Journal of General Internal Medicine

, Volume 29, Issue 8, pp 1113–1121 | Cite as

Comparative Effectiveness of Audit-Feedback Versus Additional Physician Communication Training to Improve Cancer Screening for Patients with Limited Health Literacy

  • Eboni G. Price-HaywoodEmail author
  • Jewel Harden-Barrios
  • Lisa A. Cooper
Original Research



We designed a continuing medical education (CME) program to teach primary care physicians (PCP) how to engage in cancer risk communication and shared decision making with patients who have limited health literacy (HL).


We evaluated whether training PCPs, in addition to audit-feedback, improves their communication behaviors and increases cancer screening among patients with limited HL to a greater extent than only providing clinical performance feedback.


Four-year cluster randomized controlled trial.


Eighteen PCPs and 168 patients with limited HL who were overdue for colorectal/breast/cervical cancer screening.


Communication intervention PCPs received skills training that included standardized patient (SP) feedback on counseling behaviors. All PCPs underwent chart audits of patients’ screening status semiannually up to 24 months and received two annual performance feedback reports.


PCPs experienced three unannounced SP encounters during which SPs rated PCP communication behaviors. We examined between-group differences in changes in SP ratings and patient knowledge of cancer screening guidelines over 12 months; and changes in patient cancer screening rates over 24 months.


There were no group differences in SP ratings of physician communication at baseline. At follow-up, communication intervention PCPs were rated higher in general communication about cancer risks and shared decision making related to colorectal cancer screening compared to PCPs who only received performance feedback. Screening rates increased among patients of PCPs in both groups; however, there were no between-group differences in screening rates except for mammography. The communication intervention did not improve patient cancer screening knowledge.


Compared to audit and feedback alone, including PCP communication training increases PCP patient-centered counseling behaviors, but not cancer screening among patients with limited HL. Larger studies must be conducted to determine whether lack of changes in cancer screening were due to clinic/patient sample size versus ineffectiveness of communication training to change outcomes.


communication shared decision making health literacy cancer screening standardized patients 




The authors would like to thank Dr. Roy Weiner for his critical review of this manuscript and Dr. John LeFante for his assistance with examining intraclass correlations for cancer screening outcomes.


This study was funded by the Robert Wood Johnson Foundation Harold Amos Faculty Development Program (Grant # 63523). Dr. Cooper is supported by grants from the National Heart, Lung, and Blood Institute (K24 HL83113 and P50 HL0105187).

Prior Presentations

This work was presented at the American Association for Cancer Research 3rd and 4th Annual Cancer Health Disparities Conferences in October 2010 and September 2011.

Conflict of Interest

The authors declare that they do not have a conflict of interest.


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Copyright information

© Society of General Internal Medicine 2014

Authors and Affiliations

  • Eboni G. Price-Haywood
    • 1
    Email author
  • Jewel Harden-Barrios
    • 1
  • Lisa A. Cooper
    • 2
  1. 1.Department of MedicineTulane University School of MedicineNew OrleansUSA
  2. 2.Department of MedicineJohns Hopkins University School of MedicineBaltimoreUSA

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