-->PONE-D-25-41865-->-->Clinical and cost-effectiveness of the digital intervention, MyWay Diabetes, in people with type 2 diabetes living in Greater Manchester during the COVID-19 pandemic.-->-->PLOS ONE

Dear Dr.  Ravindrarajah,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Ennio Polilli

Academic Editor

PLOS ONE

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“Innovate UK and NHS England (ref: 104658)”

Please state what role the funders took in the study.  If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

If this statement is not correct you must amend it as needed.

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

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5. Thank you for stating the following in the Competing Interests section:

“Doogie Brodie is development manager at MyWay Digital Health. Deborah J Wake is a co-founder and shareholder of MyWay Digital Health (MWDH). Martin K Rutter reports consulting fees from Eli Lilly and Brigham and Women’s Hospital and modest stock ownership in GSK, all unrelated to this work. Michael Morgan-Curran is CEO at Asclepius MedTech Limited, unrelated to this work. Scott G Cunningham is co-founder, director and CTO at MyWay Digital Health and reports grants from Scottish Government, outside the submitted work; personal fees, non-financial support and other from MyWay Digital Health. Naresh Kanumilli reports fees for lectures and advisory boards for BI, Lily, AZ, Novartis, Sanofi Manarini, Novo, Abbott, unrelated to this work. George Tilston is funded by the National Institute for Health and Care Research (NIHR) Manchester Biomedical Research Centre (BRC) (NIHR203308)

All other authors report no conflict of interests. All authors have completed the conflict-of-interest disclosure forms.

In accordance with Innovate UK’s funding agreement, the University of Manchester team conducted data analysis and manuscript writing independently of MyWay Digital Health. Both teams collaborated on study design and the Innovate UK funding application, and the MyWay Digital Health team provided feedback on the final manuscript draft; however, they did not influence the study’s results or conclusions.”

We note that one or more of the authors are employed by a commercial company: MyWay Digital Health (MWDH)

1. Please provide an amended Funding Statement declaring this commercial affiliation, as well as a statement regarding the Role of Funders in your study. If the funding organization did not play a role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript and only provided financial support in the form of authors' salaries and/or research materials, please review your statements relating to the author contributions, and ensure you have specifically and accurately indicated the role(s) that these authors had in your study. You can update author roles in the Author Contributions section of the online submission form.

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Reviewer's Responses to Questions

-->Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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-->2. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

**********

-->3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

**********

-->4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

-->5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: The paper by Ravindrarajah and colleagues aimed to explore the use of digital intervention, MyWay Diabetes (MDW) in improving glycemic control and in reducing cardiovascular risk in individuals with type 2 diabetes during the COVID-19 pandemic in Greater Manchester. It also aims to establish the cost-effectiveness of this digital intervention in view of expanding its use in larger number of individuals. The Authors demonstrated that over 2 years follow up there was a reduction of 3.1 mmol/mol of HbA1c in patients using MDW as compared to non-users. Also, there was an improve in blood pressure and cholesterol level. In terms of costs, there was a reduction in patients using MDW as compared to non-users. The study is well conducted with rigorous methodology. The statistical analysis included major cofactors and covariates to ensure the best approach. The novelty is mainly represented by the use of MDW. For the first time also the economic burden of developing type 2 diabetes and its link with the development of complications is considered and analyzed. As stated in the limitations of the study, the length of follow-up of 2 years may have limited the results, it is advisable to prolong it and check whether a higher reduction in HbA1c and in blood pressure may be obtained although this may have a more negative impact on the costs.

Minr points to be addressed and/or commented:

1) Number of non-users vs. users: this is quite different. Have the Authors taken any measure to mitigate its impact?

2) Do the Authors think that the use of certain medications may have impacted the results regardless of the use of MDW? Did they take this into account in their multivariable logistic regression?

3) Were patients monitored for glucose levels with sensors? This may have impacted in improving results of the use of MDW. The Authors may add a comment.

Reviewer #2: The authors performed an interesting study. I have the following comments:

1. The authors may want to highlight more on the importance of digital intervention – 1. During COVID where face-to-face consultations are not feasible and 2. Even after COVID pandemic, patients esp the older population face mobility issues

2. What are Changing Health, Oviva and MyCognition interventions?

3. Why were only age and sex chosen as covariates for matching? The participants should be matched based on A1c, other blood results, ethnicity…etc as well

4. Further to the comment above, while the authors argue that multivariate adjustment has been done in regression, the authors should still match the participants based on these important covariates then further adjust in the multivariate regression, known as ‘doubly-robust’ adjustment, which has been shown to further eliminate residual confounding. E.g. https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(22)00032-3/fulltext

5. Why did the authors choose to select a ratio as high as 1:20 for matching? For other studies e.g. propensity score matching it is usually as high as 1:5 only. By choosing a lower ratio, imputation may not even need to be done as you can select patients with complete set of data

6. Any information on medication compliance?

Reviewer #3: This manuscript presents a well-conducted and clearly written evaluation of the MyWay Diabetes (MDW) digital self-management intervention among people with type 2 diabetes in Greater Manchester during the COVID-19 pandemic. The topic is timely and important, addressing how large-scale digital tools can support diabetes care and long-term cost-effectiveness.

The study design is appropriate, the analytical approach is rigorous, and the conclusions are well supported by the data. The manuscript reads smoothly and maintains a professional, balanced tone. I appreciate the authors’ careful handling of real-world data and their transparent discussion of limitations.

That said, a few revisions would improve clarity, transparency, and presentation.

Major comments

1. Participant selection and engagement

The possibility of self-selection bias is acknowledged but not further explored. Including simple engagement metrics—such as login frequency, module completion rate, or duration of use—would help readers understand whether the observed effects reflect platform engagement or user motivation. If such data are unavailable, please note this explicitly and discuss the limitation.

2. Matching and baseline comparability

While age- and sex-matching is reasonable, some differences remain in ethnicity and the proportion of participants with HbA1c >53 mmol/mol. Reporting standardized mean differences or presenting a balance table would improve transparency and reader confidence in group comparability.

3. Handling of missing data

Multiple imputation is appropriate, but the manuscript would benefit from a short summary of missingness rates and patterns for key variables in the main text, not only in the Supplement. Please also confirm that the assumption of data being “missing at random” is justified.

4. Medication use and costs

The finding of a smaller increase in medication costs among MDW users is interesting but may also reflect prescribing behaviour or medication adherence rather than a direct effect of the intervention. This should be acknowledged more explicitly in the Discussion.

5. Economic modelling transparency

The economic evaluation using the UKPDS Outcomes Model (v2.1) is methodologically appropriate and consistent with NICE guidance. However, the absence of a probabilistic sensitivity analysis limits uncertainty assessment. Please highlight this limitation more clearly, and consider adding a concise table or appendix summarising key input parameters for reproducibility.

Minor comments

- A simple flow diagram outlining inclusion, exclusion, and matching would enhance clarity.

- Figure 1 (cost-effectiveness analysis): please refine the legend to explain all line types clearly (e.g., horizontal dashed = current uptake; vertical dashed = full GM licence cost; dotted = discounted cost scenarios). Ensure both axes are labelled with units.

- Table 1: consider rounding p-values to two decimal places and aligning numerical values for readability. Add short notes for abbreviations (e.g., “SD = standard deviation; IMD = Index of Multiple Deprivation”).

- Table 2: add a brief note in the legend stating that models were adjusted for baseline risk factors and time between measurements, so the table is interpretable independently from the text.

- Supplementary figures (e4.01–e4.05): line styles and colours for best- and worst-case scenarios are difficult to distinguish; use distinct line types or include an in-figure legend. Ensure all axes include units (e.g., “probability,” “cost £”).

- Referencing in the Supplement: indicate that citations correspond to those in the main manuscript to avoid confusion during typesetting.

- Summary of supplement: the supplementary material is comprehensive and strengthens the manuscript; still, briefly summarising key supplementary results (missing data, sensitivity assumptions) in the main text would make the paper more self-contained.

- Maintain tense consistency (prefer past tense in Methods).

- The paragraph on speculative behavioural mechanisms could be shortened or moved to the supplement for better flow.

- Highlight early in the Introduction that MDW directly integrates with NHS primary-care data, which distinguishes it from other digital interventions.

Ethics and data availability

Ethical approval and data governance are clearly described (Northwest GM South REC 261268). The data-availability restriction under the UK Data Protection Act is understandable; however, if feasible, providing access to analytic code or a synthetic dataset would further enhance transparency and reproducibility.

Language and presentation

The manuscript is written in fluent and professional English. The overall presentation is clear and polished. Minor stylistic edits may improve rhythm and consistency, but no substantive language issues were found. Figures and tables are generally well prepared and consistent with the results; the minor refinements above would make them publication-ready.

This is a high-quality and methodologically sound study that meets PLOS ONE standards for scientific validity. The paper makes a valuable contribution to the evidence base for digital diabetes management. Addressing the suggested clarifications—particularly regarding engagement data, baseline balance, and presentation details—will further strengthen an already excellent manuscript.

Reviewer #4: This quasi-experimental study evaluated the clinical and economic impact of the MyWay Diabetes (MDW) digital self-management platform among adults with type 2 diabetes (T2D) in Greater Manchester during the COVID-19 pandemic. The study suggested that MyWay Diabetes offers a scalable, low-cost digital tool that enhances diabetes self-management and modestly improves key cardiometabolic risk factors. The integration of MyWay Diabetes into primary care systems was considered cost effective by reducing long-term complication risks.

1. The major concern for this study is the non-randomised design, which warrants proper statement as a limitation.

2. The presentation of this study needs improvement including figures and tables. For example, in Table 1, it is unclear what N available and data mean. For outcomes, it is important to report the changes in each group before the difference between arms.

3. The cost-effectiveness model is not quite clear and a bubble plot is necessary in the main text.

4. It is relevant to apply more risk calculators such as Qrisk3 for risk assessment.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

**********

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-->PONE-D-25-41865R1-->-->Clinical and cost-effectiveness of the digital intervention, MyWay Diabetes, in people with type 2 diabetes living in Greater Manchester during the COVID-19 pandemic.-->-->PLOS One

Dear Dr.  Ravindrarajah,-->-->

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Apr 13 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:-->

• A letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

-->If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Ennio Polilli

Academic Editor

PLOS One

Journal Requirements:

1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

2. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #4: All comments have been addressed

**********

-->2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: Yes

**********

-->3. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #1: Yes

Reviewer #2: No

Reviewer #4: Yes

**********

-->4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #2: No

Reviewer #4: Yes

**********

-->5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: Yes

**********

-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: (No Response)

Reviewer #2: The authors submitted a revision of the manuscript. I have the following comments:

1. The authors calculated the sample size with 1:10 ratio. Please present in sensitivity analysis the findings if PS matching 1:10 is used, ideally these patients should be those with complete data.

2. What is meant by "age (within 1 year)"? Age should be fined according to that upon enrollment

3. Despite the authors having extensively responded to the comments regarding adjusting for covariates in regression vs PS matching, putting the covariates in the propensity score is a more commonly accepted approach. Please perform this a sensitivity analysis, accepting a lower ratio e.g. 1:5, which is also commonly adopted in the current literature. The authors may also argue that increasing the number of covariates may reduce matching, but (a) it can be done with a lower ratio (b) at the authors quoted in their own previous simulation study, logistic regression only outperformed PS when sample size is large enough. The authors may also consider use of covariate-balancing PS (CBPS) with doubly-robust adjustment - please refer to the paper I cited in my previous comments.

Reviewer #4: Thanks for the revised manuscript, which improve the paper significantly. I have no more comments or suggestions and am happy to find its publication.

**********

-->7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review?  For information about this choice, including consent withdrawal, please see our Privacy Policy.-->

Reviewer #1: No

Reviewer #2: No

Reviewer #4: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

-->

-->PONE-D-25-41865R2-->-->Clinical and cost-effectiveness of the digital intervention, MyWay Diabetes, in people with type 2 diabetes living in Greater Manchester during the COVID-19 pandemic.-->-->PLOS One

Dear Dr. Ravindrarajah,-->-->

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by May 28 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:-->

• A letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

-->

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only  the individual author can complete the verification step; PLOS staff cannot  verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Ennio Polilli

Academic Editor

PLOS One

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

**********

-->2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #2: Yes

Reviewer #3: Yes

**********

-->3. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #2: Yes

Reviewer #3: Yes

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-->4. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #2: Yes

Reviewer #3: No

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-->5. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #2: Yes

Reviewer #3: Yes

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-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #2: The authors have addressed the comments adequately.

Reviewer #3: Final version

I thank the authors for their thorough and thoughtful responses to my previous comments. The majority of revisions have been addressed satisfactorily, and the manuscript has improved considerably. However, two points require further clarification before I can recommend acceptance.

Remaining concerns

1. Baseline comparability (Major comment 3.2)

I appreciate the authors' response, but I note that the tables referenced (e2.03–e2.05) present outcome data rather than baseline covariate balance. My original request was for standardized mean differences (SMDs) or a balance table showing comparability between MWD users and controls on key baseline characteristics — particularly ethnicity and the proportion with HbA1c >53 mmol/mol, where differences remain visible in Table 1.

Reporting SMDs for baseline covariates is standard practice in observational studies and would allow readers to assess residual imbalance independently of regression adjustment. I would suggest that the authors either: (a) add a column of SMDs to Table 1, or (b) provide a brief supplementary balance table. This is a reporting addition and does not require further analysis.

2. Flow diagram (Minor comment 3.6)

The authors have offered to move the flow diagram to the main text if considered helpful. I believe this would improve clarity and would encourage its inclusion in the main manuscript rather than in the supplementary material. A participant flow diagram is standard for studies of this type and aids reader comprehension.

Points addressed satisfactorily

All other major and minor comments have been addressed to my satisfaction, including:

Engagement data limitation is now clearly stated

Missing data summary and MAR assumption are appropriately described

Medication cost interpretation has been clarified

The absence of probabilistic sensitivity analysis is acknowledged

Figure and table legends have been improved

Supplementary figures have been clarified

The behavioural mechanism discussion has been refined

NHS data integration is now clearly highlighted

This remains a high-quality and important study. The remaining points are minor and relate to presentation only. I would be happy to recommend acceptance once these have been addressed.

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Reviewer #2: No

Reviewer #3: No

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Clinical and cost-effectiveness of the digital intervention, MyWay Diabetes, in people with type 2 diabetes living in Greater Manchester during the COVID-19 pandemic.

PONE-D-25-41865R3

Dear Dr. Rutter,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Ennio Polilli

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #3: All comments have been addressed

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-->2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #3: Yes

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-->3. Has the statistical analysis been performed appropriately and rigorously? -->

Reviewer #3: Yes

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-->4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #3: Yes

**********

-->5. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #3: Yes

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-->6. Review Comments to the Author

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Reviewer #3: I thank the authors for addressing the remaining concerns from the previous round. The addition of standardized mean differences in Table 1 improves transparency in baseline comparability, and moving the participant flow diagrams into the main text enhances clarity. These revisions are satisfactory, and I have no further comments. I recommend acceptance.

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-->7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #3: No

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