Association Between Hospital Tier and Cardiogenic Shock Outcomes in the United States

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.

This study sought to assess the association between CS center tiers and outcomes.

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.

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.

Tiered CS care was associated with a stepwise improvement in survival outcome at advanced centers despite greater acuity of illness.