A Decade of Croup Management: Guideline Adherence, Practice Variation, and Opportunities for Improvement

Introduction: Despite the availability of the national clinical practice guideline (CPG) for croup treatment, adherence has not been evaluated in real-world settings. This study aimed to evaluate adherence to the national CPG for croup and to identify factors associated with incomplete adherence. Method: Patients aged 1 month to 15 years diagnosed with viral croup between 1 January 2014 and 31 December 2023 were retrospectively reviewed. Complete adherence was defined as follows: (1) corticosteroid prescription for any severity, (2) nebulised epinephrine for moderate-to-severe cases, and (3) observation for ≥4 h for moderate-to-severe croup. Furthermore, associated factors for incomplete adherence and unplanned revisits within 72 h were explored. Results: A total of 437 visits were included; 71.2% were male patients, with a mean age of 25.6 ± 19 months. Complete adherence increased from 46.7% in 2014 to 87.6% in 2023. Corticosteroid prescription showed the lowest adherence rates, particularly in mild cases. Factors associated with incomplete adherence by univariable analyses included the first croup episode (odds ratio [OR], 2.37; 95% confidence interval [CI], 1.15-5.54), a paediatrician as the primary physician (OR, 2.61; 95% CI, 1.64-4.14), outpatient visits (OR, 2.36; 95% CI, 1.49-3.73), mild croup (OR, 1.89; 95% CI, 1.21-2.98), and earlier years of the study (OR, 2.41; 95% CI, 1.55-3.78). The unplanned revisit rate was 19.7% and was not associated with adherence. Conclusions: Adherence to the national guidelines increased over the past decade. However, suboptimal treatment practices underscore the need for targeted interventions to improve guideline-based care, particularly in paediatric and outpatient settings.