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To investigate differences in the quality of emergency care for children related to differences in hospital setting, physician training, and demographic factors.This was a retrospective cohort study of a consecutive sample of children presenting with high-acuity illnesses or injuries at 4 rural non-children's hospitals (RNCHs) and 1 academic urban children's hospital (UCH). Two of 4 study physicians independently rated quality of care using a validated implicit review instrument. Hierarchical modeling was used to estimate quality of care (scored from 5 to 35) across hospital settings and by physician training.A total of 304 patients presenting to the RNCHs and the UCH were studied. Quality was lower (difference = −3.23; 95% confidence interval [CI] = −4.48 to −1.98) at the RNCHs compared with the UCH. Pediatric emergency medicine (PEM) physicians provided better care than family medicine (FM) physicians and those in the “other” category (difference = −3.34, 95% CI = −5.40 to −1.27 and −3.12, 95% CI = −5.25 to −0.99, respectively). Quality of care did not differ significantly between PEM and general emergency medicine (GEM) physicians in general, or between GEM and PEM physicians at the UCH; however, GEM physicians at the RNCHs provided care of lesser quality than PEM physicians at the UCH (difference = −2.75; 95% CI = −5.40 to −0.05). Older children received better care.The quality of care provided to children is associated with age, hospital setting, and physician training.