Abstract: Background　Current research on osteoporosis is mostly about the pathogenesis，diagnostic criteria，clinical trials and basic epidemiological investigation，but rarely on the treatment for osteoporosis patients，and prevention and control of osteoporosis in high-risk group and normal residents.Objective　To construct a complete community-based osteoporosis prevention and treatment pathway based on the referral patterns between community-based healthcare institutions and general hospitals，providing a reference for community-based prevention and treatment of osteoporosis in a standardized way.Methods　We developed the procedure and operation rules of community-based osteoporosis prevention and treatment pathway by using tools suitable for community-based screening and diagnosis of osteoporosis selected by reviewing the osteoporosis prevention and treatment tools used at home and abroad during 1999—2019，and by referring to patterns and pilot implementation experience of referrals between Fenglin Community Health Center and Shanghai Sixth People’s Hospital collected by focus group interviews with 5 individuals（including major frontline medical workers offering osteoporosis prevention and treatment services and the head of orthopaedic department） invited from Fenglin Community Health Center.Results　The Osteoporosis Self-Assessment Tool for Asians （OSTA） was selected as the primary tool for community-based osteoporosis risk assessment.The results of dual-energy X-ray absorptiometry （DXA） were determined as the gold standard for community-based diagnosis of osteoporosis.The developed community-based osteoporosis prevention and treatment pathway includes 6 parts:screening，diagnosis，differential diagnosis，prevention and treatment，rehabilitation，and follow-up.Osteoporosis risk assessment（osteoporosis screening），first diagnosis and hierarchical treatment，rehabilitation and follow-up services of osteoporosis were undertaken by the community health center，and differential diagnosis and non-essential services of osteoporosis were delivered by the general hospital，and osteoporosis GPs played a central role in the pathway for delivering services.Conclusion　This pathway may improve the prevention and control level of osteoporosis in healthcare institutions，and may provide a clinical and theoretical basis for national promotion of bidirectional referral patterns in the hierarchical medical treatment of osteoporosis.

Key words: Osteoporosis, Bidirectional referral, Prevention and treatment pathway, Community health services

摘要： 背景　目前针对骨质疏松症的研究多为发病机制、诊断标准、临床试验及基础流行病学调查，针对骨质疏松症患者、高危人群、普通居民开展的防治研究还不够。目的　以社区卫生服务机构-综合医院的双向转诊模式为基础，构建一套完整的社区骨质疏松症防治路径，为规范化开展社区骨质疏松症防治提供参考。方法　通过文献回顾法整理1999—2019年国内外骨质疏松症防治工具集合，并遴选适用于社区的筛查与诊断工具；通过焦点小组会议法，邀请枫林街道社区卫生服务中心提供骨质疏松症防治相关服务的一线业务骨干及相应科室负责人共5人参与焦点小组会议，基于枫林社区卫生服务中心-上海市第六人民医院的骨质疏松症双向转诊模式和试点经验，梳理并构建社区骨质疏松症防治路径流程和操作细则。结果　选择亚洲人骨质疏松自我筛查工具（OSTA）评分作为社区骨质疏松症筛查的首要风险评估工具，选择双能X线吸收检测法（DXA）作为社区骨质疏松症诊断的金标准判定工具；双向转诊模式下社区骨质疏松症防治路径包括筛查环节、诊断环节、鉴别诊断环节、防治环节、康复环节和随访环节；构建了由社区卫生服务中心承担骨质疏松症风险评估（筛查）、首诊诊断、分级治疗、康复与随访工作，由综合医院承担鉴别诊断和非基本服务项目，以骨质疏松症专病全科医生为路径中轴线的社区骨质疏松症防治路径。结论　本研究构建的双向转诊模式下社区骨质疏松症防治路径，能够提高医疗卫生机构开展骨质疏松症预防控制的能力，为在全国推广骨质疏松症分级诊疗的基层双向转诊模式提供了临床和理论基础。

关键词: 骨质疏松, 双向转诊, 防治路径, 社区卫生服务