The impact of training healthcare professionals’ communication skills on the clinical care of diabetes and hypertension: a systematic review and meta-analysis

Diabetes mellitus and hypertension are common chronic conditions and major risk factors for disability and mortality worldwide. It is estimated that 475 million adults were living with diabetes in 2017 and 874 million adults had systolic blood pressure of 140 mm Hg or higher in 2015 globally [1, 2]. The prevalence of diabetes and hypertension continue to increase due to aging populations and an increase in lifestyle risk factors [3, 4]. Hypertension and diabetes carry an increased risk of cardiovascular diseases, including myocardial infarction and stroke, that are among the most important causes of premature death and disability [5]. Importantly, diabetes and hypertension frequently coexist and require long-term self-management to improve outcomes and quality of life [6‐8]. However, the management of hypertension and diabetes is often poor in terms of low patient awareness, poor medication compliance and incidence of preventable complications [9, 10].

Success in diabetes and hypertension care requires effective communication between health professionals and patients [11, 12]. This can enhance patient engagement and is associated with increased understanding of treatment, adherence to recommendations and patient satisfaction, as well as improved clinical outcomes [13, 14]. One systematic review of randomized trials of integrated care programs for people with type 2 diabetes found that better communication and information flow enabled timely treatment intensification, improved control of cardiometabolic risk factors and promoted self-care behaviors [15].

Effective communication skills involve active listening, empathy, the use of open questions, forming an understanding of patients’ perspectives, knowledge and expectations, and the ability to share information appropriately [16]. Healthcare professionals should be competent at acquiring and explaining relevant health information, counselling patients, providing treatment options, and building long term therapeutic relationships in order to achieve the best possible health outcomes as a core part of their skill set.

Motivational interviewing is one approach to improving communication between physicians and patients that can be used to enhance diabetes and hypertension self-care and management. Motivational interviewing is a person‐centered counseling style that enables healthcare professionals to explore patients’ motivations and facilitate behaviour change [17]. Several systematic reviews have shown that motivational interviewing is associated with improvement in self-management and glycemic control in the short-term as well as quality of life [18, 19]. A randomized trial of motivational interviewing in hypertension management suggested that it helped to sustain the clinical benefits of adherence behavior [20].

Shared decision making (SDM) is another key approach to communication that can be appropriately applied in diabetes and hypertension care [21]. SDM is defined as patients and healthcare professionals jointly discussing clinical factors, harms and benefits of treatment options and patient preferences, in order to reach a decision based on mutual agreement [22]. SDM often requires consideration of different management options, such as dietary change, exercise and medication, that may require significant lifestyle changes [23].

Despite the rising interest in improving communication skills for healthcare professionals, it remains unclear to what extent communication skills training improves the clinical management and outcomes for patients with cardiometabolic disease. This systematic review aimed to summarise the findings of randomized controlled trials on the effectiveness of communication skills training for healthcare professionals on the outcomes and experience of patients with diabetes and hypertension.

We initially conducted a scoping search for reports of any type of studies investigating the effectiveness of communication skills training for healthcare professionals on clinical and patient-reported outcomes for diabetes and hypertension care. We conducted the scoping search in EMBASE, MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR), the Epistemonikos database (https://​www.​epistemonikos.​org/​), and PROSPERO (https://​www.​crd.​york.​ac.​uk/​PROSPERO/​) using the search terms: communication, interview, shared decision making, training, diabetes and hypertension. We were unable to identify any existing or ongoing systematic reviews summarising the effectiveness of communication skills training for healthcare professionals on outcomes for patients with diabetes and hypertension. We registered our systematic review protocol on PROSPERO (registration ID: CRD42019129696) and designed and reported our review in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) [24].

19 eligible studies were selected from 7011 potentially relevant records in this systematic review. Within these studies, a total of 21,762 patients and 785 health professionals were recruited. 13 trials investigated the communication skills training effect in diabetes and 6 trials in hypertension. There was a great clinical and methodological heterogeneity of studies in terms of training type and outcomes measurement. For the assessment of risk of bias in included studies, nearly half of trials were at a high risk of bias. The pooled results for primary outcome of HbA1C, blood pressure, BMI, TG, LDL and HDL showed that there was no evidence of differences when comparing training with usual care or no training. It was uncertain whether training for healthcare professionals was effective in secondary outcomes, e.g., quality of life, beliefs, understanding, knowledge, self-care, self-efficacy, empowerment, medication adherence and patient-doctor relationship.

The diversity of interventions and outcome measurements might be the reasons for no obvious effect or a small effect of training healthcare professionals in communication skills in this systematic review. For the training intervention, training theory, types, trainers, training assessment and evaluation, training length (only a few hours for some training) had an impact on effectiveness. It was not clear what was used to assess trained healthcare professionals in their real-world clinical practice, although three studies (Farmer 2012, Jansink 2013, Heinrich 2010) mentioned evaluations of audiotapes of consultations. In addition, the length of follow-up ranged from 3 to 24 months, so that only short-term effects were measured in the management of these long-term conditions. For clinical indicators as outcome measurements, such as HbA1_C, blood pressure control and lipids, our findings suggest that none of the methods used to train healthcare professionals lead to significant improvements in patients with diabetes or high blood pressure. For the secondary outcomes, more than 20 questionnaires were used in studies included in this systematic review, though the same unified questionnaire was occasionally used. This makes it impossible to make direct between-study comparisons for these endpoints.

To our knowledge, this is the first systematic review to evaluate the effectiveness of training programs in healthcare professionals in communicating with patients with common chronic conditions. Patients with diabetes and hypertension typically communicate with health professionals several times a year, over the whole of their lives following diagnosis. The quality of these encounters can be a major determinant of the quality of their long-term outcomes. This systematic review addressed the question of whether the short-term clinical outcomes of patients and patient's experience can be improved through training health providers in better communication skills.

This review shows serious limitations in the evidence needed to support the development of effective training programs for health professionals caring for patients with diabetes or high blood pressure. The interventions in the included trials are often poorly characterized and are very heterogeneous, both in content and duration. The studies span 9 countries with differing types of diabetes care and major differences of culture and patient expectation. Without clearer understanding of the baseline characteristics of each system and its decision-making professionals, it is difficult to compare or to extrapolate from one setting to another. Because of this great heterogeneity among studies, many patient-related outcomes could not be compared directly.

The results of our study are similar with previous studies in other clinical areas. Although sufficient evidence is lacking, some of the included studies show a small effect on patients' understanding, self-care, and doctor-patient relationships. In a systematic review on communication skills training for healthcare professionals in cancer patients, communication training programs improve some types of healthcare professionals skills related to information gathering and supportive skills. However, the sustained effects of intervention were unable to determine over time. Also, the types of communication skills training courses evaluated in these trials were diverse. They found no evidence for the beneficial of intervention in patient’s mental or physical health, and patient satisfaction [45]. One systematic review on training clinicians on patients in primary care and rehabilitation settings found it has a small effect in improving patients satisfaction [46]. Most of communication training they found emphasized patient participation. Theoretical workshops, written information, and discussion sessions with audiovisual resources were used as communication training methods. The number of intervention sessions given by trained people varied from 1 to 12 within 1 day to 6 months. In another systematic review on communication skills training for mental health professionals in patients with severe mental illness found a modest positive effect on patient-doctor relationship. However, in this systematic review, only one pilot cluster-RCT was recruited [47]. There were relatively few good quality data and the trial is too small to highlight differences in most outcome measures, such as patient satisfaction. Similarly, previous studies show that communication skills training programs employ many different teaching theories, methods and forms of evaluation [48].

Purposeful training is a key element to the improvement of any health system, especially in systems which aim to build new capacity. This applies to the care of diabetes and hypertension in most countries, where a key aim is to maximize the potential of primary care and to encourage patient understanding and self-management. It is disappointing therefore to find that the evidence to guide such training is poor or absent. There is no generic short-term solution which will work in all contexts.

The successful management of these conditions usually depends on more than one health professional and always involves the patient. Increasingly, patients with diabetes or high blood pressure are being encouraged to self-monitor and self-manage, and to share decisions about their management. We would therefore suggest that any successful training system needs to be based on these goals, and that baseline gaps in provision and understanding need to be assessed for health professionals and patients. The key metrics would therefore be the fulfilment of these prespecified gaps in care, rather than the variety of scalar metrics which were applied across the studies in this review. Future studies should be long-term and adaptive to local need.

The communication skills training interventions for healthcare professionals did not improve HbA1c, BP or other relevant outcomes in patients with diabetes and hypertension. Although the studies analyzed probably include the key ingredients for successful communication training, the timescale and format of the programs was inadequate to result in measurable change to patient-important outcomes. Better methodology is urgently needed to yield generalizable evidence for the management of these conditions of lifelong risk which affect a substantial proportion of the human population. The pooled analysis of short-term training interventions is likely to be of less value than a mixed-methods approach to training programs over longer time scales and across a range of health systems. Our study indicates that we are still some ways from identifying the methods by which patients and health professionals can reach shared understanding to achieve the best outcomes for at-risk individuals and populations.