Patient Adherence to a Digital Real-World GLP-1 RA-Supported Weight-Loss Program in the UK: A Retrospective Cohort Study

Special Article: Public Health

J Community Med Health Care. 2024; 9(1): 1070.

Patient Adherence to a Digital Real-World GLP-1 RA-Supported Weight-Loss Program in the UK: A Retrospective Cohort Study

Louis Talay, PhD*; Matt Vickers, MD

University of Sydney SDN, Randwick, New South Wales, Australia Eucalyptus, Sydney, New South Wales, Australia

*Corresponding author: Louis Talay University of Sydney SDN, Randwick, New South Wales, Australia. Email: [email protected]

Received: March 15, 2024 Accepted: April 15, 2024 Published: April 22, 2024

Abstract

This study aimed to assess why and at what point along the care journey patients tend to discontinue a real-world GLP-1 RA-supported Digital Weight-Loss Service (DWLS) for women in the UK. To achieve these objectives, a cohort of 8294 patients was retrospectively analyzed, using both descriptive statistics and correlation tests. Mean adherence to the program was 183.1 (±148.9) days and the most common reasons for discontinuation were program cost (38.7%), dissatisfaction with results (16.8%), intolerable side effects (15.4%), attainment of one’s weight-loss goal (7.3%) and temporary pause/holidays (5.6%). Patients who were older, Caucasian and Overweight tended to adhere to the program for a statistically significantly longer period than their younger, non-Caucasian and higher BMI-class peers. This study provides important foundational insights to the scarce literature on real-world GLP-1 RA-supported DWLSs, which are becoming increasingly popular in the obesity epidemic.

Introduction

Obesity is a chronic disease affecting over a quarter of the British population, with a further 37.9% of Brits estimated to be overweight [1]. In recent years, randomized controlled trials have demonstrated the unprecedented effectiveness of Glucose-like Peptide-1 Receptor Agonists (GLP-1 RAs) in inducing weight loss for people with overweight and obesity [2-4]. To access these medications in real-world settings, a growing number of people are using Digital Weight-Loss Services (DWLSs) [5]. Researchers have argued that in addition to helping overcome undesirable clinic waiting periods and travel times, DWLSs can facilitate care continuity and reduce patient perception of stigma [6,7]. However, evidence to support these views is scarce and most questions around the quality and safety of real-world DWLSs remain unanswered.

Major health institutions such as the World Health Organization (WHO) and the UK National Institute for Health and Care Excellence (NICE) emphasize the importance of specialist multidisciplinary care in the treatment of obesity, given the disease’s complexity and chronic nature [8,9]. A factor that has historically limited the effectiveness of such care in a weight-loss context is program adherence [10]. While the majority of research is limited to Face-to-Face (F2F) interventions, there is no evidence to corroborate the logic that delivering weight-loss programs through digital modalities improves adherence. Scholars have suggested that certain DWLSs could observe lower adherence rates than F2F models as they are typically unsubsidized and expensive, which can lead to treatment cycling – an ill-advised phenomenon where patients cycle on and off their subscription and often increase their risk of weight gain and the development of comorbidities [11].

Another important consideration in the DWLS discussion is the broad quality spectrum. Services range from websites that offer little more than private prescriptions for GLP-1 RA medications to programs with coordinated Multidisciplinary Teams (MDTs) that guide patients through health coaching and GLP-1 RA therapy and are supported by robust clinical governance systems [12,13]. Although it is feasible that DWLSs at the more comprehensive end of this spectrum would observe higher adherence rates, a recent study on a cohort of patients of the digital GLP-1 RA-supported Juniper Australia program suggest otherwise [14]. The study found that only 21% of the cohort’s 10,918 patients attended their week-14 and 32 follow-up consultations.

This study aims to assess why and at what stage of the care journey patients of the Juniper UK weight-loss program tend to discontinue their subscription. The Juniper UK program allocates each patient an MDT consisting of a doctor, pharmacist, health coach and medical support officer who coordinate asynchronous care through an integrated digital platform.

All patient data, including questionnaire responses and clinician decisions around both GLP-1 RA therapy and health coaching, are stored in Eucalyptus’ (Juniper parent company) central data repository. As of 12 March, the Juniper program has cared for over 55,000 weight-loss patients across Australia, Germany, Japan and the UK, including over 17,500 British patients. This study’s results will play an important foundation in the obesity care literature by generating novel insights on patient adherence to real-world GLP-1 RA DWLSs.

Methods

The study conducted a retrospective analysis of a cohort of patients who commenced the Juniper UK weight-loss program between 28 April 2022 and 1 April 2023. To be included in the study, patients needed to receive a minimum of one order of Semaglutide and satisfy all criteria that prescribing doctors use to determine patient eligibility for the Juniper weight-loss program. These criteria follow the NICE guidelines for semaglutide weight-loss therapy, such as those concerning BMI thresholds, medicine contraindications and various comorbidity risks. All relevant study data were retrieved from Eucalyptus’ central data repository on Metabase.

3 discontinuation paths exist under the Juniper program (and likely most other GLP-1 RA-supported DWLSs). 1/ Patient notified discontinuation – when a patient notifies their MDT that they are pausing or stopping their subscription; 2/ Consult drop-out – when a patient fails to attend review or follow-up consult and does not communicate the reason within 50 days (a period long enough for patient to sustain GLP-1 RA order if they stretch their dosing schedule); and 3/ Doctor decision – a patient’s prescribing doctor decides to terminate the patient’s subscription for medical reasons. For the purposes of this study, it is important to add forth discontinuation category to capture the patients of the cohort who have not paused their subscription at any point and are still active users of the Juniper weight-loss program. Despite the ‘Still active’ status of this category, the date of analysis (12 March 2024) will be taken as their discontinuation date when calculating central tendency data. For categories 1 (patient-notified discontinuers) and 3 (doctor decision), the day the decision was communicated will be taken as the discontinuation date, while for consult drop-outs, a patient’s last scheduled consult (the one they failed to attend) will be used.

Patients who notified their MDT of their decision to discontinue their subscription were asked on the same day to give their main reason for discontinuing by their medical support officer. Consult drop-out patients were asked this question 50 days after their last attended follow-up or review consult. The question was re-sent to patients from both these categories if a response wasn’t received by their MDT within 72 hours. Patients whose subscriptions were cancelled by their doctor for medical reasons were not sent this question, as the discontinuation reason was clear.

The study’s coprimary endpoints are mean adherence days, i.e., the total days from program initiation to discontinuation, and the distribution of reasons for discontinuation. Sub-group analyses of the coprimary endpoints, including groups assembled by BMI category and discontinuation category, represent the study’s exploratory endpoints.

Results

8294 patients satisfied the study criteria and were included in the final analysis. Mean age of the cohort was 44.4 (±11.2) years, mean BMI was 35.2(±7.4) kg/m2, and 82.5% of patients were of Caucasian ethnicity (Table 1). Mean adherence to the Juniper weight-loss program was 183.1 (±148.9) days. Discontinuation reason data were taken from 3754 patients, of which 3716 were from the ‘patient notified MDT’ category and 38 from the ‘consult drop-out category’. The most common reason given for discontinuation was program cost (38.7%), followed by dissatisfaction with results (16.8%), intolerable side effects (15.4%), attainment of weight-loss goal (7.3%) and temporary pause/going on holidays (5.6%).