The aim of this report from the Expert Group (see Box 1) on Health Systems Performance Assessment (HSPA) is to establish a comprehensive definition of low-value care in line with the concept of valuebased healthcare and from a health system perspective, and to identify low-value care indicators and measures to facilitate the reduction of low-value care for national HSPA practices. To achieve this aim, a “value-based healthcare” working group was established as a subgroup of the Expert Group with country representatives from Belgium, Czechia, Estonia, France, Germany, Hungary, Italy, Poland, Portugal, Romania and Slovenia as well as the European Observatory on Health Systems and Policies, the Organisation for Economic Co-operation and Development (OECD) and the DirectorateGeneral for Health and Food Safety (DG SANTE)

Total knee arthroplasty (TKA) is an effective treatment for patients with end-stage knee osteoarthritis but some patients exhibit a discrepancy between patient-reported outcomes (PROs) and patient satisfaction (PS). This study aims to identify predictors for patients reporting unfavorable PROs but high PS and vice versa.

Patient harm remains an important concern in hospital care,1 urging a reprioritisation of patient safety and healthcare quality.2 The past 20 years have been characterised by indispensable quality developments,3 including accreditation and public reporting providing foundations for monitoring and promoting healthcare organisation performance.4 Yet, the quality progress appears unsustainable in the long term, as indicated by, for example, nosocomial infections rising in the aftermath of the COVID-19 pandemic,5 6 or mortality reductions being abolished weeks after accreditation survey visits.7 A resilient safety culture with quality truly embedded into everyday practice can only occur after increased awareness of hospital-wide safety risks.3 8

In Belgium, the setting of this study, there is a lack of systematic hospital-wide quality monitoring, despite indications of important differences in patient outcomes between hospitals persisting over time.9 It has been shown for urology patients10 that outcomes such as mortality, readmissions and prolonged length of stay vary to a great extent between hospitals, largely impacting healthcare equity and patient safety.11 12 No data exist on variation in patient outcomes across all patient service lines and across multiple patient outcomes. By recognising which patient service lines are most prone to between-hospital variation and by identifying which hospitals have the highest potential for quality improvement (QI), targeted initiatives can be established. Such focused efforts are highly required in times of scarce financial and human resources and poor outcome prevalence.

The primary aim of this study was to examine inter-hospital variability in in-hospital mortality, unplanned 30-day readmissions and prolonged length of hospital stay (pLOS) across all Major Diagnostic Categories (MDCs) for all Belgian acute-care hospitals. Second, we aimed to estimate the number of outcomes potentially avoidable if successful QI policies could be established. Finally, we aimed to identify a set of high-impact-opportunity hospitals where policymakers can stimulate QI initiatives set to improve patient outcomes.