 shows patient factors that

were associated with the use of ≥2

NRIRs in the adjusted multivariable

logistic regression. The majority of the

cohort (71%) received 0 to 1 NRIR.

Patient characteristics associated with

a higher odds of receiving ≥2 NRIRs

included the following: age ≥3 years,

black race, discharge outside of the fall

season, nonminor APR-DRG severity,

and LOS >1 day.

Predictors of Variation

In the risk-adjusted analysis,

hospital-specific effects were the

main predictor of variability in the

use of parenteral steroids, CXRs,

neck radiographs, and viral studies.

By contrast, the main predictor of

variability in antibiotic use was

unmeasured patient characteristics

( Fig 2). For parenteral steroids,

observed and predicted rates were

very similar across all hospitals and

hospitals with the highest p/e ratios

corresponded to hospitals with

the highest observed proportion of

parenteral steroids. For example,

patients admitted to hospital A were

less likely to receive parenteral

steroids than would be expected on

the basis of average case mix, whereas

patients admitted to hospital Z were

more likely to receive parenteral

steroids than would be expected on

the basis of average case mix. Graphs

for CXRs, lateral neck films, and viral

studies had patterns very similar to

parenteral steroids (see Supplemental

Fig 5). In contrast, in graphs depicting

antibiotic use, observed and predicted

rates were different. Compared with

the other outcomes, the hospital

of admission had less influence on

5

TABLE 4 Associations With Utilization of ≥2 NRIRs

0–1 NRIR (71%), % ≥2 NRIRs (29%), % Unadjusted OR (95% CI) Adjusted OR (95% CI)

Patients

Age category

1 year 22 26 1.19 (1.03–1.37) 1.07 (0.91–1.25)

1 to <2 years 42 40 Ref Ref

2 to <3 years 17 14 0.92 (0.78–1.09) 0.96 (0.80–1.16)

≥3 years 18 20 1.26 (1.08–1.48) 1.33 (1.13–1.58)

Sex

Male 69 67 Ref Ref

Female 31 33 1.09 (0.96–1.22) 1.10 (0.97–1.26)

Race

White 66 66 Ref Ref

Black 10 14 1.41 (1.17–1.69) 1.26 (1.03–1.54)

Asian/other/missing 24 20 0.97 (0.83–1.12) 0.93 (0.79–1.10)

Insurance

Commercial or other 56 52 Ref Ref

Public 44 48 1.06 (0.94–1.19) 0.98 (0.95–1.01)

Season at discharge

Winter 23 26 1.38 (1.19–1.60) 1.20 (1.02–1.41)

Spring 17 19 1.31 (1.11–1.54) 1.27 (1.06–1.52)

Summer 21 23 1.24 (1.06–1.45) 1.31 (1.11–1.54)

Fall 39 33 Ref Ref

Severity

Extreme/major/moderate 25 42 2.33 (2.05–2.65) 1.53 (1.33–1.77)

Minor 75 58 Ref Ref

LOS

1 day 90 62 Ref Ref

2 days 8 20 3.87 (3.27–4.57) 3.69 (3.11–4.38)

≥3 days 2 18 15.93 (12.31–20.61) 13.48 (10.33–17.59)

Multivariable logistic regression model for the outcome of 0 to 1 compared with ≥2 resources. Resources include intravenous/intramuscular steroids, antibiotics, CXRs, lateral neck

fi lms, and viral testing. The model was adjusted for all patient-level variables (age, sex, race, insurance status, season of discharge, APR-DRG severity, and LOS) and controlled for hospital

random effect. CI, confi dence interval; OR, odds ratio; Ref, reference.


TYLER et al

whether patients received antibiotics,

indicating the variation was likely due

to unmeasured patient characteristics

rather than the hospital of admission.

Figure 3 depicts hospital-level

comparisons of risk-standardized

utilization for each resource across

the cohort. Hospitals are ordered

top to bottom from lowest to highest

risk-standardized rank sum for all

outcomes. No hospitals were ranked

uniformly in the highest quartiles or

lowest quartiles of utilization for all

outcomes, but, with the exception

of antibiotics, hospitals tended to

uniformly use a fewer or greater

number of NRIRs.

Hospital Characteristics

Characteristics of the highest-

quartile utilizers and the lowest-

quartile utilizers are shown in

Table 5. Compared with the other

hospitals in our cohort, the lowest-

quartile utilizers and the highest-

quartile utilizers were not different

from other hospitals with respect to

measured characteristics.

Patient Outcomes

Although we found wide variation

in the risk-adjusted use of NRIRs

across hospitals, the variability

in patient outcomes, such as

intubation (3%; range: 0%–6%),

return to ED within 7 days for croup

(1%; range: 0%–3%), and 30-day

readmission (2%; range: 0%–3%),

was narrow by comparison. Figure

4 displays the variability across

hospitals for patient outcomes.

No clear associations between

utilization and outcomes emerged.

For example, although hospital Z

has the second-highest proportion

of higher-severity patients and

is in the highest quartile for risk-

adjusted utilization, it has ICU

admission and intubation rates

below the hospital median. Hospital

C has the highest proportion of

higher-severity patients, is in the

lowest quartile for risk-adjusted

utilization, and has the highest

proportion of 30-day readmissions

for croup.

DISCUSSION

To our knowledge, this is the

first study to examine hospital-

level variability in the inpatient

management of croup. We observed

marked variation in the use of

NRIRs in the management of croup,

including the following: parenteral

rather than oral steroids, CXRs,

lateral neck films, viral testing,

and antibiotics. With the notable

exception of antibiotic use, in the

risk-adjusted analysis, this wide

6

FIGURE 2Risk-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-specifi c effects (o = predicted] and average case mix (x = expected). Hospital-specifi c 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.



variation did not reflect differences

in average patient case mix but

rather hospital-level practice

variability. For example, in the

case of parenteral steroids, we

observed a difference of more than

fivefold in utilization attributable to

hospital-level practice variability,

with some hospitals overutilizing

and others underutilizing resources

compared with what was expected

on the basis of patient case mix.

Conversely, we did not find

significant variability in patient

outcomes.

This level of variability in

practice may reflect the paucity

of inpatient-specific evidence for

the management of croup. Despite

the significant cost and health

care resources associated with

this common childhood illness,

and the large number of children

hospitalized for croup, there are

essentially no data on the optimal

management of inpatients with

croup. Where strong evidence

to guide care is limited, local

differences in provider practice may

become more prominent. 14

At the hospital level, we also

found striking variation in the

use of corticosteroids, with 10%

7

TABLE 5 Characteristics of Highest- and Lowest-Quartile–Ranked Hospitals for Overall Risk-Standardized Utilization

All Other Hospitals (n = 20) Lowest-Quartile Utilizers (n = 6) P

Region of country, % (n)

Midwest 20 (4) 17 (1)

Northeast 15 (3) 0 (0)

South 45 (9) 17 (1)

West 20 (4) 67 (4) .21a

Census, median (25%–75%) 200 (163–224) 199 (139–237) .82b

Croup cases per year, median (25%–75%) 64 (48–102) 83 (66–154) .32b

Admission rate, median (25%–75%) 8.8 (4.8–12.1) 13.1 (4.4–16.6) .26a

Highest-quartile utilizers (n = 6)

Region of country, % (n)

Midwest 20 (4) 17 (1)

Northeast 10 (2) 17 (1)

South 40 (8) 33 (2)

West 30 (6) 33 (2) .99a

Census, median (25%–75%) 199 (160–238) 201 (163–218) .97b

Croup cases per year, median (25%–75%) 89 (52–123) 62 (48–66) .24b

Admission rate, median (25%–75%) 9.1 (4.9–12.1) 10.8 (4.0–13.4) .93b

The lowest-quartile utilizers are hospitals in the lowest quartile for the rank sum of risk-adjusted NRIR utilization, and the highest-quartile utilizers are the hospitals in the highest quartile

for the rank sum of risk-adjusted NRIR utilization.a Fisher’s exact test.b Wilcoxon test.

FIGURE 3Risk-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.


TYLER et al

to 58% of hospitalized patients

receiving ≥2 days of corticosteroids

depending on the hospital. Given

the high rate of ICU admission,

future studies need to determine

whether inpatients may benefit

from multiple doses rather than a

single dose of dexamethasone. 6, 7 In

addition, more research is needed

to understand why, unlike other

outcomes, the hospital of admission

did not influence antibiotic use. We

hypothesize that this finding is due to

patient-level variables that were not

captured in our analysis, but other

explanations may also exist.

Similar studies have shown

that increased utilization is not

associated with improved patient

outcomes. 15 – 18 We found that

nearly 1 in 10 patients hospitalized

with croup required intensive

care services and 3% of patients

required intubation. However, ICU

admission rates varied considerably

by hospital, ranging from 1% to

27%. Furthermore, the 2 hospitals

with the highest ICU admission

rates did not have parallel rates of

8

FIGURE 4Range 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.



intubation, suggesting a possible

overutilization of intensive care

resources. This practice variation

at the hospital level that was

unexplained by differences in

patient case mix signifies that

there is significant opportunity

to improve care for patients

hospitalized with croup, and a

potential for cost savings.

Health care reform and value-based

health care models are driving

practice change nationwide. 19

Describing variation is only the first

step to improving care. Quality-

improvement interventions are

needed to reduce unnecessary

utilization and to improve care for

inpatients with croup. One strategy,

developing clinical care guidelines,

has reduced unnecessary utilization

in other pediatric illnesses. 20 –23

However, croup studies to date

have focused on outpatient

management, and inpatient-specific

evidence is needed to inform

clinical practice guidelines and

protocols in the inpatient setting.

In addition, the future success of

guideline implementation in croup

necessitates an understanding

of the factors associated with

medical providers’ decisions to

use resources and how utilization

is linked to patient-centered

outcomes such as health-related

quality of life.

Our study has several limitations.

This retrospective cohort study

included administrative data

from 26 tertiary care children’s

hospitals that had complete ED,

observation, and inpatient data for

all study variables in PHIS during

the study period. Without clinical

data, our ability to control for

severity was limited to APR-DRG

severity classifications. We used

ICD-9 codes to exclude patients

with complex chronic conditions

and other comorbidities, but ICD-9

codes may not accurately capture all

comorbidities. Because our data are

only from free-standing children’s

hospitals, our results may not be

generalizable to other settings.

Our cohort may represent a more

severe patient population than

the general population, resulting

in higher resource utilization.

Alternatively, providers at children’s

hospitals may have more experience

with croup management or may

have institutional clinical care

guidelines to guide management

and treatment decisions, in which

case our data may underestimate

utilization. Finally, during the index

hospitalization, 19% (n = 1197) of

our cohort did not have record of

receiving any steroids. Some of these

patients may have received steroids

(or NRIRs) as an outpatient before

presenting to a PHIS hospital for

admission, and these data were not

captured in our study.

CONCLUSIONS

We observed an up to fivefold

difference in utilization attributable

to hospital-level practice variability

in the inpatient management of

croup. This marked variation raises

concerns about potential over-

or underutilization of resources

not routinely indicated in the

management of croup. There is a

critical need for inpatient-specific

croup research to define the best

care for inpatients with croup

and for quality-improvement

interventions to reduce

unwarranted resource utilization

to deliver high-value care and to

improve outcomes for inpatients

with croup.

APPENDIX 1

ICD-9 codes representing viral croup

in our study included the following:

464.4 (croup), 464.20 (acute

laryngotracheitis without mention

of obstruction), 464.21 (acute

laryngotracheitis with obstruction),

464.50 (unspecified supraglottitis

without mention of obstruction),


with obstruction), and 786.10

(stridor).

APPENDIX 2

Nearly all patients, or 99.5% (n =

6208), had a primary or secondary

diagnosis code of 464.4 (croup). Two

percent (n = 145) had a primary or

secondary diagnosis code of 464.10–

464.11 (acute tracheitis with and

without mention of obstruction),

1.1% (n = 70) had a primary or

secondary diagnosis code of 464.20–

464.21 (acute laryngotracheitis

with and without mention of

obstruction), and 0.1% (n = 5) had

a primary or secondary diagnosis of


without mention of obstruction).

The majority of patients were

admitted through the ED (80%;

n = 5010), classified as APR-DRG

minor severity, and had an LOS

of 1 day. Nine percent of patients

required intensive care services, 3%

of patients were readmitted within

30 days for croup, and 2% returned

to the ED within 7 days of hospital

discharge for croup. Mortality was

rare (1 in 6236; 0.02%).

9

ABBREVIATIONS

APR-DRG: All Patient Refined

Diagnosis Related

Group

CXR: chest radiograph

ED: emergency department

ICD-9: International

Classification of Diseases,

Ninth Revision

LOS: length of stay

NRIR: not routinely indicated

resource

p/e: predicted/expected

PHIS: Pediatric Health

Information System


TYLER et al

REFERENCES

1. Denny FW, Murphy TF, Clyde WA Jr,

Collier AM, Henderson FW. Croup: an

11-year study in a pediatric practice.

Pediatrics. 1983;71(6):871–876

2. Federal Interagency Forum on Child

and Family Statistics. America’s

Children: Key National Indicators of

Well-Being, 2015. Washington, DC: US

Government Printing Offi ce; 2015

3. Klassen TP. Croup: a current

perspective. Pediatr Clin North Am.

1999;46(6):1167–1178

4. Marx A, Török TJ, Holman RC,

Clarke MJ, Anderson LJ. Pediatric

hospitalizations for croup

(laryngotracheobronchitis): biennial

increases associated with human

parainfl uenza virus 1 epidemics.

J Infect Dis. 1997;176(6):1423–1427

5. Klassen TP. Recent advances in

the treatment of bronchiolitis and

laryngitis. Pediatr Clin North Am.

1997;44(1):249–261

6. Petrocheilou A, Tanou K, Kalampouka

E, Malakasioti G, Giannios C, Kaditis AG.

Viral croup: diagnosis and a treatment

algorithm. Pediatr Pulmonol.

2014;49(5):421–429

7. Bjornson CL, Johnson DW. Croup in

children. CMAJ 2013;185(15):1317–1323

8. Russell KF, Liang Y, O’Gorman

K, Johnson DW, Klassen TP.

Glucocorticoids for croup. Cochrane

Database Syst Rev. 2011;1:CD001955

9. Amir L, Hubermann H, Halevi A, Mor

M, Mimouni M, Waisman Y. Oral

betamethasone versus intramuscular

dexamethasone for the treatment

of mild to moderate viral croup: a

prospective, randomized trial. Pediatr

Emerg Care. 2006;22(8):541–544

10. Donaldson D, Poleski D, Knipple E,

et al. Intramuscular versus oral

dexamethasone for the treatment

of moderate-to-severe croup: a

randomized, double-blind trial. Acad

Emerg Med. 2003;10(1):16–21

11. Rittichier KK, Ledwith CA. Outpatient

treatment of moderate croup with

dexamethasone: intramuscular

versus oral dosing. Pediatrics.

2000;106(6):1344–1348

12. Feudtner C, Feinstein JA, Zhong W,

Hall M, Dai D. Pediatric complex

chronic conditions classifi cation

system version 2: updated for ICD-

10 and complex medical technology

dependence and transplantation. BMC

Pediatr. 2014;14:199

13. Krumholz HM, Wang Y, Mattera

JA, et al. An administrative claims

model suitable for profi ling hospital

performance based on 30-day

mortality rates among patients

with heart failure. Circulation.

2006;113(13):1693–1701

14. In H, Neville BA, Lipsitz SR, Corso KA,

Weeks JC, Greenberg CC. The role of

National Cancer Institute-designated

cancer center status: observed

variation in surgical care depends

on the level of evidence. Ann Surg.

2012;255(5):890–895

15. Aronson PL, Thurm C, Alpern ER, et al.

Variation in care of the febrile young

infant <90 days in US pediatric

emergency departments. Pediatrics.

2014;134(4):667–677

16. Wennberg JE. Unwarranted variations

in healthcare delivery: implications

for academic medical centres. BMJ.

2002;325(7370):961–964

17. Wennberg JE. Practice variation:

implications for our health care

system. Manag Care. 2004;13(9

suppl):3–7

18. Florin TA, French B, Zorc JJ, Alpern

ER, Shah SS. Variation in emergency

department diagnostic testing and

disposition outcomes in pneumonia.

Pediatrics. 2013;132(2):237–244

19. Berwick DM, Hackbarth AD. Eliminating

waste in US health care. JAMA.

2012;307(14):1513–1516

20. Conway PH, Keren R. Factors

associated with variability in

outcomes for children hospitalized

with urinary tract infection. J Pediatr.

2009;154(6):789–796

21. Neuman MI, Hall M, Hersh AL, et al.

Infl uence of hospital guidelines on

management of children hospitalized

with pneumonia. Pediatrics.

2012;130(5). Available at: www.

pediatrics. org/ cgi/ content/ full/ 130/ 5/

e823

22. Todd J, Bertoch D, Dolan S. Use

of a large national database for

comparative evaluation of the

effect of a bronchiolitis/viral

pneumonia clinical care guideline

on patient outcome and resource

utilization. Arch Pediatr Adolesc Med.

2002;156(11):1086–1090

23. Parikh K, Hall M, Teach SJ. Bronchiolitis

management before and after the AAP

guidelines. Pediatrics. 2014;133(1).

Available at: www. pediatrics. org/ cgi/

content/ full/ 133/ 1/ e1

10

Accepted for publication Jan 10, 2017

Address correspondence to Amy Tyler, MD, MSCS, Department of Pediatrics, Children's Hospital Colorado, 13123 East 16th Ave, Mail Stop 302, Anschutz Medical

Campus, Aurora, CO 80045. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2017 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.

FUNDING: Supported by National Institutes of Health/NCATS (National Center for Advancing Translational Sciences) Colorado CTSI (Clinical & Translational

Sciences Institute) grant UL1 TR001082. Funded by the National Institutes of Health (NIH).

POTENTIAL CONFLICT OF INTEREST: Dr Dempsey serves on advisory boards for Merck and Pfi zer. She does not receive any research funding from these

companies. The other authors have indicated they have no potential confl icts of interest to disclose.


DOI: 10.1542/peds.2016-3582 originally published online March 14, 2017; 2017;139;Pediatrics

Birkholz, Daniel Hyman, Allison Kempe, James Todd and Amanda F. DempseyAmy Tyler, Lisa McLeod, Brenda Beaty, Elizabeth Juarez-Colunga, Meghan

Variation in Inpatient Croup Management and Outcomes

ServicesUpdated Information &

http://pediatrics.aappublications.org/content/139/4/e20163582including high resolution figures, can be found at:

Referenceshttp://pediatrics.aappublications.org/content/139/4/e20163582#BIBLThis article cites 22 articles, 9 of which you can access for free at:

Subspecialty Collections

http://www.aappublications.org/cgi/collection/respiratory_tract_subRespiratory Tracthttp://www.aappublications.org/cgi/collection/pulmonology_subPulmonologyhttp://www.aappublications.org/cgi/collection/hospital_medicine_subHospital Medicinefollowing collection(s): This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:


http://http://pediatrics.aappublications.org/content/139/4/e20163582

http://pediatrics.aappublications.org/content/139/4/e20163582#BIBL

http://www.aappublications.org/cgi/collection/hospital_medicine_sub

http://www.aappublications.org/cgi/collection/pulmonology_sub

http://www.aappublications.org/cgi/collection/respiratory_tract_sub

http://www.aappublications.org/site/misc/Permissions.xhtml

http://www.aappublications.org/site/misc/reprints.xhtml

DOI: 10.1542/peds.2016-3582 originally published online March 14, 2017; 2017;139;Pediatrics

Birkholz, Daniel Hyman, Allison Kempe, James Todd and Amanda F. DempseyAmy Tyler, Lisa McLeod, Brenda Beaty, Elizabeth Juarez-Colunga, Meghan

Variation in Inpatient Croup Management and Outcomes

http://pediatrics.aappublications.org/content/139/4/e20163582located on the World Wide Web at:

The online version of this article, along with updated information and services, is

http://pediatrics.aappublications.org/content/suppl/2017/03/10/peds.2016-3582.DCSupplementalData Supplement at:

1073-0397. ISSN:60007. Copyright © 2017 by the American Academy of Pediatrics. All rights reserved. Print

the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it


http://pediatrics.aappublications.org/content/139/4/e20163582

http://pediatrics.aappublications.org/content/suppl/2017/03/10/peds.2016-3582.DCSupplemental

variation in inpatient croup management and outcomes · croup affects >1.4 million children...

Documents