Remote Glucose Monitoring Engagement and Glycemic Control in Type 2 Diabetes and Prediabetes: Retrospective Cohort Study.
Suboptimal glycemic control remains a significant public health challenge among adults with type 2 diabetes and prediabetes, with 47.4% of US adults with diagnosed diabetes having hemoglobin A1c (HbA1c) ≥7%. Remote glucose monitoring programs have shown promise for supporting self-management, but real-world evidence on the causal impact of varying patient engagement levels on glycemic outcomes remains limited.
This study aimed to estimate the causal dose-response relationship between patient engagement, operationalized as weekly glucose monitoring frequency, and glycemic control measured by HbA1c among adults enrolled in a comprehensive primary care-integrated remote monitoring program.
We conducted a retrospective cohort study of 1436 adults with type 2 diabetes or prediabetes enrolled in the Unika Health program between 2019 and 2024. The program integrated Bluetooth-connected glucose meters, a mobile app, structured lifestyle coaching, and primary care coordination across 74 physician practices. Engagement was defined as mean weekly glucose monitoring frequency during the first 6 months. The causal effect of monitoring frequency on 6-month HbA1c was estimated using marginal structural models (MSMs) with inverse probability weighting to address time-varying confounding. Covariates included age, sex, BMI, baseline HbA1c, comorbidities, medication status, and physical activity level.
The cohort was predominantly older (95.4%, 1370/1436 aged ≥46 years), with 82.6% (1186/1436) having hypertension and 45.9% (659/1436) classified as obese. Overall, HbA1c decreased by a mean of 0.54 (SD 1.47; 95% CI 0.47-0.62) percentage points (P<.001) over 6 months. Cluster analysis identified 3 engagement tiers: low (n=835; mean 2.55, SD 1.35 measurements/week), medium (n=493; mean 6.19, SD 1.46 measurements/week), and high (n=108; mean 12.59, SD 3.03 measurements/week). A monotonic dose-response was observed, with mean HbA1c reductions of 0.38 (SD 1.40; 95% CI 0.29-0.48), 0.71 (SD 1.50; 95% CI 0.58-0.85), and 1.01 (SD 1.67; 95% CI 0.69-1.32) percentage points for the low, medium, and high tiers, respectively (all P<.001 by 2-tailed paired t test). In weighted MSMs, each additional weekly measurement was associated with a 0.05 (95% CI 0.03-0.07) percentage point greater HbA1c reduction (P<.001). Among patients with high baseline HbA1c (≥9%), the high-engagement group achieved a mean reduction of 3.12 (SD 1.97; 95% CI 2.29-3.94) percentage points. Findings were consistent in sensitivity analyses at 3 months (β=-0.04; P<.001) and 12 months (β=-0.03; P=.003) and across alternative weighting specifications.
Higher engagement with a digitally enabled, primary care-integrated remote glucose monitoring program was causally associated with significantly greater HbA1c reductions in adults with type 2 diabetes and prediabetes. These findings support scalable remote patient monitoring strategies that actively foster sustained patient engagement as an effective approach to improving glycemic control and reducing the burden of diabetes-related complications at a population level.
This study aimed to estimate the causal dose-response relationship between patient engagement, operationalized as weekly glucose monitoring frequency, and glycemic control measured by HbA1c among adults enrolled in a comprehensive primary care-integrated remote monitoring program.
We conducted a retrospective cohort study of 1436 adults with type 2 diabetes or prediabetes enrolled in the Unika Health program between 2019 and 2024. The program integrated Bluetooth-connected glucose meters, a mobile app, structured lifestyle coaching, and primary care coordination across 74 physician practices. Engagement was defined as mean weekly glucose monitoring frequency during the first 6 months. The causal effect of monitoring frequency on 6-month HbA1c was estimated using marginal structural models (MSMs) with inverse probability weighting to address time-varying confounding. Covariates included age, sex, BMI, baseline HbA1c, comorbidities, medication status, and physical activity level.
The cohort was predominantly older (95.4%, 1370/1436 aged ≥46 years), with 82.6% (1186/1436) having hypertension and 45.9% (659/1436) classified as obese. Overall, HbA1c decreased by a mean of 0.54 (SD 1.47; 95% CI 0.47-0.62) percentage points (P<.001) over 6 months. Cluster analysis identified 3 engagement tiers: low (n=835; mean 2.55, SD 1.35 measurements/week), medium (n=493; mean 6.19, SD 1.46 measurements/week), and high (n=108; mean 12.59, SD 3.03 measurements/week). A monotonic dose-response was observed, with mean HbA1c reductions of 0.38 (SD 1.40; 95% CI 0.29-0.48), 0.71 (SD 1.50; 95% CI 0.58-0.85), and 1.01 (SD 1.67; 95% CI 0.69-1.32) percentage points for the low, medium, and high tiers, respectively (all P<.001 by 2-tailed paired t test). In weighted MSMs, each additional weekly measurement was associated with a 0.05 (95% CI 0.03-0.07) percentage point greater HbA1c reduction (P<.001). Among patients with high baseline HbA1c (≥9%), the high-engagement group achieved a mean reduction of 3.12 (SD 1.97; 95% CI 2.29-3.94) percentage points. Findings were consistent in sensitivity analyses at 3 months (β=-0.04; P<.001) and 12 months (β=-0.03; P=.003) and across alternative weighting specifications.
Higher engagement with a digitally enabled, primary care-integrated remote glucose monitoring program was causally associated with significantly greater HbA1c reductions in adults with type 2 diabetes and prediabetes. These findings support scalable remote patient monitoring strategies that actively foster sustained patient engagement as an effective approach to improving glycemic control and reducing the burden of diabetes-related complications at a population level.
Authors
Huang Huang, Nagesh Nagesh, Subramanian Subramanian, Wang Wang, Liu Liu, Sun Sun, Hou Hou, Azimi Azimi, Rahmani Rahmani, Stafford Stafford
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