{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T18:18:44Z","timestamp":1789496324237,"version":"build-2803163510"},"reference-count":18,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"9","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Circ: Heart Failure"],"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND:<\/jats:title>\n                    <jats:p>Cardiogenic shock remains associated with high short-term mortality despite contemporary advances in care. The association between institutional cardiac capability and outcomes\u2014particularly among transferred patients and after accounting for clinical instability\u2014remains 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS:<\/jats:title>\n                    <jats:p>Using the National Inpatient Sample (2016\u20132022), hospitals were classified into 5 hierarchical tiers ranging from non\u2013percutaneous 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\u2014comprising cardiac arrest, acute kidney and liver injury, and mechanical ventilation\u2014was incorporated to model the effects of clinical instability.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS:<\/jats:title>\n                    <jats:p>Among an estimated 1\u2009177\u2009180 cardiogenic shock hospitalizations, most occurred at cardiac surgical and transplant\/LVAD centers. Crude mortality declined stepwise from non\u2013percutaneous 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\u20130.48]; tier 3 OR, 0.37 [95% CI, 0.32\u20130.43]; tier 4 OR, 0.34 [95% CI, 0.30\u20130.38]; tier 5 OR, 0.36 [95% CI, 0.31\u20130.41]). Although transfer-in status was associated with increased mortality (OR 1.36 [95% CI, 1.30\u20131.43]), this association was attenuated at cardiac surgical and transplant\/LVAD centers, consistent with mitigation of transfer-associated risk.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS:<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1161\/circheartfailure.126.014546","type":"journal-article","created":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T18:00:30Z","timestamp":1789495230000},"update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Association Between Hospital Tiers and Cardiogenic Shock Mortality: Mitigating the Transfer Penalty Through a Regionalized Hub-and-Spoke Model"],"prefix":"10.1161","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8837-4757","authenticated-orcid":true,"given":"Ankur","family":"Sethi","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emily","family":"Hiltner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7519-1743","authenticated-orcid":true,"given":"Ashish","family":"Awasthi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Casey","family":"Panebianco","sequence":"additional","affiliation":[{"name":"Division of Cardiac Surgery, Robert Wood Johnson University Hospital and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (C.P., T.L., L.Y.L., M.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tana","family":"LaPlaca","sequence":"additional","affiliation":[{"name":"Division of Cardiac Surgery, Robert Wood Johnson University Hospital and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (C.P., T.L., L.Y.L., M.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nancy","family":"Rizzuto","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leonard Y.","family":"Lee","sequence":"additional","affiliation":[{"name":"Division of Cardiac Surgery, Robert Wood Johnson University Hospital and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (C.P., T.L., L.Y.L., M.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark","family":"Russo","sequence":"additional","affiliation":[{"name":"Division of Cardiac Surgery, Robert Wood Johnson University Hospital and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (C.P., T.L., L.Y.L., M.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"key":"e_1_3_3_2_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa1208410"},{"key":"e_1_3_3_3_2","doi-asserted-by":"publisher","DOI":"10.1161\/JAHA.121.021061"},{"key":"e_1_3_3_4_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjcard.2019.05.038"},{"key":"e_1_3_3_5_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM199908263410901"},{"key":"e_1_3_3_6_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa2312572"},{"key":"e_1_3_3_7_2","doi-asserted-by":"publisher","DOI":"10.1161\/jaha.124.038317"},{"key":"e_1_3_3_8_2","doi-asserted-by":"publisher","DOI":"10.1136\/heartjnl-2024-325413"},{"key":"e_1_3_3_9_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCOUTCOMES.119.005618"},{"key":"e_1_3_3_10_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIR.0000000000000525"},{"key":"e_1_3_3_11_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.cardfail.2023.09.003"},{"key":"e_1_3_3_12_2","doi-asserted-by":"publisher","DOI":"10.1097\/01.mlr.0000182534.19832.83"},{"key":"e_1_3_3_13_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCOUTCOMES.117.003846"},{"key":"e_1_3_3_14_2","doi-asserted-by":"publisher","DOI":"10.1161\/CIR.0000000000001309"},{"key":"e_1_3_3_15_2","doi-asserted-by":"publisher","DOI":"10.1002\/ehf2.13180"},{"key":"e_1_3_3_16_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2018.07.074"},{"key":"e_1_3_3_17_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jchf.2025.102620"},{"key":"e_1_3_3_18_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jchf.2023.09.025"},{"key":"e_1_3_3_19_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.cardfail.2025.11.142"}],"container-title":["Circulation: Heart Failure"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ahajournals.org\/doi\/full\/10.1161\/CIRCHEARTFAILURE.126.014546","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T18:00:56Z","timestamp":1789495256000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ahajournals.org\/doi\/10.1161\/CIRCHEARTFAILURE.126.014546"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9]]},"references-count":18,"journal-issue":{"issue":"9","published-print":{"date-parts":[[2026,9]]}},"alternative-id":["10.1161\/CIRCHEARTFAILURE.126.014546"],"URL":"https:\/\/doi.org\/10.1161\/circheartfailure.126.014546","relation":{},"ISSN":["1941-3289","1941-3297"],"issn-type":[{"value":"1941-3289","type":"print"},{"value":"1941-3297","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9]]},"assertion":[{"value":"2026-04-05","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication 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