Digital healthcare solutions to better achieve the weight loss outcomes expected by payors and patients

Abstract

Bernd Schultes and colleagues are to be congratulated for the ADDRESS study, which highlights weight loss outcomes using liraglutide 3 mg once daily (o.d.) in a mostly (>95%) nondiabetic cohort of patients with overweight or obesity in a routine clinical practice setting.1 A notable takeaway from the publication was the significant number of patients in the study's financial reimbursement group who did not achieve the Swiss Federal Office of Public Health (FOPH) Week-16 to Month-10 weight-loss target for glucagon-like peptide-1 receptor agonist (GLP-1RA) therapy despite, on average, losing 11.1% of body weight after 10 months of treatment. As the authors conclude, the FOPH's subsequent decision to revise this reimbursement criterion recognizes the nonlinearity of weight loss and should result in significant improvements to obesity care access. ADDRESS was a multicentre, retrospective cohort study of 258 patients in routine clinical practice, but the authors say very little about the ‘real-world’ provision of multidisciplinary support services, for example, dietetic, clinical psychology and lifestyle education, that were provided to these patients, in addition to liraglutide 3 mg o.d., for the duration of the study. The guidelines are clear about what good weight-loss services should provide,2 but delivering, coordinating, and optimizing repeated face-to-face patient interactions with different healthcare professionals is challenging.3 We suspect that practical limitations and multisite variations in the provision of (physical) weight-loss services to support patients on GLP-1RA therapy—as well as issues of patient access, compliance and persistence—account for the disappointing outcomes at 43 weeks (specifically, <50% of reimbursed patients achieved the FOPH target of a further 5% body weight reduction at Week 43 vs. Week 16). One of the ways in which healthcare providers have begun to improve multidisciplinary support services for patients trying to lose weight is by launching digital care models. Initial experience in a number of countries is that digital weight-loss services (DWLSs) are popular and effective but vary widely in quality,4 ranging from websites that offer little more than private prescriptions for GLP-1RA therapy, to providers such as Eucalyptus that deliver comprehensive multidisciplinary care using telehealth and have robust clinical governance systems to quality-assure and improve service delivery and patient outcomes. We have analysed a retrospective dataset of 670 patients who did not have diabetes participating in our asynchronous DWLS (Juniper), who received structured diet and exercise coaching and liraglutide 3 mg o.d. between November 2021 and August 2023. All Juniper patients were allocated a prescribing doctor, a health coach, and a medical support officer, who proactively guided them through their holistic programme via the Juniper in-app chat feature. Diet and exercise plans were personalized to suit individual preferences and could be modified in consultation with a patient's health coach at any stage of their care journey. The study was approved by a Human Research Ethics Committee (Bellberry). Patients were included in the cohort if they completed two follow-up questionnaires at designated time windows: follow-up questionnaire #1 (FU1) at Days 90–112 and follow-up questionnaire #2 (FU2) at Days 215–234. Patients’ baseline characteristics and a patient flow diagram are presented in Table 1 and Figure 1, respectively. At Week 32 of GLP-1RA therapy, and after regular sessions of multidisciplinary coaching, the mean weight loss for the group was 11.6 ± 6.0%. A total of 88.8% of patients lost >5% of their initial body weight, 58.8% lost >10% and 25.4% lost >15%. Despite the shorter treatment period (32 weeks vs. 43 weeks), our cohort achieved comparable weight-loss outcomes to the reimbursed group in the ADDRESS study and better outcomes than both the non-reimbursed ADDRESS study cohort and the patients who participated in the SCALE randomized controlled trial5 (Figure 2). These comparisons do, however, have several limitations, including the Juniper study's predominantly White female cohort, its patient-reported data, and its high drop-out rate (93.9% at Week 32). The latter limitation can likely be explained to a large degree by the Juniper programme's high out-of-pocket costs, which reimbursement arrangements such as those available in the Swiss health system could significantly mitigate. Different diagnosis methods and the Juniper study's failure to collect dyslipidaemia data feasibly impacted baseline comorbidity disparities among the four cohorts. We believe that DWLSs overcome many of the practical limitations inherent in traditional face-to-face clinical service models to support patients trying to lose weight. Using technology to enable and optimize high-quality individualized multidisciplinary care for patients taking GLP-1RA therapy for weight loss offers a greater likelihood that payor expectations will be fulfilled. The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer-review/10.1111/dom.15513. The data that support the findings of this study are available from the corresponding author upon reasonable request.

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