|Year : 2013 | Volume
| Issue : 4 | Page : 243-247
Service quality for people with rheumatoid arthritis: Iranian patients' perspective
Saeed Karimi1, Payman Mottaghi2, Azad Shokri3, Mohammad H Yarmohammadian1, Jafar-Sadegh Tabrizi4, Kamal Gholipour5, Ayan Kordi6
1 Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Rheumatology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
3 PhD Candidate in Health Services Management, Hospital Management Research Center, Iran University of Medical Sciences, Tehran, Iran
4 Department of Health Services Management, Faculty of Management and Medical Informatics; Tabriz Health Services Management Research Center, Tabriz, Iran
5 Department of Health Services Management, Faculty of Management and Medical Informatics; Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
6 M.Sc. in Health Service Management, Faculty of Health Service Management and Medical Information, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Web Publication||16-Apr-2014|
Department of Health Services Management, Iranian Center of Excellence in Health Management, Faculty of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz
Source of Support: Financial support was provided by Health Management and Economic Research Center of Isfahan University of Medical Science., Conflict of Interest: None
Background: Service quality (SQ) refers primarily to how the care received is perceived and is influenced by the physical, social, and cultural context and nonhealth aspects of care, such as access, respect, and confidentiality. This study aimed to assess SQ for people with rheumatoid arthritis (RA) from the patients' perspective. Subjects and Methods: A cross-sectional study was conducted with 172 people with RA who received care from specialist clinics of Isfahan University of medical sciences in 2013. SQ was measured using comprehensive quality measurement in healthcare_service quality (CQMH_SQ) questionnaire. Questionnaire content validity was reviewed and confirmed by 10 experts and its reliability was confirmed based on Cronbach's alpha index (α =0. 803). A measure of SQ was derived by combining the relative importance and actual performance. Data analyzed using the SPSS-17 statistical package. Results: Study findings indicate average SQ score were 7.91 (0.87) and demonstrated which aspects of SQ took a weak score in total SQ for people with RA. Confidentiality and choice of care provider achieved the highest and availability of support group had the lowest scores SQ scores. Participants with good control of their disease had higher scores (P = 0.042) and SQ score customer quality score have positive relationship with increasing each year in elapsed time of diagnosis (P = 0. 028). Conclusions: According to average score of customer quality, study findings indicate that patient and provider participation in quality improvement activities can be used as an effective solution and also needs for focus on such aspect of health care quality that were more important for consumer, also dimension have worst quality such as availability of support group.
Keywords: Iran, patients′ perspective, rheumatoid arthritis, service quality
|How to cite this article:|
Karimi S, Mottaghi P, Shokri A, Yarmohammadian MH, Tabrizi JS, Gholipour K, Kordi A. Service quality for people with rheumatoid arthritis: Iranian patients' perspective. Int J Health Syst Disaster Manage 2013;1:243-7
|How to cite this URL:|
Karimi S, Mottaghi P, Shokri A, Yarmohammadian MH, Tabrizi JS, Gholipour K, Kordi A. Service quality for people with rheumatoid arthritis: Iranian patients' perspective. Int J Health Syst Disaster Manage [serial online] 2013 [cited 2021 Jun 21];1:243-7. Available from: https://www.ijhsdm.org/text.asp?2013/1/4/243/130749
| Introduction|| |
Rheumatoid arthritis (RA) is the prototypical chronic disease and patient care is provided by multiple physicians (primary care physician, rheumatologist, and orthopedist) and health care providers (physician, nurse, and medical assistant) and in various health care delivery settings [both outpatient (rheumatology clinic, physical therapy) and inpatient settings].  Because the nature of disease and available treatments, these patients are dependent on a wide variety of health care services for long-term. They require continuous use of medical resources that use of these services in conjunction with medical treatments depends on patient satisfaction of the services presented to them. ,, It is predicted that chronic disease will be the leading cause of disability by 2020; unless accompanied by good management.  According to recently published recommendations for the management of RA, treatment must be based on shared decisions between the patient and rheumatologist, as an overarching principle,  and quality of care from the patient's perspective is increasingly considered an important component of comprehensive chronic disease management. 
Quality of care defined from different perspective and has been defined in a number of different ways. One of the most comprehensive definitions for quality in health care recently provided by Tabrizi et al.,  According to this definition, quality in health services assessed from three dimensions: service, technical, and customer quality. Technical quality refers to the clinical and technical aspects and customer quality (CQ) focuses on service user or customer features. Service quality (SQ) refers primarily to how the care received is perceived and is influenced by the physical, social, and cultural context and nonhealth aspects of care such as access, respect, and confidentiality. 
SQ becomes increasingly important for today's business, particularly in high-customer involvement industries such as healthcare this factor is an important factor in marketing and service utilization. So, it is vital that the organization understand the way in which quality initiatives help enhance all dimensions of SQ.  Researchers have defined SQ as the ability of the organization to meet or exceed consumer expectations.  Between 1984 and 2003, researchers have been reporting nineteen conceptual SQ models and each model is representative of different point of view about services,  accurate and implementable measurement of SQ as perceived by patients has reach a consensus for healthcare organizations,  because the patients no longer see themselves as passive recipients of care, they welcome a more closed dialogue with health care staff  due to studies suggest that patients' views on care are a valuable tool for quality improvement and for making health care more responsive to patients' needs.  This study aimed to assess SQ for people with RA from the perspective of the services recipients.
| Subjects and Methods|| |
This is a cross-sectional study conducted with 170 people with RA who were received care from specialist clinics of Isfahan University of Medical Sciences in 2013. Convenience sampling used to select participants and to this purpose who was referred to clinics within from January to April 2013. SQ measured using CQMH_SQ questionnaire. 
Validity of the study questionnaire was reviewed and confirmed by 10 experts in Tabriz and Isfahan University of Medical Sciences and its reliability was confirmed according to Cronbach's alpha index (α =0.803), based on a pilot study by participate of 30 patients.
For each aspect of SQ, respondents were asked to evaluate the importance of that aspect and their perception of the quality of care they had received in relation to that aspect (performance) over the past year. Importance of SQ was scored on a four-point Likert scale, which was then scaled from 1 to 10 as 0 = not important, 3 = may be important, 6 = important, and 10 = very important. Perceived performance of care was scored on a four-point scale ranging from ''never, sometimes, usually, and always'' or ''poor, fair, good, and excellent.'' For analysis, this scale was dichotomized as: 0 = usually/always or good/excellent and 1 = never/sometimes or poor/fair. An overall measure of SQ was calculated for each SQ factor by combining the importance and performance scores using the Netherlands Institute for Health Services Research methodology.  SQ of care for each quality aspect was calculated as:
Service quality = 10-(importance × performance)
Also, according to previous studies, SQ score of less than 9 indicates a failure in quality of care and a significant opportunity for improvement. Frequencies and percentages were used to describe demographic information of people with RA and mean values (standard deviation) were used to report SQ scores and its dimensions. Independent samples t test and analysis of variance followed by Tukey HSD post hoc test were conducted to compare SQ score between categorical variables. A hierarchical linear regression analysis was applied in two steps using the enter method. Variables found to be associated with SQ in the univariate analysis were included in multivariate regression model. The P values for entry and removal variables in the stepwise regression model were 0.05 and 0.15, respectively. Data analyzed using the SPSS-17 statistical package (SPSS, Chicago, IL, USA). P values ≤ 0.05 were considered as statistically significant.
| Results|| |
Our findings indicate more than 82% of participants were female, so great parts of participant were homemaker. A total of 14% of patients were illiterate and only 22% have had academic education, Most of our participants (40%) aged over 50 years old. The majority of participants (74%) assessed their response to treatment well and 74% of were report some kind of complication. According to study findings regarding demographic characteristics and care condition only there is significant association between self-evaluations of disease control and SQ score, so, people who have assessed their care well have had greater SQ score [Table 1].
|Table 1: Service quality score in terms of demographic and care condition for people with rheumatoid arthritis|
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The average scores for importance, performance, and SQ of delivered care according to SQ aspects are shown in [Table 2]. Study finding indicates confidentiality had the highest score for performance and then there is choice of care provider, accessibility, and dignity. Basic amenities, communication, prevention, dignity, and safety had the highest score for importance. Confidentiality and choice of care provider achieved the highest SQ scores. Total SQ score is 7.91 (0.87) and we demonstrated which aspects of SQ took a weak score in total SQ for people with RA [Table 2].
|Table 2: Performance, importance, and service quality scores for people with rheumatoid arthritis|
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Using univariate analysis for overall service quality, statistically significant differences were found for SQ score by elapsed time of diagnosis (P = 0.013), self-evaluation of disease control (P = 0.027). Finally, multiple regression analysis showed that "elapsed time of diagnosis" and "self-evaluation of disease control" were significantly and independently related to SQ score [Table 3]. People who evaluate their disease control as well had report SQ scores (P = 0.042), also there are significant association between elapsed time of diagnosis and SQ scores. So that, by increasing each year in elapsed time of diagnosis, SQ score improves 0.02 unit (P = 0.028).
|Table 3: Results of multiple regression analysis for variables related to total service quality score (n=170)|
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| Discussion|| |
In our study, SQ score was relatively low for people with RA from the patient perspective in Isfahan compared with considered standards.  Of the 12 aspects of SQ, "confidentiality" and "choice of care provider" had highest (9 score) and" availability of support group" had the lowest scores. Based on the SQ score, participants in the current study were less concerned about communication, autonomy, continuity of care, accessibility, and dignity, while participants also reported inadequate quality regards to basic amenities, timeliness, safety, and prevention.
Our finding indicate low SQ for support group, Due to weak SQ score for support group (3.11), the average total score also decrease. In studies of Tabrizi et al.,  among people with Type 2 diabetes, SQ scores were higher than our study (8.62 vs. 7.91). Other study by Tabrizi et al.,  in a physiotherapy clinic show a higher score (8.45) than present study. "Supported by a group of people with a similar condition who have knowledge about the different aspects of their disease, share their personal experiences and information with other people with this disease"  has direct effect on the individual's well-being. People, who experience friendly relations and affection in their relationships with others, are helped in case of need and have social companionship once in a while, are better off than people who are not (or are less) supported in any of these ways.  These results have been also supported by Cain et al.,  among persons with cancer, Shearn et al., in patient RA  and van Uden-Kraan et al.,  indicates that participation in support groups can make a valuable contribution to the empowerment of patients. Despite its great significance and high importance (6.89), participation in this study have stated that they had not access to support group, because there are no such groups in Isfahan and other cities of Iran and the authorities are disregard it.
Participants in the current study were concerned about timeliness and basic amenities. In relation to timeliness, some participants dissatisfied due to overcrowding of patients in clinics, and long waiting time for appointments.  According to Victorian Branch of the Australian rheumatology Association reports' waiting time to see a rheumatologist according, ranged from 0 to 4 weeks in the private sector, 1−16 weeks in the public system, and 1−20 weeks for people in rural areas.  In relation to physical standards of health care facilities (amenities) such as cleanliness, comfortable chairs, sufficient ventilation, cold water, and clean toilets,  our participants concerned with inadequate attention to the basic amenities, such as the chairs in the waiting room and toilets, consistent with condition of RA patients. In studies of Tabrizi et al.,  in a physiotherapy clinic (2012) in indifferently, aspects of timeliness and basic amenities, had the highest SQ score and was higher than acceptable score (high 9 score), that was different with our study, whereas in other studies of Tabrizi et al.,  among people with Type 2 Diabetes in Australian (2008) and pregnant women in Iran (2009) like our study, SQ score in some aspects such as basic amenities was lower than acceptable score. 
Prevention is important aspects to providing appropriate services for early detection of disease and prevention of complications  and result of focus group discussions routine screening programs and receiving reminders about regular checkups were considered important.  Safety also is important aspects relate to side-effects of interventions and medications. In our study, score of prevention and safety was unacceptable. Similarly, SQ score for prevention and safety in overall studies of Tabrizi et al., ,, were lower than acceptable score.
In overall, studies of Tabrizi et al., ,, confidentiality rate was strong which similar to the results of our study. Thrall et al.,  found that people rank confidentiality was high among factors influencing their decision to seek health care and Shaikh et al.,  showed that people who received a confidentiality assurance from a health care provider, were more likely to report their behaviors to their provider and continue their care. Then, we can conclude that confidentiality has high importance among participation (0.05) and encourages people with RA to disclose information to their provider, or that lack of confidentiality prevents them from doing so.
The high SQ score for choice of care provider in our study indicates that most participants reported that they are free to choose between services providers, including general practitioners and specialists. On the contrary, this issue indicated that people with RA were highly satisfied in their ability to choose their care provider as a result of sufficient information. While this aspect have been serious concerns in studies of Tabrizi et al. ,,
| Conclusion|| |
According to study findings, SQ score was relatively low for people with RA of our study, this study indicate providers want to provide high-quality service to patients, in this regard, patient and provider participation in quality improvement activities can be used as an effective solution. Furthermore, the data from this study may be useful to decision makers to focus on such aspect of health care quality that were more important for consumer, also dimension has worst quality such as availability of support group. On the contrary, due to interactive nature of these aspects improvement in one can improve other aspects too. Also, because RA is a chronic disease, satisfaction of costumers could promote their quality of life and improve their adherence to therapies in the long-term.
| Acknowledgement|| |
We would like to thank all experts' in Department of health services management for their useful comments. Also special thanks to all RA patients' for their patient and participation in this study.
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[Table 1], [Table 2], [Table 3]