Time to treatment intensification in type 2 diabetes mellitus: factors associated with timing in a resource-constrained setting

Background Timely adjustment of antidiabetic therapy is essential for achieving optimal glycemic control and preventing diabetes-related complications. However, treatment delays remain pervasive, particularly in low-resource settings where health systems face significant constraints. Understanding the magnitude and determinants of these delays is critical for designing effective interventions. Objectives This study aimed to assess the time to treatment intensification and identify factors associated with its timing among patients with poorly controlled type 2 diabetes mellitus (T2DM) at a tertiary hospital in Ethiopia. Methods We conducted a retrospective cohort study among 403 adults with poorly controlled T2DM (defined as fasting blood glucose [FBG] ≥ 130 mg/dL, random blood sugar [RBS] ≥ 180 mg/dL, or glycated hemoglobin [HbA1c] ≥ 7% on at least two consecutive visits separated by a minimum of three months) at a tertiary hospital in central Ethiopia between January 2021 and December 2024. Data were extracted from medical records using a structured abstraction tool. Time to treatment intensification was defined as the duration from documented poor glycemic control to therapy adjustment. Kaplan–Meier survival analysis and multivariable Cox proportional hazards regression were used to estimate time to intensification and identify associated factors. The proportional hazards assumption was verified using Schoenfeld residuals. Results Of 403 patients, 326 (80.9%) received treatment intensification during follow-up, but only 133 (33.0%; 95% CI 28.5–37.7%) received it within 90 days of documented poor glycemic control. The median time to intensification was 14.2 months (95% CI 13.4–15.0). Health insurance coverage was significantly associated with a higher hazard of timely intensification (adjusted hazard ratio [AHR] = 1.60, 95% CI 1.17–2.19, p = 0.004). Conversely, chronic kidney disease (CKD) was associated with a lower hazard of intensification (AHR = 0.53, 95% CI 0.38–0.74, p < 0.001). Patients managed by general practitioners had a significantly lower hazard of timely intensification compared to those treated by specialists (AHR = 0.67, 95% CI 0.47–0.97, p = 0.032). Conclusion Treatment intensification for T2DM is substantially delayed in this resource-limited setting. Health system factors, particularly insurance coverage and physician qualifications, were significantly associated with the timing of therapy adjustment. These findings suggest that addressing financial barriers and strengthening primary care provider training may improve timely diabetes management. Prospective studies are needed to establish causality and evaluate the effectiveness of specific interventions.