rheumatoid arthritis ( ra ) is a chronic autoimmune disorder characterized by inflammation 
 of synovial tissues that leads to joint swelling , stiffness , pain , and progressive joint 
 destruction with unpredictable course and wide variation in severity . the one 
 percent of the world s population is affected by ra , suffer substantial morbidity as a 
 result of rheumatoid arthritis and early death as a result of comorbid diseases . unfortunately , cure of ra is not possible , and management and control of this disease is 
 considered with current procedures , then it can be said that , for incurable diseases the 
 quality of care is considered very important . quality of care has become increasingly critical in the evaluation of healthcare and 
 healthcare services . however , little is 
 known about whether patients with ra receive appropriate care for their disease and few 
 tools exist to evaluate this question . evaluation of the rheumatic healthcare quality is a major issue for detection of needed care 
 and long - term dependency on healthcare . 
 initially , the assessing of quality of care is often performed by healthcare professionals ; 
 however , patients perspectives on healthcare quality differ from the views of healthcare 
 professionals and policy makers . 
 quality of care from the perspective of patients is increasingly considered an important 
 component of comprehensive chronic disease management and as an instrument for evaluation of 
 health care quality . in many preceding studies , quality of care from the patient s 
 perspective has been considered as patient satisfaction . the limitation of these 
 surveys was that the scores were extremely subjective , highly skewed ( > 90% are 
 satisfied ) , and influenced by personal preference and patient expectation . therefore , a more refined and less subjective 
 instrument for evaluating healthcare quality from the patients perspective is needed . donabedian , one of the pioneers in quality promotion , proposed a model to measure quality 
 of health care using technical quality ( tq ) , structure quality ( sq ) , and process quality 
 ( pq ) . lack of a comprehensive 
 measurement method in health care has created a miss understand regard to result of quality 
 assessment in health services . also , most 
 of studies on the quality of health care focus on the technical and service aspects of care , 
 and the most important aspect in delivery of health services , customer quality , is 
 neglected . in this regard , , the quality of health services are assessed from three 
 dimensions : service , technical and customer quality . service quality refers primarily to how the care are received and is 
 influenced by the physical , social , and cultural context . technical quality refers to the 
 degree to which the delivered care meets scientific and professional standards that are 
 likely to optimize the benefits and minimize the risks . this aspect of quality 
 reflects the knowledge , skill , and ability of the care giver for self - management . customer 
 quality refers to the attributes of patients or health care consumers that enable them to 
 participate more effectively with health care delivery system in order to successfully 
 manage their own conditions . quality 
 index ( qi ) is the combination of three aspects of quality of care and indicates an overall 
 value for quality of delivered care among patients ( figure 
 1 ) . the proposed model of comprehensive quality measurement in health care 
 ( cqmh )   to the best of our knowledge , despite the importance of care among the arthritis 
 rheumatoid patients , so , our aim in 
 this study was to assess quality of delivered care among patients with rheumatoid arthritis 
 based on a model of comprehensive quality measurement in health care ( cqmh ) . this was a cross - sectional study , conducted on 170 subjects with rheumatoid arthritis who 
 were received care from specialist clinics of isfahan university of medical sciences in 
 2013 . according to the convenience sampling subjects who were referred to clinics from 
 january to april 2013 quality of delivered care -tq , sq , and cq- 
 was measured by using the reformed cqmh questionnaire for ra patients .   due to the lack of national instructions , international instructions were used for 
 measuring the technical quality of services . then standards was 
 categorized in five group of clinical care and services , paraclinical services , lifestyle 
 education , education about drugs , and assessment of drug side effects . for each aspect of 
 service quality , respondents were asked to evaluate the importance of that aspect and to 
 determine their perception about the quality of care received in relation to that aspect 
 ( performance ) , over the past year . this instrument measures 
 customer empowerment in four important stages : 1 ) believing the patients role is important , 
 2 ) having the confidence and knowledge necessary to take action , 3 ) actually taking action 
 to maintain and improve one s health , and 4 ) staying the course even under stress and 
 financial constraints . final section of study questionnaire was included demographic 
 information such as : age , education level , care provider , health insurance and rheumatoid 
 arthritis control status . validity of the study questionnaires were reviewed and confirmed by 10 faculty members at 
 tabriz and isfahan university of medical sciences . also reliability was confirmed according 
 to cronbach 's alpha index ( sq ;  = 0.721 , tq ;  = 0.766 , cq ;  = 0.803 ) , based on a pilot 
 study by participation of thirty subjects . the scores of technical quality was determined as 0 ( worst adherence ) and 1(best 
 adherence ) according to the adherence of rheumatologist to care standards . service quality 
 for each of twelve aspects was measured using the importance and performance scales based on 
 the netherlands institute for health services research methodology . crude scores of cq normalized as 0 - 100 , and then active cq scores was calculated . cq 
 active scores were categorized based on the study has been conducted by tabrizi et al . final scores for each 
 dimension were transformed to 0 - 100 scales , and higher scores indicated more quality . based 
 on the study conducted by tabrizi et al . , three dimensions of quality had same contribution , 
 so the principal component analysis was used to calculate quality index ( qi ) , instead of 
 three dimensions .   in the descriptive statistics , frequencies were used for qualitative variables and mean 
 ( sd ) for continuous variables such as : cq , sq , tq and qi scores . independent samples t - test 
 and anova test were conducted to compare cq , sq , tq and qi score between categorical 
 variables . data were analyzed through the spss-13 statistical package ( spss , chicago , il , 
 usa ) . findings indicated that 82.7% of participants were female , and the majority ( 63% ) of 
 participants was housekeeper . most of participants aged over 50 years old ( 41.4% ) , and the 
 mean disease duration was approximately 10 years . also , 14.2% of patients were illiterate 
 and only 22.6% of them had educated in the university . response to treat was assessed well by majority of participants ( 73.5% ) , and considerable 
 proportion of them ( 75.9% ) reported some kinds of complications . among these , the prevalence 
 of joint complications and arthritis among subjects were 32.7% and 43.8% , respectively . findings showed that 41.4% of patients 
 also suffered from osteoporosis , 14.1% had a history of heart disease and 35.8% of 
 participants had ophthalmic problems . whereas 73.5% of participants stated that 
 self - evaluation of disease control , were good and excellent . regarding to self - reported customer quality score , all of the participants passed the 
 first stage of self management successfully . the failure rate in second and third stage was 
 9.2% and 71% , respectively . finally , forty - five subjects reached to last stage ( table 1 ) . recommended care for patients within rheumatoid arthritis and received care based on the 
 reports of participants are presented in table 2 . findings showed that , para - clinic examinations and lifestyle education with mean 80 ( 20.32 ) 
 and 41.37 ( 27.51 ) had highest and lowest scores , respectively . the average scores for importance , performance and service quality according to sq aspects 
 are shown in table 3 . 1 was the best and 0 is the worst , 10 was the best and 0 is 
 the worst,10 was the best and 0 is the worst   findings indicated that , confidentiality had the highest score for performance and then 
 there is choice of care provider , accessibility and dignity , respectively . basic amenities , 
 communication , prevention , dignity and safety had the highest scores for importance aspect . confidentiality and choice of care provider achieved the highest sq scores the overall 
 results have shown in table 4 .   in all quality dimensions and the quality index , men had higher quality score than women , 
 but this difference was not statistically significant ( p>0.05 ) . study results indicated 
 that participations with higher educational level significantly had greater cq and quality 
 index scores ( p= 0.13 , and p<0.01 , respectively ) . patients with complication also 
 significantly had greater tq and quality index scores ( p<0.01 ) . similarly , there was a significantly positive correlation between age and tq score ( p 
 = 0.12 ) . participants who had active disease reported higher cq score than who had n't active 
 disease ( p=0.03 ) . there was also positive significant correlation between occupation and 
 quality index ( p = 0.02 ) . in this study , quality index score was relatively low for subjects with rheumatoid 
 arthritis from patient 's perspective . there is a significant gap between the quality of care 
 received by patients with ra with what was recommended in the guideline , in term of overall 
 service quality , and customer quality scores .   according to patient 's report similarly , delivered care to arthritis rheumatoid patients in canada were not met 
 standards . the largest gap in this 
 study was related to lifestyle education and clinical care and services . so , there are 
 considerable opportunities to improve ra care by paying more attention to nutritional 
 regimens , effective physical activity , and refer to orthopaedic surgery . it is important to 
 state that these guidelines are minimum of standards which must be fully implemented , then 
 there is still room for considerable improvement . there is much potential for self - management of arthritis rheumatoid with regard to long 
 term and chronic nature of disease and low ability of patients to manage their health under 
 stressful condition and financial constraints . based on the instructions of american college of rheumatology , educating self - management 
 measures to patients was considered as main component of treatment . exercise has become an important part of rehabilitation during the last decade which , main purpose for prescribing 
 therapeutic exercise to prevention of functional disability . study of van den ende indicated that dynamic exercise therapy 
 has a positive effect on physical capacity and has been shown to decrease the risk of heart disease , 
 hypertension , patient - reported 
 disability and pain as well as 
 beneficial in improving symptoms and quality of life . thus , our study suggests patient self - management education to improve 
 customer quality and ability in managing their daily problems and conditions that leads to 
 reduction in long - term and acute complications .   in our study , service quality score was relatively low for people with rheumatoid 
 arthritis from the patient perspective . of the 12 aspects of service quality , the scores of 
 " confidentiality " and " choice of care provider " were highest ( high 9 score ) , while the score 
 of " availability of support group " was lowest . based on the service quality score , 
 participants in the current study were less concerned about communication , autonomy , 
 continuity of care , accessibility and dignity , while participants also reported inadequate 
 quality in term of basic amenities , timeliness , safety and prevention . service quality and 
 non - health aspects of care has become most important factor in marketing and utilization of 
 services especially in industries with high customer like the health system . based on the experts ' viewpoint , service 
 quality is also defined as organization 's ability to meet growing expectations of 
 customer . nevertheless , scores of 
 service quality was poor from the patient 's perspectives especially in " availability of 
 support group " domain .   despite the important effect of the supportive groups to individual 's health , studies have been 
 done by doeglas et al . , and gottlieb et al . , showed that , participating in support groups 
 had valuable contribution to the empowerment of patients . it 's important to be 
 noted that , these results could be helpful for decision makers to focus on important and 
 neglected aspects of service quality . the customer quality based on the ra patients ' perspectives in the city of isfahan was 
 found to be moderate with an average score of 70.25 ( 13.20 ) . a great part of the 
 participants ( 71% ) reported taking action while faced with ra - related health problems , and 
 only about 20% of patients were able to maintain needed actions even under stress and 
 financial constraints . in our study , highly educated subjects had high scores in customer 
 quality , self - management ability , and quality index ( table 
 4 ) . these findings is consistent with other studies that showed , education level is positively 
 associated with level of patient involvement in medical decisions and patients with inactive 
 disease had better c.q score than active ones . shokri also has stated 
 increased anxiety and depression in patients with active disease . self - management and stress management education is a essential base for the empowering 
 patients and is a basic ability for patients to effectively manage their diseases and to 
 make appropriate decisions in all conditions . koehn and newman defined 
 self - management as  the individual s ability to manage the symptoms , physical , psychological 
 consequences and life - style changes inherent in living with a chronic condition.   this study has some limitation such as the high number of questions , time consuming 
 interviews , and lack of appropriate places to interview with patients . this model shows that from the patients perspective the quality of service delivery for 
 ar patients in terms of three dimensions were almost low in isfahan . this means that , despite the improvement in the status of ra patients in the last decade , 
 the quality of services is still worrying . so , regarding to technical quality , life style 
 trainings should be considered for ra patients . also , there is need for focusing on clinical 
 services through providing related equipment , physiotherapy programs , regimes , and need 
 assessment of patients for referring to orthopedist . supportive assembly for ra patients , 
 high level facilities , preventive measures , and safety in service delivery should be 
 considered to improve the service quality . also , customer quality could be promoted through involving the ra patients in treatment 
 process and educational programs such as knowledge , skill , and self - esteem increment for 
 self - management of disease . finally , it is no table that total quality of service could be 
 improved through providing intelligible information for low educated subjects , more 
 attention on the complication of disease and treating of it . 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 .
introduction : quality of care has become increasingly critical in the evaluation of healthcare 
 and healthcare services . 
 the aim of this study was to assess quality of delivered care 
 among patients with rheumatoid arthritis using a model of comprehensive quality 
 measurement in health care ( cqmh ) . 
 methods : this cross - sectional study was conducted on 172 patients with rheumatoid 
 arthritis ( ra ) who were received care from private clinics of isfahan university of 
 medical sciences in 2013 . 
 cqmh questionnaires were used for assessing the quality of care . 
 data were analyzed using spss for windows . 
 results : the mean scores of quality index , service quality ( sq ) , technical quality ( tq ) , 
 and costumer quality ( cq ) were 72.70 , 79.09 , 68.54 and 70.25 out of 100 , respectively . for 
 cq only 19.8% of participations staying the course of action even under stress and 
 financial constraints , there is a significant gap between what ra care they received with 
 what was recommended in the guideline for tq . 
 scores of service quality was low in 
 majority of aspects especially in " availability of support group " section . 
 conclusion : study shows paradoxical findings and expresses that quality scores of service 
 delivery for patients with arthritis rheumatoid from patient 's perspective is relatively 
 low . 
 therefore , for fixing this paradoxical problem , improving the participation of 
 patients and their family and empowering them for self - management and decision should be 
 regarded by health systems .