Cardiogenic Shock Teams and the Hub-and-Spoke Model: Does the Team Change the Outcome or Only the Pathway?
DOI:
https://doi.org/10.5281/zenodo.22305476Keywords:
Cardiogenic shock, Shock team, Regionalization, Hub-and-spoke, Mechanical circulatory supportAbstract
Cardiogenic shock carries an in-hospital mortality that has fallen only modestly over two decades, and much of the field's
recent optimism rests not on a new drug or device but on how care is organized: dedicated multidisciplinary shock teams, and
regionalized hub-and-spoke networks that route patients to centers with that expertise. The observational signal is consistent
and comes from more than one design: a single-center before-after comparison found 30-day survival rising from 47% to
76.6% after a standardized shock-team protocol; a 24-center registry found lower risk-adjusted mortality where a shock team
existed (23% versus 29%, adjusted odds ratio 0.72); and a national claims analysis found lower mortality among patients
transferred to an expert hub (adjusted odds ratio 0.73), despite those transferred patients being sicker on average. No
randomized trial has tested a shock team or a regionalized network as its own intervention, however, and each observational
design carries a bias a trial would remove: secular improvement in device technology, referral and survivor selection, and the
fact that clinicians choose who gets transferred. We set the team and network literature directly against the device trials that
do carry randomized evidence, and argue that the field has good reason to keep building shock teams and hub-and-spoke
networks, but not yet the evidence to say which part of that reorganization is doing the work.
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