Rural–Urban Differences in Hypertension Prevalence and Control in a Large Regional Health System Cohort

Background: Rural US populations bear a high burden of cardiovascular disease, with hypertension contributing to the rural–urban gap. We examined hypertension prevalence and control across the rural–urban continuum among patients in a large healthcare system in Northeast Texas. Methods: We analyzed the electronic health record data from 363,539 patients with at least one outpatient encounter between September 2021 and April 2025. We defined hypertension using ICD-10-CM codes, antihypertensive prescriptions, or a blood pressure ≥ 130/80 mm Hg. We classified rurality using the Rural–Urban Commuting Area categories. Multivariable logistic regression models were adjusted for age, sex, race, ethnicity, insurance, and level of engagement with the healthcare system. Results: Compared with metropolitan areas, micropolitan residents had lower odds of hypertension (OR = 0.85). We found uncontrolled hypertension also to be more common in metropolitan areas, with a lower prevalence observed across non-metropolitan categories, particularly among isolated rural residents (OR = 0.82). Black patients exhibited higher rates of uncontrolled hypertension across all rural–urban categories. Continuity of care was associated with hypertension prevalence but not control. Conclusions: Hypertension prevalence and control vary across the rural–urban continuum in Northeast Texas, with consistent differences observed between metropolitan and some non-metropolitan residents. Persistent racial differences across all geographic settings support the need for targeted prevention and management strategies.