757 - Impact of Clinical Practice Guidelines and Racemic Epinephrine Recommendations on Hospital Utilization in Children with Croup

Children with croup are frequently hospitalized after two racemic epinephrine (RE) treatments, yet few require additional interventions. This discrepancy has led hospitals to implement croup guidelines to prevent unnecessary admissions. The extent to which guidelines have influenced outcomes in children with croup remains unknown.

Objective: Our primary aim was to evaluate the impact of croup guidelines on hospital admission and costs. Our secondary aim was to evaluate the association between guideline-recommended RE treatments and hospital admission.

Design/Methods: This was a cross-sectional study of children ≥3 months to ≤8 years with a croup diagnosis (ICD-10) from 48 hospitals within the Pediatric Health Information System between January 1^st, 2019 to June 30^th, 2022. Study authors contacted each hospital and requested their most recent croup guideline. Guidelines were categorized by minimum number of RE treatments recommended prior to admission. Exclusion criteria included complex chronic or croup mimicking conditions, alternate respiratory diagnoses, and direct admissions or transfers. Primary outcomes were admission rates and standardized costs. Outcomes were compared by guideline availability and minimum number of RE treatments. Mixed effects regression was adjusted for age, sex, race, payer, previous croup encounters, and year with random effect for hospital.

Results: Thirty-eight hospitals (79.2%) responded to our query, of which 20 (52.6%) had guidelines. Among 121,284 croup encounters, the admission rate was 5.7% (range 0.6% to 18.5%) (Figure 1). Hospitals with guidelines had a lower unadjusted admission rate (4.6% vs 6.6%; mean difference -2.0, 95% CI -2.3, -1.7) and higher costs ($704 vs $651; mean difference $53, 95% CI $43, $63) compared to hospitals without guidelines (Table 1). After adjusting for confounders, admission rate (aOR 0.97, 95% CI 0.58, 1.64) and mean costs (mean difference $58, 95% CI -$124, $241) were not significantly different for hospitals with guidelines compared to hospitals without guidelines. Among hospitals with guidelines, admission rates were lower for hospitals with guidelines recommending a minimum of 1 RE (2.3%) compared to hospitals with guidelines recommending a minimum of 2 RE (5.1%) or 3 RE (5.1%), however differences were not statistically significant (Table 2).

Conclusion(s): There is substantial variation in admission for croup regardless of a guideline. Admission rates and costs were not significantly different between hospitals with or without guidelines, and did not vary significantly by number of RE treatments recommended.