中国骨健康领域面临疾病负担较重、治疗覆盖不足与长期治疗依从性不佳并存的挑战。流行病学调查、真实世界研究及临床服务质量审计显示，患者疾病认知不足、长期用药负担、药物给药要求、经济因素，以及院内治疗与院外随访衔接不畅，均可能影响规范治疗的启动与持续。临床药师主导的个体化干预研究进一步提示，将数字化提醒与专业人员主动随访相结合，有望改善患者药物覆盖率和复诊行为，但现有证据仍受到样本规模、研究设计及单中心数据等因素限制。本文从中国临床一线视角出发，提出骨健康产业应从单纯关注药物可及性与处方增长，转向以治疗启动、持续用药、复诊管理和骨折预防为核心的全周期患者服务，并通过真实世界数据评估干预效果与成本效益，为临床实践优化及市场服务模式创新提供参考。
China’s bone health sector faces the combined challenges of a substantial disease burden, inadequate treatment coverage, and suboptimal long-term adherence. Epidemiological surveys, real-world studies, and clinical quality audits suggest that limited disease awareness, treatment burden, medication administration requirements, financial constraints, and fragmented post-discharge follow-up may undermine treatment initiation and persistence. Research on clinical pharmacist-led interventions indicates that combining digital reminders with proactive professional follow-up may improve medication coverage and appointment attendance, although the evidence remains limited by sample size, study design, and single-center settings. From the perspective of frontline clinical practice in China, this article argues for a shift from focusing primarily on drug accessibility and prescription growth toward comprehensive patient services centered on treatment initiation, persistence, follow-up, and fracture prevention. Real-world evidence should be used to evaluate intervention effectiveness and cost-effectiveness, informing improvements in clinical practice and innovation in bone health market services.
一、市场现状：高疾病负担与低治疗覆盖并存 | Market Landscape: High Disease Burden, Low Treatment Coverage
中国骨健康市场的核心矛盾，正在从疾病识别与药物可及性，延伸至长期治疗的持续性。骨质疏松症具有隐匿性、慢性进展性和骨折后果严重等特点，患者在发生脆性骨折前往往缺乏明显症状，难以形成持续就医和用药的主动意识。
China’s bone health market faces a challenge that extends beyond disease recognition and drug access to long-term treatment persistence. Osteoporosis is often asymptomatic until a fragility fracture occurs, making it difficult for patients to appreciate the need for preventive treatment and sustained medication use.
中国骨质疏松症患病负担具有明确的流行病学依据。《中国骨质疏松症流行病学调查及“健康骨骼”专项行动结果》显示，50岁以上人群骨质疏松症患病率为19.2%，其中男性为6.0%、女性为32.1%；65岁以上人群患病率进一步升高。另一项覆盖中国大陆20,416名40岁及以上人群的全国性研究发现，符合骨质疏松诊断或存在相关骨折的男女中，接受抗骨质疏松治疗以预防骨折的比例分别仅为0.3%和1.4%。这些数据提示，疾病负担与预防性治疗之间存在显著落差。[1,2]
China’s osteoporosis burden is well documented. A national epidemiological survey reported a prevalence of 19.2% among adults aged 50 and older, rising to 32.1% among women and 6.0% among men in this age group. A separate nationwide study of 20,416 adults aged 40 and older found that only 0.3% of men and 1.4% of women meeting the study’s osteoporosis or fracture-related criteria were receiving anti-osteoporosis treatment for fracture prevention. These findings highlight a substantial gap between disease burden and preventive treatment.[1,2]
二、临床一线的依从性挑战：不仅是患者“不配合” | Frontline Clinical Challenges: More Than Patient Noncompliance
首先，患者对疾病风险的认知不足。部分患者将骨质疏松视为衰老的自然现象，认为补钙、晒太阳或减少活动即可应对风险；疼痛缓解或骨折愈合后，也容易误以为治疗已经结束。对于尚未发生骨折的患者，药物获益难以被直观感知，而长期用药的成本、不良反应顾虑和服药负担却十分具体。
First, patients may underestimate the risks of osteoporosis. Some regard it as an inevitable consequence of aging and assume that calcium supplementation, sunlight exposure, or reduced physical activity is sufficient. Once pain improves or a fracture heals, they may believe treatment is no longer necessary. For patients without fractures, the benefits of medication are often invisible, whereas concerns about cost, adverse effects, and treatment burden are immediate.
其次，治疗方案与日常生活之间存在摩擦。口服双膦酸盐可能涉及空腹服用、饮水量及服药后体位要求；注射类药物则需要按时复诊、承担费用并协调医疗资源。高龄患者还可能同时服用多种慢性病药物，面临记忆力下降、照护不足及往返医院困难等问题。不同药物的给药频率、给药要求和停药风险各异，因此不能将依从性简单归结为患者意愿。
Second, treatment regimens can conflict with daily routines. Oral bisphosphonates may require fasting administration, adequate water intake, and specific post-dose positioning. Injectable therapies require scheduled visits, financial planning, and access to clinical services. Older patients may also face polypharmacy, memory difficulties, limited caregiver support, and transportation barriers. Because dosing requirements and discontinuation risks differ across treatments, adherence cannot be explained by patient motivation alone.
再次，院内治疗与院外管理容易脱节。骨折患者在住院期间可能完成骨密度评估并启动治疗，但出院后缺少固定随访、复诊提醒和跨机构转诊，治疗管理随之中断。2026年发表的一项中国医院髋部骨折二级预防质量审计显示，该院住院期间骨密度评估率达到97.1%，药物启动率达到94.0%，但出院后治疗持续性仍存在明显缺口。研究者指出，医院主导的诊疗路径与基层医疗衔接不足、缺少专职骨折联络服务协调人员，是持续管理的潜在障碍。该研究属于单中心审计，不能直接代表全国水平，但揭示了值得关注的服务断点。[3]
Third, continuity between inpatient care and community-based management remains a concern. Patients may receive bone mineral density assessments and initiate treatment during hospitalization, yet lose contact with the care team after discharge. A Chinese hospital-based audit published in 2026 reported inpatient bone mineral density assessment and medication initiation rates of 97.1% and 94.0%, respectively, while identifying substantial gaps in post-discharge treatment persistence. The authors highlighted weak integration with primary care and the absence of dedicated fracture liaison coordinators as potential barriers. Although this single-center study cannot represent the entire country, it illustrates an important point of failure in the care pathway.[3]
三、数据揭示的机会：持续管理比单纯提醒更重要 | What the Evidence Reveals: Sustained Support Matters More Than Reminders Alone
一项发表于《Osteoporosis International》的中国真实世界研究，为改善依从性提供了可量化的案例。研究纳入宁波某医院85名接受地舒单抗治疗的患者，其中32人进入临床药师主导的依从性管理组，53人为对照组。随访一年后，管理组药物覆盖率指标PDC的中位数为0.9875，对照组为0.5；管理组后续复诊率为93.8%，而对照组无人返院接受后续注射。疫情相关时期，管理组后续复诊率也由93.75%下降至68.75%。[4]
A real-world study from China, published in Osteoporosis International, provides measurable evidence of the potential benefits of adherence support. The study enrolled 85 patients receiving denosumab at a hospital in Ningbo: 32 participated in a clinical pharmacist-led adherence management program, while 53 received usual care. At one year, the median proportion of days covered (PDC) was 0.9875 in the intervention group versus 0.5 in the control group. Follow-up attendance reached 93.8% in the intervention group, while no control-group patients returned for subsequent injections. During the COVID-19-related period, follow-up attendance in the intervention group fell from 93.75% to 68.75%.[4]
这项研究的价值不在于证明某一模式适用于所有医疗机构，而在于揭示了干预机制：系统提前提醒患者及家属，识别未按时复诊者，再由药师通过电话进行个体化沟通和用药教育。研究讨论指出，单靠短信并不足够，医务人员的二次提醒、风险解释和持续沟通发挥了重要作用。研究样本较小且为非随机分组，结果仍需更大规模研究验证，但为数字化管理与专业人员服务结合提供了实践依据。
The significance of this study lies not in proving that one model works everywhere, but in demonstrating a plausible intervention mechanism: automated reminders identify patients approaching their next dose, while pharmacists follow up with those who miss appointments and provide individualized education. The authors emphasized that text messages alone were insufficient; direct communication and professional counseling played important roles. Given the small sample and nonrandomized design, the findings require confirmation in larger studies, but they offer a practical rationale for combining digital tools with professional support.
四、市场洞察：从销售药物转向管理治疗结果 | Market Insight: From Selling Medicines to Managing Treatment Outcomes
对骨健康产业而言，依从性挑战意味着市场价值不应仅由患者数量、处方量或药物销售额衡量。更值得关注的指标包括治疗启动率、按期复诊率、药物覆盖率、持续治疗时间、骨折后规范治疗比例，以及患者失访原因。企业、医院与药学服务机构可以围绕这些指标建立可追踪的患者管理体系。
For the bone health industry, adherence challenges suggest that market value should not be measured solely by patient numbers, prescription volume, or drug sales. More meaningful indicators include treatment initiation, on-time follow-up, medication coverage, persistence, appropriate treatment after fracture, and reasons for patient attrition. Pharmaceutical companies, hospitals, and pharmacy service providers can build patient management systems around these measurable outcomes.
未来具有潜力的服务模式包括：基于风险分层的患者教育、药师主导的随访、注射周期管理、骨折联络服务（FLS）、院内与基层医疗协同，以及经患者授权的数据驱动失访预警。服务设计还应兼顾老年患者的数字使用能力，保留电话、家属协助和人工干预等渠道，并以患者隐私保护和临床决策规范为前提。
Promising service models include risk-stratified patient education, pharmacist-led follow-up, injection-cycle management, fracture liaison services (FLS), coordination between hospitals and primary care, and consent-based, data-driven alerts for patients at risk of dropping out. These services should accommodate older adults with limited digital literacy through telephone support, caregiver involvement, and human intervention, while safeguarding patient privacy and respecting clinical decision-making.
从市场策略看，最重要的转变是将依从性视为可设计、可测量、可持续优化的临床服务，而非单纯的患者行为问题。真正具有竞争力的骨健康解决方案，需要把循证治疗、患者沟通、复诊执行与结局评估连接起来，并通过真实世界数据验证其有效性、可及性和成本效益。
Strategically, adherence should be treated as a clinical service that can be designed, measured, and continuously improved—not merely as a patient behavior problem. Competitive bone health solutions will connect evidence-based treatment, patient communication, appointment completion, and outcome evaluation, with real-world data used to assess effectiveness, accessibility, and cost-effectiveness.
参考文献 | References
1. Wang L, Yu W, Yin X, et al. Prevalence of Osteoporosis and Fracture in China: The China Osteoporosis Prevalence Study. JAMA Network Open. 2021;4(8):e2121106.
2. 中华医学会相关骨质疏松症流行病学调查研究团队. 中国骨质疏松症流行病学调查及“健康骨骼”专项行动结果。相关患病率数据可参见中国骨质疏松症风险管理指南及其引用文献。
3. International benchmarking of secondary fracture prevention in older adults with hip fracture: a Chinese hospital-based KPI audit. Frontiers in Health Services. 2026.
4. Yang Q, He J, Yuan F. Improvement of proportion of days covered for denosumab under implementation of clinical pharmacist adherence management system: normal and COVID-19 period. Osteoporosis International. 2024;35:309–316.
5. Lu Y, et al. Osteoporotic Fracture Guidelines and Medical Education Related to the Clinical Practices: A Nationwide Survey in China. Orthopaedic Surgery. 2019.