Abstract
Background: Chronic insomnia disorder affects 10-15% of adults, causing significant individual and societal burden. Despite Cognitive Behavioral Therapy for Insomnia (CBT-I) being the recommended first-line, sleep medications remain more common due to limited access to trained providers. Digital CBT-I offers a scalable solution, but evidence of its real-world impact in U.S. clinical settings is lacking. Method: This study evaluates real-world implementation and impact of digital CBT-I in U.S. clinical settings, using Normalization Process Theory (NPT) to guide integration at Henry Ford Health, Detroit, Michigan. Implementation success was assessed through order rates, patient sign-ups and workflow acceptability. We assess the effect on healthcare utilization through a propensity-matched observational treatment-control design. Results: Implementation was successful, with 1,162 patients offered digital CBT-I. From this cohort, we analyzed a sample of 340 patients with sufficient chart data and established care (120 days) who utilized digital CBT-I, comparing them to 340 matched standard care controls. Patients who used digital CBT-I had a 64% reduction in the odds of any medication fill during the postwindow period (p < .001) and were 53% less likely to fill insomnia medication prescriptions compared with the preperiod (p = .013). Controls did not have any significant reductions in medication fill rates. Time-varied analysis showed digital CBT-I patients had transiently higher outpatient visit odds at 30-60 days, followed by sustained reductions of 28% (120-150 days) and 31% (150-180 days). After covariate adjustment, early differences were nonsignificant while later reductions remained significant. Conclusions: NPT facilitated integration of digital CBT-I into existing workflows, allowing immediate access while minimizing disruption to routine practice. Provider training sessions and reminders effectively promoted suitable patient uptake. Digital CBT-I was associated with reduced medication fills pre-to-post with an initial rise and then sustained reduction in outpatient service utilization patterns over time. A key limitation is the use of individuals who declined digital CBT-I as comparators, which may introduce selection bias. Generalizability may be limited as the study was conducted within a single healthcare system. Trial Registration: Not applicable-the assignment of the medical intervention to patients was not at the discretion of the investigators.