Practice variation in the emergency management of croup

Objective. To explore the effect of physician training background on the emergency management of croup. Methods. Two community hospitals with a general emergency department (ED) staffed by board-certified emergency medicine (EM) practitioners were the setting for this study. At both sites, pediatricians (PED) or pediatric emergency medicine specialists (PEM) managed acute pediatric visits during evening and weekend hours. Retrospective patient cohorts (6 months to 6 years) with a primary discharge diagnosis of croup were identified from a 1-year period. Data abstraction was performed by a registered nurse who was blinded to the study hypothesis. Results. There were 229, 92, and 209 patients in the PED, PEM, and EM cohorts, respectively, reflecting the practice of 69 physicians (19 PED, 12 PEM, and 38 EM). The groups had similar rates of admission and prescription of steroids at discharge. In regression models that incorporated all recorded clinical variables, EM patients were more likely to have received a chest radiograph (odds ratio [OR]: 6.6; 95% confidence interval [CI]: 3.1-14), racemic epinephrine (OR: 6.5; 95% CI: 3.1-14), albuterol in the ED (OR: 3.0; 95% CI: 1.4-6.4), and parenteral steroids (OR: 3.6; 95% CI: 2.1-6.3) and were less likely to have received oral steroids (OR: 0.41; 95% CI: 0.26-0.64). For the EM cohort, adjusted mean length of ED visit was 40 minutes longer (95% CI: 6.8-72) and mean direct costs were $90 higher (95% CI: $27-$153). Regression models comparing the PEM and PED cohorts revealed no significant management differences. Conclusion. Compared with physicians with a pediatric background, rates of resource utilization were higher for EM-trained physicians who managed uncomplicated cases of croup.