Legal-involved veterans are less likely to receive guideline-concordant colorectal cancer screening

Programs to improve health care for adults with criminal legal involvement, including those who have been released from incarceration in jails or prisons or who are under court or community supervison, understandably focus on treatment for mental illness, drug overdose, and suicide. However, criminal legal-involved adults also have higher risk of developing and dying from medical conditions, such as cancer, relative to the general population. Colorectal cancer (CRC) screening among legal-involved adults, particularly those who have been incarcerated, might be delayed or missed.

We conducted an observational study of national Veterans Health Administration (VHA) electronic health record data to compare the CRC screening rate between legal-involved Veterans, identified through their contact with the Veterans Justice Programs, and non-legal-involved Veterans. We included patients ages 46 to 75 eligible for average-risk screening in fiscal year 2022. Our main outcome of guideline-concordant CRC screening included stool-based testing, CT colonography, flexible sigmoidoscopy, and colonoscopy. Comparisons were estimated using an unadjusted multilevel logistic regression model with a random intercept for facility. Secondary analyses included examining associations between patient-level factors and screening receipt using adjusted models as well as assessing the variation in screening rates across 129 VHA facilities.

There were 27,597 legal-involved and 3,467,396 non-legal-involved patients who met screening eligibility. Only 47% of legal-involved patients were up to date with screening, compared to 54% of non-legal-involved patients (OR = 0.77 [95% CI: 0.75 to 0.79]; risk difference = -6.5% [95% CI: -7.1% to -5.9%]). Adjusted odds of screening were higher for patients with an assigned primary care provider (OR = 2.49 [95% CI: 2.48 to 2.51]). Screening rates varied widely across facilities, ranging from 24 to 75% for legal-involved patients and from 30 to 68% for non-legal-involved patients. Legal-involved patients had significantly lower screening rates at 49 facilities and a higher rate at two facilities, compared to non-legal-involved patients.

Nearly half of VHA patients were behind on recommended CRC screening, and legal-involved VHA patients had even lower rates. Current VHA efforts to improve legal-involved patients' connection to primary care providers may result in improved screening rates.