Preferences for Centralisation of Oesophageal Cancer Surgery: A Discrete Choice Experiment

Background Oesophageal cancer (OC) surgery is high risk, and surgical services are centralised to high-volume centres in many parts of the World, but not Australia, even though centralisation improves outcomes. However, patients might perceive benefits of centralisation differently and be willing to trade-off benefits for treatment closer to home. This study determined patient preferences and how preferences influence choices for surgery for OC. Methods A discrete choice experiment (DCE) included five attributes; distance travelled, hospital mortality, hospital stay length, out-of-pocket cost, and 5-year survival. Metropolitan and rural/remote respondents were recruited; patients under Barrett’s oesophagus surveillance, OC survivors, clinicians, and the general population. Data was analysed using the framework of random utility theory, using conditional logit and multinomial logit models. To determine preference changes vs attributes, reference scenarios were set for centralised (distance = 400 km, mortality = 3%, LOS = 11–20 days, cost = $1–$1000, survival = 40%) and localised services (<10 km, 8%, 320days, $0, 30%). Results 295 individuals completed the DCE; Barrett’s oesophagus—85, cancer survivors—30, clinicians—80, general population—100. Preferences were observed for travel distance <10 km (except cancer survivors), hospital mortality <3% (except general population), hospital stay <11 days, out-of-pocket costs <$1000, and 5-year survival >40% (clinicians and general population). Preferences were not influenced by location. A centralised service was preferred across all attributes for all respondents, except the general population which preferred localised services if costs were $1001–$5000 (64%) or > $5000 (69%). The general population preferred a localised service if mortality risk was 3% (51%) and 5-year survival was 40% (57%). Conclusion Centralised OC services can deliver better outcomes, and patient and clinician perspectives’ support this. However, out-of-pocket costs are potential barriers to delivery, and to overcome this support is needed for remotely located patients.