variation in inpatient croup management and outcomes · croup affects >1.4 million children...
TRANSCRIPT
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.
by guest on June 6, 2020www.aappublications.org/newsDownloaded from
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.
by guest on June 6, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 139 , number 4 , April 2017
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.
by guest on June 6, 2020www.aappublications.org/newsDownloaded from
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.
by guest on June 6, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 139 , number 4 , April 2017
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.
by guest on June 6, 2020www.aappublications.org/newsDownloaded from
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.
by guest on June 6, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 139 , number 4 , April 2017
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),
464.51 (unspecified supraglottitis
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
464.50 (unspecified supraglottitis
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
by guest on June 6, 2020www.aappublications.org/newsDownloaded from
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.
by guest on June 6, 2020www.aappublications.org/newsDownloaded from
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:
by guest on June 6, 2020www.aappublications.org/newsDownloaded from
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
by guest on June 6, 2020www.aappublications.org/newsDownloaded from