The long road home: A WTA multicenter study of patient preferences and risk tolerance in the regionalization of acute care surgery.

BACKGROUND: Regionalization of acute care surgery (ACS) aims to improve outcomes by transferring complex cases from local hospitals to tertiary centers. Although improved outcomes have been demonstrated for select conditions, regionalization may impose social and financial burdens, and patient preferences in the ACS setting remain poorly characterized. We evaluated patient preferences and risk tolerance related to ACS regionalization in a multicenter cohort.

METHODS: We prospectively surveyed 602 adults with trauma or emergency general surgery (EGS) conditions at five trauma centers. Using a modified standard gamble utility assessment, patients indicated preferences for local care versus regional transfer under scenarios of equal perioperative risk and increasing hypothetical risks at their local hospital (absolute increases of 2%, 4%, 6%). Demographics and clinical variables were collected. Univariate analyses identified factors associated with local versus regional preference, and multivariable logistic regression determined independent predictors of site preference.

RESULTS: Among 602 patients [67% EGS, 33% trauma, median age 50 (interquartile range: 24-61); 60% males], most preferred local care when complication or mortality risks were equivalent between hospitals (93% and 92%, respectively). As local risk increased, preference for local care declined; however, nearly half of patients preferred to remain at their local hospital despite a doubling of complication or mortality risk (4% vs. 2%). Preference for regional transfer at this inflection point was associated with higher household income, younger age, willingness to travel for specialty care, intensive care unit admission, and prior transfer. Trauma versus EGS diagnosis and mechanism did not predict site preference. Substantial variation in risk tolerance was observed across centers.

CONCLUSIONS: ACS patients strongly prefer local care when outcomes are equivalent, and many are willing to forego interhospital transfer despite substantially increased risk. These findings highlight a discordance between patient preferences, risk tolerance, and regionalization practices, underscoring the need to incorporate patient perspectives into ACS transfer decision-making. ( J Trauma Acute Care Surg. 2026;101: 894-902.).

LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.