Diabetes care goals and diabetic retinopathy in adults at tertiary hospitals, Rwanda: a cross-sectional hospital-based study

Abstract

Attainment of diabetes mellitus (DM) care goals is essential to improving quality of life and preventing complications in patients living with this increasingly prevalent non-communicable disease. Despite the existence of evidence-based national and international guidelines, achievement of glycaemic, blood pressure, and lipid targets remains suboptimal, particularly in resource-limited settings. This study was designed to assess the extent to which diabetes care goals are achieved at major tertiary healthcare facilities in Rwanda, in accordance with established process and intermediate outcome indicators, and to determine the prevalence of and factors associated with diabetic retinopathy. This prospective, observational cross-sectional study was conducted between September 2023 and April 2024 at four tertiary hospitals in Rwanda: King Faisal Hospital Rwanda, Centre Hospitalier Universitaire de Kigali, Rwanda Military Hospital, and Centre Hospitalier Universitaire de Butare. A total of 400 patients were enrolled using consecutive sampling type 1 diabetes patients with at least 5 years of follow-up and type 2 diabetes patients with at least 12 months of follow-up in outpatient departments. Data were collected through structured interviews, clinical examinations, and review of laboratory results using a validated data collection tool. Performance of process indicators and achievement of intermediate outcome indicators (HbA1c < 7%, blood pressure ≤ 130/80 mmHg, LDL cholesterol ≤ 2.6 mmol/L) were assessed against American Diabetes Association (ADA) 2023 standards. Retinopathy was classified by dilated fundoscopy. Statistical analysis used STATA Version 17 SE; binary logistic regression identified factors associated with poor glycaemic control and retinopathy at 95% CI, p < 0.05. The majority of participants were female (69.5%) and most had type 2 diabetes (96.75%). The overall performance of process indicators was: 100% for blood pressure measurement at every visit, 90.75% for 3- to 6-monthly glycated haemoglobin testing, 69.25% for LDL cholesterol testing, and 56.5%, 26%, and 19% for annual eye, dental, and foot examinations respectively. The proportions of participants who achieved optimal HbA1C (< 7%), blood pressure (below 130/80 mmHg), and LDL cholesterol (< 2.6 mmol/L) were 44.5%, 65.25%, and 55% respectively. In multivariate analysis, treatment type was the primary determinant of glycaemic control, with patients on oral therapy showing significantly lower odds of poor control compared to those on insulin alone (aOR: 0.306, 95% CI: 0.157–0.596, p = 0.001); diabetes duration was the strongest predictor of retinopathy, with progressively increasing risk for patients with 6–20 years (aOR = 1.985, 95% CI: 1.217–3.236, p = 0.006) and more than 20 years duration (aOR = 2.488, 95% CI: 1.100–5.630, p = 0.029). Blood pressure monitoring and HbA1c testing were consistently performed; however, foot (19%) and dental (26%) examinations remained critically underperformed across all sites. Achievement of the three diabetes care goals glycaemic, blood pressure, and lipid control was suboptimal in a substantial proportion of patients. Oral therapy was associated with better glycaemic control than insulin alone, while longer disease duration and concomitant hypertension were independently associated with higher odds of diabetic retinopathy. These findings call for targeted systemic interventions, including mandatory integration of ophthalmology, podiatry, and dental screening into routine diabetes protocols at Rwandan tertiary facilities. Not applicable.