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Published on: June 12, 2021
Association Between Hospital Tier and Cardiogenic Shock Outcomes in the United States
Shubhadarshini Pawar1, Kannu Bansal2, J Dawn Abbott3
1Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA.
Insights
Higher-tier cardiogenic shock (CS) centers, offering advanced treatments like mechanical circulatory support (MCS) and cardiothoracic surgery (CTS), are associated with improved survival outcomes for CS patients. This tiered approach demonstrates a clear benefit despite patients presenting with more severe illness at these advanced facilities.
Area of Science:
- Cardiology
- Healthcare Systems Analysis
- Clinical Outcomes Research
Background:
- Cardiogenic shock (CS) center classification relies on capabilities in percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), and cardiothoracic surgery (CTS).
- Limited data exist on patient outcomes across different tiers of CS centers.
Purpose of the Study:
- To evaluate the association between the tiered classification of cardiogenic shock centers and patient outcomes.
- To determine if hospital capabilities influence mortality, length of stay, costs, and readmission rates for CS patients.
Main Methods:
- Analysis of adult CS hospitalizations (2016-2022) from the Nationwide Readmissions Database.
- Hospitals stratified into four tiers (Level 3 to Level 1) based on PCI, MCS, and CTS capabilities.
- Propensity score matching and hierarchical regression used to adjust for baseline characteristics and analyze outcomes including in-hospital mortality, length of stay, costs, and 30-day readmissions.
Main Results:
- Higher-tier centers (Level 1) had lower odds of receiving MCS compared to lower tiers.
- In propensity-matched analysis, higher mortality was observed in lower-tier centers (Level 1A, 2, and 3) compared to Level 1.
- Survival benefit of Level 1 centers persisted across various patient subgroups.
- 30-day readmissions were lower at Level 1A and Level 3 centers compared to Level 1; no significant difference at Level 2.
- Length of stay and costs were higher at Level 1 and 1A centers.
Conclusions:
- A tiered system for cardiogenic shock care is associated with improved survival outcomes at advanced centers.
- Despite treating more acutely ill patients, higher-tier centers demonstrate better survival, highlighting the benefit of specialized capabilities.
- The findings support the stratification of CS care based on hospital resources and expertise.
Background:
Consensus documents classify cardiogenic shock (CS) centers on the basis of percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), and cardiothoracic surgery (CTS) capabilities, but outcomes data remain limited.
Objectives:
This study sought to assess the association between CS center tiers and outcomes.
Methods:
Adults (aged ≥18 years) hospitalized with CS were identified from the Nationwide Readmissions Database (2016-2022). Hospitals were stratified into the following categories: level 3 (non-PCI, non-MCS, non-CTS, intensive care unit only), level 2 (level 3 in addition to PCI, intra-aortic balloon pump, percutaneous left ventricular assist device capable), level 1A (level 2 in addition to extracorporeal membrane oxygenation, nonpercutaneous ventricular assist device, CTS capable), and level 1 (level 1A in addition to durable left ventricular assist device/cardiac transplantation capable). Outcomes included in-hospital mortality, length of stay, and costs (in all patients), as well as 30-day readmissions (only in survivors). Multinomial overlap propensity to adjust for baseline characteristics and hierarchical regression models were used.
Results:
Among 623,835 CS admissions, the distribution of hospital levels was consistent over the 7-year period (7% level 1, 27%-36% level 1A, 19%-21% level 2, and 38%-40% level 3). Compared with level 1, the odds of receiving MCS were 38% lower at level 1A (adjusted OR [aOR]: 0.62 [95% CI: 0.59-0.65]) and 73% lower at level 2 (aOR: 0.27 [95% CI: 0.25-0.28]). In the propensity-matched analysis, compared with level 1 (29.5%), patients admitted to other levels had higher in-hospital mortality (level 1A: 38.4%, aOR: 1.33 [95% CI: 1.29-1.38]; level 2: 41.1%, aOR: 1.44 [95% CI: 1.38-1.50]; level 3: 45.2%, aOR: 1.63 [95% CI: 1.54-1.71]; all P < 0.001). The survival benefit of level 1 centers persisted across age, cardiac arrest, MCS use, location, and insurance subgroups. Compared with level 1, 30-day readmissions were lower by 4% at level 1A (OR: 0.96 [95% CI: 0.94-0.98]) and 1% at level 3 (OR: 0.99 [95% CI: 0.94-0.98]) centers, with no significant difference at level 2 centers (OR: 1.02 [95% CI: 0.99-1.06]). Length of stay and costs were higher at levels 1 and 1A.
Conclusions:
Tiered CS care was associated with a stepwise improvement in survival outcome at advanced centers despite greater acuity of illness.
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