Automated Text Message Outreach to Increase Diabetes Screening: A Pragmatic Randomized Trial.

Background: Despite evidence that early intervention can prevent or delay progression to type 2 diabetes, more than 80% of individuals with prediabetes in the United States remain undiagnosed, underscoring the need for scalable strategies to increase uptake. In this study, we evaluated whether a single text message could increase completion of HbA1c-based diabetes screening in routine clinical practice. Methods: We conducted a pragmatic randomized controlled trial within Duke University Health System (DUHS). Patients aged 35 years or older who met American Diabetes Association 2022 screening criteria, had no previous diagnosis of diabetes, had not undergone HbA1c testing within the preceding 3 years, and had opted to receive text messages from DUHS were randomly assigned to receive either a single text message encouraging guideline-based diabetes screening and discussion with a primary care provider (intervention group; n=55,494) or usual care (control group; n=5,748). The primary outcome was HbA1c test completion within 24 weeks following message delivery (or no message for controls), analyzed using a Cox proportional hazards model stratified by wave. Secondary outcomes included piecewise hazard ratios for early (weeks 1-4), mid (weeks 5-12), and late (weeks 13-24) intervals and the between-group difference in cumulative testing rate. Findings: Text message outreach significantly increased HbA1c test completion over 24 weeks (HR, 1.18 [95% CI, 1.07-1.03]) with the strongest effect in the first four weeks (HR, 1.48 [95% CI, 1.18-1.86]). By the end of the 24-week observation period, cumulative testing reached 9.14% in the messaged group vs 7.83% in controls (between-group difference, 1.31% [95% CI, 0.59-2.07]), corresponding to one additional HbA1c test per 76 messages delivered ($0.51 in messaging costs per additional HbA1c test performed). Rates of prediabetes and diabetes among those screened were similar between groups, indicating no selection bias of higher-risk patients. One additional dysglycemia case was identified per 213 messages sent ($1.43 per case detected). Interpretation: A single automated text message can increase diabetes screening completion at low marginal cost without selectively engaging higher-risk patients. This low-cost, highly scalable approach could be used to narrow the gap between current and recommended diabetes screening.