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We sought to determine whether systematic care can reduce the gap in diabetes control between Maori and non-Maori.

A Primary Health Organisation implemented a chronic care management programme for diabetes in 2005. The data constitute an open, prospective cohort followed for approximately two years. Data describing process were also collected.

There were 1311 people with diabetes (354 Maori, 957 non-Maori). Maori started with higher HbA_1c (mean 8.1%, SD 1.9) than non-Maori (7.1%, SD 1.4) but over about 2 years HbA_1c for Maori improved to that of non-Maori. LDL and systolic blood pressure decreased for both groups. Improved glucose in Maori was not due to starting insulin or metformin, and rates of sulphonylurea prescription increased in both groups. Urinary albumin:creatinine ratio remained higher for Maori throughout. Smoking rates and Body Mass Index (both …