MESSAGE FROM THE EDITOR Disparities in Care: Guilty Until Proven Innocent There is little more grating than a study demonstrating that medical care is particularly suboptimal in minority populations. Although many are comfortable acknowledging that the poor receive worse healthcare, few feel that racial differences in care quality are acceptable when access to care and socioeconomic issues are held constant. Of course, the explanations for disparities may not be nefarious but due to underlying differences in risk factors, disease expression, or patient preferences, and clinicians may not be responsible. Nonetheless, studies revealing disparities will always require followon work, not only for confirmation but also to reveal the true underlying cause of the difference. In this issue of the Annals, investigators studied the use of medications and other interventions among 307 patients with newly diagnosed Parkinson disease.1 They found that parkinsonian medications were initiated in only 30% of patients within 6 months of the diagnosis. Even more important, African Americans had one-third the odds of being started on parkinsonian medications compared to whites. The difference was not explained by insurance, given that all patients in the study were covered by Medicaid, nor did it appear due to differences in age, access to a neurologist, or urban location of care. Furthermore, race doesn’t play a role in guideline recommendations for Parkinson disease, and there are no known racial differences in disease presentation, progression, or tolerance of medications. Thus, the findings are worrisome. Many other studies have found racial disparities in treatment of neurological diseases, including a prior study of Parkinson disease that found poorer overall quality of care for African-American veterans.2 Other studies have shown that tPA is less likely to be given to African Americans presenting with ischemic stroke,3 and are less likely to receive carotid endarterectomy.4 One multiple sclerosis (MS) study found that, although African Americans and whites were equally likely to receive initial disease-modifying therapy for MS, subsequent changes in treatment were less likely to be provided to African Americans even though therapy failures are more common in this group.5 Although concerns about practitioner racism are often raised, explanations may be more benign. For example, investigators discovered that African Americans with stroke were much less likely to have a carotid stenosis as the cause, and that this could fully explain differences in endarterectomy rates.6,7 Patient preferences are another potential explanation for disparities. African Americans are more likely to raise concerns about undesirable physician behavior and to profess faith in divine intervention, revealing potential problems in patient-physician communications.8 Communications are also poorer when physician and patient race are different, a much greater risk for African-American patients and another potential source of disparities.9 Improving the quality of care has become a rallying cry for insurers, hospitals, patient advocates, and politicians. All clinicians are now subjected to quality-improvement interventions and metrics, with an array of care pathways, standardized order sets, and multidisciplinary conferences. The major goals of better care are improving health and, at times, lowering costs. Just as important, however, better care should produce consistent care, and reduce inappropriate differences in quality of care by race, age, or sex. Beyond the obvious need for social justice, eliminating inappropriate disparities is essential to improving the quality of care, and has become part of the national standard. Lower rates of medical treatment after Parkinson disease diagnosis among African Americans may have a benign explanation, but we should assume otherwise until more evidence is available. The magnitude of the reported difference is so large that it seems unlikely that it is due to some statistical artifact. The findings of this study should first be replicated in a different population. Furthermore, more detail, well beyond that available from these administrative records, is required to understand the cause of a disparity. Leaving the cause unexplained is unacceptable. S. Claiborne Johnston, MD, PhD and Stephen L. Hauser, MD Editors References 1. Dahodwala N, Xie M, Noll E, et al. Treatment disparities in Parkinson's disease. Ann Neurol 2009;66:142-145. 2. Cheng EM, Siderowf AD, Swarztrauber K, et al. Disparities of care in veterans with Parkinson's disease. Parkinsonism Relat Disord 2008;14:8-14. 3. Johnston SC, Fung LH, Gillum LA, et al. Utilization of intravenous tissue-type plasminogen activator for ischemic stroke at academic medical centers: The influence of ethnicity. Stroke 2001;32:1061-1068. 4. Kennedy BS, Fortmann SP, Stafford RS. Elective and isolated carotid endarterectomy: health disparities in utilization and outcomes, but not readmission. J Natl Med Assoc 2007;99:480488. 5. Cree BA, Khan O, Bourdette D, et al. Clinical characteristics © 2009 American Neurological Association A7 . London Ethnicity and Stroke Study. Circulation 2007;116:2157-2164. 8. Ferguson JA, Weinberger M, Westmoreland GR, et al. Racial disparity in cardiac decision making: results from patient focus groups. Arch Intern Med 1998;158:1450-1453. 9. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA 1999;282:583-589. of African American versus Caucasian American multiple sclerosis. Neurology 2004;63:2039-2045. 6. Goldstein LB, Matchar DB, Hoff-Lindquist J, et al. Veterans Administration Acute Stroke (VASt) Study: lack of race / ethnic-based differences in utilization of stroke-related procedures or services. Stroke 2003;34:999-1004. 7. Markus HS, Khan U, Birns J, et al. Differences in stroke subtypes between black and white patients with stroke: the South LONG AGO in the Annals... CYTOARCHITECTONIC ABNORMALITIES IN DEVELOPMENTAL DYSLEXIA: A CASE STUDY GALABURDA AM, KEMPER TL AUGUST 1979 ABSTRACT A patient is reported who has a well-documented history of developmental dyslexia. Reading difﬁculties were present in other male members of the immediate family. Gross anatomical and cytoarchitectonic analysis of the brain in serial sections showed a consistently wider left cerebral hemisphere, an area of polymicrogyria in the left temporal speech region, and mild cortical dysplasias in limbic, primary, and association cortices of the left hemisphere. A8 Αnnals of Neurology Vol 66 No 2 August 2009 .