Advancing Lung Cancer Care in Bulgaria: A Successful Implementation of Value-Based Healthcarе

Abstract

This project aims to assess the early impact of value-based healthcare (VBHC) implementation in a Bulgarian cancer center, focusing on lung cancer treatment, and to improve care coordination, expand capacity, and introduce outcome measurement through integrated practice units (IPUs), optimized pathways, and patient-reported outcome measures (PROMs). The approach included (i) 90 h of direct observation, (ii) structured stakeholder interviews, and (iii) time-driven activity-based costing (TDABC) to map resource use. Process maps guided workflow redesign. PROM implementation, based on the International Consortium for Health Outcomes Measurement lung cancer set, involved staff training and licensing. One year post-implementation, day hospital capacity doubled (50–100 patients/day). An external call center reduced physicians’ administrative load. Interdisciplinary meetings and optimized referrals enhanced communication. PROMs now cover part of the lung cancer cohort. TDABC revealed opportunities for staff reallocation and streamlined diagnostics. Early results suggest VBHC is feasible in Eastern Europe, with measurable gains in efficiency. Future steps include PROM digitization, telemedicine expansion, and adapting the IPU model to other cancer types.

Introduction

Lung cancer is among the most prevalent and lethal malignancies globally. Its management is increasingly complex and costly, underscoring the urgent need for more efficient and patient-centered care delivery models. Traditional volume-based healthcare, which focuses on the quantity of services provided rather than their outcomes, has proven insufficient, often increasing interventions without corresponding benefits for patients. ¹ This has catalyzed the shift toward value-based healthcare (VBHC), which prioritizes outcomes that matter to patients relative to the cost of achieving them. ²

Еffective lung cancer treatment typically requires coordination among multiple specialties, including surgery, medical oncology, radiotherapy, and palliative care. However, traditional fragmented care models often lead to inefficiencies and suboptimal outcomes. To address these challenges, the integration of VBHC principles through the concept of integrated practice units (IPUs) offers a compelling strategy for enhancing both quality and efficiency in oncology care. ³ Following the Porter Playbook, IPU principles organize care around specific conditions with dedicated multidisciplinary teams, often co-located, improving coordination and outcomes.^4,5 Implementing VBHC in oncology via IPU principle integration yields better-tailored clinical outcomes, stronger reputations, higher patient volumes, and faster expertise development. ⁶ It fosters best practices, optimizes resources, and supports patient flow planning. TDABC is another critical tool, enabling precise analysis of resource utilization and cost structures along the patient pathway. This allows institutions to identify opportunities to optimize resource use and reallocate resources more effectively. ⁷

The Bulgarian oncology system presents opportunities for improvement, particularly in strengthening care integration, enhancing multidisciplinary coordination, and introducing standardized outcome measurement. Pilot projects applying VBHC principles offer a promising pathway to overcome these barriers, improve integration, and reorient care around outcomes that matter to patients. Given its high burden and complexity, oncology—particularly lung cancer—is a strong candidate for early VBHC implementation efforts in Bulgaria. ⁸

This study presents a pilot initiative for the implementation of a VBHC model in lung cancer care at a leading oncology center in Bulgaria. As part of a broader ongoing program, the project marks the first step in restructuring care delivery and a framework for introducing outcome measurement. It demonstrates how optimizing care pathways, fostering multidisciplinary collaboration, and embedding outcome measurement can enhance oncology care, addressing a gap in Eastern Europe's adaptation to global cancer care trends. ⁹

Methodology

In March 2021, a leading oncology center in Bulgaria initiated a strategic, long-term transition toward VBHC to advance care delivery and align clinical practices with patient-centered outcomes. The initiative focused specifically on lung cancer care and represents the first effort of its kind in the country. The objective was to optimize the continuum of care for lung cancer patients by enhancing integration, improving resource utilization, and laying the groundwork for systematic outcome measurement. This publication presents findings from the initial 12-month pilot phase, conducted between March 2021 and February 2022. While full VBHC implementation remains an ongoing institutional goal, this study focuses on early-stage activities, particularly those involving three departments: Medical Oncology, Nuclear Medicine, and Radiotherapy.

Data Collection and Stakeholder Engagement

To gain a comprehensive understanding of existing care practices, the project team conducted structured interviews with a diverse group of healthcare professionals. Participants included department heads, physicians, nurses, imaging specialists, pharmacists, clinical psychologists, technical assistants, and administrative staff.

The interviews aimed to capture the detailed structure of the patient journey, clarify professional roles and responsibilities, and assess interdepartmental collaboration. Particular attention was paid to identifying recurring challenges, areas for improvement, and opportunities from the perspective of those directly involved in providing care.

Direct Observation and Process Mapping

Approximately 90 h of on-site observation were conducted across the three departments to complement the interviews and provide real-time insight into workflows. Observations focused on patient flow and staff activities, documenting the sequence and timing of key steps, coordination practices, and opportunities to enhance efficiency. The process maps were developed as a structured input for subsequent TDABC modeling and operational planning.

Application of TDABC

Building on the process maps, the team developed a TDABC model to quantify resource use and evaluate cost-efficiency. This model was designed to support strategic decision-making by enabling the oncology center's leadership to better understand the relationship between time, human resources, and financial outcomes. The structured implementation of the TDABC methodology is summarized in Figure S1 (Methods—TDABC implementation stages in the oncology care pathway).

Outcome Measurement Framework and PROMs Integration

As part of the broader VBHC transformation, initial groundwork was laid for the integration of PROMs. Given the complexity of the care environment and the high workload of frontline staff, clinical psychologists were identified as the most appropriate professionals to oversee PROM collection.

In 2021, a targeted training program was launched to prepare the psychologists for this role. Following a strategic review and alignment with the International Consortium for Health Outcomes Measurement Lung Cancer Standard Set, two validated PROM instruments were selected: the EQ-5D-5L and the EORTC QLQ-LC13. The EQ-5D-5L assesses general health-related quality of life across conditions, while the QLQ-LC13 specifically captures lung cancer symptoms and treatment effects. All necessary licenses were obtained for use (Applications A–C in Appendix).

Тhis manuscript refers only to the framework for the preparation and implementation of PROMs, and not to the results of PROMs at the patient level. During the pilot phase, preparatory activities focused on the selection of standardized questionnaires (EQ-5D-5L and EORTC QLQ-LC13), licensing, and staff training. The systematic collection of PROs data officially began in 2023 as part of a separate institutional project and is not covered in this article.

Ethical Considerations

As this pilot study involved only process observation and nonidentifiable data, and did not include any clinical interventions, ethical committee approval was not required. All procedures adhered to local institutional and regulatory standards for observational quality improvement projects.

Process Overview

Figure S2 (Methods—Study flowchart: recruitment, data collection, mapping, analysis) presents a flowchart outlining the main steps of participant selection, data collection, process mapping, analysis, and follow-up. This visual summary reflects the structured process followed throughout the project, from initial engagement to the gradual implementation of improvements.

Results

The initial phase of the project revealed multiple opportunities to enhance care coordination, workflow efficiency, and patient engagement across the departments of Medical Oncology, Nuclear Medicine, and Radiotherapy. Through process mapping, structured interviews, and direct observation, the project team identified both systemic and department-specific challenges.

AS IS Analysis

The baseline (“AS IS”) assessment highlighted several areas for improvement. These included coordination between Nuclear Medicine and Radiotherapy, scheduling capacity for PET/CT diagnostics, workload distribution across staff roles, and communication pathways that could be streamlined to support more efficient patient flow.

TO BE Improvements

Targeted measures (“TO BE”) addressed these areas. An external call center reduced administrative workload by ∼50%, day-hospital capacity increased from 50 to 100 patients per day, additional imaging staff were hired, and scheduling was centralized. These measures improved throughput and strengthened multidisciplinary collaboration.

Care Pathway Mapping and Coordination Gaps

The mapping process outlined priority areas for further development, including time intervals between diagnostic and treatment phases, manual administrative burden, and suboptimal allocation of clinical and administrative staff time. These observations emphasize the need for better standardization of workflows and role clarity, aiming to ensure smoother patient experience and more integrated care delivery.

Another important development focus was developing a systematic outcome measurement framework. Although certain clinical data was collected, there was no structured framework in place for reporting PROMs or for monitoring the long-term impact of treatment.

Administrative Burden and Infrastructure Limitations

Manual and paper-based processes result in increased administrative workload and potential communication gaps between teams. These challenges were further compounded by a rising number of patients, which began to exceed the operational capacity of the existing infrastructure.

The implemented TDABC model, informed by real-time process observations and role-based time allocation, provided structured cost estimates; while specific cost data remain confidential due to institutional policy, the aggregated results are reported here, with the model's framework detailed in Supplementary File 1 to support future replication.

Operational Structure and Interdepartmental Coordination

The review of the daily organizational structure of the oncology center revealed the core clinical and administrative activities, their timing, and patterns of interdisciplinary interaction. A typical workday schedule is presented in Table S1, which highlights opportunities for improved coordination and communication across roles.

Structured interviews, direct observations, and process mapping during the pilot phase revealed several key challenges across the main departments. These challenges, together with their underlying causes, affected units, and proposed improvements, are summarized in Table S2, which contrasts the current state (AS IS) with the recommended future state (TO BE).

Implementation of Improvements and Infrastructure Expansion

The structured analysis prompted targeted departmental changes. In Medical Oncology, patient admission procedures shifted toward a centralized model, the patient information booklet was updated with current treatment guidance, and the clinical pharmacist re-established direct communication with oncologists and participation in multidisciplinary discussions. Supplementary Files 2 and 3 present process maps of the clinical pathways.

In Nuclear Medicine, workload balancing is underway through schedule restructuring and hiring initiatives. Supplementary File 4 outlines the PET/CT patient pathway.

In Radiotherapy, protocols are being developed for systematic follow-up and documentation of adverse effects. Supplementary File 5 presents the radiotherapy workflow and integration points for safety practices.

In addition to department-specific insights, the study also identified broader organizational opportunities to strengthen coordination, communication, and professional development across the Oncology Center. The center has institutionalized several initiatives to strengthen collaboration and embed an integrated, patient-centered culture. It now holds regular meetings with structured agendas to guarantee transparency, facilitate discussion of complex cases, and ensure systematic patient follow-up, while communication channels between internal clinical teams and external consultants have been streamlined to support fully coordinated treatment planning. Each morning begins with a concise briefing that reviews patient status alongside key organizational priorities; throughout the week, multidisciplinary forums bring pulmonologists, surgeons, and clinical pathologists together to craft unified therapeutic strategies. Professional development is encouraged through monthly educational sessions in which junior doctors present clinical topics, sharpening their communication skills and fostering knowledge exchange. Moreover, seasonal team-building events nurture cooperation and reinforce a cohesive working environment across departments.

Tangible Implementation Results

As part of the VBHC initiative, the oncology center achieved measurable improvements in care delivery, team coordination, and operational capacity. These outcomes validate the applicability of IPU and TDABC models in a real-world Eastern European setting.

Key Achievements

An external call center was implemented, significantly reducing administrative workload. This allowed clinical staff to reallocate time toward patient care, effectively doubling the daily patient flow—from 50 to 100.

While detailed financial figures cannot be disclosed due to institutional confidentiality, the TDABC analysis indicated an approximate 20% reduction in cost utilization across the lung cancer care pathway. This aggregate efficiency gain reflects better resource allocation, reduced administrative workload, and streamlined diagnostics. Taken together, these outcomes suggest that the VBHC model not only improved access and throughput but also generated meaningful cost savings at the system level.

A telemedicine platform is currently under development. This includes educational video resources aimed at empowering patients to manage common treatment side effects and address frequently asked questions.

Infrastructure upgrades are actively progressing. A new hospital wing is under construction to accommodate the increased patient volume and enhance service capacity. Year-over-year growth in patient numbers is illustrated in Supplementary File 6.

Enhanced Interdepartmental Collaboration

Interdepartmental communication has improved through regular meetings within and between departments, including collaborative interactions with other units. Daily morning handovers and multidisciplinary meetings now support proactive coordination and faster decision-making. Monthly internal education sessions have been introduced, strengthening professional development and promoting a collaborative learning culture.

PROMs Integration and Outcome Tracking

More than 100 lung cancer cases have been analyzed to date. Collection of PROMs is ongoing, using validated instruments (EQ-5D-5L and EORTC QLQ-LC13) to capture health-related quality of life and treatment-specific outcomes. A hospital-wide IT system is being optimized to facilitate the collection, storage, and analysis of clinical and patient-reported outcomes.

Patient Education and Safety Enhancements

To enhance patient education, the information booklet has been updated to include detailed treatment plans, potential side effects, and medication interactions. Although the clinical pharmacist is not directly involved in multidisciplinary meetings, they maintain continuous communication with medical oncologists to ensure safe prescribing practices.

The center maintains regular communication with general practitioners and external referring physicians across the country, supporting continuity of care and faster access to specialized services.

Summary of Strategic Focus Areas

Table S3 (TO BE—Strategic recommendations and implementation status) provides an overview of ongoing initiatives, along with strategic recommendations across departments. These reflect the center's commitment to scalable, high-value, and patient-centered care.

Discussion

Pilot Project Demonstration

This pilot project demonstrates that implementing VBHC principles—through IPUs, TDABC, and outcome measurement—is both feasible and impactful in enhancing oncology care within a Bulgarian healthcare context. The expansion of day hospital capacity from 50 to 100 patients represents a meaningful advancement, reflecting the benefits of optimized workflows and more effective staff deployment. To our knowledge, this is one of the first documented VBHC pilots in lung cancer care in a middle-income, Eastern European country, highlighting its novelty and adding a valuable perspective to the global VBHC literature.

Comparison with International Models

The results align with international experiences, such as the Martini Klinik in Germany and integrated cancer centers in the Netherlands, where the application of VBHC principles has led to improved coordination, higher efficiency, and better patient engagement. Similar findings have been reported in other cancer types, where multidisciplinary team (MDT) integration improved survival in colorectal cancer, ¹⁰ colon cancer, ¹¹ esophageal cancer, ¹² and lung cancer. ¹³ This study adds a valuable perspective by demonstrating the adaptability and relevance of the VBHC model within a middle-income, Eastern European healthcare environment.

Contextual Considerations and Limitations

When interpreting the findings, several contextual factors must be kept in mind. Because of institutional confidentiality policies, the financial data generated by the TDABC analysis cannot be disclosed. The study was also confined to lung-cancer care within a single center, which limits the generalizability of its conclusions. Integration of patient-reported outcome measures (PROMs) began in a later phase owing to administrative and licensing requirements, and full-scale data collection is still under way. This manuscript explicitly focuses on the preparatory framework for PROMs integration, rather than presenting patient-level PROM outcomes. These results are currently being collected as part of a separate institutional project and will be reported in future publications. Moreover, departments adopted the new model at different speeds, reflecting variations in clinical complexity and staffing resources. Even with these constraints, the active involvement of a broad spectrum of clinical and operational stakeholders provided balanced insight and ensured robust representation throughout the pilot phase.^14,15

Barriers and Enablers

Successful implementation was supported by committed leadership, clear strategic direction, and the proactive engagement of PROMs champions, particularly clinical psychologists. The use of process mapping, targeted training, and collaborative planning helped address challenges such as system integration, evolving IT infrastructure, and staff workload. These efforts were reinforced by a strong institutional focus on continuous improvement and cross-functional collaboration. ¹⁶

Impact on Patient Experience

The integration of PROMs using EQ-5D-5L and EORTC QLQ-LC13 has enriched the clinical process by incorporating the patient's voice into routine care. These tools support more informed clinical decisions and enhance communication between patients and care teams. In parallel, regular multidisciplinary meetings and more streamlined diagnostics have contributed to smoother care transitions and more responsive service delivery—benefits recognized by both patients and professionals. ¹⁷

Scalability and Future Directions

The oncology center is preparing to broaden its VBHC framework to additional high-priority cancers—specifically breast, prostate, and colorectal malignancies—and has already launched several initiatives to enable this expansion. A new hospital wing is being built to absorb the anticipated rise in patient volumes, while a research and statistics unit is being developed to monitor outcomes rigorously and steer continuous quality improvement. In parallel, the center is investing in a comprehensive digital ecosystem that will unite clinical data through an integrated IT platform and expand access to care via telemedicine. The integrated care model developed for lung cancer has proven to be transferable and adaptable, laying the foundation for sustainable transformation across the organization. ¹⁸

Success will depend not only on infrastructure and tools, but also on sustained clinical leadership, staff training, and a results-oriented culture. The forthcoming research and statistics unit will further institutionalize outcome measurement, support data-driven decision-making, and expand research and training capabilities. ¹⁹

Conclusion

This pilot study demonstrates that implementing VBHC principles in lung cancer care is both feasible and impactful within a middle-income Eastern European healthcare setting. By introducing IPUs, optimizing workflows through TDABC, and initiating systematic outcome measurement using PROMs, the oncology center successfully improved care coordination, operational efficiency, and patient-centeredness.

Key outcomes include a doubling of daily patient capacity, reduced administrative burden through the implementation of an external call center, enhanced interdisciplinary collaboration, and the integration of PROMs into routine practice. These achievements reflect a strong institutional commitment to high-value care and lay the foundation for broader adoption of VBHC models.

Looking ahead, the center plans to expand this approach to additional cancer types, scale digital infrastructure, and launch a research and statistics unit to institutionalize outcome measurement and continuous improvement. These efforts position the center as a regional leader in patient-centered oncology care and demonstrate that strategic, scalable transformation is achievable—even in resource-constrained environments.

Ultimately, this experience offers a replicable model for other institutions seeking to align care delivery with outcomes that matter most to patients, reinforcing the global relevance of VBHC in driving health system evolution.

Abbreviations

IPU

Integrated Practice Unit

VBHC

Value-Based Healthcare

TDABC

Time-Driven Activity-Based Costing

ICHOM

International Consortium for Health Outcomes Measurement

PROMs

Patient-Reported Outcome Measures

EQ-5D-5L

EuroQol 5-Dimension 5-Level Questionnaire

EORTC QLQ-LC13

European Organization for Research and Treatment of Cancer Quality of Life Questionnaire for Lung Cancer 1

Glossary

Integrated Practice Unit (IPU): A care model where a multidisciplinary team treats a specific medical condition to improve outcomes.

Value-Based Healthcare (VBHC): A system focused on maximizing patient outcomes relative to costs.

Time-Driven Activity-Based Costing (TDABC): A method to accurately calculate healthcare costs based on resource use.

International Consortium for Health Outcomes Measurement (ICHOM): An organization standardizing health outcome measurements globally.

Patient-Reported Outcome Measures (PROMs): Patient feedback on health status and treatment impact.

EQ-5D-5L Questionnaire: A tool for assessing health-related quality of life.

EORTC QLQ-LC13: A lung cancer-specific quality of life questionnaire.

Supplemental Material

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Supplemental material, sj-docx-1-jpx-10.1177_23743735251415061 for Advancing Lung Cancer Care in Bulgaria: A Successful Implementation of Value-Based Healthcarе by Yoanna Vutova, Adriana Dacheva, Tsvetelina Angelova, Rositsa Krasteva, Zahari Zahariev and Slaveyko Djambazov in Journal of Patient Experience

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