151 - Differences in care for children with croup by practice setting and hospital classification: secondary analysis from a national quality improvement initiative

Publication Number: 3145.151

Kelly R.. Bergmann, Children's Minnesota, Minneapolis, MN, United States; Ellen Kerns, University of Nebraska Medical Center, Omaha, NE, United States; Makayla Schissel, University of Nebraska College of Medicine, Omaha, NE, United States; Gabrielle Z. Hester, Essentia Health, Duluth, MN, United States; Irina Topoz, University of Colorado School of Medicine, Aurora, CO, United States; Brittany Jennings, American Academy of Pediatrics, Itasca, IL, United States; Kendall Arslanian, American Academy of Pediatrics, Chicago, IL, United States; Randi Trope, Stony Brook Children's Hospital, Stony Brook, NY, United States; Ryan K. Sewell, Children's Nebraska, Omaha, NE, United States; Lisa Schroeder, Children's Mercy Hospitals and Clinics, Olathe, KS, United States; Amanda Nedved, Children's Mercy, Lenexa, KS, United States; Adolfo Molina, University of Alabama School of Medicine, Birmingham, AL, United States; Daniela Hochreiter, Yale School of Medicine, New Haven, CT, United States; Amy M. DeLaroche, Children's Hospital of Michigan, Detroit, MI, United States; Beth A. Condley, University of Oklahoma Fran & Earl Ziegler College of Nursing, Norman, OK, United States; Bolanle T. Akinsola, Emory University School of Medicine, Atlanta, GA, United States; Amy Tyler, Nationwide Children's Hospital, Columbus, OH, United States; Vivian Lee, Children's Hospital Los Angeles, Los Angeles, CA, United States

Background: Practice variation can lead to low-value care, including unnecessary testing and hospitalization. Currently, there is limited understanding of such care practices for children with croup who are treated in different healthcare settings.

Objective: To examine differences in preventable hospitalizations, and utilization of not routinely recommended testing (NRRT) among children with croup who were evaluated in 1) an emergency department (ED) vs urgent care (UC), and 2) a children's hospital (CH) vs non-children's hospital (NCH).

Design/Methods: We conducted a planned secondary analysis of data from the Better Assessment for Croup in Kids (BARCK) quality improvement (QI) initiative. Our QI initiative spanned 6/16/2024 to 8/15/2025, and included children 6 months to ≤6 years of age with a primary diagnosis of croup. Our primary outcome was preventable hospitalization, and our secondary outcome was NRRT utilization. Balancing measures were ED length of stay (LOS) and revisits for croup or croup-mimicking conditions. Our process measure was the proportion of encounters that received ≥3 nebulized racemic epinephrine (RE) treatments prior to admission. Interrupted time series models and autoregressive integrated moving average models with intervention (when seasonal variation was detected) were used to evaluate outcome changes.

Results: A total of 30592 encounters from 107 sites were included, of which 30288 (99.0%) were from and ED or UC, and 27877 (91.1%) were from either a CH or NCH (Table 1). For preventable hospitalizations, we observed a level change among CH of -1.04 (95% CI -1.98, -0.1). No other significant level or slope changes were observed for preventable hospitalizations. For NRRTs, we observed a level change among UCs of -4.33 (-6.33, -2.02) for neck or chest radiographs (Figure 1). We observed both a level change of -2.78 (95% CI -4.35, -1.21) and slope change (-0.31 (95% CI -0.51, -0.12) among EDs for comprehensive viral testing. Among CH, we observed a level change of -2.37 (95% CI -4.09, -0.65) for neck or chest radiographs, and a level change of -2.46 (95% CI -3.97, -0.94) and slope change (-0.28, (95% CI -0.46, -0.09) for comprehensive viral testing (Figure 2). Balancing and process measures are shown in Table 1.

Conclusion(s): Through implementation of a QI initiative, improvements in care for children with croup varied by practice location and hospital classification. Future studies should target setting and hospital specific interventions.

Demographics, clinical characteristics, and outcome measures by acute care location and by hospital classification.


Interrupted time series analysis for preventable hospitalization.
Panels indicate a) ED only, b) UC only, c) children's hospital, and d) non-children's hospital. QI interventions consisted of educational webinars, coaching calls, resources for electronic health record and clinical pathway updates, literature and marketing bundles, and education resources. Confidence intervals (95%) are indicated in gray.

Interrupted time series analysis for not routinely recommended testing.
Panels indicate chest and neck radiographs, and comprehensive viral testing for a-b) ED only, c-d) UC only, e-f) children's hospital, and g-h) non-children's hospitals. Confidence intervals (95%) are indicated in gray.