Patient preferences for location of care: implications for regionalization

Abstract

Background: Regionalization of high-risk surgical procedures to selected high-volume centers has been proposed as a way to reduce operative mortality. For patients, however, travel to regional centers may be undesirable despite the expected mortality benefit.

Objective: To determine the strength of patient preferences for local care.

Design: Using a scenario of potentially resectable pancreatic cancer and a modification of the standard gamble utility assessment technique, we determined the level of additional operative mortality risk patients would accept to undergo surgery at a local rather than at a distant regional hospital in which operative mortality was assumed to be 3%. We used multiple logistic regression to identify predictors of willingness to accept additional risk.

Subjects: One hundred consecutive patients (95% male, median age 65) awaiting elective surgery at the Veterans Affairs Medical Center in White River Jct., VT.

Main outcome measure: Additional operative mortality risk patients would accept to keep care local.

Results: All patients preferred local surgery if the operative mortality risk at the local hospital were the same as the regional hospital (3%). If local operative mortality risk were 6%, which is twice the regional risk, 45 of 100 patients would still prefer local surgery. If local risk were 12%, 23 of 100 patients would prefer local surgery. If local risk were 18%, 18 of 100 patients would prefer local surgery. Further increases in local risk did not result in large changes in the proportion of patients preferring local care.

Conclusions: Many patients prefer to undergo surgery locally even when travel to a regional center would result in lower operative mortality risk. Therefore, policy makers should consider patient preferences when assessing the expected value of regionalizing major surgery.