Hybrid care engagement phenotypes and glycemic outcomes in diabetes: a cluster analysis across two health systems

OBJECTIVE: Prior studies often examine single telehealth encounter types or aggregate all digital care, overlooking how patients combine multiple digital and in-person modalities in hybrid care. To address this gap, we derived hybrid care engagement phenotypes and assessed sociodemographic differences and associations with glycemic control among adults with type 2 diabetes (T2DM). METHODS: We conducted a retrospective cohort study of 10 671 adults with T2DM receiving primary care at an academic (UCSF) or safety-net system (SFHN) from April 2021 to March 2023. K-medoids clustering was applied to five encounter modalities (in-person, video, telephone visits; portal messages; unscheduled telephone calls) to derive four engagement phenotypes. We assessed sociodemographic differences using chi-square and Kruskal-Wallis tests and evaluated associations between phenotype and follow-up HbA1c control using logistic regression. We tested interactions with baseline HbA1c and estimated predicted probabilities using Tukey-adjusted contrasts. RESULTS: Four phenotypes emerged per system: Digitally Engaged Multimodal, Traditional High Utilizers, Digitally Leaning (UCSF), Telephone Reliant (SFHN), and Low Digital. UCSF patients belonged to digitally forward phenotypes, whereas SFHN patients concentrated in traditional, lower-tech phenotypes. Among patients with uncontrolled diabetes, digitally forward phenotypes had 13-20 percentage points higher predicted probability of achieving control (UCSF: 56% Digitally Leaning vs 36% Traditional; SFHN: 53% Multimodal vs 40% Telephone). DISCUSSION: Phenotypes varied by health system and sociodemographic factors, with modest, system-specific associations between digitally forward phenotypes and glycemic control among patients with uncontrolled diabetes. Findings underscore structural and sociodemographic inequities in hybrid care engagement and the need for proactive, tailored strategies to promote equitable hybrid care.