Rural–Urban and Appalachian Disparities in Geographic Access to Colonoscopy and Screening Prevalence Across the Contiguous US

Sima Namin

doi:10.5888/pcd23.260126

Rural–Urban and Appalachian Disparities in Geographic Access to Colonoscopy and Screening Prevalence Across the Contiguous US

ORIGINAL RESEARCH — Volume 23 — August 27, 2026

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Composition of colonoscopy providers/procedures aggregated by rurality, Appalachian status, and procedure type, using 2023 Medicare Physician and Other Practitioners by Provider and Service Public Use File; CMS National Plan and Provider Enumeration System May 2025 Data Dissemination File; 2020 US Census tract boundaries; Rural–Urban Commuting Area codes 2020; and Appalachian Regional Commission county designation. The proportion of colonoscopies attributed to each provider category (gastroenterology, general surgery, ambulatory surgical centers, other) was calculated as the share of total colonoscopy services contributed by that category within each census tract.
Geography/procedure	Stratum	Type of colonoscopy provider	No. of services provided	Provider share, %
Contiguous US
Diagnostic/therapeutic procedures	Rural	Gastroenterology	134,041	49.0
		General surgery	74,221	27.1
		Ambulatory surgical centers	40,517	14.8
		Other	24,603	9.0
	Urban	Gastroenterology	1,704,112	59.2
		General surgery	102,479	3.6
		Ambulatory surgical centers	847,739	29.4
		Other	224,795	7.8
Screening procedures	Rural	Gastroenterology	24,854	39.4
		General surgery	20,719	32.9
		Ambulatory surgical centers	11,355	18.0
		Other	6,089	9.7
	Urban	Gastroenterology	285,329	50.4
		General surgery	30,481	5.4
		Ambulatory surgical centers	203,311	35.9
		Other	47,490	8.4
Appalachian states
Diagnostic/therapeutic procedures	Rural Appalachia	Gastroenterology	28,951	54.3
		General surgery	11,112	20.8
		Ambulatory surgical centers	9,937	18.6
		Other	3,310	6.2
	Rural non-Appalachia	Gastroenterology	40,380	58.2
		General surgery	13,177	19.0
		Ambulatory surgical centers	8,737	12.6
		Other	7,044	10.2
	Urban Appalachia	Gastroenterology	100,579	59.9
		General surgery	7,454	4.4
		Ambulatory surgical centers	46,140	27.5
		Other	13,728	8.2
	Urban non-Appalachia	Gastroenterology	476,976	60.3
		General surgery	26,754	3.4
		Ambulatory surgical centers	205,077	25.9
		Other	82,684	10.4
Screening procedures	Rural Appalachia	Gastroenterology	5,807	48.6
		General surgery	2,520	21.1
		Ambulatory surgical centers	2,722	22.8
		Other	910	7.6
	Rural non-Appalachia	Gastroenterology	7,785	47.1
		General surgery	4,344	26.3
		Ambulatory surgical centers	2,258	13.7
		Other	2,136	12.9
	Urban Appalachia	Gastroenterology	17,711	52.4
		General surgery	2,174	6.4
		Ambulatory surgical centers	10,922	32.3
		Other	3,011	8.9
	Urban non-Appalachia	Gastroenterology	79,027	50.9
		General surgery	8,965	5.8
		Ambulatory surgical centers	49,643	32.0
		Other	17,575	11.3

Figure 1. Composition of colonoscopy providers/procedures aggregated by rurality, Appalachian status, and procedure type, using 2023 Medicare Physician and Other Practitioners by Provider and Service Public Use File; CMS National Plan and Provider Enumeration System May 2025 Data Dissemination File; 2020 US Census tract boundaries; Rural–Urban Commuting Area codes 2020; and Appalachian Regional Commission county designation. The proportion of colonoscopies attributed to each provider category (gastroenterology, general surgery, ambulatory surgical centers, other) was calculated as the share of total colonoscopy services contributed by that category within each census tract.

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A map of the contiguous US shows that geographic access to colonoscopy providers varies substantially. Areas with lower access are concentrated in many rural regions, particularly across the western US and parts of the Appalachian region, whereas higher access is more common in metropolitan and densely populated areas. Within Appalachia, access is heterogeneous, with localized clusters of both high and low access, reflecting considerable variation across the region.

Figure 2. Geographic access to colonoscopy providers at the census tract level in A) the contiguous US and B) in Appalachian states, 2020 US Census tract boundaries and American Community Survey 2019–2023 5-year estimates. Access quintiles (Map A) and E2SFCA quintiles (Map B) represent the same E2SFCA accessibility measure, categorized into quintiles, with Q1 indicating the lowest geographic access and Q5 indicating the highest geographic access. Panel B provides a zoomed-in view of the Appalachian region. Abbreviations: E2SFCA, enhanced 2-step floating catchment area; NA, not applicable

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