Our Process & Methods
"Appropriate care guides" or ACGs provide concise and evidence-based recommendations on care practices and pathways to guide specific areas of clinical practice. Cost-effectiveness considerations are also incorporated where relevant. Where MOH Clinical Practice Guidelines (CPGs) are available, ACGs complement the CPGs by providing timely additions and updates as reflected in the evidence at the time of the ACG development.
The following are the main process steps which ACE follows in the development of an ACG:
ACG topics are selected based on topics raised by MOH divisions and relevant professional bodies in the annual call for topics. In addition, ACGs are also developed as extensions of technology guidances (e.g. drug guidance) issued by ACE.
Topics are shortlisted for development based on the following:
- Alignment with national health priorities
- Disease burden
- Evidence of suboptimal outcomes
- Practice variation
- Knowledge gap
- Potential impact on patient outcomes
Once topics are selected, an ACG expert group is appointed for each ACG topic to ensure that recommendations are accurate, current, and relevant for local practice and intended users. Each expert group consists of 8-12 practising health professionals who are subject matter experts including, but not limited to, specialists, general practitioners, pharmacists and nurses.
A step-wise approach is taken to review the literature, focusing on reviewing existing high-quality guidelines first before published literature. Reference guidelines are identified by the expert group and are assessed for quality using the AGREE II guideline assessment checklist.
Additional literature searches and appraisals of primary or secondary literature are undertaken if there are:
- few or no guideline(s) available
- gaps in the guidelines
- important updates in the evidence
- conflicting recommendations in the guidelines
Where applicable, cost-effectiveness considerations based on relevant technology guidances developed by ACE are included in the ACGs. Drugs or other medical technologies, available for subsidy through public healthcare institutions and primary care networks, are also highlighted in the ACGs.
Review and endorsement
Professional bodies such as the Academy of Medicine and the College of Family Physicians are invited to provide comments and endorse the ACGs.
Development time and review
The development of an ACG takes approximately 8-12 months.
ACGs are reviewed three years after publication, or earlier if new evidence emerges that requires substantive changes to the recommendations.
What is health technology assessment (HTA)?
HTA is an established scientific research methodology to inform policy and clinical decision-making on the relative value of new health technologies, such as drugs, devices and medical services, compared to existing standards of care. It is conducted using analytical frameworks, drawing on clinical, epidemiological and health economic information to determine how best to allocate limited healthcare resources.
HTA helps to answer the following questions:
- Does the health technology work?
- What benefit does it provide and for whom?
- What does it cost (to the healthcare service, to the patient, etc.), including opportunity costs?
- How does it compare with the available alternatives?
The goal of HTA is to inform the development of effective health policies about the use of health technologies in a manner that is patient-focused and achieves best value.
There are currently 3 main process steps which ACE follows when evaluating drugs to inform decision-making:
Topic submission and selection
A call for applications is put out annually to the public healthcare institutions to submit requests for drug subsidy consideration. ACE works with the MOH Drug Advisory Committee (DAC) to select the topics for evaluation.
Once a topic is selected, technical evaluations are conducted at two levels - expedited or full – depending on the estimated budget impact and uncertainty around the clinical and cost parameters for each drug. All evaluations are conducted internally by the technical team in ACE, with supporting evidence provided by local clinical experts and pharmaceutical manufacturers.
- Higher cost technologies (estimated budget impact >$2 million a year) are typically subject to full evaluation which includes a systematic review of the clinical evidence, and economic modelling to estimate the cost-effectiveness of the technologies in the local context (where feasible);
- Technologies with lower budget impact are subject to expedited evaluations (without modelling), which are usually informed by published clinical evidence and international cost-effectiveness studies.
Value-based pricing is conducted in parallel with drug evaluations to ensure that the price of drugs recommended for subsidy represents a cost-effective use of healthcare resources and is commensurate with the drugs' value in Singapore's context. Under this process, manufacturers are invited to submit their best cost prices for their drugs, which then inform ACE's cost-effectiveness analyses and budget impact assessments.
The evidence in ACE's technical evaluations informs the DAC's drug subsidy deliberations around four core decision-making criteria:
- Clinical need of patients and nature of the condition
- Clinical effectiveness and safety of the drug
- Cost-effectiveness (value for money) – the incremental benefit and cost of the technology compared to existing alternatives
- Estimated annual cost of the drug and the number of patients likely to benefit from the technology
Additional factors, including social and value judgments, may also inform the DAC's considerations.
On the basis of the available evidence, the DAC recommends whether a drug should receive subsidy through listing on the Standard Drug List (SDL) or the Medication Assistance Fund (MAF).
ACE's Drug Evaluation Methods and Process Guide (Version 1) outlines the core processes and methods underpinning ACE's assessment of clinical and economic evidence for drugs which are being considered for government subsidy. The guide also documents value-based pricing processes and the DAC's decision-making framework.
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