JRHS 2009; 9(2): 1-9

Copyright © Journal of Research in Health Sciences

Quality of Delivered Care for People with Type 2 Diabetes: A New Patient-Centered Model

Jafar S Tabrizi, MD, PhD

Dept. of Management and Public Health, Faculty of Health and Nutrition, Tabriz Medical Sciences University/Tabriz, Iran

*Correspondence: Dr Jafar S. Tabrizi, E-mail: tabrizijs@tbzmed.ac.ir

Received: 7 July 2009; Accepted: 12 Nov 2009


Background: The quality of care from the perspective of people with Type 2 diabetes using a new model (CQMH) including three dimensions of quality in health care (Technical, Service and Customer Qual­ity) was assessed.

Methods: A cross-sectional survey with a sample of 577 people with Type 2 diabetes was conducted. Meas­ures were self-reported adherence to national guidelines for technical quality, the Netherlands Institute for Health Services Research questionnaire for service quality and the short form of the Patient Activation Measure for Customer Quality.

Results: There was a significant gap in technical quality between what diabetes care the patients re­ported receiving and what was recommended in the guideline, particularly for management and life­style aspects. For service quality, the lowest scores were for choice of care provider and accessibility of care. The mean Customer Quality score was 64.5 (meaning higher score indicating better quality). A positive relationship was demonstrated between higher technical, service and customer quality scores, and better diabetes control status as well as maintaining continuity of care. The average Qual­ity Index was 70.0 of a 0-100 scale.

Conclusion: Customer Quality appears to be a useful third dimension in conceptualizing quality in health care, particularly in the context of chronic disease, where good self-management can improve the outcomes of care. A high proportion of Queensland adults with Type 2 diabetes reported receiving sub­optimal care in the majority aspects of provided care services as reflected in the overall Quality In­dex score indicating substantial room for quality improvement.

Keywords: Quality in health care, Technical quality, Service quality, Customer quality, Type 2 di­abetes


The commonly established dimensions of quality in health care are “technical quality” and “service quality”. Technical quality deals with the specific aspects of care of dis­ease as reflected by care-related processes and/or care- related outcomes and indicates how well health systems handle the specific condition (1). Service quality reflects the rela­tionship be­tween customers, providers, and care pro­cesses which measures two as­pects that people value: the way people are treated by the health system and the environ­ment they are treated in (2). While evidence demon­strates the influence of the health care customers on quality of health care (3-5), it seems that the vital role of health care custom­ers and the important attributes that customers can add to quality content and out­come measures of care have been neg­lected.

Type 2 diabetes (T2D) is one of the most com­mon chronic diseases, causing major bur­dens on the health systems due to its in­creasing prevalence, micro, and macro vas­cu­lar complications (6), psychosocial ef­fects on patients and diabetes related finan­cial im­pact (7). Improving quality of care for T2D is not only important for diabetic pa­tients but also for health care policymakers, managers and providers. So, we have applied care for T2D as an example of a high prior­ity com­mon chronic disease in order to de­velop and demonstrate the usefulness of a model of quality in health care which encom­passes a third dimension (Fig. 1), that we have bas­ically referred to as Customer Quality. This new model as a model of Com­prehensive Quality Measurement in Health care (CQMH) has close relevance in the con­text of chronic disease where it is widely recognized that self-management is a key component of good care. Self-management is highly dependent on characteristics of the customer.

Figure 1: The proposed model of Comprehensive Qual­ity Measurement in Health care (CQMH)

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 man­age successfully their own conditions. In the direction of improve Customer Quality, con­sumers need to improve their capacity in three major areas: knowledge and skills (in disease specific and quality improvement areas), confidence in self-care and use of the health system.

Finally, a further application of this model is the potential for a single quality score, the “Quality Index”, combining information on the three quality dimensions (Fig. 1). This Qual­ity Index would provide an overall val­ue for quality of delivered care when com­paring care received in different systems.

The present study aimed to measure quality of delivered care as perceived by people with T2D. This study aimed to measure Cus­tomer Quality as a third dimension of quality along with technical and service quality, and consequently to derive an overall Quality In­dex through combining all three dimen­sions.


A cross-sectional survey of people with T2D was conducted in Australia in 2005/06. The study design, procedures and materials were approved by the Ethics Committee of the School of Population Health, University of Queensland. The eligible participants were Diabetes Australia-Queensland members (DAQ) over 25 yr old with T2D diagnosed at least one year prior to the study. The re­sponse rate from the 1500 mailed out question­naires was 44.8% (672), decreasing to 38.5% (577) after excluding other types of diabetes and miss­ing values. Non-respon­dents were a little youn­g­er (P< 0.001) than study participants but similar in gender (P> 0.05).

Technical Quality was measured as patient reported adherence to nationally accepted T2D clinical guidelines (8-10) using eleven clinical, lifestyle and management indicators (11). Service Quality was measured using local adaptations of The Netherlands Institute for Health Services Research validated questionnaire (12) based on the relative impor­tance and actual performance for each ser­vice quality attribute. 

There is no accepted measure of Customer Quality but for chronic disease, so we chose the 13-item Patient Activation Measure (PAM) questionnaire (13) because it meas­ures attri­butes we believe are important in Customer Quality. It measures general as­pects of pa­tient knowledge, skills and confi­dence, and in addition is well validated and highly prac­tical because of its brevity.

Principal Component Analysis (PCA) was used to calculate a single summary (Quality Index) by combining the three separate values of “Technical”, “Service” and “Customer Quality” for each individual with minimum loss of information (14). There was a pair wise correlation of 0.3 between each combination of the three dimensions of quality, which can be interpreted as meaning that about a third of the variability in quality of care being measured by the three-sets of questions are shared or similar and two-thirds are individ­ual contribution. The PCA provided a logical combination of three variables with equal contribution (0.76, 0.72 and 0.72) of each dimension to component one, and explained 54% of variability across three separate variables. Uniform contribution of three dimensions suggests a simple score averaging with sim­ilar weight­ing to calculate one summary in­dex instead of three separate variables.

Demographic and disease related informa­tion was obtained by using the self-reported questionnaire. Two types of outcome va­riables were used in this study. These were conti­nuous variables: service, technical, and cus­tomer quality scores and quality index scores (each of these was referred on a 0-100 scale with high values indicating better qual­ity), and participant-reported binary va­riables: diabetes complications, continuity of care and diabetes control status. For these, partici­pants were asked to identify; any di­abetes complications identified by their doc­tor or nurse; whether their usual pattern of care involved seeing the same care provider for diabetes management for at least the past 12 months, and their view of the overall sta­tus of their diabetes control over the past 12 months (poorly or well controlled).

All statistical analyses were conducted using SPSS 13.0 for Windows and P values 0.05 were considered statistically significant. Chi-squared and analysis of variance tests were used to investigate associations between ca­te­gorical and continuous variables respec­tive­ly. General Linear Modeling was used for univariate and multivariate analysis.


Around 15% of participants were younger than 65 yr; nearly half of them were female and obese and one quarter were studying or had completed tertiary level education. Al­most two-thirds reported well controlled di­abetes and 60% had diabetes for more than 5 yr. Most were not treated by specialists and maintained continuity of care for their di­abetes management.

The overall results are shown in Table 1. For all three quality dimensions and the Quality Index, participants with well controlled di­abetes and those who maintained continuity of diabetes care had significantly higher scores than participants with poorly con­trolled di­abetes and those who did not report con­tinu­ity of care, respectively. Younger participants had lower Service Quality and Quality Index scores than older participants. Participants who had studied or completed tertiary educa­tion had higher Customer Qual­ity scores but not Technical and Service Quality scores than those who completed only primary and/ or secondary level of educa­tion.

Overall Technical, Service and Customer qual­ity scores as well as Quality Index scores (scaled from 0-100) were less than 75. There was no significant difference in the quality scores in terms of gender and di­abetes com­plications.

As presented in Table 1, overall Technical, Service and Customer Quality scores as well as Quality Index scores were low. There were no significant differences in the Quality scores in terms of gender and diabetes complications.

The Technical Quality results demonstrated significant quality gaps in the management of T2D people particularly for lifestyle and management indicators. (Detailed informa­tion is presented else where (11)). Based on adherence to the minimum standard, al­though nearly all subjects reported checking of HbA1c, blood lipids and blood pressure in the last 12 months, almost half of partici­pants reported receiving neither medication nor self-management and physical activity re­view by care providers in the last 12 months.      

Service Quality scores were in general high for support of people with the same condi­tion (support group), the quality of basic amen­ities, dignity and confidentiality and low for choice of care provider and acces­sibil­ity of care. Mean scores for all as­pects of Service Quality, except quality of basic amenities and timeliness, were signifi­cantly higher for well versus poor self-re­ported di­abetes control status (Detailed infor­mation is presented elsewhere (12).

Table 1: Quality score and demographic and diabetes characteristics


Quality of delivered care for Type 2 diabetes

Technical Quality

Service Quality

Customer Quality

Quality Index

Mean (95% CI1)

P value

Mean (95% CI)

P value

Mean (95% CI)

P value

Mean (95% CI)

P value


58.8 (57.2, 60.7)

86.3 (85.2, 87.4)

64.5 (63.2, 65.8)

70.0 (69.0, 71.0)



59.5 (56.9, 62.0)


86.7 (85.1, 88.4)


64.7 (62.8, 66.5)


70.5 (69.0, 71.9)



58.4 (56.0, 60.9)

85.9 (84.3, 87.4)

64.4 (62.6, 66.1)

69.5 (68.1, 71.0)

Age (yr)

< 65

57.2 (54.6, 59.9)


83.9 (82.3, 85.6)


64.4 (62.4, 66.3)


68.5 (66.8, 70.2)



61.6 (58.4, 64.8)

88.4 (86.4, 90.4)

65.0 (62.6, 67.3)

71.7 (70.0, 73.5)


58.8 (55.4, 62.3)

88.1 (85.9, 90.3)

64.3 (61.8, 66.9)

70.5 (68.6, 72.4)

Tertiary Education


59.0 (57.0, 61.0)


86.5 (85.2, 87.8)


63.8 (62.2, 65.3)


69.9 (68.7, 71.1)



58.6 (55.2, 62.1)

85.5 (83.4, 87.7)

66.5 (64.0, 69.9)

70.1 (68.0, 72.2)

Type 2 diabetes control status


54.1 (51.2, 57.0)


81.7 (79.9, 83.5)

< 0.001

58.1 (56.0, 60.1)


64.7 (63.0, 66.3)



61.9 (59.7, 64.0)

89.0 (87.6, 90.4)

68.2 (66.6, 69.7)

73.0 (71.7, 74.2)

Diabetes complication


58.0 (55.7, 60.2)


86.9 (85.5, 88.3)


65.0 (63.3, 66.6)


70.0 (68.7, 71.3)



60.7 (57.7, 63.7)

84.7 (82.9, 86.6)

63.8 (61.6, 66.0)

69.8 (68.1, 71.6)

Maintaining continuity of care


48.2 (44.4, 52.0)


80.6 (78.1, 83.1)


59.1 (56.2, 61.9)


62.5 (60.3, 64.7)



62.1 (60.1, 64.0)

87.7 (86.4, 88.9)

65.9 (64.4, 67.4)

71.8 (70.7, 73.0)

1. Confidence Intervals


The participants in this study reported a signifi­cant gap between what diabetes care they received and what was recommended in the Australian guideline, and overall Service Quality, Customer Quality scores and, con­se­quently, the Quality Index scores were all less than 75. We consider these low scores.   

Evidence indicates that T2D management based on guidelines improves the short and long-term quality of life (15). These guide-lines support care providers and people with diabetes to achieve well-integrated and high-quality care (16), reduce diabetes complications (17), achieve better clinical outcomes (18), and high level of patient satisfaction (8). Consistent with the other studies worldwide (9, 10, 17, 19, 20) in our study T2D care, according to patient reports, failed to meet the technical standard in many cases (11). The largest gap, related to life­style and management standards, suggests that a new way of improving such aspects of care need to be considered. The importance of multi-discip­linary care for diabetes has been repeatedly emphasized. We would stress also the impor­tance of active engage­ment of the patient, the customer, in this, hence the argument for this as a new dimen­sion in quality of care.

The concept of service quality is poorly de­vel­oped in health care systems. Service quality requires that “the services should cor­res­pond to the customers expectations and sa­tisfy their needs and requirements” (21). This is usually taken to mean the non-clin­ical aspects of health care including physi­cal, managerial and organizational as­pects. Ser­vice quality, by definition, should be as­sessed and judged directly by health care customers based on their experience of health care. In this study, customers reported non-satisfactory service quality (12), which could be due to several factors, such as un­aware­ness of health care systems about the cus­tom­ers perspective, inadequate support of health care providers to serve customers well (22), lack of control access of custom­ers to clini­cal services, lack of knowledge over the condition, and the effect of health care pro­viders performance and behaviors. Failings in one of those factors may influ­ence overall service delivery and can affect customers perception and outcomes.

Quality improvement in health care systems requires effective engagement of informed and skilful customers, capable health care providers, and well organized systems for con­tinuous quality improvement. The effec­tive engagement in the management pro­grams and follow up processes as well as efficient communication with care providers are associated with receiving recommended diabetes care (23), better glycemic control (24, 25) and fewer diabetes complications (26).

Despite the significant evidence of the bene­fits of good self-management in diabetes, patients willingness to be informed and in­volved in decision making (27, 28), and exist­ing evidence of benefit of educational pro­grams (4, 29) and educational interven­tions (30, 31); the results of this study re­vealed that a considerable proportion of people with T2D did not have required know­ledge, skills and confidence for self-management as re­flected in the Customer Quality scores. The capacity for improve­ment may be related to underlying education as suggested by sig­nif­icant association be­tween educational attain­ment and Customer Quality scores (Table 1).         

Our results also demonstrated that people with diabetes who scored higher on Cus­tomer Quality were more likely to maintain continuity of care and, in turn, patients with continuity of care are more likely to visit their diabetes care providers with appropri­ate frequency (32). High-quality customers would remind the service providers of the services they need and will raise their con­cerns and ask questions. They would seek screening and monitoring tests when not pro­vided at the right interval. They would be more likely to seek nutritionists consulta­tions about diet, meal preparation, and physi­cal activity and they will be more likely to use the obtained information for self-man­age­ment at home. Therefore, Customer Qual­ity can facilitate the improvement of service and technical quality.

The Quality Index score would appear to be a useful tool for globally comparing overall health systems quality and is likely to be the type of measure of most use to policy makers. Measurement of all three dimensions is more informative in quality improvement as it pro-vides clinicians, manag­ers and policymakers with a more com­prehensive perspective on the quality of health services and a better guide to quality improvement programs.

There is a significant evidence base (5, 23) indicating that high-quality (knowledgeable, skilful and confident) customers are funda­mental to better T2D outcomes and probably for other chronic diseases (including pulmo­nary disorders, cardiovascular diseases, arthri­tis, and mental disorders) and possibly most preventive care. They may be of less importance in the management of acute ill­nesses and/or surgery. However, knowledge is certainly fundamental to informed consent that should underpin all but the emergent situa­tions and skills and confidence are funda­mental to the broader concept of in­formed decision-making. Arguably, there­fore, the concepts inherent in Customer Qual­ity probably apply more broadly in health care. Thus, further studies are needed to test the feasibility of the proposed model (particularly Customer Quality) to assess the quality of delivered care for other chronic diseases, preventive services, acute condi­tions, and non-urgent surgeries.

The key advantage of this study is using cus­tomer based report. It is amenable to large surveys independent of the practitioner and practice setting. Clinician surveys are depen­dent on the willingness and interest of the clinician in participating. Medical audits are resource intensive and dependent on the qual­ity of information recorded which can be highly variable. For example, medical record based studies have frequently reported high rates of missing or non-recorded data (33). There is very limited population wide adminis­trative data in Australia but access to that information is still dependent on the doc­tors willingness to participate. In addi­tion, evidence supports validity and reliabil­ity of patients perception for assessing the quality of care for chronic diseases (34) and its positive association with glycemic con­trol (23), actual health outcomes and objec­tive measures of quality of care in T2D (35).

The results of this study might be limited by recall bias, as for other self-reported studies, and the accuracy of patient reports is likely to be variable. In this study, non-respondent bias might be a concern, although non-res­pond­ers were slightly younger (P< 0.001) than study participants without gender differ­ences (P> 0.05). Another limitation can be low response rate (nearly 40%), which may reflect a range of factors, including the overall length of the questionnaire, the me­thods of contact and the understanding and interest of patients in participating. How­ever, the most likely consequence of any selec­tion bias that may have resulted from the low response rate is that the survey over represents patients with higher health lite­racy, more optimal care or more interest in self-care.

Participants in this study were drawn ran­domly among DA-Q members, who account for nearly half of expected T2D people in Queensland (36, 37). These members are sup­ported by information and educational sessions. Therefore, participating patients may represent a more educated and moti­vated group of patients. However, it is un­likely that such a bias is under-estimating the general quality of services.

In conclusion, this study proposes a modifica­tion of the existing paradigm for measuring quality in health care to include the dimension of Customer Quality, which refers to attributes of the health care user, who is expected to be a knowledgeable, skil­ful, and confident customer. Findings re­vealed substantial room for quality improve­ment on all three dimensions. It demon­strated a significant association between the measure of all three dimensions and self-re­ported diabetes control and continuity of care.

The present study has a number of implica­tions for health care systems. Customers perception can be measured using a rela­tively inexpensive, easy and quick method based on patient report and also can be use­ful for determining priorities for quality im­prove­ment programs. The proposed model (CQMH) in this study can be used as a compre­hensive model to evaluate almost all aspects of health care quality as a baseline for quality improve­ment programs and to benchmark or compare several practices in term of a particular health care. This model and Customer Quality may be applicable to many chronic diseases and preventive care with modification of the technical quality section based on the target condition.


This study was funded by Tabriz University of Medical Sciences and a Queensland Gov­ernment-Growing the Smart State PhD Fund­ing Program. I would also like to ac­knowl­edge the support of Diabetes Australia, Queen­sland branch who distributed study questionnaires among their Type 2 diabetes members, sending reminders and collecting completed questionnaires. The authors dec­lare that they have no conflicts of interest.


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