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Disparities in care Guilty until proven innocent.

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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
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
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
London Ethnicity and Stroke Study.
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
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
in the Annals...
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.
Αnnals of Neurology
Vol 66 No 2 August 2009
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care, innocent, guilt, disparities, proven
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