Despite being one of the most prevalent bone diseases in Hong Kong, osteoporosis is estimated to go undiagnosed and untreated in up to 80% of those affected, largely because the disease is asymptomatic until a fracture occurs. By embedding screening within the familiar and accessible setting of community pharmacies, this programme represents a significant step forward in closing the gap between disease burden and clinical intervention.

Osteoporosis Can Lead to Fragility Fractures with Mortality Rates Comparable to Major Cancers

Osteoporosis affects approximately 30% of women and 8% of men aged over 50 or above in Hong Kong, causing progressive deterioration of bone density that leaves patients vulnerable to fragility fractures — fractures that occur from low-impact forces such as a minor fall or even a sudden movement. These fractures carry consequences far beyond physical injury.

Research demonstrates that the one-year mortality rate following a hip fracture can exceed that of certain common cancers, including prostate and breast cancer. Local hospital data further indicate that nearly half of all patients who sustain a fragility hip fracture do not survive beyond five years. Despite these grave outcomes, public awareness remains alarmingly low: international studies suggest that fewer than one in ten at-risk individuals proactively seek a bone mineral density assessment.

Community Pharmacies as an integral part of Primary Healthcare with Pharmacists Playing a Key Role

Recognising the urgent need for a scalable, community-based approach to osteoporosis detection, community pharmacies are increasingly recognised as one of the vital platforms for screening and health education. Community pharmacies play a unique position in the primary healthcare ecosystem — they are among the most frequently visited and trusted healthcare touchpoints in daily life, offering not only medication dispensing but also accessible health consultations, disease prevention education, risk assessments, and referrals, serving as a critical component of the primary healthcare ecosystem.

Standardising the COSA Screening Process to Reach High-Risk Individuals in the Community

Since 2026, the Department of Pharmacology and Pharmacy at HKUMed has collaborated with multiple community pharmacies to introduce a standardised osteoporosis risk assessment protocol into the community, enabling specially trained community pharmacists to utilise the COSA tool to screen high-risk individuals. The assessment requires only four data points — sex, age, body weight, and prior fracture history — and can be completed within minutes during a routine pharmacy visit.

Pharmacists trained in the protocol explain results to patients immediately upon completion. Individuals identified as high-risk receive a written referral to a family physician or other healthcare professionals for further evaluation, including Dual-energy X-ray Absorptiometry (DXA) scanning to confirm diagnosis. All participants, regardless of risk classification, receive bone health education, including guidance on calcium and vitamin D intake, balanced diets, appropriate weight-bearing exercise, fall prevention, and other lifestyle modifications. Studies have demonstrated that these non-pharmacological interventions independently reduce fracture incidence, offering bone protection even in the absence of drug therapy.

Promising Early Results: Approximately 60% of High-Risk Individuals Willing to Undergo Assessment

Since the programme's launch, community pharmacists have proactively approached over 1,000 high-risk individuals — defined as men aged 70 or above, women aged 65 or above, and adults aged 50 or above with at least one additional osteoporosis risk factor — and invited them to complete the COSA assessment. Notably, approximately 60% of those approached agreed to undergo the assessment, demonstrating that community pharmacy-based osteoporosis screening is an effective means of raising public awareness of the disease and encouraging individuals to take an active role in managing their own health. Of those assessed, more than 100 individuals were identified as being at very high risk for osteoporosis and were referred to family physicians for further diagnostic workup. These findings confirm that this service model can effectively reach and identify undiagnosed high-risk individuals hidden within the community, facilitating early detection and timely intervention.

"Osteoporosis is a disease that is too often discovered only after a fracture has already occurred," said Professor Cheung Ching-lung, Associate Professor, Department of Pharmacology and Pharmacy, HKUMed. "By integrating COSA screening into community pharmacies, we have been able to reach a substantial number of high-risk individuals who had never previously undergone assessment. Establishing routine screening services within community pharmacies not only helps elevate public understanding of bone health but also facilitates the early identification of undiagnoised patients, promoting timely diagnosis and treatment through established referral pathways."

Proactive Outreach by Community Pharmacies Enhances Screening Accessibility

The Diamond Hill Family Pharmacy, operated by the Christian Family Service Centre (CFSC), is among the participating sites offering osteoporosis screening and health counselling as part of this programme. "Community pharmacies are places people trust and visit regularly. This programme demonstrates precisely how community-based healthcare can extend disease prevention and health education into everyday life. We are delighted to support this clinical model that brings practical osteoporosis screening services into the community so that more high-risk individuals can receive early assessment." said Mr Gary Kong Ching-yue, Programme Director - Primary Health Care Services, CFSC.

Ms Kuki Ku, a CFSC community pharmacist involved in the programme, highlighted a natural entry point that has proven particularly effective: many older adults visit pharmacies routinely to purchase calcium supplements or vitamin D — products directly associated with bone health. This provides pharmacists with an organic opportunity to initiate a conversation about bone health, introduce the COSA assessment, and deliver personalised guidance on nutrition and exercise to support bone density maintenance. Ms Ku recalled one particularly illustrative case: during a routine COSA screening, she identified an elderly woman as being at high risk for osteoporosis and promptly referred her to a family doctor for further evaluation, including a DXA scan. The scan revealed osteoporosis . She is currently consulting with her doctor on follow-up management to reduce further bone loss.

Ms Shum, a participant of COSA screening service in her eighties living with hypertension, hyperglycaemia, and hypercholesterolaemia, visited the pharmacy to collect a blood glucose meter. At the pharmacist's invitation, she completed the COSA osteoporosis screening — an encounter she had not anticipated. Her results indicated a high risk for osteoporosis, and she was issued a referral letter alongside personalised advice on fracture-preventive exercise and dietary calcium intake.

Standardised Guidelines and Training Readiness Pave the Way for Expanded Osteoporosis Screening

With Hong Kong's rapidly ageing population, the number of osteoporosis patients is projected to rise continuously, with hip fracture cases potentially surging several-fold to reach 27,468 cases by 2050. To strengthen community bone health management, the Department of Pharmacology and Pharmacy at HKUMed has developed a comprehensive practice guideline for community-based osteoporosis screening services. These guidelines encompass the latest disease management information, standardised screening protocols, public education materials, and referral mechanisms, and have been officially reviewed by The Osteoporosis Society of Hong Kong (OSHK).

Additionally, the Department has launched an online Continuing Pharmacy Education (CPE) course to provide training for pharmacists, supporting the standardised development of the service. With guidelines, training courses, and referral pathways now established, the community screening service is fully equipped for expansion. This sets the foundation for more community pharmacies to adopt the service and enables future integration into District Health Centres (DHCs) and other primary healthcare platforms, working collaboratively to build a comprehensive bone health management network rooted in "early identification, timely diagnosis, and prompt treatment."

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About the Chinese Osteoporosis Screening Algorithm (COSA)

The Chinese Osteoporosis Screening Algorithm (COSA) is a risk prediction tool developed by The Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, the University of Hong Kong, specifically tailored for the Chinese population. Unlike previous risk prediction tools, such as FRAX and OSTA, which have demonstrated biases due to ethnic differences, COSA offers greater accuracy for Chinese demographics. This algorithm assesses an individual's risk of developing osteoporosis by posing four straightforward questions related to gender, weight, age, and fracture history, achieving an accuracy rate between 74% and 94%.

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