JACC. Heart failure · 2026
Association Between Hospital Tier and Cardiogenic Shock Outcomes in the United States.
СтатьяПоддержка NIH: внешняя программаНазвание и аннотация: Перевод в очереди
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Pawar Shubhadarshini, Bansal Kannu, Abbott J Dawn, Katz Jason N, Dudzinski David M, van Diepen Sean, Solomon Michael A, Ton Van-Khue, Vallabhajosyula Saraschandra
Аннотация
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.
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.