Patient preferences for location of care: implications for regionalization.

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.