Association Between Hospital Tiers and Cardiogenic Shock Mortality: Mitigating the Transfer Penalty Through a Regionalized Hub-and-Spoke Model

BACKGROUND: Cardiogenic shock remains associated with high short-term mortality despite contemporary advances in care. The association between institutional cardiac capability and outcomes-particularly among transferred patients and after accounting for clinical instability-remains incompletely defined. We sought to evaluate the association between hierarchical hospital cardiac capability and in-hospital mortality using a latent measure of acute physiological severity. METHODS: Using the National Inpatient Sample (2016-2022), hospitals were classified into 5 hierarchical tiers ranging from non-percutaneous coronary intervention (tier 1) to heart transplant/durable left ventricular assist device (LVAD) centers (tier 5). Generalized structural equation modeling assessed the relationship between hospital tier and mortality. A latent Acute Severity construct-comprising cardiac arrest, acute kidney and liver injury, and mechanical ventilation-was incorporated to model the effects of clinical instability. RESULTS: Among an estimated 1 177 180 cardiogenic shock hospitalizations, most occurred at cardiac surgical and transplant/LVAD centers. Crude mortality declined stepwise from non-percutaneous coronary intervention hospitals (64.4%) to transplant/LVAD centers (36.5%). After adjustment, a higher hospital tier was independently associated with lower mortality (tier 2 odds ratio [OR], 0.43 [95% CI, 0.38-0.48]; tier 3 OR, 0.37 [95% CI, 0.32-0.43]; tier 4 OR, 0.34 [95% CI, 0.30-0.38]; tier 5 OR, 0.36 [95% CI, 0.31-0.41]). Although transfer-in status was associated with increased mortality (OR 1.36 [95% CI, 1.30-1.43]), this association was attenuated at cardiac surgical and transplant/LVAD centers, consistent with mitigation of transfer-associated risk. CONCLUSIONS: Higher hospital cardiac capability is independently associated with lower mortality among patients with cardiogenic shock. Advanced centers are associated with mitigation of transfer-associated risk, supporting regionalized hub-and-spoke systems with early referral to high-capability centers.