Interpersonal processes of care survey: patient-reported measures for diverse groups

Health Services Research, June, 2007 by Anita L. Stewart, Anna M. Napoles-Springer, Steven E. Gregorich, Jasmine Santoyo-Olsson

Evidence of racial/ethnic disparities in quality of care is accumulating rapidly. Widespread disparities have been observed in many components of quality such as effectiveness of care for chronic and acute health conditions, patient safety, timeliness, communication, respectfulness, and discrimination (Cooper-Patrick et al. 1999; Collins et al. 2002; Agency for Healthcare Research and Quality 2003, 2004; Smedley, Stith, and Nelson 2003; Weech-Maldonado et al. 2003; Johnson et al. 2004). Because many of these quality of care indicators have been linked to poorer health, they may partially account for race/ethnic disparities in health status (Smedley, Stith, and Nelson 2003). Within Donabedian's structure-process-outcomes quality of care paradigm (Donabedian 1968), most quality indicators in these studies pertain to technical processes of care; only a small proportion address interpersonal aspects of care. Interpersonal care may be a critical pathway to optimal health outcomes for minority, lower socioeconomic status (SES), or limited English proficiency (LEP) patient subgroups considered as priority populations (Foundation for Accountability: FACCT 1997; Clancy and Chesley 2003). Interpersonal quality of care may be as important as technical quality in determining health outcomes (Fung et al. 2005). Thus, research on the role of interpersonal aspects of care is needed, especially among diverse ethnic groups.

Such research has been hampered in several ways by a lack of adequate measures that allow for valid comparisons across groups. First, research on disparities in interpersonal aspects of care has been heavily based on coding audio or videotapes of encounters (Cooper-Patrick et al. 1999; Gallagher, Hartung, and Gregory 2001; Eide et al. 2004), precluding large-scale investigations. Second, although interpersonal processes are multidimensional (Stewart et al. 1999), most patient report measures assess one or two domains such as decision making (Kaplan et al. 1995). In two widely used multidimensional quality-of-care instruments--the Consumer Assessment of Health Plans" (CAHPS) and the Primary Care Assessment Survey (PCAS) (Safran et al. 1998)--interpersonal care comprises only a small portion. The CAHPS 2.0 assesses only provider communication and staff helpfulness (Hargraves, Hays, and Cleary 2003) and the PCAS assesses communication and interpersonal treatment (Safran et al. 1998). Third, most patient-reported research on disparities in interpersonal processes is based on single items (Collins et al. 2002; Agency for Healthcare Research and Quality 2003, 2004); although practical, single items are limited in scope and reliability, have questionable validity, and may result in biased estimates of group differences. Fourth, concepts and measures of interpersonal processes must reflect adequately the concerns of minority, lower SES, or LEP subgroups. Most existing measures were not designed with these groups in mind, and may miss relevant dimensions. Last, measures should have equivalent psychometric properties--factorial invariance--across groups, which allow for meaningful quantitative group comparisons (Meredith 1993; Gregorich 2006).

This article presents a multidimensional, patient-reported interpersonal processes of care (IPC) instrument, designed to be appropriate for four diverse groups (African Americans, English- and Spanish-speaking Latinos, and non-Latino whites).

METHODS

Item Development

Items were developed based on: (1) 19 focus groups stratified by race/ethnicity (African American, Latino, non-Latino white) and language (Spanish, English) (Napoles-Springer et al. 2005); (2) our original conceptual framework and items (Stewart et al. 1999), (3) literature on quality of care and physician--patient communication, and (4) cognitive interviews with adults representing the same four ethnic/language groups (Napoles-Springer, Santoyo, O'Brien, and Stewart 2006). Items were developed simultaneously in Spanish and English, aiming for semantic equivalence (Matin and Marin 1991). The item development process yielded 85 items. The measurement model included three broad domains (communication, decision making, and interpersonal style); each had several subdomains (Table 1). Respondents reported on the care they had received from their doctors over the past 12 months. For each item, they were asked how often that type of care had been provided using a five-point scale (1, never; 2, rarely; 3, sometimes; 4, usually; 5, always).

Nature and Sources of Telephone Survey Respondents

Adult patients with at least one visit in the prior 12 months were sampled from a patient database of adult general medicine practices at an academic health center. We recruited approximately 400 patients within each of four groups: African Americans, English-speaking Latinos, Spanish-speaking Latinos, and non-Latino whites. Recruitment and sampling procedures are described elsewhere (Napoles-Springer, Santoyo, and Stewart 2005). Telephone interviews (conducted October 2001 through January 2002) lasted about 30 minutes. All procedures were approved by the academic health center's Institutional Review Board.