Scaling CRC Screening: How Automated Text Nudges Close Gaps Cost-Effectively

A recent randomized clinical trial conducted at NYU Langone Health demonstrates that automated, behaviorally informed text message reminders significantly improve colorectal cancer (CRC) screening completion rates compared to traditional nurse phone calls. The findings, published in JAMA Network Open on April 23, 2026, suggest a scalable and low-cost strategy to address persistent gaps in preventive care uptake.

Study Design and Key Findings

The trial, led by researchers from the Division of Healthcare Delivery Science at NYU Grossman School of Medicine, enrolled 1,275 adults with new fecal immunochemical test (FIT) orders across NYU Langone’s Family Health Centers. Participants were randomly assigned to one of three groups: automated text message reminders with embedded behavioral nudges, nurse phone call reminders, or usual care (no additional outreach beyond standard instructions).

Results showed that 58.9% of patients who received the automated text messages completed their FIT screening, compared to 43.2% in the nurse call group and 35.1% in the usual care group. The text message intervention achieved a 15.7 percentage-point higher completion rate than nurse calls and a 23.8 percentage-point increase over usual care, with statistical significance (P < .001 for both comparisons).

Behavioral Nudges in Text Messaging

The automated text messages incorporated principles from behavioral economics to encourage action. Key features included:

• Personalized framing, such as addressing recipients by first name and referencing their specific clinic location.
• Pre-commitment prompts, asking patients to reply “YES” to confirm their intent to complete the test.
• Loss-framed messaging emphasizing the risks of missing early detection opportunities.
• Simplified instructions with direct links to scheduling or test kit pickup.
• Follow-up messages for non-responders, escalating urgency over time.

Lead author Olivia Korostoff-Larsson, BA, noted that the intervention’s success hinged on reducing friction for patients. The text messages met patients where they were—on their phones—with clear, actionable steps tailored to their individual context, she said. The approach also minimized the cognitive burden associated with traditional outreach methods, which often require patients to answer calls or navigate complex instructions.

Cost and Scalability Advantages

The study highlighted the cost-effectiveness of automated text messaging compared to nurse-led outreach. While the trial did not provide a detailed cost analysis, the authors estimated that text message interventions could be deployed at a fraction of the cost of phone-based reminders, which require significant staff time and resources. The automated system also demonstrated potential for rapid scaling across large patient populations without additional labor demands.

William C. King, MS, a co-author and researcher at NYU Grossman School of Medicine, emphasized the broader implications: This isn’t just about colorectal cancer screening. The principles we tested could be adapted to other preventive services, such as mammograms, vaccinations, or chronic disease management, where patient engagement is critical.

Limitations and Future Directions

The trial had several limitations. It was conducted within a single healthcare system serving a predominantly urban, low-income population in New York City, which may limit generalizability to other settings. The study focused exclusively on FIT completion, rather than colonoscopy or other screening modalities. The authors acknowledged that further research is needed to assess long-term adherence and the intervention’s effectiveness in diverse populations, including rural communities and non-English speakers.

Despite these constraints, the findings align with a growing body of evidence supporting digital health interventions to improve preventive care uptake. A 2025 meta-analysis published in The Lancet Digital Health found that text message reminders increased screening rates by an average of 12% across multiple cancer types, though the effect varied by population and message design.

Public Health Implications

Colorectal cancer remains the third most commonly diagnosed cancer and the second leading cause of cancer-related deaths in the United States, according to the American Cancer Society. Screening rates have improved in recent years but remain below national targets, particularly among underserved populations. The U.S. Preventive Services Task Force recommends regular screening for adults aged 45 to 75, yet as of 2024, only 68% of eligible adults were up to date with screening.

Dr. Isaac Dapkins, MD, Chief Medical Officer of the Family Health Centers at NYU Langone and a co-author of the study, underscored the potential of automated nudges to address disparities. Many of our patients face barriers like transportation, language, or competing priorities. A text message can’t solve all of those, but it can remove one more hurdle by making it easier to follow through on a test they already intend to complete.

Implementation Challenges

While the trial’s results are promising, experts caution that successful implementation requires careful attention to patient privacy, message timing, and cultural appropriateness. The study team worked closely with NYU Langone’s Medical Center Information Technology department to ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) and to tailor messages for the health system’s diverse patient population.

Kelly Eng, BA, a co-author and IT specialist at NYU Langone Health, noted that the system was designed to integrate seamlessly with existing electronic health records (EHRs). We built the text message platform to pull real-time data from the EHR, so patients received reminders only if they had an active FIT order and no recent completion. This avoided unnecessary outreach and reduced the risk of alert fatigue.

Broader Applications for Digital Health

The trial’s success adds to a growing toolkit of digital health strategies aimed at improving patient engagement. Similar interventions have shown promise in increasing vaccination rates, medication adherence, and chronic disease management. For example, a 2025 study in Health Affairs found that automated text reminders improved flu vaccination rates by 8% among adults aged 65 and older.

However, experts warn that digital interventions are not a panacea. A 2026 editorial in JAMA Internal Medicine argued that while text messages can enhance outreach, they should complement—not replace—human-centered care. The editorial’s authors wrote, Automated nudges are most effective when they are part of a broader strategy that includes patient education, shared decision-making, and access to follow-up care.

What’s Next for CRC Screening Outreach

The NYU Langone team is now exploring ways to refine the text message intervention, including testing different message frequencies, incorporating multimedia elements, and adapting the approach for other languages. They are also investigating the potential for artificial intelligence to personalize messages based on patient behavior and preferences.

For now, the trial’s findings offer a clear takeaway for healthcare providers: simple, low-cost digital tools can meaningfully improve preventive care uptake. As Korostoff-Larsson put it, We don’t need to reinvent the wheel. Sometimes, the most effective solutions are the ones that make it easier for patients to do what they already want to do.

The study was funded by the National Cancer Institute and the Agency for Healthcare Research and Quality. No conflicts of interest were reported by the authors.