S253 Colorectal Cancer Screening Rates at Federally Qualified Health Centers in 2019 and 2020 Varied Based on Urban-Rural Status and Predominant Racial/Ethnic Group

Abstract

Introduction: Over 30 million low-income and underinsured individuals in the U.S. receive primary care services, including colorectal cancer (CRC) screening, at Federally Qualified Health Centers (FQHCs). Given known differences in healthcare access in rural settings, we aimed to quantify CRC screening rates and factors associated with a decline in screening between 2019 and 2020 at FQHCs based on urban-rural status. Methods: We abstracted data from the Uniform Data System (UDS)—which compiles preventive health utilization data, including CRC screening rates among patients ages 50-74—for each FQHC. Our primary outcome was screening rate change (SRC), calculated as 2020 CRC screening rate minus 2019 CRC screening rate. We separated FQHCs based on urban-rural status and then created quartiles based on SRC. We used Wilcoxon Rank-Sum and x2 testing to compare rural and urban FQHCs and performed backward stepwise multivariable logistic regression to determine FQHC-level characteristics (2020 data) associated the largest decline in screening participation between 2019 and 2020 (SRC Q1 status). Results: In 2020, 734 urban and 527 rural FQHCs served 6,438,433 patients who were age-eligible for CRC screening. FQHC characteristics were significantly different between urban and rural FQHCs (Table). CRC screening rates were lower in rural FQHCs than urban FQHCs in 2019 (p=0.04) and 2020 (p< 0.0001), and SRC was lower in urban (-3.6%) than rural (-1.2%) FQHCs (p< 0.0001) (Table). Urban FQHCs were more likely to see a decline in CRC screening in 2020 if they served a majority non-Hispanic Black patients (aOR 2.05, 95%CI=1.19-3.52) or if they served a high proportion of uninsured patients (data not shown). Rural FQHCs were more likely to see a decline in CRC screening in 2020 if they served a majority Hispanic/Latinx patients (aOR 2.78, 95% CI=1.50-5.15) or if they were in a non-Medicaid expansion state (aOR 1.81, 95% CI 1.09-2.99) (data not shown). SRC was calculated by state for rural FQHCs and mapped in the Figure. Conclusion: Urban FQHCs had a greater decline in CRC screening rates from 2019 to 2020 than rural FQHCs and experienced larger declines if the patient population was predominantly Black or uninsured. Rural FQHCs saw a steep decline if they served a majority Hispanic/Latinx population or were in a non-Medicaid expansion state. These findings suggest that efforts to increase CRC screening at US FQHCs may need to be tailored to their location, demographics, and insurance and Medicaid eligibility status.Figure 1.: Map of screening rate change (2020 CRC screening rate – 2019 CRC screening rate) by state for rural FQHCs and indication of Medicaid expansion status as of 2020 Table 1. - FQHC characteristics (2020 data), colorectal cancer (CRC) screening rates (2019 and 2020), and screening rate changes (SRC) for urban and rural FQHCs in the US overall and by SRC comparison groups All FQHCs (n=1261) Urban FQHCs (n=734) Rural FQHCs (n=527) p-value* Frequency or percent SRC Q1 (n=218) SRC Q2+Q3+Q4 (n=516) Total (n=734) SRC Q1 (n=98) SRC Q2+Q3+Q4 (n=429) Total (n=527) Total patients eligible for CRC screening (age 50-74) 6,438,433 1,328,330 2,811,734 4,140,064 483,110 1,815,259 2,298,369 n/a CRC screening rate in 2019 (median %) 42.9 48.0 38.3 41.6 48.5 43.7 44.7 0.04 CRC screening rate in 2020 (median %) 38.8 32.4 38.8 36.9 32.7 43.9 42.4 < 0.0001 Median 2019-2020 SRC -2.7 -13.7 -1.2 -3.6 -12.6 0.1 -1.2 < 0.0001 Male patients (median %) 42.9 42.1 42.3 42.2 43.4 43.9 43.8 < 0.0001 Majority Race/Ethnicity served at FQHC (median %) Non-Hispanic White 36.4 16.0 25.2 21.7 66.9 70.4 70.1 < 0.0001 Non-Hispanic Black 8.2 12.7 19.1 17.3 2.6 1.6 1.6 < 0.0001 Hispanic/Latinx 15.8 33.4 24.7 26.8 7.7 5.5 6.1 < 0.0001 Other Non-Hispanic 4.6 5.2 5.9 5.7 2.5 3.4 3.3 < 0.0001 Patients with a preference for non-English Language (median %) 11.7 27.1 17.9 19.2 6.7 3.5 3.8 < 0.0001 Patients experiencing homelessness (median %) 1.8 3.2 2.6 2.7 1.1 1.0 1.0 < 0.0001 Patients with income Level >200% FPL (median %) 4.6 2.9 3.8 3.5 6.5 8.1 7.8 < 0.0001 Uninsured patients (median %) 19.6 23.9 21.5 22.3 19.7 16.2 16.7 < 0.0001 Medicaid Expansion (%) 71.6 76.6 73.6 74.5 59.2 69.5 67.6 0.007 *p-values represent Wilcoxon rank-sum or chisq tests comparing overall characteristics between urban and rural FQHCs.