关键词: 骨质疏松, 社区卫生服务, 临床路径, 项目管理, 指南, 实践

Abstract: Background　In Shanghai，the construction of community-based prevention and treatment of osteoporosis has entered the second round，during which many new relevant guides have been issued，such as osteoporosis guidelines for primary care，guiding principles for osteoporosis management，and standardized management options for osteoporosis，providing rich evidence for primary care practice. However，successful application of guides in primary practice can not be achieved overnight，which should be done according to the real conditions of the community，such as human，financial and material resources，size and roles of the community. Objective　To develop a pathway for the second round construction of community-based prevention and treatment of osteoporosis based on our experience summarized from the first round of construction，and the latest osteoporosis guidelines，offering a reference for appropriate use of guidelines in community-based practice. Methods　The entire development process of the pathway to community-based osteoporosis prevention and treatment includes pre-development preparation phase，development phase，information realization phase，and acceptance phase before the offline use. The first two phases were completed from May 2018 to December 2019. In the pre-development preparation phase，we formulated project management options for developing the pathway by reviewing the latest evidence-based studies regarding osteoporosis prevention and treatment and two rounds of group discussions. In the development phase，we developed a standardized process of osteoporosis prevention and treatment used as a reference guide to primary care by analyzing and modifying the first version of osteoporosis prevention and treatment pathway in the community based on the literature review results of in the pre-development preparation phase，three rounds of expert consultation and two rounds of group discussions. Results　The document library formed in the pre-development preparation phase has updated 7 domestic guidelines and 5 foreign guidelines. The osteoporosis prevention and treatment pathway in the community was developed by general medical management and executive representatives from the community health center，orthopedics specialists from the general hospital，in collaboration with the information company，with the help of a third-party healthcare and medical and health consulting firm for data collection，analysis and translation. The final osteoporosis prevention and treatment pathway in the community demonstrates logic in terms of community-based osteoporosis screening and diagnosis，transferring to the general hospital，and osteoporosis follow-up for monitoring treatment. Conclusion　The successful application of osteoporosis guidelines in primary care practice requires multilateral cooperation（the general hospital，community health center，information company，translator as well as third-party communication and coordination）. Our exploratory process may be used as a reference for colleagues to carry out new explorations，and our pathway may be considered as a logical basis for community-based prevention and treatment of osteoporosis using the guidelines appropriately.

Key words: Osteoporosis, Community health services, Critical pathways, Project management, Guidelines, Practice