{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,4]],"date-time":"2026-11-04T17:13:48Z","timestamp":1793812428432,"version":"4.6.1"},"reference-count":50,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2026,7,3]],"date-time":"2026-07-03T00:00:00Z","timestamp":1783036800000},"content-version":"unspecified","delay-in-days":2,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Fam Med Com Health"],"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>Osteoporosis is a major contributor to morbidity and mortality worldwide, yet underdiagnosis and undertreatment remain pervasive across diverse health systems, including Singapore\u2019s mixed public\u2013private primary care landscape. In 2025, the Agency for Care Effectiveness (ACE), Ministry of Health, Singapore, updated its national clinical guideline \u2018Osteoporosis: Diagnosis and Management\u2019 to address these persistent gaps. This paper describes the development of the guideline and examines its implications for primary care using conceptual frameworks.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>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\u2013UCLA consensus from a multidisciplinary Expert Group.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Singapore\u2019s mixed public-private primary healthcare system.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>Oversight was provided by ACE\u2019s 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>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\u2019s 4Cs (comprehensive, continuous, coordinated and first-contact care) and ACE\u2019s multilevel impact model, highlighted how the guideline may strengthen primary care functions and influence policy-level, organisational-level, clinician-level and patient-level pathways.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Singapore\u2019s 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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/fmch-2025-003802","type":"journal-article","created":{"date-parts":[[2026,7,3]],"date-time":"2026-07-03T13:09:03Z","timestamp":1783084143000},"page":"e003802","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Translating evidence into primary care: Singapore\u2019s 2025 national osteoporosis guideline and a multilevel framework for assessing guideline impact in mixed health systems"],"prefix":"10.1136","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8790-0842","authenticated-orcid":false,"given":"M","family":"Premikha","sequence":"first","affiliation":[{"name":"Evidence to Practice Division, Agency for Care Effectiveness, Ministry of Health, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Valentina","family":"Ricci","sequence":"additional","affiliation":[{"name":"Evidence to Practice Division, Agency for Care Effectiveness, Ministry of Health, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shu Jun","family":"Kan","sequence":"additional","affiliation":[{"name":"Evidence to Practice Division, Agency for Care Effectiveness, Ministry of Health, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"Expert Group of the Osteoporosis ACG","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Phyllis","family":"Kim","sequence":"additional","affiliation":[{"name":"Evidence to Practice Division, Agency for Care Effectiveness, Ministry of Health, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,7,3]]},"reference":[{"key":"2026070306051346000_14.3.e003802.1","doi-asserted-by":"crossref","unstructured":"Shen Y , Huang X , Wu J , et al . The Global Burden of Osteoporosis, Low Bone Mass, and Its Related Fracture in 204 Countries and Territories, 1990-2019. Front Endocrinol 1990;13. doi:10.3389\/fendo.2022.882241","DOI":"10.3389\/fendo.2022.882241"},{"key":"2026070306051346000_14.3.e003802.2","doi-asserted-by":"crossref","DOI":"10.1007\/s11657-018-0463-3","article-title":"Consensus on best practice standards for Fracture Liaison Service in the Asia-Pacific region","volume":"13","author":"Chan","year":"2018","journal-title":"Arch Osteoporos"},{"key":"2026070306051346000_14.3.e003802.3","unstructured":"Ministry of Health Singapore . Incidence of hip and non-hip fracture-related healthcare utilisation in men and women from 2015 to 2023."},{"key":"2026070306051346000_14.3.e003802.4","doi-asserted-by":"crossref","first-page":"879","DOI":"10.1007\/s00198-019-04839-5","article-title":"Hip fractures in Singapore: ethnic differences and temporal trends in the new millennium","volume":"30","author":"Yong","year":"2019","journal-title":"Osteoporos Int"},{"key":"2026070306051346000_14.3.e003802.5","doi-asserted-by":"crossref","first-page":"1037","DOI":"10.1007\/s00198-022-06657-8","article-title":"Prevalence of osteoporosis and incidence of related fractures in developed economies in the Asia Pacific region: a systematic review","volume":"34","author":"Chandran","year":"2023","journal-title":"Osteoporos Int"},{"key":"2026070306051346000_14.3.e003802.6","doi-asserted-by":"publisher","DOI":"10.1007\/s00198-004-1680-8"},{"key":"2026070306051346000_14.3.e003802.7","doi-asserted-by":"crossref","first-page":"505","DOI":"10.47102\/annals-acadmedsg.202545","article-title":"Upper limb fragility fractures: A missed opportunity","volume":"54","author":"Lee","year":"2025","journal-title":"Ann Acad Med Singap"},{"key":"2026070306051346000_14.3.e003802.8","doi-asserted-by":"crossref","first-page":"3460","DOI":"10.1002\/nop2.1607","article-title":"Fragmented care and chronic illness patient outcomes: A systematic review","volume":"10","author":"Joo","year":"2023","journal-title":"Nurs Open"},{"key":"2026070306051346000_14.3.e003802.9","doi-asserted-by":"crossref","DOI":"10.1186\/s12916-023-03021-3","article-title":"Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: a Danish nationwide cohort study","volume":"21","author":"Prior","year":"2023","journal-title":"BMC Med"},{"key":"2026070306051346000_14.3.e003802.10","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2018-022965","article-title":"Prevalence of care fragmentation among outpatients attending specialist clinics in a regional hospital in Singapore: a cross-sectional study","volume":"9","author":"Kailasam","year":"2019","journal-title":"BMJ Open"},{"key":"2026070306051346000_14.3.e003802.11","doi-asserted-by":"publisher","DOI":"10.1370\/afm.971"},{"key":"2026070306051346000_14.3.e003802.12","unstructured":"World Health Organization; United Nations Children\u2019s Fund (UNICEF) . 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