Examining the uptake, retention, and effectiveness of a national online type 2 diabetes self-management intervention in England (Healthy Living): A retrospective cohort study

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BACKGROUND: The prevalence of type 2 diabetes (T2DM) is increasing rapidly in the UK and worldwide and is linked to adverse outcomes including premature death. Previous studies have shown that developing self-management skills in this population can lead to health improvements. The National Health Service in England has implemented Healthy Living (HL), an online Diabetes Self-Management Education and Support (DSMES) intervention, offering information about T2DM and help with adopting healthy behaviours. AIMS: To examine the uptake and retention of people living with T2DM registered with Healthy Living and how its use is associated with changes in 1-year clinical outcomes (effectiveness) compared with people with T2DM who did not register (controls). METHODS: Anonymised linked patient-level Healthy Living and National Diabetes Audit (NDA) data were used to identify adults with T2DM in England. Multivariable logistic regression models identified predictors of participation in Healthy Living (uptake). Using 1-to-5 case-control propensity score matching (on age, sex, baseline HbA1c, body mass index (BMI), blood pressure (BP), cholesterol, ethnicity, deprivation) and multivariable linear and logistic models, we examined how Healthy Living use was related to 1-year HbA1c, BMI, BP, new insulin use, and completion of eight care processes recommended for people with diabetes (effectiveness). Several sensitivity and sub-group analyses were conducted to assess the robustness of the findings. RESULTS: A total of 21,820 people with T2DM activated a Healthy Living account. Compared with non-participants, account activators (cases) were more likely to be female (OR: 1.91; 95%CI: 1.85, 1.96), less likely to be Asian (OR: 0.35; 95% CI: 0.33, 0.37) or Black (OR: 0.56; 95% CI: 0.52, 0.60) compared with white people. Assessing effectiveness, 4,940 Healthy Living cases were matched to 24,685 NDA controls. Compared with controls, at 1-year, Healthy Living cases had lower HbA1c (by -1.3 mmol/mol (95% CI: -1.7, -0.8) or -0.1% (95% CI: -0.2, -0.1)); BMI (-0.2 kg/m2; 95% CI: -0.3, -0.1), systolic BP (-1.2 mmHg; 95% CI: -1.6, -0.7), and diastolic BP (-0.6 mmHg; 95% CI: -0.9, -0.3); higher odds of completing care processes (OR: 1.6; 95% CI: 1.5, 1.8), but non-significant for insulin use (OR: 1.0; 95% CI: 0.8, 1.2). The results of the sensitivity and sub-group analyses were consistent with the main findings. CONCLUSIONS: People who activated a Healthy Living account experienced, on average, moderate health benefits compared with non-participants. These benefits would be expected to reduce risks for diabetes-related complications at a population level.

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