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Originally published by 2 Minute Medicine® (view original article). Reused on AccessMedicine with permission.

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1. Hospital-specific factors were found to be the main predictor of differences in use of not routinely indicated resources (NRIRs) for inpatient croup management.

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2. The largest variation in use of NRIR among hospitals was seen in completion of viral studies and administration of parenteral steroids over preferred oral steroids.

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Evidence rating level: 2 (Good)

Study Rundown:

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Croup is generally a mild, self-limited, clinically-diagnosed disease of viral-induced upper airway obstruction. Studies show that except in rare circumstances, use of ancillary testing is not warranted. While the majority of research surrounding croup is outpatient-based, up to 6% of the >1.4 million children diagnosed in the United States each year are admitted to the hospital. This retrospective cohort study attempted to address the paucity of data that exists regarding inpatient croup care. Researchers analyzed variation in NRIR use for inpatient management of croup in 26 hospitals across the United States, and attempted to identify patient and hospital-specific factors predicting NRIR utilization. Results showed patient characteristics including age, disease severity and days of hospitalization were associated with greater number of NRIR use. Overall, however, hospital-level rather than patient-related characteristics had a greater influence on variation in use of all NRIRs except antibiotics. The greatest variation in use among NRIRs included route of steroid administration for treatment and use of viral studies for diagnosis.

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Of note, all hospitals included in this study were free-standing children’s hospitals, potentially representing a more severely ill patient population resulting in higher NRIR use. Alternatively, presence of more experienced providers or institutional care guidelines at these hospitals may have contributed to a lower NRIR use in this cohort. Further research specific to inpatient management of croup is needed to define best care practices in order to reduce unnecessary resource utilization while optimizing patient outcomes.

In-depth [retrospective cohort]:

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Study participants included 6236 generally healthy children aged 6 months to 14 years (median 18 months) admitted at 26 children’s hospitals with a primary or secondary diagnosis of croup. Those whose charts indicated that croup was likely secondary to another condition (e.g. surgical diagnoses, airway anomalies, etc.) were excluded from analysis. Researchers collected data from the Pediatric Health Information System database, including patient level information (demographics, clinical presentation, treatment and outcomes) and hospital characteristics (croup admissions and annual patient census). NRIRs analyzed included parenteral steroids, viral studies, chests and lateral neck radiographs, and antibiotics. Results showed several variations in croup management based on hospital. For example, depending on the hospital, parenteral steroid use ranged from 16-88%, use of viral studies ranged from 1-40% and use of ≥ 2 NRIRs ranged from 16-60% at the hospital level. Patient characteristics including age ≥ 3years, black race, discharge in a season other than fall, and disease severity were associated with higher odds of receiving ≥2 NRIRs. Apart from antibiotic use, risk-adjusted analysis showed wide differences in use of NRIR across hospitals, demonstrating hospital-specific effects were the main predictor of variability. Conversely, hospital-level variation in patient outcomes were not as pronounced. Based on hospital, rates of intubation ranged from 0-6%, proportion of 30 day readmission ranged from 0-3% and rates of return to ED within one week were between 0-3%. Data failed to show a clear association between NRIR use and patient outcomes.

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