Reimbursement of Coagulation Medications in Latvia in 2014

Reimbursement of Coagulation Medications in Latvia in 2014 Latvia Hemophilia Society (LHB) 20.02.2015., translated from Latvian on 07.03.2015.

Summary on year 2014

Hemophilia A

Hemophilia B

Von Willebrand

disease (VWD)

FACTOR VII deficiency

ACQUIRED hemophilia

FACTOR XII deficiency

Thalasse-mia Beta

Number of patients 129 26 120 5 1 1 1

Number of unique patients that received reimbursed treatment (from KZS) 64 11 41 0 (1) 0 0 Number of treatment options at reimbursed list 5 2 1 1 2 0 0 Reimbursement spending, EUR 1,515,545 1,217,778 10,990 - - - - From that, for inhibitor treatment, % 31% 84% 0% 0% 100% 0% 0% Clotting FACTOR Concentrate (CFC) Consumption, IU 4 207 750 617 000 0 0 NA 0 NA CFC use, IU per capita 2.12 0.31 NA 0 NA NA NA CFC use per patient at KZS, IU per patient 65 746 56 091 NA 0 NA NA NA CFC use per patient at LHB, IU per patient 32 618 23 731 NA 0 NA NA NA

2

General data Spending on reimbursed treatments

3

Reimbursement of purchase costs of medications and medical devices made under general procedure (KZS* A, B and C list), 2005-2014*KZS – Kompensējamo zāļu saraksts – List of reimbursed medicines

Source: NVD KZS statistics

M EUR

43.03

62.75

90.04

109.82 102.08 105.09

116.26 114.22 116.21 118.93

0.00

20.00

40.00

60.00

80.00

100.00

120.00

140.00

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

4

Reimbursement of purchase costs of tretment for diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (group B), 2005-2014


M EUR

0.76 0.77 0.95

1.79 1.71

2.00 1.82

2.26

2.66 2.86

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

5

About Reimbursement list (KZS) ¡  Executed accordingly to the Regulations No.899 “Procedure of the compensation of

procurement of medications and medical devices meant for outpatient treatment” of 31 October 2006

¡  The main goal to ensure compensation of the expenditures of medicines and medical devices meant for the outpatient treatment due to a diagnosis of patient’s disease. Consists of: ¡  List A – medications with equal therapeutic efficacy (NVD pays for the cheapest – reference drug only) ¡  List B – medications that do not have substitutes with equal therapeutic efficacy ¡  List C – medications that cost more than 4268,62 EUR per patient a year and pharmaceutical

company covers expenses for particular number of patients ¡  NVD reimburses 100%, 75% or 50% of treatment costs depending on diagnosis

¡  LHB comment: although all bleeding disorders are said to be reimbursed 100%, since 2009, when plasma factor concentrates were illegally moved from List B to List A, NVD pays only the reference price (which is Dried factor for adults and Recombinate for children with hemophilia A and Replenine-VF for hemophilia B), since all factors are meant to stop bleeding and all are infused i/v, they are considered identical. To include factors in List B, where the hematologist would be the authority to choose most appropriate for the patient, significant benefit of the other factor concentrate should be proven (such as less bleeding episodes, cost of treatment, any). In reality, patients have just one treatment option, which is dangerous: there have been numerous cases when factors were not available to patients due to inability to deliver them to drugstores in time and no mechanism to substitute with another is in place

6

Spending on reimbursement for treatment of coagulation

disorders Total spending

Spending by companies Spending by medicines

7

Reimbursement of purchase costs of blood coagulation disorders treatment, 2005-2014


M EUR

0.72 0.73 0.88

1.68 1.56

1.90 1.77

2.16

2.59 2.74

-

0.50

1.00

1.50

2.00

2.50

3.00

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

8

Spending on reimbursement of blood coagulation disorders treatment, 2005-2014: by companies


EUR

833,199 813,117 1,093,966

1,355,895 1,399,623

437,148 425,207

521,584

460,912 468,242 621,532 518,300

532,678

623,024 739,764

- -

-

136,272 123,404

9,805 9,091

9,354

12,779 13,279

-

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

2010 2011 2012 2013 2014

Ferring

Octapharma

BTS

Baxter

NovoNordisk

9

Spending on reimbursement of blood coagulation disorders treatment, 2005-2014: by companies, market shares


%

43.8% 46.1% 50.7% 52.4% 51.0%

23.0% 24.1%

24.2% 17.8% 17.1%

32.7% 29.4% 24.7% 24.1% 27.0%

0.0% 0.0% 0.0% 5.3% 4.5% 0.5% 0.5% 0.4% 0.5% 0.5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010 2011 2012 2013 2014

Ferring

Octapharma

BTS

Baxter

NovoNordisk

10

Spending on reimbursement of blood coagulation disorders treatment, 2005-2014: by diagnoses


EUR

621,319 611,132 687,664

984,795 1,033,584

1,334,633

1,221,683 1,246,018

1,364,279

1,515,545

99,247 113,195 187,218

690,063

516,115 560,560 536,622

904,094

1,210,472 1,217,778

3,353 7,322 7,082 9,270 10,666 6,492 7,409 7,470 11,433 10,990 2,697 0 -

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Hemophilia A Hemophilia B VWD FVII

11

55% of spending in 2014 went to hemophilia A treatment, but 44% - to treatment of hemophilia B. Spending on hemophilia A grew faster than that of hemophilia B


85.8% 83.5% 78.0%

58.5% 66.2% 70.2% 69.2%

57.8% 52.7% 55.2%

13.7% 15.5% 21.2%

41.0% 33.1% 29.5% 30.4%

41.9% 46.8% 44.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

FVII

VWD

Hemophilia B

Hemophilia A

12

About treatment options ¡  Hemophilia A is treated with:

¡  Plasma Factor VIII concentrates – Dried Factor Fraction 8Y by BPL (before – also Human by Kedrion and Immunate by Baxter)

¡  Recombinate Factor VIII concentrates – Recombinate by Baxter ¡  Desmopressin (DDAVP) for mild hemophilia A – Octostim by Ferring

¡  Hemophilia B is treated with: ¡  Plasma Factor IX concentrates – Replenine-VF by BPL (before – also Octanine by Octapharma

and Immunine by Baxter)

¡  Hemophilia A and B with inhibitors are treated with: ¡  Special medicines – NovoSeven by Novo Nordisk and FEIBA by Baxter (KZS C list – needs

special authorization from medical consilium)

¡  Von Willebran disease (VWD) is treated with: ¡  Desmopressin (DDAVP) – Octostim by Ferring ¡  No von Willebrand factor (VWF) or Factor VIII are available to patients with VWD. Tranaxemic

acid is also not reimbursed for patients in Latvia

¡  Factor VII deficiency is treated with: ¡  Factor VII concentrate by Baxter Source: Hemofilijas aprūpes un ārstēšanas vadlīnijas,

KZS Izrakstīšanas noteikumi

13

Reimbursement list spending on various types of drugs, 2010-2014, EUR and % of total spending on treatment for bleeding disorders

EUR 2010 2011 2012 2013 2014 Inhibitors 921,600 939,125 1,093,966 1,499,906 1,489,628 FVIII 754,824 712,700 970,115 903,822 1,040,796 FVIII 754,824 712,700 828,220 589,618 662,560 rFVIII - - 141,895 314,204 378,236 FIX 215,456 104,799 84,147 169,678 200,609 DDAVP 9,805 9,091 9,354 12,779 13,279 FVII - - - 2,697 -

1,901,685 1,765,715 2,157,582 2,588,882 2,744,312

Inhibitors 48% 53% 51% 58% 54% FVIII 40% 40% 45% 35% 38% FVIII 40% 40% 38% 23% 24% rFVIII 0% 0% 7% 12% 14% FIX 11% 6% 4% 7% 7% DDAVP 1% 1% 0% 0% 0% FVII 0% 0% 0% 0% 0%


14


Total budget division by medication types, 2010-2014: amount and dynamics

EUR

-

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

2010 2011 2012 2013 2014

FVII DDAVP FIX rFVIII FVIII Inhibitors

15


Total budget division by medication types, 2010-2014, proportions

%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010 2011 2012 2013 2014

FVII DDAVP FIX rFVIII FVIII Inhibitors

16

Dynamics of amounts of consumed factor concentrates in Latvia, 2010-2014, IU

IU

3619500 3541500

3979750 3811750

4207750

3516750

2788500 3000250

0 0

463000

1023250 1207500

494400

164500 357700 460500

617000

0 0 0 5400 0 0

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

4500000

2010 2011 2012 2013 2014

FVIII, total FVIII rFVIII FIX FVII


17

FVIII per capita consumption in Latvia has exceeded 2IU pc. Consumption of FIX has also considerably grew in 2014.Since numbers of patients significantly differs among sources (KZS and LHB), there are considerable differences in per patient use of factors

IU 2010 2011 2012 2013 2014 FVIII, total 3619500 3541500 3979750 3811750 4207750 FVIII 3619500 3541500 3516750 2788500 3000250 rFVIII 0 0 463000 1023250 1207500 FIX 494400 164500 357700 460500 617000 FVII 0 0 0 5400 0 FVIII IU per capita 1.71 1.71 1.95 1.88 2.12 FIX IU per capita 0.23 0.08 0.17 0.23 0.31

FVIII IU per patient @KZS 46,404 52,081 65,242 66,873 65,746 FIX IU per patient @KZS 41,200 12,654 32,518 35,423 56,091

FVIII IU per patient @LHB 25,854 30,013 32,890 29,321 32,618 FIX IU per patient @LHB 19,776 6,580 14,308 17,056 23,731

Source: NVD KZS, CSB statistics

*KZS and LHB have different numbers of patients in Latvia, see at each diagnosis

18

Dat

a fo

r com

paris

on:

FVIII

and

FIX

per

cap

ita

cons

umpt

ion

in E

urop

e

Source: WFH Global Survey 2013

19

Data for comparison: according to World Bank data, Latvia belongs to High GDP per capita group (A), so the mean FVIII consumption should be 4.35 IU per capita and 84 333 IU per patient

Average FVIII per capita consumption in the world

Average FVIII per patient consumption in the world

Source: WFH Global Survey 2013

20

Reimbursements of particular medicines, 2010-2014, EUR

2010 2011 2012 2013 2014

Inhibitors NovoSeven 833,199 813,117 1,093,966 1,355,895 1,399,623

Inhibitors FEIBA 88,400 126,008 - 144,011 90,006

FVIII Immunate 133,292 264,622 377,995 - -

FVIII Dried 621,532 383,363 227,933 351,930 653,493

FVIII Human - 64,715 222,292 237,688 9,067

rFVIII Recombinate - - 141,895 314,204 378,236

FIX Immunine 215,456 34,577 1,694 - -

FIX Replenine - 70,222 82,453 33,406 77,205

FIX Octanine - - - 136,272 123,404

DDAVP Octostim 9,805 9,091 9,354 12,779 13,279

FVII Factor VII - - - 2,697 -

KOPĀ 1,901,685 1,765,715 2,157,582 2,588,882 1,399,623


21

Proportions of budget spending on various medicines, 2010-2014, % of all spending for bleeding disorders

2010 2011 2012 2013 2014 Inhibitors NovoSeven 43.8% 46.1% 50.7% 52.4% 51.0%

Inhibitors FEIBA 4.6% 7.1% 0.0% 5.6% 3.3%

FVIII Immunate 7.0% 15.0% 17.5% 0.0% 0.0%

FVIII Dried 32.7% 21.7% 10.6% 13.6% 23.8%

FVIII Human 0.0% 3.7% 10.3% 9.2% 0.3%

rFVIII Recombinate 0.0% 0.0% 6.6% 12.1% 13.8%

FIX Immunine 11.3% 2.0% 0.1% 0.0% 0.0%

FIX Replenine 0.0% 4.0% 3.8% 1.3% 2.8%

FIX Octanine 0.0% 0.0% 0.0% 5.3% 4.5%

DDAVP Octostim 0.5% 0.5% 0.4% 0.5% 0.5%

FVII Factor VII 0.0% 0.0% 0.0% 0.1% 0.0%

TOTAL 100% 100% 100% 100% 100%


22


EUR

-

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

2010 2011 2012 2013 2014

Factor VII Octostim Octanine Replenine Immunine Recombinate Human Dried Immunate FEIBA NovoSeven

23 Budget division by medicines brand names, 2010-2014 (amount)

Budget division by medicines brand names, 2010-2014 (proportions)


%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010 2011 2012 2013 2014

Factor VII Octostim Octanine Replenine Immunine Recombinate Human Dried Immunate FEIBA NovoSeven

24

Hemophilia A D66

25

Out of 129 knewn patients, only 64 or 50% receive reimbursed treatment: slightly more than in 2013, but still less than in 2010

¡  1-3 children with hemophilia A are born annually in Latvia ¡  In 2014, one case of acquired hemophilia (D68.4) was found, but NVD

statistics lack data on reimbursement of Novo Seven (which is opposite to real situation)

¡  After repeated problems with access to factors, many patients joined clinical research in 2012/2013, which provides unlimited amounts of factor

¡  Several families have left Latvia in recent years – due to economic conditions and because they cannot get appropriate treatment here

Source: LHB and NVD KZS statistics

91 103 104 107 115

140 118 121 130 129

78 68 61 57 64

2 2 2 2 2 2 2 2 2

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Pacientu skaits @LHB Pacientu skaits @KZS ar inhibitoriem

26

Number of patients @LHB

Number of patients @KZS

Number of patients with inhibitors

Spending on hemophilia A treatment in 2014 exceeded 1.5M EUR; it was possible to buy more FVIII, but it is still too little to reach EDQM minimum of 3IU per capita. Children have to discontinue treatment with recombinant factor when reaching adult age (18 years)


EUR

621,319 611,132

687,664

984,795 1,033,584

1,334,633 1,221,683 1,246,018

1,364,279

1,515,545

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

27


321 287 270 274 247 251

211 220 192 204

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Number of prescriptions

1,936 2,129 2,547 3,594 4,185

5,317 5,790 5,664 7,106 7,429

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Average prescription value, EUR

28 Number of prescriptions and value

Children receive rFVIII (Recombinate Baxter, 1st generation recombinant factor) since 2012. Kedrion stopped fractionation of Latvian plasma and production of Human factor in early 2014, not available to patients since February. Brand name of “Dried Factor VIII Fraction Type 8Y” has been changed to “Faktora VIII sausā frakcija tips 8Y” (same name, in Latvian)


EUR

-

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

2010 2011 2012 2013 2014

DDAVP Octostim

rFVIII Recombinate

FVIII Human

FVIII Dried

FVIII Immunate

Inhibitors FEIBA

Inhibitors NovoSeven

29

Slightly decreased proportion for inhibitor treatment (-3pp). Slightly increased proportion of spending on recombinant factor concentrates (+2pp). All other spending – 44% - on plasma factor concentrates


%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010 2011 2012 2013 2014

DDAVP Octostim

rFVIII Recombinate

FVIII Human

FVIII Dried

FVIII Immunate

Inhibitors FEIBA


30

Hemophilia B D67

31

Only 11 of 26 known patients with hemophilia B receives reimbursed treatment

¡  On average, 1 child with hemophilia B is born in Latvia every 2-3 years

¡  The number of unique patients in NVD statistics implies that less than half of all people that have been diagnosed with hemophilia B in Latvia receives reimbursed treatment

¡  There have not been new inhibitor cases in past years, 2 patients with inhibitors since 2008

Source: LHB un NVD KZS statistics

17 20 20 20

24 25 25 25 27 26

12 13 11

13 11

1 1 2 2 2 2 2 2 2

2005 2006 2007 2008 2009 2010 2011 2012 2013

Pacientu skaits @LHB Pacientu skaits @KZS ar inhibitoriem

32

Number of patients @LHB


Number of patients with inhibitors

The growth of spending on hemophilia B treatment slowed considerably in 2014 (it was only +1% YOY, compared to +34% a year before and +68% 2011/2012). State bought considerably more units of FIX. Spending on inhibitor treatment decreased


EUR

99,247 113,195 187,218

690,063

516,115 560,560 536,622

904,094

1,210,472 1,217,778

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

33


54

31 45

64 54 60

46 34 36 41

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014


1,838 3,651 4,160 10,782 9,558 9,343 11,666

26,591 33,624 29,702

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014



In 2014, budget for reimbursement of FIX grew by 31K EUR or 18% YOY, but 34% more FIX IU were bought. Spending for inhibitor treatment decreased by 24K EUR, but was still 84% of all spending for hemophilia B


EUR

-

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

2010 2011 2012 2013 2014


FIX Octanine

FIX Replenine

FIX Immunine

35

Since 01.07.2014. the only 100% reimbursed factor IX concentrate again is Replenine-VF, which previously was excluded from the list due to delivery problems. 4/5 of hemophilia B budget goes to inhibitor treatment


%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2010 2011 2012 2013 2014


FIX Octanine

FIX Replenine

FIX Immunine

36

Von Willebrand Disease D68.0

37

Only one third of outreached patients receives treatment under reimbursment

¡  Von Willebrand disease (VWD) is the most popular bleeding disorder, but many times left undiagnosed, because lack of complaints

¡  LHB statistics show that there are more than 120 people with VWD in Latvia, but only 41 of them receives treatment, that is reimbursed by the state

¡  Since it is impossible to diagnose VWD type in Latvia, all patients are treated with DDAVP. Tranaxeamic acid, which is the cheapest and simpliest drug, has never been included to reimbursement list. Prescription conditions do not allow to prescribe few patients, who would need that, Factor VIII(+VWF) concentrates. There are no VWF concentrates available in Latvia


34 30 37

49 41

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

38


After rapid decrease in 2010, spending on VWD treatment increased. In first half of 2014, spending had surpassed all spending in 2010, but in 9 months – all spending of 2012. Unfortunately total yearly spending for treatment of VWD in 2014 did not surpass the spending in 2013


EUR

3,353

7,322 7,082

9,270

10,666

6,492 7,409 7,470

11,433 10,990

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

39


19

43 38 48 48

34 35 43

58 54

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014


176 170 186 193 222

191 212 174 197 204

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014



Factor VII deficiency D68.2

41

5 patients – only 1 receives factor concentrate. No prescriptions since 2013

¡  There were 2 patients with factor VII deficiency in Latvia until 2011

¡  In the end of 2012, factor VII deficiency was found in one more family, so the number of patients increased to 5

¡  Factor VII concentrate has been included in Reimbursed list for many years (free of charge for patients with specific prescription), but for the first time a patient received it only in August 2013

Source: LHB, NVD KZS statistics

2 2

5 5 5

- - - 1

0

2010 2011 2012 2013 2014

Pacientu skaits @LHB Pacientu skaits @KZS

42

Number of patients @LHB Number of patients @KZS

1 of 5 patients receives Factor VII concentrate first and only time in August 2013


EUR

- - -

2,697

0

2010 2011 2012 2013 2014

43

Number of prescriptions and value


0 0 0

1

0

2010 2011 2012 2013 2014


- - -

2,697

0

2010 2011 2012 2013 2014


44

Thank you! Baiba Ziemele

Latvia Hemophilia Society

+371 29 157 967 [email protected]

45

Appendix

46

In short

¡  To stop bleeding in internal organs, joints and muscles, people who have a bleeding disorder usually use particular clotting factor concentrate intra venously – that helps to improve blood clotting process

¡  Necessary amount of clotting factor concentrate depends on severity of disease, location of the bleed and its severity, as well as on patient’s weight

¡  In Latvia, we use Guidelines for treatment and management of Hemophilia, as well as various international researches and guidelines (available on www.hemofilija.lv)

¡  Hemphilia treatment around the world is compared based on average clotting factor concentrate consuption per capita in country, which is calculated by dividing yearly consumption of factor VIII in international units (IU) by number of inhabitants. Minimal recomended factor consumption level is 2 IU per capita, but latest EDQM Guidelines (2013) requires 3 IU per capita in Europe as the minimal standard.

47

SSK-10 classification of diseases

¡  III Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) ¡  Coagulation defects, purpura and other haemorrhagic conditions (D65-D69)

¡  D65 Disseminated intravascular coagulation [defibrination syndrome] ¡  D66 Hereditary factor VIII deficiency ¡  D67 Hereditary factor IX deficiency ¡  D68 Other coagulation defects

¡  D68.0 Von Willebrand disease ¡  D68.1 Hereditary factor XI deficiency ¡  D68.2 Hereditary deficiency of other clotting factors ¡  D68.3 Haemorrhagic disorder due to circulating anticoagulants ¡  D68.4 Acquired coagulation factor deficiency ¡  D68.5 Primary Thrombophilia ¡  D68.6 Other Thrombophilia ¡  D68.8 Other specified coagulation defects ¡  D68.9 Coagulation defect, unspecified

¡  D69 Purpura and other haemorrhagic conditions (D69.0-D69.9) Source: SPKC

WHO @ http://apps.who.int/classifications/icd10/browse/2015/en#/D65-D69

48

Coagulation disorders for which treatment is reimbursed by state Receives drugs from KZS ¡  Hemophilia A (inherited factor VIII

deficiency) – D66

¡  Hemophilia B (inherited factor IX deficiency) – D67

¡  Von Willebrand disease (VWD) – D68.0

¡  Inherited factor VII deficiency – D68.2

¡  Acquired hemophilia (acquired deficiency of coagulation factors) – D68.4

¡  Coagulation disorders, nonspecified – D68.9

No data about patients or treatment options ¡  I, II, V, V+VIII, X, XI or XIII

factor deficiency

¡  Glanzmann thrombasthenia

¡  Bernard–Soulier syndrome

¡  Other thrombocyte disorders

49

According to LHB data, there were 283 persons with various bleeding disorders in Latvia in 2014 Diagnosis COUNT HEMOPHILIA A 129

INHIBITORS 2 MILD 49 MODERATE 15 SEVERE 47 (no info) 16

HEMOPHILIA B 26 INHIBITORS 2 MILD 8 MODERATE 5 SEVERE 7 (no info) 4

VON WILLEBRAND DISEASE 120 FACTOR VII DEFICIENCY 5 ACQUIRED HEMOPHILIA 1 FACTOR XII DEFICIENCY 1 THALASEMIA BETA 1 TOTAL 283

It is still impossible to diagnose VWD type; no information on patients below apr. 20 y.o.

50

Source: WFH

Annual global clotting factor concentrate consumption(2013) 51

List of Sources 1.  Information on Reimbursement list by State

Health Service: http://www.vmnvd.gov.lv/lv/kompensejamie-medikamenti/kompensacijas-kartiba

2.  Public statistics on Reimbursements list by State Health Service:http://www.vmnvd.gov.lv/lv/503-ligumpartneriem/operativa-budzeta-informacija/valsts-budzeta-lidzeklu-izlietojums-valsts-kompensejamo-zalu-apmaksa

3.  Statistics from Latvia Hemophilia Society 4.  Latvian Guidelines for treatment and

management of hemophilia, 2007 5.  Annual Global Surveys data by World

Federation of Hemophilia (WFH): http://www1.wfh.org/publications/files/pdf-1574.pdf

6.  Data by The Centre for Disease Prevention and Control:http://preda.spkc.gov.lv/ssk/indexcfdd.html?p=%23361

7.  Central Statistics Bureau data: www.csb.gov.lv

52

Healthcare

Reimbursement of Coagulation Medications in Latvia in 2014