A PubMed search using the full name and acronym of MUMM gave no references and a search combining the search terms ‘HTA’, ‘hospital’ and ‘Finland’ yielded only one study . The Finnish portal for healthcare professionals (Terveysportti), which contains information from the Finnish professional journals that are not Medline indexed, was consulted using the corresponding Finnish search terms, and resulted in 13 articles mentioning the MUMM program [12-24].
History of collaboration
In the early years, the late 1990s and early 2000s, the national HTA agency, Finohta, provided methodological, and sometimes also financial support for research projects in hospitals, mainly for randomised trials and systematic reviews. The aim was to increase the critical mass of people able to conduct evaluation research in Finnish hospitals. According to some of the interviewees, this activity was considered useful by hospitals and Finohta but it was stopped due reorganisations and cost cuttings in the late 2000s.
Since the turn of the millennium, several articles were published in national professional journals about the importance of systematic evaluation of both new and obsolete healthcare technologies, particularly in hospitals. A structured approach to nationally coordinate the evaluation and uptake of new medical technologies was, according to the interviewees, clearly desired, especially by hospital decision-makers. Starting in 2004, a series of discussions began between hospitals on how to identify joint topics for assessment. The idea was to encourage the hospitals to systematically demand critically appraised information on effectiveness, safety and costs of new technologies, and make joint decisions concerning their uptake. This was considered necessary for reducing the geographical variation in the availability of new technologies and for securing rational use of resources. Models from other countries, such as Denmark and the United Kingdom, stimulated the development.
In September 2005, a group of hospital directors decided in their yearly meeting to establish collaboration between hospital districts and Finohta. The focus of the programme was set on new technologies. The kick-off meeting of the new collaboration was in December 2005. One of the initiators toured the 20 hospital districts of Finland in 2006 and 2007, promoting the new MUMM program and engaging the clinicians and hospital managers to its principles. It was clearly outlined from the beginning that MUMM is a joint venture of Finohta and the hospital districts. Almost all hospital districts agreed to join, or at least to follow-up on the progress of the program.
MUMM has been a priority function in Finohta and, despite resource restrictions, the input to MUMM-HTAs has remained relatively stable during the years. However, there is currently some pressure for Finohta to prioritise actions, and therefore some deliberations have been made to streamline the organisational structure of MUMM and even diminish MUMM-HTA production.
Content of collaboration
The collaborative MUMM-HTA product is typically a 5- to 10-page document based on a systematic review of evidence on effectiveness and safety, and in some cases the purchasing and running costs of the new technology. The duration of the overall project, from topic selection to recommendation, is typically more than 1 year. The manuscripts of the MUMM-HTAs are submitted for peer review and published in the Finnish Medical Journal.
Hospitals select the topics, which include mainly medical devices and procedures. Pharmaceuticals were deliberately excluded because of resource constraints and because it was long anticipated that there would be another HTA function within Fimea to cover these later. This activity is currently being developed by Fimea.
A typical MUMM-HTA is drawn up by two clinical experts, usually physicians, from hospitals, and two HTA-specialists and an information specialist from Finohta. Finohta carries the responsibility of coordination of the MUMM-HTA projects. Hospital clinicians participate either as authors or expert consultants in the MUMM-HTAs. They are recruited specifically for each project, and their identification is based on individual networks and contacts of the Advisory Board and Finohta instead of a formal procedure for nomination.
After the MUMM-HTA has been completed, the hospital districts are responsible for formulation of the recommendations based on the review. The Advisory Board of MUMM, which consists of clinical experts from hospitals, prepares a preliminary recommendation which is then discussed and finalised by the MUMM Board, consisting of chief medical officers of the hospital districts.
Assessment and appraisal are clearly separated in the MUMM process. This means that the recommendations are drawn up by other people than those who performed the review; this has been considered a valid principle. It was even suggested that the recommendation phase should be taken out of the current MUMM framework and performed completely within the hospitals, incorporating it into the existing meeting and decision-making structures. This would probably promote the actual implementation of the recommendations in hospitals as it currently discretionary for each hospital to adopt the MUMM recommendations.
Volume of collaboration
Presently, there are 51 MUMM reviews, based on which 56 recommendations have been given. Some of the reviews have led to two or three different recommendations for different indications. Resource input for MUMM has been greater from the side of Finohta than from the hospitals. During the first 7 years of collaboration, Finohta has contributed to the collaborative MUMM project a total of 4 to 5 person years and approximately €60,000 annually as additional direct costs. The hospital districts have overall provided 90 clinical expert inputs from 30 disciplines during the same time. The role of the clinical experts from hospitals is clearly part time, sometimes consultative, which means that most of the actual work in the assessment phase has been performed in Finohta.
Impact on decision-making
In 2012, an internal evaluation of the MUMM program was performed using information from hospital registers and interviews of chief physicians. The aim was to evaluate the perceptions concerning MUMM and its impact on decision-making in hospitals. Results showed that 57% of chief physicians felt that the content of the MUMM recommendations are unambiguous, 28% felt that the recommendations are sufficiently communicated, and 29% stated that the recommendations are followed . Hospital managers had a more positive attitude towards HTA activity than other professional groups in hospitals.
Hospitals are dependent on Finohta’s input in the MUMM-HTAs and would have difficulties in replacing the skills and resources provided by Finohta. On the other hand, the knowledge concerning MUMM in hospitals is still inadequate and the current MUMM-HTAs and recommendations are scarcely used in decision-making, which indicates that hospitals do not depend on the outputs of the collaboration. MUMM is a strategically important function for Finohta but not essential for its overall functions. There are other competing national HTA functions and tasks where the resources could be shifted if there was no MUMM.
According to most interviewees, the MUMM program seems to remain poorly known and underutilized in decision-making in hospitals. One obvious reason is that the results of MUMM reviews are not systematically required or used in the clinics’ purchase decisions.
The hospital clinicians pointed out the need for two-stepped decisions: conditional with the requirement for re-assessment when new evidence emerges, and final. MUMM recommendations were considered “too vague” to sufficiently guide decisions of conditional decisions. The requirements for data to be collected in the clinic should be detailed and the timeline agreed upon after which a reassessment is made before the final decision. Some clinics have their own systems to collect evidence and monitor the uptake of new technologies. Teaching clinics may perform evaluation research, e.g. randomised controlled trials and systematic reviews, on which to base their decisions. MUMM seems to be only one of the possible routes through which evidence is taken into decision-making in hospitals.
Barriers of collaboration
HTA can still today be considered a threat to clinical autonomy according to the interviewed clinicians. According to some interviewees, clinics want to be “frontline” and compete with other clinics about reputation and staff. The original indications of a new technology may be narrow and it is tempting to use the technology also in less severe cases, although expanding indications at a certain point may cause more harm than good to the patients. Unnecessary interventions may also be performed for fear of claims, or because of extra earnings gained. All these issues, together with the constant budget competition between clinics, maintain the current situation where physicians are not willing to limit the uptake or use of new technologies. Furthermore, HTA, and consequently also MUMM, is considered mainly as a tool to restrict the uptake.
In order to increase the impact of MUMM in decision-making, hospital clinicians suggested that MUMM reviews and recommendations should be more regularly communicated to the clinic management level where the actual decisions are made. Currently, the information is distributed to the higher level in the hospital hierarchy, which is apparently not sufficient .
Signs of a role conflict and resulting mistrust occurring between hospitals and Finohta were also identified. Mistrust is reflected in expressions such as “hospital clinicians do not feel that they belong to MUMM” and “Finohta isolates and wants to steer too much the collaboration”. On the other side, Finohta staff felt that “hospitals’ attitude is arrogant” and stressed that “Finohta is not willing to act only in a coordinating role, but have a say in the design and content of the program in the future too.”
The slow assessment process is one of the main barriers of MUMM. As the technologies appear and evolve rapidly, the MUMM reviews should be quicker and more effort should be made in updating them regularly. An ideal time span for a MUMM review was originally set to 6–9 months. In the early years of the program this was considered a realistic target, but in recent years it has become apparent that this is not the case. A slow and thorough process may be justified, however, if the topic requires careful and multifaceted evaluation including ethical considerations. Nevertheless, for most topics, a quicker process was required; this is particularly claimed by hospitals but acknowledged by Finohta as well.
Several factors have led to the process being so slow. Clinicians participate through minor input, often on their own time. The staff of Finohta is occupied with several parallel tasks, and prioritisation has not always favoured MUMM. With the current resources, the already slow process of MUMM reviews is not going to be accelerated; on the contrary, it will most likely be even slower.
Reflecting on the hypotheses
Collaboration between Finnish hospitals and the national HTA unit cannot be considered successful when looking at the indicators of success defined for this case study. The use of HTA information in hospital decision-making has not increased substantially. The transparency of the clinical implementation and purchase processes in hospitals is still poor, which also prevents exact evaluation of the impact of HTA. All other success indicators related to increased patient safety, equity and acceptability as well as innovation support, could not be observed in the interviews or published documents used for this case study.
One of our hypotheses was that powerful HTA, which has a legal mandate, predicts successful collaboration. In Finland, HTA has no power as there is no clear legal obligation to use evidence in decision-making nationally or in hospitals. This is probably one of the reasons why the collaboration between hospitals and the national HTA unit has not been particularly successful. Another hypothesis, which is supported by the case study in Finland, is that the differing expectations seemed to be a major barrier for collaboration.
Finally, it was hypothesised that collaboration between hospitals and HTA units would be deeper in countries with a long history of HTA. Finohta is one of the oldest HTA units in Europe, founded in 1995, but still the collaboration was not strikingly successful. It was anticipated that sharing people and knowledge strengthens the collaboration, but also this remained unverified by the results of this study. As mentioned above, Finland is a small country with 5.4 million inhabitants, the funding of HTA is based on state budget, and the decision-making structures regarding technologies for hospitals are extremely decentralised. Whether these features represent barriers of a successful collaboration needs to be confirmed by further studies.