Appropriate and Value-Based Care: Towards a Transformation of the Belgian Healthcare System: From Concept to Evidence: A Bottom-Up Implementation in Hip and Knee Arthroplasty in a Belgian Local-Level Hospital
Paul d'Otreppe¹: ORCID: 0009-0009-4374-3473
, Samy Aouachria²: ORCID:0009-0006-3686-268
Grégory Lambeaux³: ORCID: 0009-0009-5718-043X
¹ Independent Consultant; former Hospital Chief Executive Officer; former Chair, Belgian Association of Hospital Managers (BVZD/ABDH), Brussels, Belgium
² Deputy Medical Director, Groupe Santé CHC, Liège, Belgium
³ Department of Surgery, Groupe Santé CHC, Liège, Belgium
Abstract
Background
The Belgian healthcare system is internationally recognised for its broad insurance coverage and high-quality medical expertise. However, demographic ageing, increasing chronic disease burden, rising healthcare expenditure, and fragmented care pathways threaten the long-term sustainability of the current model. Existing reforms have largely focused on financial adjustments rather than structural transformation of care delivery.
Objective
This perspective and quality improvement report explores the implementation of Appropriate and Value-Based Care (VBHC) principles within a Belgian local-level hospital and examines the feasibility of translating strategic healthcare reform concepts into measurable clinical practice.
Methods
A single-centre observational continuous quality improvement initiative was conducted within the Department of Orthopaedic Surgery at CHC Waremme Hospital, Belgium, between February 2025 and January 2026. The implementation followed the International Consortium for Health Outcomes Measurement (ICHOM) Hip & Knee Osteoarthritis standard set and incorporated Clinician-Reported Outcome Measures (CROMs), Patient-Reported Outcome Measures (PROMs), and Patient-Reported Experience Measures (PREMs). The programme was structured around a virtual Integrated Practice Unit (IPU) model.
Results
A total of 270 primary arthroplasties and 16 revisions were included. External quality indicators demonstrated highly favourable outcomes, including a Hospital Standardized Mortality Ratio (HSMR) of zero and zero potentially preventable readmissions within 15 days. PROMs demonstrated clinically meaningful functional improvement, particularly in total hip arthroplasty patients. PREMs revealed high patient satisfaction regarding clinical care and communication, although infrastructural aspects such as room comfort and meal quality were identified as areas for improvement. The initiative demonstrated the operational feasibility of a bottom-up VBHC implementation within a medium-sized Belgian hospital.
Conclusions
This pilot project demonstrates that Appropriate and Value-Based Care can be operationalised through clinician-led, bottom-up transformation without large-scale structural reform or external consultancy dependence. The integration of multidisciplinary collaboration, digital infrastructure, outcome measurement, and continuous learning may provide a scalable pathway toward sustainable healthcare reform in Belgium and comparable European healthcare systems.
Keywords
Value-Based Healthcare; Appropriate Care; healthcare reform; arthroplasty; PROMs; PREMs; Integrated Practice Unit; Belgium; orthopaedic surgery; healthcare sustainability
Introduction
The Belgian healthcare system has long been recognised for its broad insurance coverage, high accessibility, and strong clinical expertise. Nevertheless, the current organisational and financing structure is increasingly unable to meet the demands of modern healthcare systems characterised by demographic ageing, chronic disease prevalence, workforce shortages, and escalating expenditure.
This situation creates what may be described as the “Belgian paradox”: despite excellent individual clinical performance, healthcare outcomes remain heterogeneous while costs continue to rise. Fragmented care pathways, duplication of investigations, insufficient coordination, and limited transparency of integrated data contribute to inefficiencies throughout the healthcare system.
Historically, Belgian healthcare financing evolved within a model centred on acute episodic care and fee-for-service reimbursement. However, chronic disease management requires coordinated longitudinal care pathways rather than isolated medical interventions. Existing reforms focusing on tariff regulation, financing modifications, and hospital networking have generated only incremental improvements without fundamentally transforming the underlying logic of care delivery.
Appropriate and Value-Based Care (VBHC) proposes a conceptual shift from procedural activity toward patient-centred outcomes and healthcare value. In this framework, healthcare value is defined not by the quantity of services delivered, but by the outcomes achieved relative to total cost across the complete patient care pathway.
This article describes the implementation of a bottom-up VBHC pilot initiative within a Belgian orthopaedic surgery department and explores its implications for broader healthcare transformation.
The Conceptual Foundations of Value-Based Healthcare
The central principle of Value-Based Healthcare is that healthcare systems should organise care around the patient journey rather than around isolated procedures or hospital episodes.
In the VBHC model:
- The unit of analysis becomes the complete care pathway
- Clinical outcomes are prioritised over procedural volume
- Patient experience and quality of life are integrated into evaluation
- Organisational performance is assessed through value creation rather than activity generation
Healthcare value is therefore assessed across several complementary dimensions:
- Clinical outcomes
- Patient-reported outcomes
- Patient experience
- Organisational efficiency
- Cost-effectiveness
- Equity of access
Unlike traditional healthcare financing models focused primarily on reimbursement mechanisms, VBHC aims to restructure healthcare delivery itself.
A successful transition toward value-based systems requires pragmatic implementation through clinical pilot projects rather than immediate nationwide restructuring. These pilot environments function as “sandboxes” allowing healthcare teams to:
- Test new organisational models
- Evaluate clinical outcomes
- Identify barriers
- Measure unintended consequences
- Develop local expertise
From Strategic Vision to Clinical Implementation
Why Hip and Knee Arthroplasty?
Primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) represent particularly suitable entry points for VBHC implementation because:
- Care pathways are relatively standardisable
- Surgical volumes are sufficient for measurement
- International outcome standards exist
- Validated PROMs are available
- Clinical outcomes are measurable longitudinally
The implementation project was conducted at CHC Waremme Hospital, a local-level Belgian hospital within the CHC Groupe Santé network in Liège, Belgium.
Methods
Study Design
A single-centre observational continuous quality improvement initiative was conducted between 1 February 2025 and 31 January 2026 within the Department of Orthopaedic Surgery.
The implementation followed the SQUIRE 2.0 reporting framework for healthcare quality improvement initiatives and adopted the International Consortium for Health Outcomes Measurement (ICHOM) Hip & Knee Osteoarthritis standard set.
Integrated Practice Unit (IPU)
The initiative was structured around a virtual Integrated Practice Unit (IPU) model incorporating:
- Orthopaedic surgeons
- Anaesthesiologists
- Rehabilitation teams
- Pre-hospitalisation staff
- Social services
- Hygiene teams
- Medical management
Unlike traditional IPU models requiring dedicated physical infrastructure, the CHC implementation functioned as a coordinated digital and organisational structure integrated through shared governance and a common clinical pathway.
Outcome Measures
Three categories of outcomes were evaluated:
Clinician-Reported Outcome Measures (CROMs)
These included:
- Hospital Standardized Mortality Ratio (HSMR)
- Potentially Preventable Readmissions (PPR)
- Nosocomial infection rates
- Revision surgery rates
- Length of stay (LOS)
Importantly, HSMR and PPR data were externally computed through national and independent systems, limiting institutional bias.
Patient-Reported Outcome Measures (PROMs)
Patients completed validated digital questionnaires preoperatively and postoperatively at:
- 6 weeks
- 3 months
- 6 months
The programme used:
- KOOS-PS for total knee arthroplasty
- HOOS-PS for total hip arthroplasty
Patient-Reported Experience Measures (PREMs)
PREMs evaluated:
- Patient satisfaction
- Communication quality
- Coordination of care
- Discharge preparation
- Overall patient experience
Results
Activity and Population
During the study period:
- 183 total knee arthroplasties were performed
- 87 total hip arthroplasties were performed
- 16 revision procedures were recorded
The patient population reflected typical arthroplasty demographics, including substantial rates of hypertension, obesity, and diabetes.
Clinician-Reported Outcomes
The programme demonstrated highly favourable external quality indicators:
- HSMR: 0
- Potentially Preventable Readmissions: 0%
- Nosocomial infections: 1% for TKA and 2% for THA
- Median orthopaedic length of stay: approximately 2.2 days
These results suggest effective pathway standardisation and low complication rates within the implemented ERAS framework.
However, the authors appropriately acknowledge that:
- The study period was limited to 12 months
- Volumes remained relatively modest
- Outcomes reflected elective standardised procedures
- Results cannot automatically be generalised to broader hospital activity
Patient-Reported Outcomes
PROMs collection rates reached:
- 31% for TKA
- 37% for THA
Although below international benchmark targets, clinically meaningful functional improvement was observed, particularly among THA patients.
HOOS-PS improvement among THA patients demonstrated:
- Mean improvement of +13.7 at 6 weeks
- +21.3 at 3 months
- +27.1 at 6 months
These improvements exceeded established minimal clinically important difference (MCID) thresholds.
Patient Experience Measures
Patient satisfaction results were highly favourable:
- 86% reported being very satisfied
- 92% would recommend the service
- 86% felt actively involved in their care
The surgical and medical teams achieved particularly strong ratings regarding:
- Respect
- Courtesy
- Communication
- Privacy
- Pain management
Areas identified for improvement included:
- Room comfort
- Meal quality
- Nursing staff identification visibility
Discussion
A Bottom-Up Transformation Model
One of the most important aspects of this initiative is that it was developed internally rather than imposed through external consultancy or top-down national reform.
The implementation emerged from:
- Local clinical leadership
- Internal expertise
- Organisational collaboration
- Institutional support
This bottom-up model may be particularly relevant for healthcare systems where large-scale reform encounters political, financial, or organisational resistance.
The Importance of Multidisciplinary Collaboration
The project highlights the importance of coordinated multidisciplinary teams functioning as integrated systems rather than isolated professionals.
The “Formula One pit crew” metaphor described by the authors effectively illustrates how patient outcomes depend not solely on surgical performance, but on:
- Anaesthesia
- Nursing
- Rehabilitation
- Hygiene
- Social support
- Coordination
- Leadership
This cultural shift from isolated procedures toward integrated pathway performance represents a core principle of VBHC.
Digital Infrastructure as an Enabler
The initiative also demonstrates the critical importance of digital infrastructure for:
- Outcome measurement
- Data integration
- Pathway coordination
- Continuous evaluation
Without integrated digital systems, implementation of longitudinal outcome measurement and continuous improvement processes would likely be substantially more difficult.
Limitations
Several important limitations should be acknowledged.
First, this was a single-centre observational pilot project without a control group or pre-implementation comparison.
Second, PROMs response rates remained below international recommendations, potentially introducing selection bias.
Third, formal Time-Driven Activity-Based Costing (TDABC) was not yet implemented, limiting full economic evaluation of value creation.
Finally, the project focused exclusively on elective orthopaedic procedures within a highly standardisable clinical pathway and may not be directly transferable to more complex or heterogeneous healthcare settings.
Future Directions
Future implementation cycles aim to:
- Improve PROMs response rates
- Incorporate broader health-related quality-of-life measures
- Introduce Time-Driven Activity-Based Costing
- Expand integrated outcome evaluation
- Strengthen general practitioner integration into care pathways
The integration of primary care physicians is likely to become increasingly important because value creation extends beyond hospital admission itself into preoperative preparation, rehabilitation, and long-term recovery.
Conclusion
This pilot initiative demonstrates that Appropriate and Value-Based Care can be implemented pragmatically within a Belgian local-level hospital through clinician-led bottom-up transformation.
The project illustrates how multidisciplinary collaboration, integrated outcome measurement, digital infrastructure, and continuous learning may collectively support more sustainable healthcare delivery models.
Rather than imposing large-scale administrative reform, VBHC transformation may emerge progressively through pathway-specific implementation, local clinical leadership, and iterative organisational learning.
As healthcare systems across Europe confront growing demographic and financial pressures, scalable value-based models may become increasingly necessary to preserve healthcare quality, workforce sustainability, and equitable access to care.
Open Access & Copyright
© 2026 The Authors. Published by the European Medical Specialist Review (EMSR) under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0).