A survival gap between nearby and distant hospitals
Patients with cardiogenic shock living more than an hour from a major hospital had an in-hospital death rate of 38.8%, compared with 29.6% among those living less than 10 minutes away, according to a nationwide South Korean study of 80,263 adults. The gap persisted after researchers accounted for differences including age, illness severity and treatment.
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The difference amounts to 9.2 percentage points, or about nine more deaths for every 100 patients in the group with the longest estimated journey. At one year, cumulative mortality reached 52.9% in that group, compared with 41.4% among patients with the shortest estimated journey.
The research, published in Critical Care Medicine, puts hospital accessibility at the center of a condition in which rapid treatment is essential. Cardiogenic shock happens when the heart cannot pump enough blood around the body, leaving organs without the blood and oxygen they need.
Samsung Medical Center researchers called for regional hospital networks and faster identification of critically ill patients before they reach hospital. Their findings connect the geography of emergency care with survival both during hospitalization and over the following year.
What the researchers measured
The study combined the Korean National Health Insurance Service database with hospital accessibility indicators from the Korea Transport Institute. It covered adults aged 18 or older admitted to intensive care units at tertiary hospitals, major centers providing advanced specialist care.
Critical Care Medicine's published study abstract gives the enrollment period as 2017 through 2022; the hospital announcement described it as 2018 through 2022. The analysis included 80,263 patients.
Researchers used regional averages for daytime passenger car travel from patients' residential areas to the nearest tertiary hospital. These were estimates of geographic access rather than records of each patient's ambulance journey. The median estimated travel time was 9.15 minutes, meaning half the study population had estimates at or below that time and half at or above it.
The observational study examined the relationship between regional accessibility and mortality. The contribution of an individual patient's actual transport delay to their outcome remains uncertain because the travel measure was based on regional averages.
The team was led by Samsung Medical Center professors Yang Jeong-hoon of critical care medicine, Choi Ki-hong of cardiology and Kang Dan-bi of the Clinical Epidemiology Research Center. Korea's National Institute of Health supported the research.
How deaths varied across four travel groups
Researchers divided patients into four groups according to estimated travel time. The percentage who died during hospitalization increased with each successive group:
- Under 10 minutes: 29.6%.
- 10 to 30 minutes: 33.5%.
- 30 to 60 minutes: 34.9%.
- More than 60 minutes: 38.8%.
The shortest and longest travel groups therefore had about 30 and 39 deaths per 100 patients, respectively. Even the group living closest to advanced care faced a substantial risk, while patients living farthest away experienced a larger burden.
Researchers then used statistical models to account for other patient and treatment differences. Compared with the group under 10 minutes away, the adjusted odds of dying in hospital were 1.27 times as high for journeys of 10 to 30 minutes, 1.24 times as high for 30 to 60 minutes, and 1.51 times as high for more than 60 minutes.
Odds compare the number of deaths with the number of survivors, while a death rate compares deaths with all patients. The 1.51 figure therefore means 51% higher adjusted odds of death. The actual observed death rates were 38.8% and 29.6% in the longest and shortest travel groups.
The adjusted figures for the two middle groups were close, with the estimate for 30 to 60 minutes slightly below that for 10 to 30 minutes. The largest adjusted difference was between patients living more than an hour away and those living within 10 minutes.
The gap continued over one year
One-year cumulative mortality was 41.4% in the group with estimated travel times under 10 minutes and 52.9% in the group over 60 minutes. That is a difference of 11.5 percentage points, or roughly 12 more deaths per 100 patients in the more distant group.
The researchers also examined how the rate of death over the follow-up period differed after adjustment. The adjusted hazard ratio was 1.16 for both middle travel groups and 1.31 for the group more than an hour away, compared with the group under 10 minutes away.
A hazard ratio compares the rate at which deaths occur during follow-up. Here, the figure of 1.31 corresponds to a 31% higher adjusted rate in the most distant group. The cumulative percentages, 52.9% and 41.4%, describe how many patients had died by one year.
Patients who survived hospitalization were also examined separately. Among those discharged alive, living more than 60 minutes from a tertiary hospital was associated with a 1.21 times higher risk of death within a year than living under 10 minutes away.
The 1.21 estimate concerns hospital survivors, while the 1.31 estimate comes from the broader one-year analysis. Keeping those patient groups separate helps explain why both figures appear in the findings. The survival gap extended beyond the initial hospital stay, making outcomes after discharge another concern for people living farther from advanced care.
A pattern across different forms of shock
Cardiogenic shock can follow an acute myocardial infarction, the medical term for a heart attack. It can also arise from other causes. The researchers found a similar association between longer estimated travel times and mortality in both categories.
The published abstract also describes consistent associations in de novo shock and acute-on-chronic shock. De novo means a new episode, while acute-on-chronic describes a sudden deterioration in someone with an existing chronic heart condition.
The findings therefore extended across different clinical groups, rather than being concentrated in patients whose shock followed a heart attack. The common concern was access to advanced care when the heart's pumping function had become dangerously weak.
Cardiogenic shock has been associated with mortality exceeding 40% within 30 days. That short time frame explains the researchers' focus on treatment before organs sustain permanent damage. Their study separately measured deaths during hospitalization and over one year, following patients across different stages of recovery.
What regional shock networks would change
Professor Yang Jeong-hoon, a critical care specialist at Samsung Medical Center, called for stronger connections between hospitals and quicker recognition of severely ill patients before arrival. Describing the team's proposed response, he said:
We need to establish close inter-hospital networks centered on regional hub hospitals for cardiogenic shock and build a system that can quickly identify critically ill patients in the field,
A regional hub hospital would serve as a specialist center within a connected group of medical institutions. The proposal brings together two tasks: identifying a patient who urgently needs advanced care and connecting that patient with a hospital able to provide it.
For patients in areas more than an hour from a tertiary hospital, the practical concern is the route into specialist treatment. The researchers argued that the system before hospital arrival deserves attention alongside the treatment available inside the hospital.
Yang also called for broader public engagement to help patients receive care promptly:
Greater public awareness and nationwide campaigns are needed so that more patients can receive prompt treatment.
The proposals focus on coordination, early identification and public awareness. No implementation timetable or list of designated regional shock hubs was given.
From patient records to a call for action
The research followed patients across several years before its findings were announced. Its main dates are:
- 2017 to 2022: The patient enrollment period stated in the published study abstract.
- October 2026: The journal issue in which the findings were reported to have appeared.
- November 10, 2026: Samsung Medical Center announced the research and the team's recommendations.
The national scale gives the study a broad view of access among adults with cardiogenic shock who reached intensive care at tertiary hospitals. Its most direct finding is a measurable survival gap between residential areas with short and long estimated journeys to advanced care.
The researchers' proposed response connects hospital capability with the route patients take to reach it. For communities farther from tertiary centers, the priority they identify is a coordinated system that recognizes critical illness early and links patients promptly to appropriate treatment.
Key Points
- The study analyzed 80,263 adults with cardiogenic shock admitted to intensive care at South Korean tertiary hospitals.
- In-hospital mortality was 29.6% in areas under 10 minutes away and 38.8% in areas more than 60 minutes away.
- The most distant group had 1.51 times the adjusted odds of dying in hospital.
- One-year cumulative mortality was 41.4% in the nearest group and 52.9% in the farthest group.
- Travel times were regional daytime car estimates, rather than individual ambulance journey records.
- Researchers called for regional shock networks, rapid identification of critically ill patients and greater public awareness.
