The Influence of Baseline Hemoglobin A1c on Digital Health Coaching Outcomes in Adults With Type 2 Diabetes: Real-World Retrospective Cohort Study

Abstract

Background: Digital health coaching is an increasingly common diabetes self-management support strategy for individuals with type 2 diabetes and has been linked to positive mental and physical health outcomes. However, the relationship between baseline risk and outcomes is yet to be evaluated in a real-world setting.

Objective: The purpose of this real-world study was to evaluate trends in digital health coaching outcomes by baseline hemoglobin A_1c (HbA_1c) to better understand which populations may experience the greatest clinical and psychosocial benefit.

Methods: A retrospective cohort study design was used to evaluate program effect in a convenience sample of participants in a 12-week digital health coaching program administered by Pack Health. Participants were referred through their health care provider, payer, or employer. The program included patient-centered lifestyle counseling and psychosocial support delivered via telephone, text, and/or email. Self-reported HbA_1c and weight were collected at baseline and completion. Physical and mental health were assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health Short Form and the Diabetes Distress Scale-2. Changes in HbA_1c, weight, BMI, and physical and mental health were analyzed within three participant cohorts stratified by baseline HbA_1c level.

Results: Participants with complete HbA_1c data sets (n=226) were included in the analysis. The sample population was 71.7% (162/226) female, with 61.5% (139/226) identifying as white and 34.1% (77/226) as black. Most participants (184/226, 81.4%) reported a baseline HbA_1c ≥7%, and 20.3% (46/226) were classified as high risk (HbA_1c >9%). Across HbA_1c cohorts, the mean baseline BMI was 35.83 (SD 7.79), and the moderate-risk cohort (7% ≤ HbA_1c ≤ 9%) reported the highest mean value (36.6, SD 7.79). At 12 weeks, patients reported a significant decrease in HbAlc, and high-risk participants reduced their levels by the greatest margin (2.28 points; P<.001). Across cohorts, BMI improved by 0.82 (P<.001), with the moderate-risk cohort showing the greatest reduction (-0.88; P<.001). Overall, participants reported significant improvements for PROMIS scores, with the greatest change occurring in the high-risk cohort for whom physical health improved 3.84 points (P<.001) and mental health improved 3.3 points (P<.001). However, the lowest-risk cohort showed the greatest improvements in diabetes distress (-0.76; P=.005).

Conclusions: Acknowledging the limitations in this real-world study design, the results reported here suggest that adults with type 2 diabetes with a high baseline HbA_1c or high BMI may benefit the most from patient-centered digital health coaching programs when compared to their lower risk counterparts. While all participants improved in physical and mental health categories, participants with high HbA_1c experienced the greatest HbA_1c reduction and individuals with the highest baseline BMI lost the most weight. These results may be used to inform referrals for patients who are more likely to benefit from digital health coaching.

Keywords: body mass index; diabetes distress; diabetes support program; digital health coaching; digital therapy; hemoglobin A1c; mobile health; type 2 diabetes.