Translating evidence into primary care: Singapore's 2025 national osteoporosis guideline and a multilevel framework for assessing guideline impact in mixed health systems.

Abstract

Objective: Osteoporosis is a major contributor to morbidity and mortality worldwide, yet underdiagnosis and undertreatment remain pervasive across diverse health systems, including Singapore's mixed public-private primary care landscape. In 2025, the Agency for Care Effectiveness (ACE), Ministry of Health, Singapore, updated its national clinical guideline 'Osteoporosis: Diagnosis and Management' to address these persistent gaps. This paper describes the development of the guideline and examines its implications for primary care using conceptual frameworks.

Design: The guideline was developed using a transparent, GRADE-aligned adaptation process that incorporated 10 high-quality international guidelines, local epidemiological and cost data, and formal RAND-UCLA consensus from a multidisciplinary Expert Group.

Setting: Singapore's mixed public-private primary healthcare system.

Participants: Oversight was provided by ACE's internal team, with content expertise drawn from a 21-member multidisciplinary expert group (EG), of whom 10 members (47.6%) were practising in public and private primary care settings. The panel included primary care physicians, specialists (ie, endocrinologists, rheumatologists, geriatricians, gynaecologists, orthopaedic surgeons), nurses and pharmacists, ensuring representation across care levels and disciplines.

Results: The updated guideline comprises six recommendations spanning risk assessment, lifestyle optimisation, diagnostic thresholds, pharmacologic treatment and referral for complex presentations. Key adaptations include earlier case finding in men, pragmatic vitamin D guidance, locally derived treatment thresholds for osteopenia and selective use of anabolic agents for patients at very high fracture risk. Conceptual analysis using Starfield's 4Cs (comprehensive, continuous, coordinated and first-contact care) and ACE's multilevel impact model, highlighted how the guideline may strengthen primary care functions and influence policy-level, organisational-level, clinician-level and patient-level pathways.

Conclusion: Singapore's experience illustrates how mixed health systems can translate global evidence into concise, context-appropriate primary care guidance that supports system redesign and strengthens longitudinal management of chronic disease. Five transferable lessons emerge for similar systems: targeted adaptation of international evidence, pragmatic contextualisation of recommendations to local workflows and resources, strategic use of conditional recommendations, alignment of guideline implementation with broader system reforms and anchoring of chronic disease management in primary care.