Research on race/ethnic disparities in interpersonal aspects of care has been limited by a lack of measures that reflect the multidimensional nature of these processes and allow valid, unbiased comparisons across diverse groups. This study helps fill this gap by conceptualizing and operationalizing interpersonal processes as multidimensional. We provide a patient-reported survey developed through a sequence of qualitative and quantitative studies, with Spanish and English versions developed in parallel, with evidence of reliability and validity, and demonstrating scalar invariance of a subset of items in each domain. The final empirically based framework shared many features of the hypothesized model, which in turn was based on previous work done in this area. However, it had fewer subdomains, in part because hypothesized constructs were interrelated in more complex ways than originally thought.
The IPC Survey should facilitate research to explore how specific aspects of interpersonal care affect various health outcomes and whether interpersonal care explains disparities in such outcomes. The 29-item survey performed well within each group and can be used for within-group studies. The 18-item short form can be used to make unbiased mean comparisons across the four groups represented in this sample. Analyses of determinants and outcomes of IPC using these measures are forthcoming.
One notable finding was the relatively high scores overall. Relatively good processes could be the true state in these practices located in a major medical teaching university serving a highly diverse population. Also, many patients had attended these clinics for over a decade and may have found providers with whom they were comfortable. Despite the relatively high scores, there is room for improvement, particularly with respect to patient-centered decision making.
Although there were significant group differences in interpersonal processes, these differences did not consistently favor any group. Our finding that African Americans obtained the best scores on two communication scales are consistent with results on provider communication from a CAHPS Medicaid Managed Care survey (Weech-Maldonado et al. 2003
), and our finding that whites had the highest scores on decided together
is consistent with one other study (Cooper-Patrick et al. 1999
We envision four broad applications of the IPC Survey. First, the short-form facilitates comparative population- or clinic-based studies of disparities in interpersonal processes (e.g., by race/ethnicity). Another application is to determine if the measures predict technical processes (e.g., procedures or tests) or patient outcomes (e.g., patient adherence or satisfaction) (Stewart 1995
; Blanchard and Lurie 2004
; Fung et al. 2005
A third application is to use the IPC Survey as an outcome of quality improvement policies (e.g., provider training). There is evidence that race/ethnic concordance of physicians and patients is associated with better communication (Saha et al. 1999
) and more participatory decision making (Cooper-Patrick et al. 1999
). If such findings are replicated with these measures, systems of care might be more likely to diversify their health care professional staff and develop targeted interventions to improve specific aspects of interpersonal processes (Cegala, Post, and McClure 2001
). Finally, the IPC Survey could be useful to administrators as measures of outcomes of continuous quality improvement (e.g., to monitor disparities or provide feedback to physicians on interpersonal care).
We recommend continued validation research on the IPC Survey across a range of groups and settings. We empirically eliminated several conceptually relevant subdomains such as empowerment and cultural sensitivity that warrant continued measurement efforts. Because power differentials between patients and physicians place vulnerable patients at a unique disadvantage, empowerment may be an outcome of quality care. Cultural sensitivity was found to be multidimensional in our qualitative analyses (Nápoles-Springer et al. 2005
), possibly explaining why our efforts to derive a unidimensional scale were unsuccessful. Cultural sensitivity may be difficult to measure because it is manifested through a broad spectrum of behaviors and attitudes (e.g., respect, compassion) toward nonwhite patients (Clancy and Stryer 2001
Our results should be interpreted in light of several limitations. The study was conducted within a single university-based system of care in a geographic area known for diversity. We did not include Asian Americans or other ethnic subgroups. The measurement models were tested and modified using a single data set, thus results are provisional, conditional on future replication in independent samples. To achieve invariance across four groups, we eliminated items that worked well within some of the groups (e.g., were culture-specific). Future studies might supplement invariant scales with ethnic-specific scales when evidence suggests that a construct may help explain disparities in that group. Because we used telephone administration to accommodate persons with limited literacy or English proficiency, we do not know how well self-administration would work.
Numerous reports and policy statements call for quality measures that are relevant, valid, and unbiased across ethnic and linguistic groups to assess possible quality-of-care disparities (Bethell et al. 2003
; Fortier and Bishop 2003
; Beach et al. 2004
). Although, we demonstrated the methodological complexities associated with doing so, the IPC Survey should help to fill this gap, and may prove useful in assessing quality of care disparities in other settings and ethnic groups.