Socioeconomic Determinants of Hypertension and Complications in Georgia: Age-Stratified Analysis of the All of Us Cohort

Moultrie, GA

Introduction: Hypertension (HTN) contributes disproportionately to cardiovascular morbidity and mortality in Georgia. While demographic disparities in prevalence are well characterized, less is understood about how socioeconomic conditions shape both hypertension risk and downstream complication burden. We examined two questions: Question A - what factors are associated with hypertension presence compared to controls, and Question B - among hypertensive patients, what factors predict complications, with particular interest in whether associations varied by age stratum.

Methods: Retrospective cohort study using the All of Us Controlled Tier dataset. Hypertension required ≥2 diagnostic codes. Participants were restricted to Georgia ZIP3 prefixes (300–319, 398), yielding 1,848 uncomplicated HTN, 1,677 complicated HTN, and 4,680 controls (N=8,205). Individual-level exposures included employment, insurance, income, education, housing, and marital status; area-level exposures included ZIP3-linked census deprivation index, poverty fraction, uninsured fraction, and median income. Age strata: < 50, 50–64, ≥65. Multivariable logistic regression compared HTN vs. controls (Question A; N=8,205) and complicated vs. uncomplicated HTN (Question B; N=3,525), with age-stratified models fit within each stratum. All of Us small-cell suppression requirements applied.

Results: The cohort was 54.0% Black/African American, 36.0% White, mean age 49.3 years; 47.6% of HTN patients had complicated disease.

Question A — HTN vs. Controls: Older age was the strongest predictor of hypertension. Uninsured status was inversely associated with diagnosed HTN, likely reflecting ascertainment bias among those with limited care access. Non-employment and lower educational attainment were independently associated with higher odds of hypertension. In age-stratified models, the non-employment association was strongest in adults under 50 (OR 2.06, 95% CI 1.70–2.49), attenuated at 50–64 (OR 1.28, 95% CI 1.08–1.51), and non-significant at ≥65, consistent with near-universal Medicare coverage. Black/African American race was associated with hypertension in the < 50 stratum only.

Question B — Complications Among HTN Patients: Male sex was independently associated with more than twice the odds of complications (OR 2.02, 95% CI 1.75–2.33). Higher income was independently protective against complications, while race was not significant after adjustment. Non-employment predicted complications in adults under 50 and 50–64, but not at ≥65. Race-by-age subgroup estimates were suppressed per All of Us data use policies.

Discussion: Among Georgia-based All of Us participants, non-employment and uninsured status were the dominant socioeconomic predictors of hypertension presence, while male sex and lower income were the primary drivers of complication risk. Both gradients were concentrated in working-age adults and largely absent in the ≥65 stratum, consistent with patterns expected under near-universal Medicare coverage, though formal mediation analysis was not conducted. The convergence of employment instability and insurance gaps in adults under 65 represents a critical window for cardiovascular intervention. Limitations include EHR ascertainment bias, ZIP3-level geographic imprecision, constraints on generalizability due to volunteer recruitment, and a cross-sectional design that precludes causal inference.