Patrick Pessaux is Professor of Visceral and Digestive Surgery at the New Civil Hospital in Strasbourg. Within U1110, he leads the thematic group focused on the relevance of care pathways and the ecological transition in healthcare.

The healthcare sector, and particularly the field of surgery, does not have a strong culture of quality assurance. Quality assessment in medicine is largely limited to process or quantitative indicators, or to analyzing the technological equipment available. The lack of appropriateness in care is often synonymous with waste and over-consumption. Yet under-consumption is equally harmful: forgoing care is also a form of inappropriate care. To ensure an appropriate care pathway, the quality of individual procedures is not sufficient; it confines each actor to siloed, short-term reasoning. Speaking of appropriateness means going further and looking at the entire pathway, breaking down barriers between practices and including the evaluation of organisation, indications, follow-up, and coordination among the different actors.

Value in Health (value-based health care, or VBHC) is a model that proposes comparing outcomes that matter to patients (clinical outcomes, patient-reported experience measures, and patient-reported quality-of-life outcomes) with the costs required to achieve those outcomes (1). This voluntary approach lays the foundations and conditions for creating a virtuous cycle of practice improvement. Measuring and comparing means better knowing and understanding one’s own practices, learning from others, and continuously questioning oneself.

These new approaches require the development of appropriate tools for monitoring and information sharing. Continuous evaluation using real-world data would make it possible to introduce greater agility between innovations and their implementation. New technologies, including digitalisation and the contribution of Artificial Intelligence, support the evolution of medicine toward so-called 4.0, or rather 4P Medicine: Preventive, Predictive, Participatory and Personalised.

At a time when health systems are facing unprecedented ecological challenges, an evolution of Value-Based Health Care (VBHC) that incorporates environmental indicators appears inevitable (2).

A central issue for a modern health system today is ensuring its sustainability, which relies on three pillars: economic efficiency, social equity, and environmental sustainability

These environmental indicators should assess every stage, from diagnosis to rehabilitation, from the perspective of patient outcomes, costs, and ecological impact. By adopting this holistic vision, the healthcare sector could reduce its environmental footprint while ensuring quality care.

Including these new environmental indicators is essential for evaluating care pathways, with:

• An impact on Public Health: By integrating environmental indicators, health systems could identify and reduce polluting practices, thereby improving long-term public health. The WHO has even described climate change as “the greatest public health threat of the 21st century” and climate action as “the greatest opportunity for health.”
• Ecological responsibility: Like other sectors, healthcare must play a role in combating climate disruption. The 2020 Lancet Countdown report highlights the lack of preparedness of health systems for these environmental challenges. Environmental indicators would encourage sustainable resource management and reduce the ecological footprint of healthcare activities.
• Anticipation of future health crises: The COVID-19 crisis revealed the importance of resilient health systems. Environmental indicators could help anticipate and mitigate the impacts of future ecological crises, strengthening the sector’s preparedness for tomorrow’s challenges.

Integrating these indicators into Value in Health requires interdisciplinary collaboration among policymakers, healthcare professionals, environmental experts, and researchers.

This is precisely the challenge and objective of the thematic group: to develop research on the appropriateness of care while incorporating an ecological dimension.

Many professional societies have initiated the reorganization of their care practices through an ecological lens. For this reason, several scientific societies and professional associations have come together to create CERES, the Collective for Eco-Responsibility in Healthcare, chaired by Professor Pessaux, to provide responses that are “pluralistic, cross-cutting, interdisciplinary, and interprofessional.”

The team will also be able to draw on the resources of the European Institute for Ecological Transition in Health (IETES), chaired by Professor Pessaux and based in Strasbourg, with the following founding members:

ASAR – Association Strasbourgeoise d’Anesthésie Réanimation (Strasbourg Association of Anaesthesia and Intensive Care)

ADSNA – Agir Durablement en Santé en Nouvelle-Aquitaine (Acting Sustainably in Health in Nouvelle-Aquitaine)

CERES – Collectif d’Écoresponsabilité en Santé (Collective for Eco-Responsibility in Healthcare), bringing together a group of scientific societies

Mines Paris – PSL (Paris School of Mines – PSL), a major higher education and research institution committed to transitions

EHESP – École des Hautes Études en Santé Publique (School of Advanced Studies in Public Health)

FEHAP – Fédération des Établissements Hospitaliers et d’Aide à la Personne privés non lucratifs (Federation of Non-Profit Private Hospitals and Care Facilities)

FHF – Fédération Hospitalière de France (French Hospital Federation)

RESAH – Réseau des Acheteurs Hospitaliers (Network of Hospital Buyers)

1. Pessaux P, Cherkaoui Z. Value-based healthcare: a novel approach to the evaluation of patient care. Hepatobiliary Surg Nutr. 2018;7:125-126.
2. Pessaux P, Cherkaoui Z, Collectif d’écoresponsabilité en santé (CERES). A new healthcare paradigm: Integration of the environment in value-based health care. EROMs: Environment-related outcome measures. J Visc Surg. 2025 Feb;162(1):2-3.