Currently submitted to: Journal of Medical Internet Research
Date Submitted: Apr 8, 2026
Open Peer Review Period: Apr 9, 2026 - Jun 4, 2026
(closed for review but you can still tweet)
NOTE: This is an unreviewed Preprint
Warning: This is a unreviewed preprint (What is a preprint?). Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn (a note "no longer under consideration" will appear above).
Peer review me: Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period (in this case, a "Peer Review Me" button to sign up as reviewer is displayed above). All preprints currently open for review are listed here. Outside of the formal open peer-review period we encourage you to tweet about the preprint.
Citation: Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author).
Final version: If our system detects a final peer-reviewed "version of record" (VoR) published in any journal, a link to that VoR will appear below. Readers are then encourage to cite the VoR instead of this preprint.
Settings: If you are the author, you can login and change the preprint display settings, but the preprint URL/DOI is supposed to be stable and citable, so it should not be removed once posted.
Submit: To post your own preprint, simply submit to any JMIR journal, and choose the appropriate settings to expose your submitted version as preprint.
Warning: This is an author submission that is not peer-reviewed or edited.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
Citation
Request queued. Please wait while the file is being generated. It may take some time.
Copyright
© The authors. All rights reserved. This is a privileged document currently under peer-review/community review (or an accepted/rejected manuscript). Authors have provided JMIR Publications with an exclusive license to publish this preprint on it's website for review and ahead-of-print citation purposes only. While the final peer-reviewed paper may be licensed under a cc-by license on publication, at this stage authors and publisher expressively prohibit redistribution of this draft paper other than for review purposes.