Rural–Urban Differences in Out-of-Pocket Spending Associated With Colonoscopies Among US Residents Aged 40 and Older

Background

Colorectal cancer (CRC) remains the second most common cause of death in the United States. Morbidity and mortality of CRC are significantly reduced by early detection through colonoscopy, but rural screening rates are lower (and mortality rates higher) than urban rates. Understanding factors influencing screening adherence in rural populations is crucial for reducing disparities in cancer mortality. This study examines differences in out-of-pocket colonoscopy payment category between rural and urban populations.

Methods

This cross-sectional study used data from the National Health Interview Survey 2019 and 2021. Our main exposure was rurality, and our main outcome was how much the individual paid out of pocket for the most recent colonoscopy: none, part, or all of the cost. We estimated a multinomial logistic regression model, adjusted for sociodemographic covariates.

Results

Rural residents were more likely than urban residents to report paying all of the cost (4.12% vs. 3.01%, p = 0.042). Sociodemographic covariates were differentially associated with out-of-pocket colonoscopy spending levels; compared to non-Hispanic whites, significantly more Hispanic individuals reported paying all of the cost (OR: 1.54, 95% CI: 1.03–2.30), and being uninsured or having other or unknown insurance status versus having private insurance was a strong predictor of higher out-of-pocket cost.

Conclusions

We found a modest but statistically significant rural–urban difference in patient-reported out-of-pocket colonoscopy payment. Variation in patient financial responsibility may represent part of the broader access barriers experienced by rural populations. Initiatives directed towards reducing the financial burden of colonoscopies and improving access to alternative screening modalities may help reduce disparities and improve rural outcomes.