Collaborating to strengthen evidence-based care

In this issue, we publish our first Agency for Care Effectiveness (ACE) Clinical Guidelines Evidence-to-Recommendation (EtR) framework, focusing on mild-to-moderately severe atopic dermatitis (AD).[1] ACE has been instrumental in publishing evidence-based national guidelines to address clinical uncertainties for primary care physicians.[2] This collaboration extends these resources to a wider pool of practitioners.

In Singapore, AD is highly prevalent, imposing substantial burden on patients’ quality of life (QoL), mental health and healthcare resources. Most cases are mild-to-moderate and are managed in non-acute settings. However, diagnostic uncertainty and suboptimal treatment adherence are common, driving specialist referrals and suboptimal outcomes. This guideline aimed to strengthen AD management in primary care and improve treatment outcomes. Guideline development was led by ACE, with multidisciplinary stakeholder input and a rigorous evidence appraisal process using established methodologies, including GRADE and the RAND/UCLA Appropriateness Method. The rationale for each recommendation is included to clarify the context, judgement and trade-offs. While updated evidence-based guidelines summarise current knowledge, recommendations should be interpreted in light of evidence quality and tailored to individual patient circumstances. Access to detailed EtR frameworks is important for critical appraisal and contextualised application. The overarching aim is to strengthen primary care capacity, improve patients’ outcomes and QoL, promote appropriate right-siting of care, and optimise specialist resources.

While the ACGs primarily target primary care physicians, they are equally important for specialists. National guidelines development cannot rest solely on the Ministry of Health or ACE due to the scope, competing priorities and need for timely incorporation of emerging scientific evidence into clinical practice. A bottom-up approach involving professional academic societies ensures discipline-specific needs are addressed. Internationally, such societies are actively involved in developing and updating clinical guidelines to improve management practices.[3,4,5,6,7,8] The SMJ has likewise supported Ministry-led and high-quality locally initiated guidelines from professional societies and expert groups.[8,9,10,11,12] Despite the abundance of Western guidelines, it is important to develop local guidelines when clinically relevant. Disease patterns, demographics, practice environments and cost–benefit considerations may differ, making wholesale adoption inappropriate. Local guidelines should not merely replicate external ones but instead reflect contextual realities and the needs of the healthcare system.

Medicolegal concerns should not deter guideline development. Guidelines are not legal standards of care and require critical appraisal. Relying sorely on overseas guidelines may misalign with local practices and pose medicolegal risks. Key factors in guideline development include identifying the need, following a robust methodology, engaging all stakeholders and ensuring broad dissemination. Resources on evidence-based medicine, GRADE methodology and guideline development can enhance clinical practice and quality of guidelines.