Insurance Coverage and Distribution of DXA Screening in Saudi Arabia: Evidence from Major Healthcare Settings.

Background: Osteoporosis is a major public health concern, and early detection through dual-energy X-ray absorptiometry (DXA) has been pivotal. However, evidence on how insurance coverage relates to the distribution of patients receiving DXA examinations in Saudi Arabia remains limited. This study examines the distribution of patients receiving DXA examinations across different insurance types and healthcare settings among adult patients in Saudi Arabia. Methods: This retrospective observational study used de-identified electronic health record data from a public tertiary academic center and a large private healthcare system in Saudi Arabia between 1 January 2023 and 28 February 2026. Dual-energy X-ray absorptiometry (DXA) was employed as an imaging method used to measure bone mineral density and support osteoporosis diagnosis and fracture-risk assessment. Adult patients aged ≥18 years with completed DXA examinations recorded in radiology service records were included. This study assessed the distribution of patients receiving DXA examinations across insurance types, healthcare setting, ordering department, and year of service. Insurance type was categorized as government coverage, private insurance, or self-pay. Descriptive statistics, chi-square tests, one-way ANOVA, Cramér's V, and standardized residuals were used to compare distribution patterns across groups. Results: The data of 8930 DXA recipients were analyzed. Clear differences were observed in the distribution of patients by insurance type and healthcare setting (p < 0.001). Privately insured patients were predominantly treated in private facilities, whereas government-insured and self-pay patients were primarily concentrated in public healthcare facilities. Significant variations were also observed across healthcare departments and over time, demonstrating strong system-level and financial stratification in the distribution of patients receiving DXA examinations. Conclusions: The findings of this study demonstrate significant differences in the distribution of patients receiving DXA examinations according to insurance type and healthcare setting. Notably, self-pay patients were predominantly managed in public healthcare facilities, whereas privately insured patients primarily received DXA examinations in private healthcare settings. These observed patterns suggest that differences in healthcare organization and insurance financing may be associated with where patients receive DXA examinations; however, because this study included only individuals who underwent DXA examinations, the findings should not be interpreted as measures of screening uptake, access, or equity among all patients eligible for osteoporosis screening. Future healthcare strategies should focus on strengthening equitable insurance coverage, improving coordination between public and private healthcare sectors, standardizing referral pathways, and supporting integrated preventive care in line with Saudi Arabia's Vision 2030 healthcare transformation.