Characteristics of High-Performing Hospitals in Cardiogenic Shock Following Acute Myocardial Infarction

Abstract

Cardiogenic shock after acute myocardial infarction (AMI-CS) carries significant mortality despite advances in revascularization and mechanical circulatory support. We sought to identify process-based and structural characteristics of centers with lower mortality in AMI-CS. We analyzed 16,337 AMI-CS cases across 440 centers enrolled in the Chest Pain-MI Registry, a retrospective cohort database, between January 1, 2015, and December 31, 2018. Centers were stratified across tertiles of risk-adjusted in-hospital mortality rate (RAMR) for comparison. Risk-adjusted multivariable logistic regression was also performed to identify hospital-level characteristics associated with decreased mortality. Median participant age was 66.0 (IQR 57.0-75.0) years, and 33.0% (n = 5,390) were women. Median RAMR was 33.4% (IQR 26.0-40.0%) and ranged from 26.9% to 50.2% across tertiles. Even after risk adjustment, lower-RAMR centers saw patients with fewer comorbidities. Lower-RAMR centers performed more revascularization (92.8% versus 90.6% versus 85.9%, P <0.001) and demonstrated better adherence to associated process measures. Left ventricular assist device (LVAD) capability (OR 0.78 [0.67-0.92], P = 0.002), more frequent revascularization (OR 0.93 [0.88-0.98], P = 0.006), and higher AMI-CS volume (OR 0.95 [0.91-0.99], P = 0.009) were associated with lower in-hospital mortality. However, several such characteristics were not more frequently observed at low-RAMR centers despite potentially reflecting greater institutional experience or resources. This may reflect the heterogeneity of AMI-CS even after risk adjustment. In conclusion, low-RAMR centers do not necessarily exhibit factors associated with decreased mortality in AMI-CS, which may reflect the challenges in performing outcomes research in this complex population.