Analysis of the Quality of Diagnosis and Treatment of Osteoporosis in Shanghai Community Health Service Institutions

ZHANG Hanzhi¹,²,³, JIN Hua¹,²,³,⁴, MA Le¹,²,³,⁴, SHI Ling⁴,⁵, CHEN Chen⁴,⁶, HUAN Hongmei⁴,⁷, YU Dehua¹,²,³,⁴*

¹Department of General Practice, Yangpu Hospital, School of Medicine, Tongji University, Shanghai 200090, China
²Shanghai General Practice and Community Health Development Research Center, Shanghai 200090, China
³Research Center for General Practice, School of Medicine, Tongji University, Shanghai 200090, China
⁴Shanghai General Practice Clinical Quality Control Center, Shanghai 200090, China
⁵Community Health Management Center of Putuo District, Shanghai 200062, China
⁶Shanghai Jing'an District Jiangning Subdistrict Community Health Center, Shanghai 200040, China
⁷Shanghai Minhang District Gumei Community Health Center, Shanghai 201102, China

Corresponding author: YU Dehua, Professor/Chief physician/Doctoral supervisor; E-mail: ydh1404@sina.com

Abstract

Background: The diagnosis and treatment level of osteoporosis in Shanghai community health service institutions remains unclear, with systematic evaluation and monitoring lacking. Objective: To understand the current status of osteoporosis diagnosis and management in Shanghai community health services, evaluate their diagnostic and treatment capacity, and explore existing problems and improvement measures. Methods: In December 2023, a questionnaire was distributed to 248 community health service centers and 1,873 general practitioners (GPs) across 16 administrative districts of Shanghai, investigating the current status, knowledge, and competencies related to osteoporosis diagnosis and management in both urban and suburban community health institutions. Results: Among the 248 community health centers, 79 (31.9%) were in urban areas and 169 (68.1%) in suburban areas. Among the 1,873 GPs, 497 (26.5%) were in urban areas and 1,376 (73.5%) in suburban areas. Regarding examination and testing equipment, the availability rates of bone mineral density (BMD) testing and bone turnover marker tests in urban versus suburban centers were 92.4% vs. 50.9% and 50.6% vs. 12.4%, respectively (P<0.05). For medication provision, the availability rates of bisphosphonates and active vitamin D analogs were 73.4% vs. 45.0% and 69.9% vs. 53.3%, respectively (P<0.05). In terms of non-pharmacological treatments, the implementation rates of exercise therapy, physical factor therapy, and occupational therapy in urban versus suburban centers were 73.4% vs. 50.3%, 73.4% vs. 37.9%, and 65.8% vs. 38.5%, respectively (P<0.05). The main difficulties in disease management included insufficient examination equipment and incomplete drug provision, which were more pronounced in suburban areas (P<0.05). Regarding GP cognition of high-risk groups and screening tools, awareness of postmenopausal women (99.2% vs. 97.8%) and the Osteoporosis Self-assessment Tool for Asians (OSTA) (88.3% vs. 84.4%) was higher among urban GPs (P<0.05). For symptom recognition, awareness of compression fractures was higher in urban GPs (97.0% vs. 92.2%, P<0.05), as was awareness of bone turnover markers (67.6% vs. 45.2%, P<0.05). For treatment modalities, urban GPs showed higher awareness of physical factor therapy (89.3% vs. 84.7%) and occupational therapy (86.3% vs. 81.2%) (P<0.05). The main difficulties in diagnosis and treatment included insufficient ability to identify high-risk groups, inadequate osteoporosis risk assessment capability, lack of diagnostic confidence, and poor drug selection and compatibility skills, with suburban GPs reporting more significant challenges (P<0.05). Conclusion: Shanghai community health service institutions, particularly those in suburban areas, need to strengthen the provision of osteoporosis-related examinations and tests such as BMD and bone turnover markers, improve the availability of essential therapeutic drugs including bisphosphonates and active vitamin D analogs, enhance the implementation of relevant appropriate technologies including exercise therapy, physiotherapy, and occupational therapy, and develop systematic comprehensive management approaches for osteoporosis. It is recommended to improve information system construction and coordinate multidisciplinary teams and multi-party resources.

Keywords: Osteoporosis; Community health centers; Practice management, medical; Diagnosis and treatment standard; Quality of care; Shanghai

Osteoporosis is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to increased bone fragility and fracture susceptibility. It can occur in any age group but is most common in postmenopausal women and elderly men. With China's aging population, osteoporosis incidence continues to rise annually. Surveys show that among osteoporosis patients in mainland China, the 10-year growth rates are approximately 15% for men and 20% for women, with an overall prevalence of 24.62% in people over 40 years old, affecting up to 140 million individuals. Early symptoms are often insidious and easily overlooked, yet serious complications such as fractures can severely impact patient prognosis and quality of life. Therefore, early prevention and standardized management of osteoporosis are particularly important. However, systematic evaluation and monitoring of community health service institutions' capacity remain lacking, leaving their diagnostic and treatment capabilities unclear. This study employed a multi-center, cross-sectional survey method to investigate the current status of osteoporosis-related diagnostic capacity and management in Shanghai's community health service centers and their GPs, aiming to understand the current situation, identify problems, and propose improvement measures to enhance primary care services and improve patient outcomes.

1. Methods

1.1 Study Participants

In December 2023, GPs from 248 community health service centers across Shanghai's 16 administrative districts were selected as survey participants. Based on the number and professional structure of practicing GPs at each center, a stratified simple random sampling method was used to select samples at 25% proportion from each professional rank (resident, attending, associate chief, and chief physicians), ultimately identifying 1,873 GPs as questionnaire respondents. Inclusion criteria were: (1) currently employed community GPs; (2) informed consent and willingness to participate. Exclusion criteria were: non-cooperation or incomplete/invalid questionnaire completion. This study was approved by the Ethics Committee of Yangpu Hospital Affiliated with Tongji University (Approval No.: LL-2023-LW-020).

1.2 Questionnaire Design and Distribution

The research team developed the questionnaire based on key points for community-based osteoporosis diagnosis and management mentioned in clinical guidelines [3-4], with separate versions for community institutions and GPs. The community institution questionnaire (Questionnaire 1) served as a baseline survey on osteoporosis diagnosis standardization and management quality, covering: (1) availability of osteoporosis-related examinations, tests, and medications; (2) implemented treatment technologies; (3) current disease management status and difficulties; and (4) existing training methods. This was completed by quality control officers at each community health center.

The GP questionnaire (Questionnaire 2) assessed GPs' knowledge of osteoporosis, including high-risk populations, screening tools, common symptoms, fracture risk, medication types and treatment methods, patient referral criteria, and difficulties in diagnosis and management.

Questionnaires were distributed and collected through the quality control network of the Shanghai General Practice Clinical Quality Control Center, with point-to-point contact between quality control secretariat staff and liaison officers at each community health center to ensure response rates and quality control. Both questionnaires were distributed online via Questionnaire Star in two rounds, achieving 100% response rates for both.

1.3 Statistical Analysis

Collected questionnaire data were analyzed using SPSS 23.0 software. Normally distributed continuous data were expressed as (x̄±s), while categorical data were expressed as frequencies and percentages. Inter-group comparisons used χ² tests or Fisher's exact test. Statistical significance was set at P<0.05.

2. Results

2.1 Basic Information of Community Health Centers and GPs

A total of 1,873 GPs from 248 community health centers in Shanghai's 16 administrative districts participated in the survey. The 248 centers were categorized by location into urban (79 centers, 31.9%) and suburban (169 centers, 68.1%). Among the 1,873 GPs, 497 (26.5%) were from urban areas and 1,376 (73.5%) from suburban areas. The GP cohort included 574 males (30.7%) and 1,299 females (69.4%), with a mean age of 38.94±7.78 years and mean work experience of 15.54±9.13 years. Additionally, 58.8% (1,102/1,873) had obtained standardized residency training certificates in general practice. The distribution of GPs by location, professional title, and education level is shown in Table 1 [TABLE:1].

2.2 Osteoporosis Diagnosis and Management Implementation in Community Health Centers

2.2.1 Availability of Osteoporosis Examination Equipment

Comparisons between urban and suburban community health centers showed no statistically significant differences in the availability of X-ray, magnetic resonance imaging (MRI), or nuclear medicine examinations (P>0.05). However, urban centers had significantly lower availability of computed tomography (CT) but higher availability of dual-energy X-ray absorptiometry (DXA) bone density testing compared to suburban centers (P<0.05) [TABLE:2].

2.2.2 Availability of Osteoporosis Laboratory Tests

No significant differences were observed between urban and suburban centers in the availability of urinary calcium/phosphorus/creatinine tests (P>0.05). Urban centers demonstrated significantly higher availability of bone turnover markers and serum calcium/phosphorus tests compared to suburban centers (P<0.05) [TABLE:3].

2.2.3 Availability of Osteoporosis-Related Medications

Overall, 94.4% (234/248) of community health centers had at least one type of anti-osteoporosis medication available, while 10.9% (27/248) only had traditional Chinese patent medicines. Regarding specific medications, no significant differences were found between urban and suburban centers in the availability of calcitonin, RANKL monoclonal antibody (denosumab), sclerostin monoclonal antibody (romosozumab), parathyroid hormone analogs, estrogen, selective estrogen receptor modulators, vitamin K2, calcium receptor modulators, or traditional Chinese patent medicines (P>0.05). However, urban centers had significantly higher availability of active vitamin D analogs and bisphosphonates compared to suburban centers (P<0.05) [TABLE:4].

2.2.4 Implementation of Osteoporosis-Related Treatments

No significant difference was observed between urban and suburban centers in the implementation of traditional Chinese medicine appropriate techniques (P>0.05). Urban centers showed significantly higher implementation rates for exercise therapy, physical factor therapy, and occupational therapy compared to suburban centers (P<0.05) [TABLE:5].

2.2.5 Implementation of Osteoporosis-Related Management

Only 36 community health centers (14.5%) had established osteoporosis management information systems, with just 7 of these achieving interoperability with regional medical consortium hospital information systems (HIS). The urban-suburban distribution was 13 centers (16.5%) versus 23 centers (13.6%), with no statistically significant difference (P>0.05). Urban centers demonstrated significantly higher implementation rates for routine chronic disease management (regular intervention and follow-up), screening, rehabilitation, standardized medical record documentation, specialized clinics, patient self-management groups, and community health education compared to suburban centers (P<0.05) [TABLE:6].

2.2.6 Management Difficulties in Osteoporosis Care

No significant differences were found between urban and suburban centers regarding difficulties related to limited physician competency, lack of two-way referral pathways with higher-level hospitals, or insufficient expert guidance at community level (P>0.05). However, suburban centers reported significantly higher rates of insufficient examination equipment and incomplete drug provision compared to urban centers (P<0.05) [TABLE:7].

2.2.7 Training Methods for Osteoporosis Care

No significant differences were observed between urban and suburban centers in the use of in-house lectures or absence of any training (P>0.05). Urban centers showed significantly higher rates of self-directed learning and participation in academic conferences or training programs compared to suburban centers (P<0.05) [TABLE:8].

2.3 GP Knowledge of Osteoporosis Diagnosis and Treatment

2.3.1 Knowledge of Osteoporosis High-Risk Populations

No significant differences were found between urban and suburban GPs in recognizing advanced age, family history of fragility fractures, long-term unhealthy lifestyles, diseases affecting bone metabolism, or medications affecting bone metabolism as risk factors (P>0.05). However, urban GPs showed significantly higher awareness of postmenopausal women as a high-risk group compared to suburban GPs (P<0.05) [TABLE:9].

2.3.2 Knowledge of Osteoporosis Screening Tools

No significant differences were observed between urban and suburban GPs in awareness of the International Osteoporosis Foundation (IOF) One-Minute Osteoporosis Risk Test or the Fracture Risk Assessment Tool (FRAX®) (P>0.05). Urban GPs demonstrated significantly higher awareness of the Osteoporosis Self-assessment Tool for Asians (OSTA) compared to suburban GPs (P<0.05) [TABLE:10].

2.3.3 Knowledge of Osteoporosis-Related Symptoms

No significant differences were found between urban and suburban GPs in recognizing back pain, significant height loss/kyphosis, or spinal deformity as osteoporosis symptoms (P>0.05). However, urban GPs showed significantly higher awareness of compression fractures compared to suburban GPs (P<0.05) [TABLE:11].

2.3.4 Knowledge of Osteoporosis Fracture Risk

No significant differences were observed between urban and suburban GPs in recognizing recent fragility fractures (especially within 24 months), fractures during anti-osteoporosis treatment, multiple fragility fractures, use of bone-damaging medications (e.g., high-dose steroids ≥7.5 mg/d prednisolone for >3 months), high fall risk or chronic disease-related fall history, or FRAX-calculated 10-year major osteoporotic fracture risk >30% or hip fracture risk >4.5% (P>0.05). Urban GPs demonstrated significantly higher awareness of DXA-measured bone density (T<-3.0) as a fracture risk factor compared to suburban GPs (P<0.05) [TABLE:12].

2.3.5 Knowledge of Osteoporosis-Related Examinations and Tests

No significant differences were found between urban and suburban GPs in awareness of X-ray, nuclear medicine examinations, ultrasound bone densitometry, or liver/kidney function tests (P>0.05). Urban GPs showed significantly higher awareness of bone density testing, bone turnover markers, serum calcium/phosphorus, urinary calcium/phosphorus, and blood/urine routine tests, but lower awareness of CT and MRI compared to suburban GPs (P<0.05) [TABLE:13].

2.3.6 Knowledge of Osteoporosis Treatment Medications

No significant differences were observed between urban and suburban GPs in awareness of active vitamin D analogs, parathyroid hormone analogs, estrogen, selective estrogen receptor modulators, or vitamin K2 (P>0.05). Urban GPs demonstrated significantly higher awareness of bisphosphonates, calcitonin, RANKL monoclonal antibody (denosumab), sclerostin monoclonal antibody (romosozumab), and traditional Chinese patent medicines compared to suburban GPs (P<0.05) [TABLE:14].

2.3.7 Knowledge of Osteoporosis Treatment Modalities

No significant differences were found between urban and suburban GPs in awareness of exercise therapy or rehabilitation engineering (P>0.05). Urban GPs showed significantly higher awareness of physical factor therapy and occupational therapy compared to suburban GPs (P<0.05) [TABLE:15].

2.3.8 Knowledge of Osteoporosis Patient Referral Criteria

No significant differences were observed between urban and suburban GPs in recognizing indications for referral, including patients with pain or fracture symptoms requiring diagnosis, serious fracture complications, lack of access to necessary examinations, medication adverse reactions, or absence of relevant treatment drugs at the community level (P>0.05) [TABLE:16].

2.3.9 Difficulties in Osteoporosis Diagnosis and Treatment

No significant differences were found between urban and suburban GPs regarding insufficient experience with newer medications or inadequate ability to establish treatment control targets (P>0.05). However, suburban GPs reported significantly higher rates of insufficient ability to identify high-risk groups, inadequate osteoporosis risk assessment capability, lack of diagnostic confidence, and poor drug selection and compatibility skills compared to urban GPs (P<0.05) [TABLE:17].

2.3.10 Difficulties in Osteoporosis Management

No significant differences were observed between urban and suburban GPs regarding poor patient compliance or limited outpatient consultation time (P>0.05). Suburban GPs reported significantly higher rates of inadequate health education capacity, insufficient examination equipment, incomplete drug provision, lack of expert guidance at community level, and absence of two-way referral pathways with higher-level hospitals compared to urban GPs (P<0.05) [TABLE:18].

3. Discussion

3.1 Community-Based Osteoporosis Diagnosis and Treatment from a Systems Management Perspective

Community health service centers face shortages in osteoporosis examination equipment and laboratory tests, with even more limited treatment options, particularly in suburban areas. Regarding examinations and tests, urban centers achieved availability rates of 92.4% for DXA bone density testing, 50.6% for bone turnover markers, and 91.1% for serum calcium and phosphorus tests—significantly higher than suburban centers' rates of 50.9%, 12.4%, and 65.1%, respectively. No significant urban-suburban differences were observed for X-ray availability (88.6% vs. 87.6%). DXA bone density testing is crucial for early osteoporosis detection and diagnosis, while X-ray examinations, though capable of showing trabecular bone rarefaction, are subjectively influenced and only detect bone loss after 30% depletion, making early detection difficult. Although bone turnover markers and serum calcium/phosphorus tests cannot diagnose osteoporosis, they play important roles in differential diagnosis of bone diseases, fracture risk prediction, treatment adherence monitoring, and drug efficacy evaluation. These findings indicate substantial deficiencies in objective conditions for osteoporosis diagnosis and assessment at the community level, particularly the critically low configuration of bone density testing and bone turnover marker tests in suburban areas.

Notably, suburban centers showed higher CT availability (45.6%) than urban centers, while MRI and nuclear medicine examination availability remained around 1% in both areas. These examinations are valuable for detecting subtle fractures and differential diagnosis of bone diseases, though research indicates CT is even less effective than X-ray for early osteoporosis diagnosis, offering diagnostic value only when patients have obvious osteoporosis or compression fractures. This suggests communities need to better utilize and integrate existing resources according to disease diagnosis requirements and equipment characteristics to further improve osteoporosis care quality.

Regarding medication provision, 94.4% of community health centers had at least one anti-osteoporosis drug available, primarily including active vitamin D analogs, bisphosphonates, and traditional Chinese patent medicines. Urban centers showed significantly higher availability of bisphosphonates and active vitamin D analogs (73.4% and 69.6%) compared to suburban centers (45.0% and 53.3%). Additionally, 10.9% of centers only had traditional Chinese patent medicines available. Research on osteoporosis-related drug consumption in a community setting found that while calcium supplements consistently ranked first in usage, alendronate sodium consumption showed an upward trend while some traditional Chinese patent medicines significantly declined. This indicates current demand for more comprehensive provision of commonly used anti-osteoporosis drugs in community health centers, particularly in suburban areas needing strengthened availability of essential medications.

In terms of treatment modalities, traditional Chinese medicine appropriate techniques were widely implemented with no urban-suburban difference (79.7% vs. 80.5%). However, urban centers showed higher implementation rates for exercise therapy (73.4% vs. 50.3%), physical factor therapy (73.4% vs. 37.9%), and occupational therapy (65.8% vs. 38.5%). Osteoporosis management requires comprehensive approaches, and guidelines mention multiple rehabilitation modalities including exercise, physiotherapy, and occupational therapy. Literature also reports that combinations such as traditional Chinese medicine with exercise interventions or anti-osteoporosis drugs with physiotherapy can improve symptoms, reduce pain, regulate bone metabolism, and increase bone density. This suggests community health centers, particularly in suburban areas, have substantial potential to expand non-pharmacological treatment technologies.

Regarding chronic disease management, routine chronic disease management work was significantly underdeveloped, with implementation rates of only 35.4% in urban centers and even lower at 16.6% in suburban areas. Notably, urban centers outperformed suburban centers in rehabilitation services (64.6% vs. 28.4%), specialized clinics (41.8% vs. 14.2%), screening (26.4% vs. 24.9%), and health education (70.9% vs. 55.6%). A community survey revealed that 90.12% of residents hoped to receive osteoporosis-related knowledge training, preferring online or community health promotion activities. This indicates communities need to strengthen not only systematic chronic disease management but also health education tailored to residents' needs for better prevention and early intervention. Regarding information systems, only 36 centers had osteoporosis-related information infrastructure, with no urban-suburban difference. Studies have reported that information-based management integrating multidisciplinary teams can better improve pain symptoms, quality of life, and health literacy in chronic disease patients. This suggests that strengthening information system construction is an important strategy for osteoporosis chronic disease management.

Community health centers reported that main management difficulties included insufficient examination equipment, incomplete drug provision, and limited physician competency. Regarding equipment and drug shortages, suburban centers reported higher rates (86.4% and 90.5%) than urban centers (72.2% and 78.5%). Combined with findings that urban centers had better provision of key examinations (bone density) and medications (bisphosphonates, active vitamin D analogs) while suburban centers had higher CT availability, this suggests communities need not only to strengthen equipment and drug provision but also make rational prioritization decisions based on their characteristics. Regarding limited physician competency, urban and suburban centers showed no significant difference (79.7% vs. 82.8%). However, only 1.3% of urban centers reported no training activities, compared to 6.5% of suburban centers, indicating current training still falls short of meeting community needs for disease diagnosis and management.

3.2 Community-Based Osteoporosis Diagnosis and Treatment from an Individual Competency and Standardization Perspective

For disease screening and assessment, GPs generally demonstrated high awareness of osteoporosis high-risk populations, with suburban GPs showing slightly lower awareness of postmenopausal women (97.8%) compared to urban GPs (99.2%). Postmenopausal women represent the primary population affected by osteoporosis. A systematic review noted that postmenopausal osteoporosis and fragility fractures variably reduce health-related quality of life (HRQoL), with bone density positively correlated and fracture severity negatively correlated with HRQoL. This suggests suburban GPs need to strengthen disease assessment and prevention awareness for this population.

Regarding screening tools, urban GPs showed higher awareness of OSTA (88.3%) compared to suburban GPs (84.4%). Although OSTA has relatively low specificity and is primarily used for postmenopausal women, it is intuitive and convenient, with positive results indicating the need for bone density testing and offering predictive value for fracture risk. This indicates that GPs in community health centers need to enhance OSTA awareness and screening consciousness for at-risk populations.

For symptom recognition, suburban GPs showed lower awareness of compression fractures (92.2%) compared to urban GPs (97.0%). For fracture risk assessment, fewer than 90% of GPs recognized "DXA-measured bone density (T<-3.0)" and "high fall risk or chronic disease-related fall history" as risk factors, and fewer than 80% recognized "FRAX-calculated 10-year major osteoporotic fracture risk >30% or hip fracture risk >4.5%." Bone density values and FRAX are important risk assessment tools for osteoporotic fractures. A survey reported osteoporosis prevalence of 5.0% in men and 20.6% in women over 40 years old in China, with vertebral fracture rates of 10.5% in men and 9.7% in women. This suggests community GPs need to strengthen fracture risk assessment for osteoporosis patients.

Regarding examinations, urban GPs showed higher awareness of bone density testing (97.2% vs. 92.1%), while suburban GPs demonstrated higher awareness of X-ray, CT, and MRI (70.6% and 34.9% vs. 66.2% and 27.4%). Combined with insufficient bone density equipment availability and higher CT availability in suburban areas, this suggests GP diagnosis is limited by equipment conditions while also indicating potential for utilizing existing X-ray, CT, and MRI for differential diagnosis and fracture assessment. For laboratory tests, urban GPs showed higher awareness of bone turnover markers (67.6% vs. 45.2%), serum calcium/phosphorus (92.6% vs. 87.0%), and urinary calcium/phosphorus (53.9% vs. 46.9%), suggesting GPs need to strengthen utilization of these tests for disease assessment. Notably, awareness of blood/urine routine tests was 44.9% in urban GPs versus 39.2% in suburban GPs, while liver/kidney function test awareness was 52.3% and 47.5%, respectively, with no significant difference. Reports have linked anti-osteoporosis drug adverse reactions to patients' 25-hydroxyvitamin D levels, suggesting GPs need to strengthen individualized patient education based on disease treatment characteristics.

For treatment medications, urban GPs showed higher awareness of bisphosphonates, calcitonin, RANKL monoclonal antibody (denosumab), sclerostin monoclonal antibody (romosozumab), and traditional Chinese patent medicines. Urban GPs' awareness of bisphosphonates reached 95.4%, while urban centers' provision rate was 73.4%, suggesting treatment is limited by existing conditions. Awareness of active vitamin D analogs and traditional Chinese patent medicines was 64.6%/43.9% in urban GPs and 60.6%/32.8% in suburban GPs, indicating need for strengthened knowledge and application of these important osteoporosis medications.

For non-pharmacological treatments, community GPs demonstrated good awareness of exercise therapy, physical factor therapy, occupational therapy, and rehabilitation engineering (all >85%), suggesting substantial potential for expanding these underutilized treatments.

Regarding patient referral criteria, no urban-suburban differences were observed in recognizing indications such as medication adverse reactions or lack of community treatment drugs, though awareness rates were below 80%. Studies have reported that a two-way referral model based on hierarchical diagnosis and treatment systems can improve bone metabolism, bone density, and quality of life in elderly osteoporosis patients. This suggests community GPs need to strengthen awareness of drug indications, contraindications, and adverse reactions while enhancing two-way referral consciousness in disease management.

Regarding diagnostic difficulties, the most frequently reported challenge was "insufficient experience with newer medications" (85.3% urban, 82.8% suburban). Other difficulties including "insufficient drug selection and compatibility ability," "inadequate osteoporosis risk assessment capability," and "insufficient high-risk group identification ability" were more pronounced among suburban GPs. For management difficulties, suburban GPs reported higher rates of insufficient examination equipment (84.2%) and lack of expert guidance (76.6%). These findings indicate that improving osteoporosis diagnosis and management requires simultaneous enhancement of GP competency and community support with essential equipment and resources.

3.3 Strategies for Improving Community-Based Osteoporosis Diagnosis and Management Quality

Based on current survey findings regarding community health centers and GPs, the following strategies are proposed to improve osteoporosis care quality: (1) Strengthen and improve provision of essential diagnostic equipment and medications in primary care institutions, focusing on bone density testing, bone turnover markers, active vitamin D analogs, and bisphosphonates. Community health centers should also appropriately develop non-pharmacological treatments such as exercise therapy, physical factor therapy, occupational therapy, and traditional Chinese medicine appropriate techniques based on their conditions and foundations. (2) GP training should address identified needs and disease characteristics, emphasizing key priorities while strengthening practical skills, including detailed explanations of examination and treatment modalities, rational selection and application of relevant tests, and knowledge of drug contraindications, indications, dosages, and administration to enhance diagnostic confidence and treatment capability. (3) Given current equipment shortages and limited physician competency, communities should strengthen systematic comprehensive management through improved information system construction, streamlined service processes encompassing community education, screening, specialized diagnosis and treatment, standardized documentation, and patient self-management, while coordinating multidisciplinary teams and multi-party resources such as enhanced specialist-GP collaboration for osteoporosis care.

4. Conclusion

Current community health service institutions in Shanghai face inadequate conditions for osteoporosis diagnosis and treatment, particularly in suburban areas, with shortages of essential examination and testing equipment such as bone density and bone turnover markers, insufficient provision of key medications including bisphosphonates and active vitamin D analogs, and limited implementation of non-pharmacological treatments like exercise, physiotherapy, and occupational therapy. Management approaches lack systematic disease education, screening, and information-based specialized disease management. Community GPs currently have insufficient diagnostic and treatment competency, particularly in suburban centers, manifested by inadequate health education capacity, limited knowledge of specific applications for examinations, tests, and medications, and insufficient awareness of osteoporotic fracture risks. In addition to strengthening equipment, medication provision, and personnel training, it is recommended to enhance information system construction and integrate multidisciplinary teams and multi-party resources for systematic comprehensive disease management.

This study has certain limitations. The investigation and analysis of osteoporosis diagnostic and treatment capacity in Shanghai community health service institutions primarily relied on self-reported feedback from community GPs and quality control officers. Deeper problem identification will require future on-site inspections and verification of relevant data.

Author Contributions: ZHANG Hanzhi was responsible for questionnaire design, data analysis, manuscript drafting, and revision; JIN Hua and MA Le contributed to questionnaire revision, distribution, and data collection; SHI Ling, CHEN Chen, and HUAN Hongmei participated in questionnaire revision and study design; YU Dehua conceived the research idea, designed the overall study protocol, and takes responsibility for the manuscript.

Conflict of Interest: The authors declare no conflict of interest.

ORCID iDs:
ZHANG Hanzhi: https://orcid.org/0009-0005-4640-3221
YU Dehua: https://orcid.org/0000-0001-7652-938X

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Received: 2025-04-24; Revised: 2025-07-09
Edited by: KANG Yanhui