Currently submitted to: Journal of Medical Internet Research
Date Submitted: Apr 8, 2026
Open Peer Review Period: Apr 9, 2026 - Jun 4, 2026
(currently open for review)
Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.
Impact of Patient Engagement in Remote Diabetes Management on Glycemic Outcomes: A Causal Inference Approach
ABSTRACT
Background:
Suboptimal glycemic control remains a major public health challenge for patients with type 2 diabetes and prediabetes. Remote glucose monitoring offers scalable support for self-management, but evidence on its real-world effectiveness and the causal impact of varying engagement levels is limited.
Objective:
To estimate the effect of patient engagement measured through glucose monitoring frequency on hemoglobin A1c (HbA1c).
Methods:
We analyzed 1,479 adults with type 2 diabetes or prediabetes enrolled in the iHealth Unified Care program, integrating Bluetooth glucose meters, a mobile app, lifestyle coaching, and primary care coordination. Engagement during the first six months was defined as the weekly frequency of glucose monitoring. The causal effect of monitoring frequency on HbA1c was estimated using marginal structural models with inverse probability weighting to address time-varying confounding.
Results:
At 6 months, HbA1c decreased by 0.53 (SD 1.46) percentage points (p < 0.001). We observed a dose-response relationship across engagement tiers: the highest-engagement group (16.99 measurements/week) achieved a 1.00 percentage point HbA1c reduction versus 0.34 in the lowest tier. In weighted models, each additional weekly measurement was associated with a 0.03 percentage point greater HbA1c reduction (p < 0.01). Findings were consistent in sensitivity analyses at 3 and 12 months.
Conclusions:
Engagement with a digitally enabled, primary care-integrated remote glucose monitoring program significantly improved glycemic outcomes across all engagement levels. Higher monitoring frequency produced greater HbA1c reductions, underscoring the importance of fostering sustained patient engagement to optimize diabetes management. Clinical Trial: Not Applicable
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