Roadmap for embedding health equity research into learning health systems.

BACKGROUND: Achieving health equity is vital to fulfil the quadruple aim for optimal healthcare system performance. Traditionally, academic medicine and healthcare systems have focused their efforts on addressing health inequities with an emphasis on improving workforce diversity. Although this approach is an important requisite, a diverse workforce alone is not sufficient; rather holistic health equity should be established as the anchoring principal mission of all academic medical centres, residing at the intersection of clinical care, education, research and community. METHODS: NYU Langone Health (NYULH) has embarked on significant institutional changes to position itself as an equity-focused learning health system. One-way NYULH accomplishes this is through the establishment of a health equity research roadmap, which serves as the organising framework through which we conduct embedded pragmatic research in our healthcare delivery system to target and eliminate health inequities across our tripartite mission of patient care, medical education and research. RESULTS: This article outlines each of the six elements of the NYULH roadmap. These elements include: (1) developing processes for collecting accurate disaggregate data on race, ethnicity and language, sexual orientation and gender identity and disability; (2) using a data-driven approach to identify health equity gaps; (3) creating performance and metric-based quality improvement goals to measure progress toward elimination of health equity gaps; (4) investigating the root cause of the identified health equity gap; (5) developing and evaluating evidence-based solutions to address and resolve the inequities; and (6) continuous monitoring and feedback for system improvements. CONCLUSION: Application of each element of the roadmap can provide a model for how academic medical centres can use pragmatic research to embed a culture of health equity into their health system.

Analysis of the 2007-2018 National Health Interview Survey (NHIS): Examining Neurological Complications among Children with Sickle Cell Disease in the United States.

This study compared neurological complications among a national sample of United States children with or without sickle cell disease (SCD) and evaluated health status, healthcare and special education utilization patterns, barriers to care, and association of SCD status and demographics/socioeconomic status (SES) on comorbidities and healthcare utilization. Data was acquired from the National Health Interview Survey (NHIS) Sample Child Core questionnaire 2007-2018 dataset that included 133,542 children. An affirmation from the guardian of the child determined the presence of SCD. Regression analysis was used to compare the associations between SCD and demographics/SES on neurological conditions at p < 0.05. Furthermore, adjusted odds ratios (AORs) were estimated for having various neurological conditions. Of the 133,481 children included in the NHIS, the mean age was 8.5 years (SD: 0.02) and 215 had SCD. Of the children with SCD, the sample composition included male (n = 110), and Black (n = 82%). The SCD sample had higher odds of having neuro-developmental conditions (p < 0.1). Families of Black children (55% weighted) reported household incomes < 100% of federal poverty level. Black children were more likely to experience longer wait times to see the doctor (AOR, 0.3; CI 0.1-1.1). Compared to children without SCD, those with SCD had a greater chance of seeing a medical specialist within 12 months (AOR 2.3; CI 1.5-3.7). This representative sample of US children with SCD shows higher odds of developing neurological complications, increased healthcare and special education services utilization, with Black children experiencing a disproportionate burden. This creates the urgency to address the health burden for children with SCD by implementing interventions in healthcare and increasing education assistance programs to combat neurocognitive impairments, especially among Black children.

AddREssing Social Determinants TO pRevent hypErtension (The RESTORE Network): Overview of the Health Equity Research Network to Prevent Hypertension.

BACKGROUND: The American Heart Association funded a Health Equity Research Network on the prevention of hypertension, the RESTORE Network, as part of its commitment to achieving health equity in all communities. This article provides an overview of the RESTORE Network. METHODS: The RESTORE Network includes five independent, randomized trials testing approaches to implement non-pharmacological interventions that have been proven to lower blood pressure (BP). The trials are community-based, taking place in churches in rural Alabama, mobile health units in Michigan, barbershops in New York, community health centers in Maryland, and food deserts in Massachusetts. Each trial employs a hybrid effectiveness-implementation research design to test scalable and sustainable strategies that mitigate social determinants of health (SDOH) that contribute to hypertension in Black communities. The primary outcome in each trial is change in systolic BP. The RESTORE Network Coordinating Center has five cores: BP measurement, statistics, intervention, community engagement, and training that support the trials. Standardized protocols, data elements and analysis plans were adopted in each trial to facilitate cross-trial comparisons of the implementation strategies, and application of a standard costing instrument for health economic evaluations, scale up, and policy analysis. Herein, we discuss future RESTORE Network research plans and policy outreach activities designed to advance health equity by preventing hypertension. CONCLUSIONS: The RESTORE Network was designed to promote health equity in the US by testing effective and sustainable implementation strategies focused on addressing SDOH to prevent hypertension among Black adults.

Tracking adaptation strategies of an HIV prevention intervention among youth in Nigeria: a theoretically informed case study analysis of the 4 Youth by Youth Project.

BACKGROUND: Although many behavioral interventions are adapted, little is known about the reasons for adaptations and the process and outcomes influencing adaptations. To address this gap, we explored the adaptations made to promote HIV prevention services, including HIV self-testing (HIVST), among Nigerian youth. METHODS: The main objective of this qualitative case study design was to document the adaptations made over time using the Framework for Reporting Adaptations and Modifications - Expanded (FRAME). Between 2018 and 2020, we organized four participatory activities as part of the 4 Youth by Youth project to increase the uptake of HIVST services in Nigeria-an open call, a designathon, a capacity-building bootcamp and a pilot feasibility trial. We also began the process of implementing a final intervention using a pragmatic randomized control trial (RCT). The open call solicited creative strategies to promote HIVST among Nigerian youth and then had experts evaluate them. The designathon brought together youth teams to further develop their HIVST service strategies into implementation protocols. Teams determined to be exceptional were invited to a four-week capacity-building bootcamp. The five teams that emerged from the bootcamp were supported to pilot their HIVST service strategies over a 6-month period. The adapted intervention is currently being evaluated in a pragmatic RCT. We transcribed meeting reports and conducted document reviews of study protocols and training manuals. RESULTS: Sixteen adaptations were identified and categorized into three domains: (1) modifications to the content of the intervention (i.e. photo verification system and/or Unstructured Supplementary Service Data (USSD) system to verify HIVST); (2) modifications to the delivery the intervention (i.e. implement participatory learning community sessions to provide supportive supervision and technical support); (3) modifications to the evaluation processes (i.e. economic evaluation to estimate the cost of implementing intervention on a larger scale). Frequent reasons for adaptation included increasing intervention reach, modifying interventions to enhance their appropriateness and fit with the recipient, and increasing the intervention's feasibility and acceptability. Most adaptations were planned and reactive, and the need for modifications was determined by the youths, 4YBY program staff, and advisory group. CONCLUSIONS: Findings suggest that the nature of adaptations made throughout the implementation process reflects the necessity of evaluating services in context while adjusting to specific challenges as they are identified. Further research is needed to understand the effect of these adaptations on the overall intervention effect as well as the quality of youth engagement.

Medication adherence and blood pressure control: A preliminary assessment of the role of health insurance in Nigeria and Ghana.

Objectives: This study sought to assess the current impact of health insurance coverage on medication adherence and blood pressure control of patients being managed for hypertension in Ghana and Nigeria. Methods: The study was a prospective study among 109 patients with hypertension in two health facilities with similar population dynamics in Ghana and Nigeria. Patients were systematically selected, categorized as having health insurance coverage or not, and followed up monthly for 6 months. The outcome variables (medication adherence and blood pressure control) were then measured and compared at 6 months. Analysis was done using Stata with level of significance set at p ⩽ 0.05. Results: There was a 90% insurance coverage among participants from Ghana compared to 15% from Nigeria. National Health Insurance Authority enrolees in both countries had better blood pressure control and medication adherence compared to non-enrolees (adjusted odds ratio = 2.6 and 4.5, respectively). Conclusion: National Health Insurance Authority enrolment was found to be poor among respondents in Nigeria compared to Ghana. Enrolment into the National health financing schemes in both countries led to better blood pressure control and medication adherence among patients with hypertension at primary health facilities. There is therefore the need for system strengthening to improve their sustainability.

Needs assessment and planning for a clinic-community-based implementation program for hypertension control among blacks in New York City: a protocol paper.

BACKGROUND: Hypertension (HTN) control among Blacks in the USA has become a major public health challenge. Barriers to HTN control exist at multiple levels including patient, physician, and the health system. Patients also encounter significant community-level barriers, such as poor linkage to social services that impact health (unstable housing, food access, transportation). We describe a multi-component needs assessment to inform the development, implementation, and evaluation of a program to improve HTN management within a large healthcare system in New York City (NYC). METHODS: Guided by the Community-Based Participatory Research (CBPR) and Consolidated Framework for Implementation Research (CFIR) frameworks, data will be collected from four main sources: (1) quantitative surveys with health systems leadership, providers, and staff and with community-based organizations (CBOs) and faith-based organizations (FBOs); (2) qualitative interviews and focus groups with health systems leadership, providers, and staff and with CBOs and FBOs; (3) NYC Community Health Survey (CHS); and (4) New York University (NYU) Health system Epic Electronic Health Record (EHR) system. The data sources will allow for triangulation and synthesis of findings. DISCUSSION: Findings from this comprehensive needs assessment will inform the development of a clinic-community-based practice facilitation program utilizing three multi-level evidence-based interventions (nurse case management, remote blood pressure (BP) monitoring, and social determinants of health (SDoH) support) integrated as a community-clinic linkage model for improved HTN control in Black patients. Integration of stakeholders' priorities, perspectives, and practices into the development of the program will improve adoption, sustainability, and the potential for scale-up. TRIAL REGISTRATION: NCT05208450; registered on January 26, 2022.

Assessing descriptions of scalability for hypertension control interventions implemented in low-and middle-income countries: A systematic review.

BACKGROUND: The prevalence of hypertension continues to rise in low- and middle-income- countries (LMICs) where scalable, evidence-based interventions (EBIs) that are designed to reduce morbidity and mortality attributed to hypertension have yet to be fully adopted or disseminated. We sought to evaluate evidence from published randomized controlled trials using EBIs for hypertension control implemented in LMICs, and identify the WHO/ExpandNet scale-up components that are relevant for consideration during "scale-up" implementation planning. METHODS: Systematic review of RCTs reporting EBIs for hypertension control implemented in LMICs that stated "scale-up" or a variation of scale-up; using the following data sources PubMed/Medline, Web of Science Biosis Citation Index (BCI), CINAHL, EMBASE, Global Health, Google Scholar, PsycINFO; the grey literature and clinicaltrials.gov from inception through June 2021 without any restrictions on publication date. Two reviewers independently assessed studies for inclusion, conducted data extraction using the WHO/ExpandNet Scale-up components as a guide and assessed the risk of bias using the Cochrane risk-of-bias tool. We provide intervention characteristics for each EBI, BP results, and other relevant scale-up descriptions. MAIN RESULTS: Thirty-one RCTs were identified and reviewed. Studies reported clinically significant differences in BP, with 23 studies reporting statistically significant mean differences in BP (p < .05) following implementation. Only six studies provided descriptions that captured all of the nine WHO/ExpandNet components. Multi-component interventions, including drug therapy and health education, provided the most benefit to participants. The studies were yet to be scaled and we observed limited reporting on translation of the interventions into existing institutional policy (n = 11), cost-effectiveness analyses (n = 2), and sustainability measurements (n = 3). CONCLUSION: This study highlights the limited data on intervention scalability for hypertension control in LMICs and demonstrates the need for better scale-up metrics and processes for this setting. TRIAL REGISTRATION: Registration PROSPERO (CRD42019117750).

A Social Media-Based Diabetes Intervention for Low-Income Mandarin-Speaking Chinese Immigrants in the United States: Feasibility Study.

BACKGROUND: Chinese immigrants bear a high diabetes burden and face significant barriers to accessing diabetes self-management education (DSME) and counseling programs. OBJECTIVE: The goal of this study was to examine the feasibility and acceptability and to pilot test the potential efficacy of a social media-based DSME intervention among low-income Chinese immigrants with type 2 diabetes (T2D) in New York City. METHODS: This was a single group pretest and posttest study in 30 Chinese immigrants with T2D. The intervention included 24 culturally and linguistically tailored DSME videos, focusing on diabetes education and behavioral counseling techniques. Over 12 weeks, participants received 2 brief videos each week via WeChat, a free social media app popular among Chinese immigrants. Primary outcomes included the feasibility and acceptability of the intervention. Feasibility was evaluated by recruitment processes, retention rates, and the video watch rate. Acceptability was assessed via a satisfaction survey at 3 months. Secondary outcomes, that is, hemoglobin A1c (HbA1c), self-efficacy, dietary intake, and physical activity, were measured at baseline, 3 months, and 6 months. Descriptive statistics and paired 2-sided t tests were used to summarize the baseline characteristics and changes before and after the intervention. RESULTS: The sample population (N=30) consisted of mostly females (21/30, 70%) who were married (19/30, 63%), with limited English proficiency (30/30, 100%), and the mean age was 61 (SD 7) years. Most reported an annual household income of

The National Heart Lung and Blood Institute Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Alliance.

OBJECTIVE: To describe the National Heart Lung and Blood Institute (NHLBI) sponsored Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease (DECIPHeR) Alliance to support late-stage implementation research aimed at reducing disparities in communities with high burdens of cardiovascular and/or pulmonary disease. STUDY SETTING: NHBLI funded seven DECIPHeR studies and a Coordinating Center. Projects target high-risk diverse populations including racial and ethnic minorities, urban, rural, and low-income communities, disadvantaged children, and persons with serious mental illness. Two projects address multiple cardiovascular risk factors, three focus on hypertension, one on tobacco use, and one on pediatric asthma. STUDY DESIGN: The initial phase supports planning activities for sustainable uptake of evidence-based interventions in targeted communities. The second phase tests late-stage evidence-based implementation strategies. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: We provide an overview of the DECIPHeR Alliance and individual study designs, populations, and settings, implementation strategies, interventions, and outcomes. We describe the Alliance's organizational structure, designed to promote cross-center partnership and collaboration. CONCLUSIONS: The DECIPHeR Alliance represents an ambitious national effort to develop sustainable implementation of interventions to achieve cardiovascular and pulmonary health equity.

Advancing Equity in Blood Pressure Control: A Response to the Surgeon General's Call-to-Action.

Hypertension is an established risk factor for cardiovascular disease. Although controlling blood pressure reduces cardiovascular and stroke mortality and target organ damage, poor blood pressure control remains a clinical and public health challenge. Furthermore, racial and ethnic disparities in the outcomes of hypertension are well documented. In October of 2020, the U.S. Department of Health and Human Services published The Surgeon General's Call to Action to Control Hypertension. The Call to Action emphasized, among other priorities, the need to eliminate disparities in the treatment and control of high blood pressure and to address social determinants as root causes of inequities in blood pressure control and treatment. In support of the goals set in the Call to Action, this review summarizes contemporary research on racial, ethnic, and socioeconomic disparities in hypertension and blood pressure control; describes interventions and policies that have improved blood pressure control in minoritized populations by addressing the social determinants of health; and proposes next steps for achieving equity in hypertension and blood pressure control.

The 4 Youth by Youth (4YBY) pragmatic trial to enhance HIV self-testing uptake and sustainability: Study protocol in Nigeria.

BACKGROUND: The World Health Organization recommends HIV self-testing (HIVST) as an additional approach to HIV testing and the Nigerian government is supportive of this policy recommendation. However, effectively increasing uptake and sustainability among Nigerian youth is unknown. The goal of this study is to conduct a full-powered type I hybrid effectiveness-implementation trial to test the effectiveness of youth-friendly implementation science strategies in increasing uptake and sustainability of HIVST led by and for Nigerian youth. METHODS: Our 4 Youth by Youth (4YBY) strategy combines four core elements: 1) HIVST bundle consisting of HIVST kits and photo verification system; 2) a participatory learning community; 3) peer to peer support and technical assistance; and 4) on-site supervision and performance feedback to improve uptake and sustainability of HIVST and enhance linkage to youth-friendly health clinics for confirmatory HIV testing where needed, sexually transmitted infection (STI) testing (i.e. syphilis, gonorrhea, chlamydia, and hepatitis, STI treatment, and PrEP referral. Utilizing a stepped-wedge, cluster-randomized controlled trial, a national cohort of youth aged 14-24 recruited from 32 local government areas across 14 states and four geo-political zones in Nigeria will receive the 4YBY implementation strategy. In addition, an economic evaluation will explore the incremental cost per quality adjusted life year gained. DISCUSSION: This study will add to the limited "how-to-do it literature" on implementation science strategies in a resource-limited setting targeting youth population traditionally underrepresented in implementation science literature. Study findings will also optimize uptake and sustainability of HIVST led by and for young people themselves. TRIAL REGISTRATION: This study is registered in ClinicalTrials.govNCT04710784 (on January 15, 2021).

Actions to Transform US Preventive Services Task Force Methods to Mitigate Systemic Racism in Clinical Preventive Services.

Importance: US life expectancy and health outcomes for preventable causes of disease have continued to lag in many populations that experience racism. Objective: To propose iterative changes to US Preventive Services Task Force (USPSTF) processes, methods, and recommendations and enact a commitment to eliminate health inequities for people affected by systemic racism. Design and Evidence: In February 2021, the USPSTF began operational steps in its work to create preventive care recommendations to address the harmful effects of racism. A commissioned methods report was conducted to inform this process. Key findings of the report informed proposed updates to the USPSTF methods to address populations adversely affected by systemic racism and proposed pilots on implementation of the proposed changes. Findings: The USPSTF proposes to consider the opportunity to reduce health inequities when selecting new preventive care topics and prioritizing current topics; seek evidence about the effects of systemic racism and health inequities in all research plans and public comments requested, and integrate available evidence into evidence reviews; and summarize the likely effects of systemic racism and health inequities on clinical preventive services in USPSTF recommendations. The USPSTF will elicit feedback from its partners and experts and proposed changes will be piloted on selected USPSTF topics. Conclusions and Relevance: The USPSTF has developed strategies intended to mitigate the influence of systemic racism in its recommendations. The USPSTF seeks to reduce health inequities and other effects of systemic racism through iterative changes in methods of developing evidence-based recommendations, with partner and public input in the activities to implement the advancements.

Representation of Racial/ Ethnic Minority Individuals in the Leadership of Major Medical Journals.

Medical journals play an important role in achieving health equity by diversifying their leadership, but there is a dearth of published data on how they are faring. The objective of this study was to assess the proportions of the underrepresented in medicine (UIM) racial/ ethnic minorities in medical journal leadership. We pre-selected 6 prominent general medicine journals, 9 prominent specialty journals, and 5 "control" journals (covering public health, health equity, and bench research), assembled names of all editors/ editorial board members listed on the website-based journal mastheads and used major public internet search engines to obtain information about sex, race, and ethnicity. We searched the journal databases for all articles published on racial/ethnic disparities or health equity by each journal between January 2015 to October 2020. Among general medicine journals, there were no UIM Editors-in-Chief or Deputy Editors; 1 (2%) Black and 3 (5%) Hispanic among Associate Editors (n=65); and 8 (6%) Black, and 2 (2%) Hispanic among Editorial Board Members (n=136). Among specialty journals, there were no UIM Editors-in-Chief; 3 (7%) Black and 0 (0%) Hispanic Deputy or Associate Editors (n=43); 6 (6%) Black and 5 (5%) Hispanic Editorial Board Members (n=105). Among "control" journals, there were Black Editors-in-Chief, but no Hispanic Editors-in-chief; 7 (8%) Black and 1(1%) Hispanic Deputy and Associate editors (n=86); 43 (47%) Black and 3 (3%) Hispanic Editorial Board Members (n=92). There is considerable room for improvement to enhance the involvement of UIM racial/ethnic minority individuals in leadership of prominent general and specialty medical journals.

Assessment of Racial/Ethnic Disparities in Hospitalization and Mortality in Patients With COVID-19 in New York City.

Importance: Black and Hispanic populations have higher rates of coronavirus disease 2019 (COVID-19) hospitalization and mortality than White populations but lower in-hospital case-fatality rates. The extent to which neighborhood characteristics and comorbidity explain these disparities is unclear. Outcomes in Asian American populations have not been explored. Objective: To compare COVID-19 outcomes based on race and ethnicity and assess the association of any disparities with comorbidity and neighborhood characteristics. Design, Setting, and Participants: This retrospective cohort study was conducted within the New York University Langone Health system, which includes over 260 outpatient practices and 4 acute care hospitals. All patients within the system's integrated health record who were tested for severe acute respiratory syndrome coronavirus 2 between March 1, 2020, and April 8, 2020, were identified and followed up through May 13, 2020. Data were analyzed in June 2020. Among 11 547 patients tested, outcomes were compared by race and ethnicity and examined against differences by age, sex, body mass index, comorbidity, insurance type, and neighborhood socioeconomic status. Exposures: Race and ethnicity categorized using self-reported electronic health record data (ie, non-Hispanic White, non-Hispanic Black, Hispanic, Asian, and multiracial/other patients). Main Outcomes and Measures: The likelihood of receiving a positive test, hospitalization, and critical illness (defined as a composite of care in the intensive care unit, use of mechanical ventilation, discharge to hospice, or death). Results: Among 9722 patients (mean [SD] age, 50.7 [17.5] years; 58.8% women), 4843 (49.8%) were positive for COVID-19; 2623 (54.2%) of those were admitted for hospitalization (1047 [39.9%] White, 375 [14.3%] Black, 715 [27.3%] Hispanic, 180 [6.9%] Asian, 207 [7.9%] multiracial/other). In fully adjusted models, Black patients (odds ratio [OR], 1.3; 95% CI, 1.2-1.6) and Hispanic patients (OR, 1.5; 95% CI, 1.3-1.7) were more likely than White patients to test positive. Among those who tested positive, odds of hospitalization were similar among White, Hispanic, and Black patients, but higher among Asian (OR, 1.6, 95% CI, 1.1-2.3) and multiracial patients (OR, 1.4; 95% CI, 1.0-1.9) compared with White patients. Among those hospitalized, Black patients were less likely than White patients to have severe illness (OR, 0.6; 95% CI, 0.4-0.8) and to die or be discharged to hospice (hazard ratio, 0.7; 95% CI, 0.6-0.9). Conclusions and Relevance: In this cohort study of patients in a large health system in New York City, Black and Hispanic patients were more likely, and Asian patients less likely, than White patients to test positive; once hospitalized, Black patients were less likely than White patients to have critical illness or die after adjustment for comorbidity and neighborhood characteristics. This supports the assertion that existing structural determinants pervasive in Black and Hispanic communities may explain the disproportionately higher out-of-hospital deaths due to COVID-19 infections in these populations.

Association of Race/Ethnicity-Specific Changes in Antihypertensive Medication Classes Initiated Among Medicare Beneficiaries With the Eighth Joint National Committee Panel Member Report.

Importance: In December 2013, the panel members appointed to the Eighth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC8) published a recommendation that non-Black adults initiate antihypertensive medication with a thiazide-type diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB), whereas Black adults initiate treatment with a thiazide-type diuretic or calcium channel blocker. ß-Blockers were not recommended as first-line therapy. Objective: To assess changes in antihypertensive medication classes initiated by race/ethnicity from before to after publication of the JNC8 panel member report. Design, Setting, and Participants: This serial cross-sectional analysis assessed a 5% sample of Medicare beneficiaries aged 66 years or older who initiated antihypertensive medication between 2011 and 2018, were Black (n = 3303 [8.0%]), White (n = 34 943 [84.5%]), or of other (n = 3094 [7.5%]) race/ethnicity, and did not have compelling indications for specific antihypertensive medication classes. Exposures: Calendar year and period after vs before publication of the JNC8 panel member report. Main Outcomes and Measures: The proportion of beneficiaries initiating ACEIs or ARBs and, separately, ß-blockers vs other antihypertensive medication classes. Results: In total, 41 340 Medicare beneficiaries (65% women; mean [SD] age, 75.7 [7.6] years) of Black, White, or other races/ethnicities initiated antihypertensive medication and met the inclusion criteria for the present study. In 2011, 25.2% of Black beneficiaries initiating antihypertensive monotherapy did so with an ACEI or ARB compared with 23.7% in 2018 (P = .47 for trend). Among beneficiaries initiating monotherapy, the proportion filling a ß-blocker was 20.1% in 2011 and 15.4% in 2018 for White beneficiaries (P < .001 for trend), 14.2% in 2011 and 11.1% in 2018 for Black beneficiaries (P = .08 for trend), and 11.3% in 2011 and 15.0% in 2018 for beneficiaries of other race/ethnicity (P = .40 for trend). After multivariable adjustment and among beneficiaries initiating monotherapy, there was no evidence of a change in the proportion filling an ACEI or ARB before to after publication of the JNC8 panel member report overall (prevalence ratio, 1.00; 95% CI, 0.97-1.03) or in Black vs White beneficiaries (prevalence ratio, 0.96; 95% CI, 0.83-1.12; P = .60 for interaction). Among beneficiaries initiating monotherapy, the proportion filling a ß-blocker decreased from before to after publication of the JNC8 panel member report (prevalence ratio, 0.89; 95% CI, 0.84-0.93) with no differences across race/ethnicity groups (P > .10 for interaction). Conclusions and Relevance: A substantial proportion of older US adults who initiate antihypertensive medication do so with non-guideline-recommended classes of medication.