title: Variation in Inpatient Croup Management and Outcomes.
abstract: OBJECTIVE
  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.
authors.affiliation: Children's Hospital Colorado, Aurora, Colorado; amy.tyler@childrenscolorado.org.|Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; and.
authors.forename: Amy
authors.initials: A
authors.lastname: Tyler
authors.affiliation: Children's Hospital Colorado, Aurora, Colorado.|Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; and.|Adult and Child Center for Health Outcomes Research and Delivery Science, Aurora, Colorado.
authors.forename: Lisa
authors.initials: L
authors.lastname: McLeod
authors.affiliation: Adult and Child Center for Health Outcomes Research and Delivery Science, Aurora, Colorado.
authors.forename: Brenda
authors.initials: B
authors.lastname: Beaty
authors.affiliation: Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; and.|Adult and Child Center for Health Outcomes Research and Delivery Science, Aurora, Colorado.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Juarez-Colunga
authors.affiliation: Children's Hospital Colorado, Aurora, Colorado.
authors.forename: Meghan
authors.initials: M
authors.lastname: Birkholz
authors.affiliation: Children's Hospital Colorado, Aurora, Colorado.|Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; and.
authors.forename: Daniel
authors.initials: D
authors.lastname: Hyman
authors.affiliation: Children's Hospital Colorado, Aurora, Colorado.|Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; and.|Adult and Child Center for Health Outcomes Research and Delivery Science, Aurora, Colorado.
authors.forename: Allison
authors.initials: A
authors.lastname: Kempe
authors.affiliation: Children's Hospital Colorado, Aurora, Colorado.|Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; and.
authors.forename: James
authors.initials: J
authors.lastname: Todd
authors.affiliation: Children's Hospital Colorado, Aurora, Colorado.|Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; and.|Adult and Child Center for Health Outcomes Research and Delivery Science, Aurora, Colorado.
authors.forename: Amanda F
authors.initials: AF
authors.lastname: Dempsey
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003440:Croup / Q000628:therapy*; D016208:Databases, Factual; D019468:Disease Management; D005260:Female; D006295:Health Resources / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007297:Inpatients / Q000706:statistics & numerical data*; D008297:Male; D012189:Retrospective Studies