A population health approach to insomnia using internet-based cognitive behavioral therapy for insomnia

Abstract

Study objectives: To determine if a population health approach to insomnia using internet-based cognitive behavioral therapy for insomnia (ICBT-I) affects dispensed medications and provider encounters compared with usual care.

Methods: A pragmatic hybrid study design was used to evaluate both the implementation strategy and the long-term effects of ICBT-I on health care utilization in an integrated health system. Adult members with insomnia (a diagnosis or insomnia medication dispensation) or at high risk of insomnia (a diagnosis of depression or anxiety) were randomized to receive information on either an ICBT-I program (intervention arm) or in-person classes on insomnia (usual-care arm). Outcomes included dispensed insomnia medications and provider encounters over 12 months. The effectiveness of our implementation of ICBT-I on the target population was determined by an intention-to-treat analysis and by regression models comparing those who engaged in ICBT-I with matched usual-care arm controls.

Results: A total of 136,630 participants were randomized. Six hundred thirty-eight (0.96%) accessed the ICBT-I program while 431 (0.66%) attended 1 or more usual-care insomnia classes. Dispensed insomnia medications and provider encounters were no different in the ICBT-I arm vs the usual-care arm (intention-to-treat) or among those who engaged in ICBT-I vs matched usual-care arm controls.

Conclusions: Since ICBT-I program engagement was low, additional strategies to improve engagement should be explored. ICBT-I did not result in a reduction in several measures of health care utilization; nevertheless, it offers an alternative and accessible approach to managing population insomnia.

Clinical trial registration: Registry: ClinicalTrials.gov; Name: Trial of Internet-Based Cognitive Behavioral Therapy for Insomnia in Patients Prescribed Insomnia Medications; URL: https://ichgcp.net/clinical-trials-registry/NCT03313466; Identifier: NCT03313466.

Citation: Derose SF, Rozema E, Chen A, Shen E, Hwang D, Manthena P. A population health approach to insomnia using internet-based cognitive behavioral therapy for insomnia. J Clin Sleep Med. 2021;17(8):1675-1684.

Keywords: cognitive behavioral therapy; hybrid study design; insomnia; pragmatic study.

© 2021 American Academy of Sleep Medicine.

Figures

Figure 1. Enrollment process.

Flowchart detailing the study’s recruitment and enrollment cycle. The cycle was repeated until enough participants were accumulated. iCBT = internet cognitive behavioral therapy.

Figure 2. Enrollment flowchart.

Flowchart detailing study randomization, exclusions, recruitment reach, enrollment, and analyses. *Death records and membership take several weeks to update; these exclusions were discovered after outreach. KP = Kaiser Permanente, R&E = research and evaluation department.