Disparities in Initial Antihypertensive Intensity by Sex, Race and Ethnicity in Newly-Treated Patients with Hypertension

Shailina Keshwani; Kayla M Smith; Almut G Winterstein; Matthew J Gurka; Marta G Walsh; Anne Libby; William Hogan; Carl J Pepine; Rhonda M Cooper-DeHoff; Steven M Smith

doi:10.1093/ajh/hpaf060

Disparities in Initial Antihypertensive Intensity by Sex, Race and Ethnicity in Newly-Treated Patients with Hypertension

Am J Hypertens. 2025 Apr 22:hpaf060. doi: 10.1093/ajh/hpaf060. Online ahead of print.

Authors

Shailina Keshwani¹, Kayla M Smith¹, Almut G Winterstein¹, Matthew J Gurka², Marta G Walsh¹, Anne Libby³, William Hogan⁴, Carl J Pepine⁵, Rhonda M Cooper-DeHoff^{5

6

7}, Steven M Smith^{1

5

6}

Affiliations

¹ Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA.
² Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, USA.
³ Department of Emergency Medicine, School of Medicine, University of Colorado Denver, Aurora, CO, USA.
⁴ Data Science Institute, Medical College of Wisconsin, Milwaukee, WI, USA.
⁵ Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA.
⁶ Center for Integrative Cardiovascular and Metabolic Disease, University of Florida, Gainesville, FL, USA.
⁷ Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.

PMID: 40259567
DOI: 10.1093/ajh/hpaf060

Abstract

Background: Sex, race, and ethnicity disparities in hypertension (HTN) treatment intensity have been previously described. It remains unclear if these disparities occur at treatment onset and whether they can be explained by differences in clinical factors.

Methods: We conducted a retrospective cross-sectional study of adults with newly-treated HTN using linked EHR+claims data from OneFlorida+ Consortium. We included Florida Medicaid & Medicare-recipients diagnosed with HTN and prescribed ≥1 first-line antihypertensive during 2013-2020. We used generalized linear models to estimate differences in total therapeutic intensity score (TTIS)-a patient's total daily dose (TDD) divided by recommended maximum TDD for a drug, summed across entire regimen-by sex, race, and ethnicity. We then modeled the same, controlling for demographics, blood pressure, and relevant comorbidities.

Results: In total 4,094 patients (mean age 58 ± 16; female 57.6%; White 56.7%) were included. We observed variations in the initiation of antihypertensive classes by sex, race and ethnicity. In univariate analyses, men averaged 7.6% (95%CI:3.9%-11.3%) greater TTIS versus women and Black individuals averaged 10.5% (95%CI:6.6%-14.3%) greater TTIS versus White individuals, whereas no disparities were observed by ethnicity. After adjusting for clinical factors, these disparities persisted: men had 7.6% (95%CI:3.9%-11.4%) greater TTIS versus women, and Black individuals had 17.9% (95%CI:13.8%-21.9%) greater TTIS versus White individuals.

Conclusion: We observed disparities in treatment intensity by sex and race that were not explained by differences in clinical factors. There was sex-based variation in practice patterns, and Black individuals received more intensive initial antihypertensive therapy than White individuals.

Keywords: EHR-linked Claims Data; Health Disparity; Hypertension; Real-World Data; Therapeutic Intensity.

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