Geographic Access to Care and Mortality in Cardiogenic Shock: A Nationwide Cohort Analysis
Ki Hong Choi, Danbee Kang, Junwoo Seo, Ji Hyun Cha, Taek Kyu Park, Joo Myung Lee, Young Bin Song, Joo-Yong Hahn, Seung-Hyuk Choi, Hyeon-Cheol Gwon, Juhee Cho, Jeong Hoon YangImportance:
Timely access to advanced care is critical for patients with cardiogenic shock (CS), yet the impact of regional disparities in hospital arrival time on mortality remains unclear.
Objectives:
To investigate whether regional disparities in hospital arrival time are associated with in-hospital and long-term mortality among patients with CS.
Design:
Population-based, nationwide cohort study.
Setting:
Tertiary hospitals in South Korea, using data from the Korean National Health Insurance Service database and regional hospital accessibility indicators from the Korea Transport Institute.
Participants:
A total of 80,263 adults (≥ 18 yr) admitted to an ICU with a diagnosis of CS between 2017 and 2022. The study population was stratified by estimated hospital arrival time using region-level average daytime travel times (< 10, 10–30, 30–60, and > 60 min) for the present study.
Interventions:
None.
Main Outcomes and Measures:
The primary outcome was all-cause mortality, including in-hospital and post-discharge mortality. Multivariable logistic and Cox regression models were used to assess associations.
Results:
Median estimated hospital arrival time was 9.15 minutes. In-hospital mortality increased progressively with longer arrival times: 29.6% (< 10 min), 33.5% (10–30 min), 34.9% (30–60 min), and 38.8% (> 60 min). Compared with less than 10 minutes, the adjusted odds ratios for in-hospital mortality were 1.27 (95% CI, 1.23–1.32), 1.24 (95% CI, 1.14–1.35), and 1.51 (95% CI, 1.29–1.75), respectively. At 1-year follow-up, the adjusted hazard ratios for all-cause mortality were 1.16 (95% CI, 1.14–1.19 for 10–30 min), 1.16 (95% CI, 1.09–1.21 for 30–60 min), and 1.31 (95% CI, 1.19–1.43 for > 60 min), relative to less than 10 minutes. These associations were consistent in both de novo and acute-on-chronic CS.
Conclusions:
Longer hospital arrival times are significantly associated with increased in-hospital and long-term mortality in patients with CS. These findings underscore the need for system-level interventions, such as regionally coordinated shock networks and early prehospital triage, to ensure timely access to definitive care.