Clinical And Cost Efficacy Of Immunotherapy As A First Line Of Treatment Of Nonsquamous Metastatic Non-Small-Cell Lung Cancer

The aim of the study was to modelling local data on costs and health benefits of alternative immunotherapies for first-line treatment of patients with non-squamous metastatic non-small cell lung cancer (ncqNSCLS) and to make an indirect comparison of their health cost ratios and benefits based on network meta-analysis. The inputs data for the model were measured and evaluated clinical endpoints in the randomized multicentre clinical trials IM power 130, KEYNOTE 189, and Check Mate 026. Modelling data for future health benefits and costs after the end of clinical trials using Markov model had three health states, one of which is an absorbent condition. Tree Age Pro Healthcare software was used to modelling the data. Atezolizumab in combination with chemotherapy (nab-paclitaxel, carboplatin) is a cost-effective first-line therapy for patients with nsqNSCLC compared to pembrolizumab in combination with chemotherapy (pemetrexed, carboplatin) and nivolumab immunotherapy alone. A probabilistic susceptibility analysis found that the probability of atezolizumab in combination with chemotherapy being a cost-effective therapy compared to pembrolizumab in combination with chemotherapy and compared to nivolumab monotherapy was 88% and 75%, respectively. Modelling data on health benefits and costs after the end of clinical trials creates some uncertainty about therapeutic efficacy and safety in the long-term monitoring

Cost-Effectiveness Analysis Of The Prevention And Treatment Of Cytomegalovirus (CMV) Infections After Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) In Adults

Целта на изследването е да се представи моделиране на локални данни за разходи и здравни ползи на алтернативните антивирусни терапии за профилактика и лечение на цитомегаловирус (CMV) - серопозитивни пациенти след алогенна трансплантация на хемопоетични стволови клетки (HSCT) и да се реализира косвено сравнение, базирано на мрежов метаанализ. Входящи данни в мо- дела са измерените и оценени клинични крайни точки в рандомизираното многоцентрово клинично изпитване МК-8228-001. Моделирането на данните за бъдещи здравни ползи и разходи след края на клиничните изпитвания е проведено чрез модел на Марков с 6 здравни и 1 абсорбиращо състояние. В модела са включени всички възможни здравни състояния, отразяващи хода на заболяването, и са предвидени всички вероятности за преход от едно здравно състояние в друго. Входящите данни в модела са първичните и вторичните крайни точки в рандомизираното клинично изпитвани МК- 8228-001 - клинично значима CMV инфекция на седмица 12-а и 24-та, превантивна терапия за CMV виремия и крайни органни заболявания, свързани с CMV. Времевият хоризонт на модела е до живот. Разходите и ползите са дисконтирани с 5% годишно. Избраната перспектива е гледната точка на третата страна платец.Заключението от проведените оценки е, че letermovir доминира valganciclovir с подобрена тера- певтична ефикасност и по-нисък разход за курс на лечение на CMV-серопозитивните пациенти след HSCT.The aim of the study was to model the local data on the costs and health benefits of alternative antiviral therapies for the prevention and treatment of CMV seropositive patients after HSCT and to perform an indirect comparison based on meta-analysis. Input data in the model are the measured and evaluated clinical endpoints in the randomized multicentre clinical trial MK-8228-001. The modeling of the data for future health benefits and costs after the end of the clinical trials was conducted using a Markov model with 6 health conditions and 1 absorbent state. The model includes all possible health conditions reflecting the course of the disease and all the probabilities of transition from one health condition to another are envisaged. Input data in the model are the primary and secondary endpoints in the randomized clinical trial MK-8228-001 - clinically significant CMV infection at weeks 12 and 24, preemptive therapy for CMV viremia and CMV-related terminal organ diseases.The time horizon of the model is lifelong. Costs and benefits are discounted at 5% per annum. The perspective chosen is the point of view of the third party payer. The conclusion of the evaluations is that letermovir dominates valganciclovir with improved therapeutic efficacy and lower cost of treatment for cytomegalovirus-seropositive patients after allogeneic hematopoietic stem cell transplantation

Health technology assessment of Ixekizumab for treatment of plaque psoriasis in Bulgaria

Целта на изследването е чрез анализ на публикувани данни от оценки на здравни технологии за лечение на плакатен псориазис (ПП), проведени в други страни, да се моделират разходите и здравните ползи на ixekizumab в сравнение с терапевтичните алтернативи, използвани в българската клинична практика. Косвеното сравнение чрез мрежов метаанализ включва ixekizumab, secukinumab, ustekinumab, adalimumab, etanercept, infliximab. Използваният икономически анализ е разход-полезност. Проучването стига до извода, че Ixekizumab е разходно ефективна терапия за лечение на пациенти с плакатен псориазис, след неуспех със стандартна терапия в България, в сравнение с ustekinumab, adalimumab и infliximab.The aim of the study is to analyze the published data from health technology assessments for the treatment of plaque psoriasis (PS) conducted in other countries to model the costs and health benefits of ixekizumab compared to the therapeutic alternatives used in Bulgarian clinical practice. Indirect comparison through network meta-analysis includes ixekizumab, secukinumab, ustekinumab, adalimumab, etanercept, infliximab. The economic analysis used is cost-utility. The study concludes that Ixekizumab is a cost-effective treatment for patients with plaque psoriasis after failure with standard therapy in Bulgaria compared to ustekinumab, adalimumab and infliximab

Enfortumab vedotin for the treatment of patients with urothelial cancer after failure of the treatment with PD-1/PD-L1 inhibitor—cost-effectiveness analysis

Introduction: Bladder cancer (BC) is one of the most common malignancies in industrialized countries. The incidence of BC increases with age and is almost 3 times more common in men than in women. The therapy in adult patients with locally advanced or metastatic BC who have previously received chemotherapy containing platinum and a PD-1/PD-L1 inhibitor requires the inclusion of enfortumab vedotin (EV) or docetaxel- or paclitaxel-based chemotherapy.Aim: The aim of the study is to model local data on long-term costs and health benefits from the application of alternative health technologies for the treatment of patients with BC to decide which therapy has an advantage in terms of the ratio of therapeutic efficacy and cost-effectiveness.Materials and Methods: Inputs in the prognostic model used were measured and evaluated as clinical endpoints in the EV-301 multicentre randomized clinical trial. The modelled data on future health benefits and costs after the end of the clinical trial are based on Markov’s model with three health conditions, one of which is absorbent.Conclusion: Despite therapeutic superiority of enfortumab vedotin over chemotherapy (docetaxel, paclitaxel), it is not a cost-effective approach to treat patients with urothelial carcinoma after failure with PD-1/PD-L1 inhibitors. The only reason for this is its high price. The value of the cost-benefit ratio of enfortumab vedotin is around BGN 659,000/QALY and significantly exceeds the cost-effectiveness threshold (ICER ≤ BGN 50,000/QALY), which is equal to three times the gross domestic product per capita of the population in Bulgaria for the previous year

DINAMICA PIEȚEI FORȚEI DE MUNCĂ ÎN BULGARIA

BACKGROUND. Bulgaria, as many countries in the world is experiencing a critical period for the health workforce. The shortage of qualified nurses is one of the biggest obstacles for improving the health-system performance. Lack of strategic planning based on profound market research and elaboration of scientifically based prognosis further deteriorate the current nursing labor market disequilibrium. THE AIM of the study is to explore the main factors influencing the nursing market disequilibrium in Bulgaria and to make an evidence-based forecast of the future needs for nurses in order to suggest relevant workforce development strategies. MATERIAL AND METHODS. The study employs a combination of sociological and statistical methods. The analysis is based on the official statistical data on Bulgarian nursing personnel up to 2012. Primary information is collected through self-administered questionnaires distributed among 337 practicing nurses from April 2007 to December 2012. Data are processed with the packages MS Office Excel 2010 and SPSS v. 13. RESULTS. Results indicate that a decrease in the demand for nursing labour caused large staff layoffs during the first stage of the restructuring period (1990-2000) followed by a severe drop in the number of nurses due to emigration and exodus from the profession. There are also educational and qualification problems along with unattractiveness of the nursing practice due to high workload and low remuneration. With the mean age of 49 severe nursing workforce’s deficit is expected in 10-15 years due to retirement. According to our estimations the deficit of nurses will account for 3162 specialists by 2030. CONCLUSION. The Bulgarian nursing labor market disequilibrium is due to long-term structural imbalances. As the market mechanism is unable to attain equilibrium Bulgarian government should be urgently involved in workforce planning and initiate actions and strategies for producing and retaining the highly qualified nurse professionals in Bulgaria.   Key words: nursing workforce market, Bulgaria, disequilibrium, factors.  CONTEXT. Similar multor state, Bulgaria traversează, de asemenea, o perioadă critică în ceea ce privește piața forței de muncă din sănătate. Lipsa de asistente medicale calificate este unul dintre cele mai mari obstacole pentru îmbunătățirea performanței sistemului de sănătate. Lipsa planificării strategice bazată pe cercetare amănunțită a pieței și lipsa prognozelor și proiecțiilor bazate pe argumente științifice conduc la dezechilibrul existent pe piața muncii asistentelor medicale, existent la momentul actual. SCOPUL studiului este de a explora factorii principali care influențează dezechilibrul de pe piața muncii asistentelor medicale în Bulgaria și de a face prognoze, bazate pe dovezi, ale nevoilor viitoare de asistente medicale, în scopul de a sugera strategii viitoare de dezvoltare a forței de muncă. MATERIAL ȘI METODE. Studiul  de față abordează o combinație de metode sociologice și statistice.  Analiza are la bază date statistice oficiale privind personalul medical din Bulgaria, date disponibile inclusiv pentru anul 2012. Informatiile primare au fost colectate cu ajutorul unor chestionare auto-administrate, distribuite unui număr de 337 asistente medicale practicante, în perioada aprilie 2007 - decembrie 2012. Datele sunt prelucrate cu pachetele de analiză MS Office Excel 2010 și SPSS v. 13. REZULTATE. Rezultatele indică faptul că scăderea cererii pentru asistentele medicale a cauzat  disponibilizările masive din timpul primei etape a perioadei de restructurare 1990-2000, urmată de o scădere severă a numărului de asistente medicale din cauza emigrării și exodul profesional. Există probleme educațiomale și de calificare, alături de lipsa de atractivitate a practicii de asistentă medicală din cauza volumului mare de muncă și a nivelului redus de salarizare. Cu o medie crescută a vârstei asistentelor medicale, de 49 de ani,  un deficit sever este așteptat în următorii 10+15 ani, din cauza fenomenului de pensionare. Conform estimărilor noastre, deficitul de asistente medicale, până în anul 2030, va fi de 3162 de specialiști. CONCLUZII. Dezechilibrul numeric de asistente medicale de pe piața forței de muncă din sănătate este cauza unor dezechilibre structurale pe termen lung. Cum mecanismul piaței nu este în măsură să rezolve acest dezechilibru, guvernul din Bulgaria va trebui urgent să  se implice în planificarea forței de muncă și să inițieze acțiuni și strategii de creare și menținere a asistentelor medicale calificate, în Bulgaria.  Cuvinte cheie: piața forței de muncă, asistente medicale, dezechilibru, factori frenatori, Bulgaria &nbsp

Global Retinoblastoma Presentation and Analysis by National Income Level.

Importance: Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale. Objectives: To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis. Design, Setting, and Participants: A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017. Main Outcomes and Measures: Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis. Results: The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 [95% CI, 4.30-7.68]). Conclusions and Relevance: This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs

Travel burden and clinical presentation of retinoblastoma: analysis of 1024 patients from 43 African countries and 518 patients from 40 European countries

BACKGROUND: The travel distance from home to a treatment centre, which may impact the stage at diagnosis, has not been investigated for retinoblastoma, the most common childhood eye cancer. We aimed to investigate the travel burden and its impact on clinical presentation in a large sample of patients with retinoblastoma from Africa and Europe. METHODS: A cross-sectional analysis including 518 treatment-naïve patients with retinoblastoma residing in 40 European countries and 1024 treatment-naïve patients with retinoblastoma residing in 43 African countries. RESULTS: Capture rate was 42.2% of expected patients from Africa and 108.8% from Europe. African patients were older (95% CI -12.4 to -5.4, p<0.001), had fewer cases of familial retinoblastoma (95% CI 2.0 to 5.3, p<0.001) and presented with more advanced disease (95% CI 6.0 to 9.8, p<0.001); 43.4% and 15.4% of Africans had extraocular retinoblastoma and distant metastasis at the time of diagnosis, respectively, compared to 2.9% and 1.0% of the Europeans. To reach a retinoblastoma centre, European patients travelled 421.8 km compared to Africans who travelled 185.7 km (p<0.001). On regression analysis, lower-national income level, African residence and older age (p<0.001), but not travel distance (p=0.19), were risk factors for advanced disease. CONCLUSIONS: Fewer than half the expected number of patients with retinoblastoma presented to African referral centres in 2017, suggesting poor awareness or other barriers to access. Despite the relatively shorter distance travelled by African patients, they presented with later-stage disease. Health education about retinoblastoma is needed for carers and health workers in Africa in order to increase capture rate and promote early referral

The global retinoblastoma outcome study : a prospective, cluster-based analysis of 4064 patients from 149 countries

DATA SHARING : The study data will become available online once all analyses are complete.BACKGROUND : Retinoblastoma is the most common intraocular cancer worldwide. There is some evidence to suggest that major differences exist in treatment outcomes for children with retinoblastoma from different regions, but these differences have not been assessed on a global scale. We aimed to report 3-year outcomes for children with retinoblastoma globally and to investigate factors associated with survival. METHODS : We did a prospective cluster-based analysis of treatment-naive patients with retinoblastoma who were diagnosed between Jan 1, 2017, and Dec 31, 2017, then treated and followed up for 3 years. Patients were recruited from 260 specialised treatment centres worldwide. Data were obtained from participating centres on primary and additional treatments, duration of follow-up, metastasis, eye globe salvage, and survival outcome. We analysed time to death and time to enucleation with Cox regression models. FINDINGS : The cohort included 4064 children from 149 countries. The median age at diagnosis was 23·2 months (IQR 11·0–36·5). Extraocular tumour spread (cT4 of the cTNMH classification) at diagnosis was reported in five (0·8%) of 636 children from high-income countries, 55 (5·4%) of 1027 children from upper-middle-income countries, 342 (19·7%) of 1738 children from lower-middle-income countries, and 196 (42·9%) of 457 children from low-income countries. Enucleation surgery was available for all children and intravenous chemotherapy was available for 4014 (98·8%) of 4064 children. The 3-year survival rate was 99·5% (95% CI 98·8–100·0) for children from high-income countries, 91·2% (89·5–93·0) for children from upper-middle-income countries, 80·3% (78·3–82·3) for children from lower-middle-income countries, and 57·3% (52·1-63·0) for children from low-income countries. On analysis, independent factors for worse survival were residence in low-income countries compared to high-income countries (hazard ratio 16·67; 95% CI 4·76–50·00), cT4 advanced tumour compared to cT1 (8·98; 4·44–18·18), and older age at diagnosis in children up to 3 years (1·38 per year; 1·23–1·56). For children aged 3–7 years, the mortality risk decreased slightly (p=0·0104 for the change in slope). INTERPRETATION : This study, estimated to include approximately half of all new retinoblastoma cases worldwide in 2017, shows profound inequity in survival of children depending on the national income level of their country of residence. In high-income countries, death from retinoblastoma is rare, whereas in low-income countries estimated 3-year survival is just over 50%. Although essential treatments are available in nearly all countries, early diagnosis and treatment in low-income countries are key to improving survival outcomes.The Queen Elizabeth Diamond Jubilee Trust and the Wellcome Trust.https://www.thelancet.com/journals/langlo/homeam2023Paediatrics and Child Healt

CEREREA INDUSĂ LA NIVELUL SERVICIILOR SPITALICEŞTI DIN BULGARIA – TENDINŢE ACTUALE ŞI FACTORI

Background.   The aim of this paper is to explore the trends of hospitalization and to analyse the main determining factors for over-hospitalization.Methods. The analysis is based on the Annual financial reports of the National Health Insurance Fund (NHIF) in Bulgaria, the Annuals of Public Health Statistics published by the National Centre of Health Informatics, and corresponding data for European countries the European Health for All Database for the period 2000-2009.Results.   Conclusion. The main reasons for the enormous increase in hospital admissions have been mainly related to the increased induced demands for hospital services, ineffective referrals and treatment of chronic diseases in hospitals for acute diseases, patients’ mistrust to outpatient care, low efficiency of primary health care, inadequate supervision and regulation by the National Health Insurance Fund. Improper and ineffective health policy and hospital management led to consumerist attitudes in health care that contribute more to health care providers than to the patients in need.Key words: over-hospitalization, induced demand, hospital services cost, hospital management.For a period of ten years, the expenditures for hospital services have increased by 390% while the GDP has grown in real terms only by 47%. The number of hospital admissions since 2004 to 2009 has increased more than twice (from 738 978 to 1 769 230). The critical point of increase was observed between 2005 and 2006 when all the financing of hospital services was totally undertaken by the NHIF.Changing the management and financing in Bulgarian health care system after 2000 led to many new problems in organization and management of medical activities, especially in hospital care, after the adoption of the Health Care Establishments Act in 1999. Serious problems in hospital care occurred in relation to the induced demands for hospital services which contribute to over-hospitalization and overexpenditures.Context.&nbsp;&nbsp;&nbsp;Scopul&nbsp;&nbsp;&nbsp;Metode.&nbsp;&nbsp;&nbsp;Rezultate.&nbsp;&nbsp;&nbsp;Concluzii.&nbsp;&nbsp;&nbsp;Cuvinte cheie:&nbsp;&nbsp;&nbsp;supra-spitalizare, cerere indusă, cost, servicii spitaliceşti, managementspitalicescPrincipalele motive ale creşterii enorme a numărului de internări a fost legat, &icirc;n principal, de creşterea cererii induse pentru serviciile spitaliceşti, trimiteri ineficiente şi tratarea afecţiunilor cornice &icirc;n spitale pentru acuţi, ne&icirc;ncrederea pacienţilor &icirc;n calitatea &icirc;ngrijirilor ambulatorii, eficienţă scăzută a asistenţei primare, supraveghere şi reglementare necorespunzătoare din partea NHIF. Politică de sănătate şi management spitalicesc neadecvate şi ineficiente orientate mai mult spre furnizorii de servicii medicale şi mai puţin spre nevoile pacienţilor.&Icirc;n perioada analizată (zece ani), cheltuielile serviciilor spitaliceşti au crescut p&acirc;nă la 390%, &icirc;n timp ce PIB-ul a crescut, &icirc;n valoare reală, cu doar 47%. Numărul de internări a crescut de peste 2 ori (de la 738 978 &icirc;n anul 2000, la 1 769 230 &icirc;n anul 2009). Punctul critic al creşterii a fost observat &icirc;n perioada 2005-2006, c&acirc;nd &icirc;ntreaga finanţare a serviciilor spitaliceşti a fost preluată de către NHIF.Analiza este bazată pe rapoartele anuale financiare ale Casei Naţionale de Asigurări de Sănătate (NHIF) din Bulgaria, pe statisticile anuale de sănătate publică publicate de către Centrul Naţional de Informatică &icirc;n Sănătate, şi pe date corespondente pentru ţările europene colectate din baza de date Health for All, la nivelul anilor 2000-2009.acestui articol este de a explora tendinţa evolutivă a spitalizărilor şi de a analiza principalii factori determinanţi ai supra-spitalizării.Schimbarea management-ului şi finanţării sistemului de sănătate din Bulgaria, după anul 2000, a condus la apariţia a noi probleme &icirc;n organizarea şi managementul activităţii medicale, &icirc;n special &icirc;n ceea ce priveşte &icirc;mgrijirile spitaliceşti, probleme ce au apărut după adoptarea Legii Unităţilor Medicale, &icirc;n anul 1999. Probleme serioase privind serviciile spitaliceşti au apărut &icirc;n legătură cu cererea indusă pentru serviciile spitaliceşti care contribuie la supra-spitalizare şi cheltuieli suplimentare

OPINIA PACIENTILOR SI A MEDICILOR ASUPRA REFORMEI INGRIJIRILOR DE SANATATE DIN BULGARIA

BACKGROUND. Bulgarian health system is undergoing fundamental organizational changes started since 1998 with the adoption of three new fundamental laws - Health Insurance Act (1998), Health Care Establishments Act (1999) and Law for professional organizations of physicians and dentists (1998). The new legislation laid the foundations of radical transformation of financing and delivery of health services to the population with introduction of market mechanisms for resource management. The aim of this paper is to analyse the acceptance and critical evaluation of Bulgarian health reform based on patients’ and physicians’ opinion.METHODS. The study was carried out in 2010 in 9 randomly selected urban regional centres. From 18 outpatient medical centres and 11 hospitals the samples of 1863 patients and 718 physicians were chosen by convenience. The data were collected by self-administered questionnaire of 26 open-ended questions encompassing identification data, questions about awareness, expectations, acceptance and satisfaction with different aspects of health reform.RESULTS. Significant differences in responses concerning the information and awareness on main aspects of health reform were found in favour of physicians and low level of knowledge for patients. Both groups demonstrated unrealistic and maximalist over expectations for rapid and large increase in the quality of medical services significantly higher in the group of physicians except for the physicians’ wages. Much lower were the expectations about the negative effects that really occurred during the process of reform.Conclusions. Significant unawareness on various aspects of reform was demonstrated among respondents more explicit in the group of patients. The phenomenon of information asymmetry is the leading factor for the failure of health reform and serious changes should be undertaken to increase the public and professional acceptance and satisfaction of the health reform.Keywords: Bulgaria, healthcare reform, patients’ opinion, physicians’opinion, information asymmetryCONTEXT. Sistemul bulgar de sanatate trece prin schimbari organizationale fundamentale, care au inceput in anul 1998, odata cu adoptarea a trei legi noi esentiale – Legea Asigurarilor de Sanatate (1998), Legea Unitatilor de Ingrijiri de Sanatate (1999) si Legea organizatiilor profesionale ale medicilor si ale medicilor dentisti (1998). Noua legislatie a cladit temelia transformarii radicale a finantarii si a furnizarii serviciilor de sanatate catre populatie, cu introducerea mecanismelor de piata pentru managementul resurselor.  SCOPUL acestui articol este sa analizeze nivelul de acceptare si sa evalueze critic reforma sanitara din Bulgaria, pe baza opiniei pacientilor si a medicilor. METODE. Studiul s-a desfasurat in 2010 in 9 centre regionale urbane selectate aleator. Au fost selectate esantioane nereprezentative de 1863 pacienti si 718 medici din 18 centre medicale ambulatorii si din 11 spitale.  COLECTAREA DATELOR s-a facut cu ajutorul unui chestionar auto-administrat cu 26 intrebari deschise cuprinzand date de identificare, intrebari despre constientizarea, asteptarile, acceptarea si satisfactia fata de diferitele aspecte ale reformei sanitare. REZULTATE. Au rezultat diferente semnificative la raspunsurile referitoare la informatii si la cunoasterea principalelor aspecte ale reformei din sanatate, si un nivel scazut de cunostinte la pacienti. Ambele grupuri au manifestat asteptari nerealiste si maximaliste pentru cresterea consistenta si rapida a calitatii serviciilor medicale, semnificativ mai ridicate in randul grupului de medici, cu exceptia subiectului salariilor acestora. Asteptarile privind efectele negative care au intervenit realmente in timpul procesului de reforma au fost mult mai scazute. CONCLUZII. S-a constatat un nivel semnificativ de necunoastere a diferitelor aspecte ale reformei in randul respondentilor, mai explicit in grupul pacientilor. Intrucat fenomenul asimetriei informationale reprezinta principalul factor al esecului reformei sanitare, ar trebui facute schimbari serioase pentru cresterea nivelului de acceptare publica si profesionala si a satisfactiei fata de reforma din sanatate.  Cuvinte cheie: Bulgaria, reforma ingrijirilor de sanatate, opinia pacientilor, opinia medicilor, asimetrie informational