Economic and Demographic Associations in Hypertension-Related Complications Among Florida Participants in the All of Us Research Program

Introduction

Hypertension-related complications are a major contributor to cardiovascular morbidity and mortality worldwide. While many demographic and socioeconomic factors are associated with hypertension, determinants of progression to complications among individuals with established disease remain less clearly defined. We examined key predictors of hypertension-related complications in a Florida-restricted cohort from the All of Us (AoU) Research Program.

Methods

We conducted a cross-sectional analysis of Controlled Tier v8 data using Jupyter Notebook. Adults with hypertension were classified as having uncomplicated (cohort 0) or complicated disease (cohort 1). These adults were also compared to a control cohort (cohort 2). The AoU cohorts were then restricted to Florida using ZIP3 regions: 320-339, 341, 342, 344, 346, 347, and 349. Two analytic datasets were created. For Question A, hypertension cases (complicated and uncomplicated) were compared with controls (N=12,061). For Question B, participants with complicated hypertension were compared to those with uncomplicated hypertension (N=6,042). Multivariable logistic regression assessed associations between demographic and socioeconomic factors within the hypertension cohort with documented complications vs uncomplicated hypertension.

Results

Among 12,061 Florida participants, 6,042 (50.1%) had documented hypertension. In multivariable models comparing hypertensive participants to controls (Question A), older age was strongly associated with hypertension diagnosis. Black/African American participants had significantly higher adjusted odds of hypertension compared with White participants. Lower educational attainment was independently associated with increased odds of hypertension, while higher annual income was associated with reduced odds.

Among the 6,042 adults with hypertension (Question B), 2,640 (43.7%) had documented complications. Participants with complicated hypertension were older (mean 58.8 years) than those with uncomplicated hypertension (54.3 years). Older age remained independently associated with increased odds of complications (OR 1.03 per year, 95% CI 1.02–1.03). Male sex was associated with higher odds (OR 1.30, 95% CI 1.16–1.45). A strong income gradient was observed. Participants reporting annual incomes greater than $150,000 had substantially lower odds of complications (OR 0.43, 95% CI 0.33–0.57), with progressively lower odds across increasing income categories.

Discussion

In this Florida-restricted cohort, demographic and socioeconomic factors were associated with both hypertension diagnosis and progression to complications. Hypertension diagnosis was more strongly associated with older age, Black race, lower educational attainment, and lower income, suggesting that structural and educational disadvantage may contribute to disease development. Among adults with established hypertension, progression to complications was most strongly associated with older age, male sex, and income. The persistent income gradient within the hypertensive cohort suggests that economic resources may influence long-term disease management, access to care, and cumulative cardiovascular risk exposure. These findings indicate that social determinants may operate differently across the hypertension continuum, with educational and racial disparities more prominent in disease onset, and economic position and sex-related differences more influential in disease severity. Stage-specific prevention and management strategies may therefore be warranted to reduce hypertension-related morbidity.