Sex-specific trends in hip fracture incidence and disparities in DXA utilization in Brazil: a nationwide ecological analysis

This study analyzed sex-specific trends in hip fracture incidence, DXA utilization, and device distribution in Brazil from 2008 to 2022. Hip fracture incidence increased over time, whereas DXA use, particularly among men, remained markedly lower, with substantial disparities in device availability between the public and private sectors. PURPOSE: We aimed to evaluate temporal trends in hip fracture incidence and DXA exam utilization in Brazil, stratified by sex, and to assess DXA device distribution across public and private healthcare sectors. METHODS: This was a retrospective analysis of Brazilian public healthcare databases from January 1, 2008, to December 31, 2022, examining hip fracture hospitalizations, DXA exam utilization, and DXA device availability. RESULTS: From 2008 to 2022, 583,205 hip fractures occurred in individuals ≥ 50 years living in Brazil. In 2022, incidence rates were 155/100,000 in women and 94/100,000 in men; median ages were 80 and 74 years, respectively. Hip fracture incidence increased by 25.8%, with a more pronounced rise after 2015. DXA rates in 2022 were 2177/100,000 in women and 182/100,000 in men ≥ 50; in guideline-recommended groups, 2840/100,000 in women ≥ 65 and 385/100,000 in men ≥ 70. The hip fracture ratio between men and women was ~ 2:3, whereas the DXA exam ratio was 1:10. DXA device availability was 12.2 per million inhabitants overall, with 6.2 in the public sector versus 27 in the private sector. CONCLUSIONS: Hip fracture incidence in Brazil increased over the study period, particularly after 2015, without a proportional expansion in DXA utilization. This mismatch is more pronounced in men, who experience a substantial fracture burden but remain markedly underscreened. These findings highlight structural inequities in access to osteoporosis diagnosis and suggest persistent underdiagnosis, particularly in the public healthcare system.