Tsilimingras et al. 1 investigate whether patients from urban and rural areas have similar rates of adverse events. They carefully consider a sample in one urban community hospital and track rates of adverse events using a rigorous, independently adjudicated method of detecting and classifying adverse events. There was little difference between the two patient groups; both had high rates of adverse events, with the majority being either preventable or ameliorable.

The focus on patients discharged from one hospital is important to consider and is a study strength, as it holds constant the quality and practices of the specific facility. But it raises an additional element to consider: if rural patients “bypassing” their local hospital have better insurance (e.g., commercial), and are more likely to be admitted for complex conditions,2 the patients may differ in their baseline risk of adverse events. Curiously, the patient populations appear to exhibit some of these differences (e.g., slightly more secondary discharge diagnoses in rural) but not others (rural have lower income and are more likely to be on public insurance). Naturally, this reflects the difference in the underlying prevalence of conditions within the two patient groups. In this case, the urban patients of the hospital tend to live much closer to the study hospital: 90 % of the urban Medicare beneficiaries admitted to the hospital lived within 20 miles of Tallahassee Memorial Hospital (TMH), compared to 10 % of the rural Medicare beneficiaries.3 Although this suggests potential barriers to timely post-acute care—combined with more complex conditions and poorer socioeconomic status among the rural group—there seemed to be little difference in risk. Understanding the pathway to these similar rates of adverse events in the face of multiple risk factors would help improve transitions to post-acute care, something from which all acute patients would benefit.