116 Chapter 3 local/ regional audits regularly. One promising area is further research into clinician awareness and prescribing behavior, the core activity of Ig demand. This includes better understanding of psychological factors, group dynamics, and even logistical reasons for why various initiatives in hospitals to control demand are not successful for the long-term.54 Additionally, lessons can be learned and replicated from the hospital stewardship programs/organizational interventions that have sprung up, which exhibits varying levels of (dramatic) success in curbing Ig usage.59,71,72 Strengths of this study include using the combination of a scoping review and interview study that allowed for identifying the contextual factors related to Ig demand. This methodology is customizable for any country, in that it highlights country-specific issues regarding the future demand of Ig and the implications thereof. Using this approach could be an alternate, and more independent (non-biased) approach to purchasing reports from commercial companies. Other blood establishments could use this work as a starting point and modify it accordingly, even taking it further by assessing the mitigating measures to mitigate the threats and embrace the opportunities,107 or using traditional scenario methodology and choosing to focus on certain transformational factors to create specific future scenarios.15 This methodology was used by Sanquin to make recommendations to the Ministry of Health regarding the need for increased plasma collections, which resulted in the opening of the first plasma-only collection in the Netherlands center in 2020. The main limitation of this study was its lack of numerical data for the Dutch setting for questions such as the number of patients requiring Ig, estimates of future demand or extrapolating trends. Further, in interviewing 15 experts, of which 8 are clinicians, with one neurologist and two haematologists, we may have missed other, or more nuanced, perspectives. Due to the limited time frame of this study, we made choices to interview a wide range of key experts and chose these clinicians as representatives of their fields due to their reputation and output, which may have introduced a selection bias. Additionally, including SPP employees may have also introduced bias, but these persons were chosen for their content knowledge and their remarks were compared and validated with clinicians and the other representatives during interviews. 3.5 Conclusion Using a scenario approach, we have identified that neurology, immunology, and hematology are the main drivers of Ig demand along with four groups of transformational factors that may impact demand. Future demand for the Netherlands and
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