Digital technologies for providing specialist weight-management services

The evidence suggests that 5 out of the 8 technologies (Gro Health W8Buddy, Liva, Oviva, Roczen and Second Nature) have a potential benefit for adults who are eligible for treatment with weight-management medicine. But only 1 published full-text study included people who were taking weight-management medicine. There was limited evidence for CheqUp and Juniper and no evidence for Wellbeing Way.

The evidence base consists of 26 studies reported across 31 publications. Four studies for Second Nature were excluded from the EAG assessment report because they were not considered relevant to the decision problem. But these studies were later considered relevant to the assessment by the committee. The evidence included 1 randomised controlled trial (RCT), 4 non-randomised comparative studies, 1 pilot RCT (which did not compare the technology with standard care), 13 non-comparative studies and 7 unpublished studies that were provided by the companies. The EAG explained that comparative evidence reported equivalent or more weight loss when using the technologies compared with in-person specialist weight-management services, but that this evidence is limited. The statistical significance beyond 1 year is uncertain, but the evidence suggests equivalence with standard care at 2 years. The evidence generally reported weight loss for the technologies when compared with baseline (for Liva, Oviva, Roczen and Second Nature). The clinical experts agreed that the non-comparative evidence was enough to demonstrate at least equivalent weight loss when the technologies were compared with having no access to specialist weight-management services. The committee heard that longer-term follow up is needed because obesity is a chronic condition.

There is some evidence on programme adherence, programme engagement, health-related quality-of-life outcomes and psychological outcomes. The RCT for Liva reported no difference in the EQ‑5D‑5L or Short Warwick–Edinburgh Mental Wellbeing Scale scores compared with in-person support or with baseline at 6 months and 12 months. The committee concluded that more evidence is needed for these outcomes.

During consultation, further evidence was submitted for CheqUp, Gro Health W8Buddy, Juniper, Oviva and Second Nature. Gro Health W8Buddy provided an additional poster report on weight loss outcomes and an unpublished paper. The committee concluded that the additional evidence provided was enough to support the use of Gro Health W8Buddy in the NHS while further evidence is generated. Second Nature provided a conference poster of a retrospective cohort study, and Oviva provided an abstract on adverse event data when using Oviva with weight-management medicine. This conference poster and abstract did not change the outcome of the assessment.

CheqUp submitted a preliminary data summary of an ongoing study using the technology alongside weight-management medicine, and Juniper provided interim results on 2 ongoing studies and details of a third ongoing study. The committee concluded that the evidence provided was not of good enough quality to recommend CheqUp and Juniper for use in the NHS while further evidence is generated, but recommended that further research is done through company, research or non-core NHS funding.

Further evidence will be generated while 5 technologies (Gro Health W8Buddy, Liva, Oviva, Roczen and Second Nature) are used in the NHS to address the immediate unmet need, with appropriate risk-management processes in place. The clinical experts and committee stressed the importance of clinical risk management. The companies advised that they have risk-management processes and safeguarding systems in place. Most of the technologies have monitoring systems to pick up any key words relating to safety or adverse events, as well as regular contact with healthcare professionals. The committee highlighted that there is a lack of evidence relating to how the technologies monitor and report adverse events, and limited evidence for people taking weight-management medicine. The committee concluded that these technologies can be used, while evidence is generated, as an option to deliver specialist weight-management services to manage weight-management medicine. But they should only be used with appropriate safeguarding and risk-management processes in place.

The clinical experts raised that there is limited information on how multidisciplinary teams (MDTs) are used in the programmes offered by the technologies. But they noted that this is also the case for standard care and that MDTs can vary significantly between weight-management services. The clinical experts also highlighted that a full clinical assessment and referral for weight-management medicine is needed before using these technologies, to make sure the technologies are suitable. They also noted that the programmes' MDTs must include or have access to psychological support because obesity is a complex condition that requires a lot of support. People may have additional co-morbidities and a large proportion of people with obesity have mental health issues. The clinical experts said that it is important to monitor behaviour on restricted diets to minimise the risk of potential harms, such as developing disordered eating. The committee concluded that both psychological monitoring and appropriate referral procedures are important.

The preliminary results of the early economic modelling showed that the technologies are cost effective when compared with in-person services. The EAG said that there was limited data to populate the parameters of the model, and that the results are uncertain. Based on the sensitivity and threshold analysis, the biggest factor affecting the results is the estimate of standard care costs used for current tier 3 services. The threshold analysis showed that if standard care costs were reduced by approximately 25%, or the technology costs were increased by 35%, then standard care would become the cost-effective option. The committee concluded that further evidence on clinical effectiveness including health-related quality of life and resource use is needed to reduce uncertainty in the cost modelling.

The evidence suggests that 7 technologies (Counterweight, Gro Health W8Buddy, Liva, Oviva, Roczen, Second Nature and Weight Loss Clinic) have a potential benefit in supporting specialist weight-management services. But, only 4 studies included people in tier 3 or 4 specialist weight-management services, only 1 study met the decision problem in all areas, and there is an unknown likelihood of crossover between some of the publications. There was limited evidence for CheqUp, Habitual and Juniper and no evidence for Gloji and Wellbeing Way. The committee concluded that the evidence provided was not of good enough quality to recommend CheqUp, Habitual and Juniper for use in the NHS while further evidence is generated.

The evidence base consists of 53 published studies for 7 technologies (Oviva [n=20], Counterweight [n=11], Second Nature [n=8], Gro Health W8Buddy, Liva [n=5], Roczen [n=3] and Weight Loss Clinic [n=3]) and 21 unpublished studies for 7 technologies (Liva [n=6], Oviva [n=6], Habitual [n=3], Juniper [n=2], Roczen [n=2], CheqUp [n=1] and GroHealth [n=1]). Published evidence included 4 randomised controlled trials (RCT), 7 non-randomised comparative studies, 1 pilot RCT (which did not compare the technology with standard care), 40 non-comparative studies and 1 study comparing Liva, Oviva and Second Nature. The EAG explained that comparative evidence reported equivalent or more weight loss when using the digital technologies compared with in-person services, but that this evidence is limited. The statistical significance beyond 1 year is uncertain, but the evidence suggests equivalence with standard care at 2 years. Non-comparative evidence generally reported weight loss when using the technologies compared with baseline. There was a lack of evidence comparing digital technologies to no treatment. The committee heard that longer-term follow up is needed because obesity is a chronic condition.

There is some evidence on programme adherence, programme engagement, health-related quality-of-life outcomes and psychological outcomes. An RCT for Counterweight reported an increase in health-related quality of life in the intervention group compared with the control group. The RCT for Liva reported no difference in the EQ‑5D‑5L or Short Warwick–Edinburgh Mental Wellbeing Scale scores compared with in-person support or with baseline at 6 months and 12 months. The committee concluded that more evidence is needed for these outcomes and highlighted the importance of consistency in the patient reported outcome measures used when collecting psychological outcomes in future research and evidence generation.

The clinical experts stated that there is limited information on what the digital specialist weight-management programmes consist of and how they differ between technologies. But, they noted that this is also the case for standard care and that offerings can vary significantly between in-person specialist weight-management services. The clinical experts highlighted the importance of having appropriate qualifications (such as a SCOPE certification) and suitable levels of experience managing obesity. They also noted that the programmes' MDTs should include access to physiotherapy and psychological support because obesity is a complex condition that needs a lot of support. People may have additional comorbidities and a large proportion of people with obesity have mental health issues. The clinical experts said that it is important to monitor behaviour on restricted diets to minimise the risk of potential harms, such as developing disordered eating. The committee concluded that digital specialist weight-management programmes should be delivered by appropriately qualified and experienced healthcare professionals and must include or have access to psychological monitoring.

Engagement and adherence should be monitored and followed up throughout the duration of the programme. Clinical experts explained that there is a lack of information about why people stop using digital programmes. The companies explained that engagement is monitored during regular meetings with healthcare professionals. If this drops below a pre-determined threshold, users may be prompted to reengage through automated messages, nudges, peer mentoring or direct contact with a healthcare professional. Some companies also stated that engagement can be tracked automatically through user interaction with app content. The committee concluded that referral procedures are important, and more evidence is needed to establish why people stop taking part in programmes.

Digital programmes should be personalised and incorporate user feedback. The companies explained that user feedback is continuously sought throughout the programmes. Some companies stated that users are sent feedback questionnaires and suggestions can be incorporated into the programme on a bi-weekly basis. Some companies stated that using digital technologies allows detailed levels of feedback to be collected for each piece of content, which can be amended immediately. The clinical experts highlighted the importance of user feedback and how this can be used to enable individualised care for people with obesity. They also acknowledged that implementing user feedback and improvements may be faster and more consistent with digital technologies compared with in-person services. The committee concluded that collecting feedback to improver user experience and enable individualised care is important when delivering specialist weight-management services using digital technologies.

The preliminary results of the early economic modelling showed that the technologies are cost saving and cost effective when compared with standard care and a 6-month delay to standard care. With a 12-month delay to treatment, or when compared with no treatment, the technologies become cost incurring but increase quality of life. The EAG said that there was uncertainty in both the cost and quality of life outcomes because there is limited data and long-term outcomes are not included in the model. The committee concluded that further evidence on clinical effectiveness including health-related quality of life and resource use is needed to reduce uncertainty in the cost modelling.

The technologies may release NHS resources and increase access to specialist weight-management services, but more evidence is needed. The clinical experts stated that the implementation of digital technologies in the NHS could impact current NHS staff workload positively or negatively. The companies stated that some of their staff previously worked in the NHS, some have worked privately and some continue to work in the NHS alongside their work with digital technologies. The EAG said that there was a lack of evidence related to the cost of implementing digital technologies alongside current NHS services. The model does not take into account the potential inefficiencies of these 2 services working together to deliver specialist weight-management services. The committee concluded that further evidence should be collected on the NHS staff time needed to support using the technologies.