46 results found
Cowling TE, Cromwell DA, Bellot A, et al., 2021, Logistic regression and machine learning predicted patient mortality from large sets of diagnosis codes comparably., J Clin Epidemiol, Vol: 133, Pages: 43-52
OBJECTIVE: The objective of the study was to compare the performance of logistic regression and boosted trees for predicting patient mortality from large sets of diagnosis codes in electronic healthcare records. STUDY DESIGN AND SETTING: We analyzed national hospital records and official death records for patients with myocardial infarction (n = 200,119), hip fracture (n = 169,646), or colorectal cancer surgery (n = 56,515) in England in 2015-2017. One-year mortality was predicted from patient age, sex, and socioeconomic status, and 202 to 257 International Classification of Diseases 10th Revision codes recorded in the preceding year or not (binary predictors). Performance measures included the c-statistic, scaled Brier score, and several measures of calibration. RESULTS: One-year mortality was 17.2% (34,520) after myocardial infarction, 27.2% (46,115) after hip fracture, and 9.3% (5,273) after colorectal surgery. Optimism-adjusted c-statistics for the logistic regression models were 0.884 (95% confidence interval [CI]: 0.882, 0.886), 0.798 (0.796, 0.800), and 0.811 (0.805, 0.817). The equivalent c-statistics for the boosted tree models were 0.891 (95% CI: 0.889, 0.892), 0.804 (0.802, 0.806), and 0.803 (0.797, 0.809). Model performance was also similar when measured using scaled Brier scores. All models were well calibrated overall. CONCLUSION: In large datasets of electronic healthcare records, logistic regression and boosted tree models of numerous diagnosis codes predicted patient mortality comparably.
Parry MG, Nossiter J, Sujenthiran A, et al., 2021, Impact of High-Dose-Rate and Low-Dose-Rate Brachytherapy Boost on Toxicity, Functional and Cancer Outcomes in Patients Receiving External Beam Radiation Therapy for Prostate Cancer: A National Population-Based Study, INTERNATIONAL JOURNAL OF RADIATION ONCOLOGY BIOLOGY PHYSICS, Vol: 109, Pages: 1219-1229, ISSN: 0360-3016
Parry MG, Nossiter J, Cowling TE, et al., 2021, Patient-reported functional outcomes following external beam radiation therapy for prostate cancer with and without a high-dose rate brachytherapy boost: A national population-based study, RADIOTHERAPY AND ONCOLOGY, Vol: 155, Pages: 48-55, ISSN: 0167-8140
Cowling TE, Cromwell DA, Sharples LD, et al., 2020, A novel approach selected small sets of diagnosis codes with high prediction performance in large healthcare datasets, JOURNAL OF CLINICAL EPIDEMIOLOGY, Vol: 128, Pages: 20-28, ISSN: 0895-4356
Parry MG, Nossiter J, Cowling TE, et al., 2020, Toxicity of Pelvic Lymph Node Irradiation With Intensity Modulated Radiation Therapy for High-Risk and Locally Advanced Prostate Cancer: A National Population-Based Study Using Patient-Reported Outcomes, INTERNATIONAL JOURNAL OF RADIATION ONCOLOGY BIOLOGY PHYSICS, Vol: 108, Pages: 1196-1203, ISSN: 0360-3016
Wallace D, Cowling TE, Walker K, et al., 2020, The Impact of Performance Status on Length of Hospital Stay and Clinical Complications Following Liver Transplantation., Transplantation
BACKGROUND: Impaired pretransplant performance status (PS) is associated with chronic liver disease (CLD). We studied its impact on hospital length of stay (LOS), complications and readmissions in the first year after liver transplantation. METHOD: The Standard National Liver Transplant Registry was linked to a hospital administrative dataset and all first-time liver transplant recipients with CLD aged ≥ 18 years in England were identified. A modified 3-level Eastern Cooperative Oncology Group score was used to assess PS. Linear and logistic fixed effect regression models were used to estimate the effect of specific posttransplant complications, and readmissions in the first year after transplantation. RESULTS: 6968 recipients were included. Impaired PS was associated with an increased LOS in the initial posttransplant period (comparing ECOG 1 to 3, adjusted difference 7.2 days, 95%CI: 4.8-9.6, p<0.001) and in time spent on the ITU (adjusted difference 1.2 days, 95%CI: 0.4-2.0, p<0.001). There was no significant association between ECOG status and total LOS of later admissions (adjusted difference, 2.5 days, 95%CI: -0.4-5.5, p=0.23). Those with a poorer ECOG status had an increased incidence of renal failure (odds ratio 1.5, 95%CI: 1.1-2.0, p=0.004) and infection (odds ratio 1.2, 95%CI: 1.1-1.4, p=0.02) but not an increased incidence of readmission (odds ratio 1.2, 95%CI: 0.9-1.5, p=0.13). CONCLUSION: In liver transplant recipients with CLD, impaired pretransplant PS is associated with prolonged LOS in the immediate posttransplant period but not with LOS of later admissions in the first year after transplantation. Impaired PS increased the risk of renal failure and infection.
Cowling TE, Bellot A, Boyle J, et al., 2020, One-year mortality of colorectal cancer patients: development and validation of a prediction model using linked national electronic data, BRITISH JOURNAL OF CANCER, Vol: 123, Pages: 1474-1480, ISSN: 0007-0920
Wallace D, Cowling TE, Walker K, et al., 2020, Liver transplantation outcomes after transarterial chemotherapy for hepatocellular carcinoma, BRITISH JOURNAL OF SURGERY, Vol: 107, Pages: 1183-1191, ISSN: 0007-1323
Berry B, Parry MG, Sujenthiran A, et al., 2020, Comparison of complications after transrectal and transperineal prostate biopsy: a national population-based study, BJU INTERNATIONAL, Vol: 126, Pages: 97-103, ISSN: 1464-4096
Wallace D, Cowling T, McPhail MJ, et al., 2020, Assessing the Time-Dependent Impact of Performance Status on Outcomes After Liver Transplantation, HEPATOLOGY, Vol: 72, Pages: 1341-1352, ISSN: 0270-9139
Lee TY, Zhao Y, Atun R, et al., 2020, Physical multimorbidity, health service use and catastrophic health expenditure by socio-economic groups in China: a population-based panel data analysis, The Lancet Global Health, Vol: 8, Pages: e840-e849, ISSN: 2214-109X
Background Multimorbidity, the presence of two or more mental or physical chronic non-communicable diseases (NCDs), is a major challenge for the health system in China, which faces unprecedented ageing of its population. This study examined: (1) the distribution of physical multimorbidity in relation to socio-economic status, (2) the relationships between physical multimorbidity, healthcare service use, and catastrophic health expenditures, and (3) whether these relationships varied by socio-economic groups and social health insurance schemes. Methods Panel data study design utilized three waves of the nationally-representative China Health and Retirement Longitudinal Study (CHARLS 2011, 2013, 2015), which included 11 718 participants aged ≥50 years, and 11 physical NCDs. Findings Overall, 62% of participants had physical multimorbidity in China in 2015. Multimorbidity increased with age, female gender, higher per capita household expenditure, and higher educational level. However, multimorbidity was more common in poorer regions compared with the most affluent regions. An additional chronic NCD was associated with an increase in the number of outpatient visits of 28.8% (IRR=1.29, 95% CI: 1.27 to 1.31), and days of hospitalisation (IRR=1.38, 95% CI: 1.35 to 1.41). There were similar effects in different socio-economic groups and among those covered by different social health insurance programmes. Overall, multimorbidity was associated with a substantially greater odds of experiencing CHE (AOR=1·29 for the overall population, 95% CI=1·26, 1·32). The effect of multimorbidity on catastrophic health expenditures persisted even among the higher socio-economic groups and those with more generous health insurance coverage.Interpretation Multimorbidity was associated with higher levels of health service use and greater financial burden. Concerted efforts are needed to reduce health inequalities that arise due to multimorbidity, and its adverse econom
Parry MG, Cowling TE, Sujenthiran A, et al., 2020, Risk stratification for prostate cancer management: value of the Cambridge Prognostic Group classification for assessing treatment allocation, BMC MEDICINE, Vol: 18, ISSN: 1741-7015
qin VM, McPake B, Raban M, et al., 2020, Rural and urban differences in health system performance among older Chinese adults: cross-sectional analysis of a national sample, BMC Health Services Research, Vol: 20, ISSN: 1472-6963
Background Despite improvement in health outcomes over the past few decades, china still experiences striking urban-rural health inequalities. There is limited research on the rural-urban differences in health system performance in China. Method We conducted a cross-sectional analysis to compare health system performance between rural and urban areas in five key domains of the health system: effectiveness, cost, access, patient-centredness and equity, using data from the WHO Study on Global AGEing and adult health (SAGE), China. Multiple logistic and linear regression models were used to assess the first four domains, adjusting for individual characteristics, and a relative index of inequality (RII) was used to measure the equity domain. Findings Compared to urban areas, rural areas had poorer performance in the management and control of hypertension and diabetes, with more than 50% lower odds of having breast (AOR= 0.44; 95% CI: 0.30, 0.64) and cervical cancer screening (AOR= 0.49; 95% CI: 0.29, 0.83). There was better performance in rural areas in the patient-centredness domain, with more than twice higher odds of getting prompt attention, respect, clarity of the communication with health provider and involvement in decision making of the treatment in inpatient care (AOR=2.56, 2.15, 2.28, 2.28). Although rural residents incurred relatively less out-of-pocket expenditures (OOPE) for outpatient and inpatient services than urban residents, they were more likely to incur catastrophic expenditures on health (AOR=1.30; 95% CI 1.16, 1.44). Wealth inequality was found in many indicators related to the effectiveness, costs and access domains in both rural and urban areas. Rural areas had greater inequalities in the management of hypertension and coverage of cervical cancer (RII=7.45 vs 1.64).ConclusionOur findings suggest that urban areas have achieved better prevention and management of non-communicable disease than rural areas, but access to healthcare was equivalent. A
Boyle JM, Kuryba A, Cowling TE, et al., 2020, Determinants of Variation in the Use of Adjuvant Chemotherapy for Stage III Colon Cancer in England, CLINICAL ONCOLOGY, Vol: 32, Pages: E135-E144, ISSN: 0936-6555
Wallace D, Cowling TE, Walker K, et al., 2020, Short- and long-term mortality after liver transplantation in patients with and without hepatocellular carcinoma in the UK, BRITISH JOURNAL OF SURGERY, Vol: 107, Pages: 896-905, ISSN: 0007-1323
Nossiter J, Sujenthiran A, Cowling TE, et al., 2020, Patient-Reported Functional Outcomes After Hypofractionated or Conventionally Fractionated Radiation for Prostate Cancer: A National Cohort Study in England, JOURNAL OF CLINICAL ONCOLOGY, Vol: 38, Pages: 744-+, ISSN: 0732-183X
Parry MG, Cowling TE, Sujenthiran A, et al., 2019, Identifying skeletal-related events for prostate cancer patients in routinely collected hospital data, CANCER EPIDEMIOLOGY, Vol: 63, ISSN: 1877-7821
Cowling TE, Cromwell DA, Sharples LD, et al., 2019, Protocol for an observational study evaluating new approaches to modelling diagnostic information from large administrative hospital datasets
<jats:title>Abstract</jats:title><jats:sec><jats:title>Introduction</jats:title><jats:p>The Charlson and Elixhauser indices define sets of conditions used to adjust for patients’ comorbidities in administrative hospital data. A strength of these indices is the parsimony that results from including only 19 and 30 conditions respectively, but the conditions included may not be the ones most relevant to a specific outcome and population. Our objectives are to: (1) test an approach to developing parsimonious indices for the specific outcome and populations being studied, while comparing performance to the Charlson and Elixhauser indices; and (2) evaluate several approaches that involve models with more diagnosis-related terms and aim to improve prediction performance by capturing more of the information in large datasets.</jats:p></jats:sec><jats:sec><jats:title>Methods and analysis</jats:title><jats:p>This is a modelling study using a linked national dataset of administrative hospital records and death records. The study populations are patients admitted to hospital for acute myocardial infarction, hip fracture, or major surgery for colorectal cancer in England between 1 January 2015 and 31 December 2017. The outcome is death within 365 days of the date of admission (acute myocardial infarction and hip fracture) or procedure (colorectal surgery). In the ‘First analysis’, prognostic indices will be developed based on the presence/absence of individual ICD-10 codes in patients’ medical histories. Logistic regression will be used to estimate associations with a full set of sociodemographic and diagnostic predictors from which reduced models (with fewer diagnostic predictors) will be produced using a step-down approach. In the ‘Second analysis’, models will also account for the timing that each ICD-10 code was last recorded and allow for non-linear relationships and
Parry MG, Sujenthiran A, Cowling TE, et al., 2019, Treatment-Related Toxicity Using Prostate-Only Versus Prostate and Pelvic Lymph Node Intensity-Modulated Radiation Therapy: A National Population-Based Study, JOURNAL OF CLINICAL ONCOLOGY, Vol: 37, Pages: 1828-+, ISSN: 0732-183X
Parry MG, Sujenthiran A, Cowling TE, et al., 2019, Impact of cancer service centralisation on the radical treatment of men with high-risk and locally advanced prostate cancer: A national cross-sectional analysis in England, INTERNATIONAL JOURNAL OF CANCER, Vol: 145, Pages: 40-48, ISSN: 0020-7136
Wallace D, Walker K, Charman S, et al., 2019, Assessing the Impact of Suboptimal Donor Characteristics on Mortality After Liver Transplantation: A Time-dependent Analysis Comparing HCC With Non-HCC Patients, TRANSPLANTATION, Vol: 103, Pages: E89-E98, ISSN: 0041-1337
Parry MG, Sujenthiran A, Cowling TE, et al., 2019, Imputation of missing prostate cancer stage in English cancer registry data based on clinical assumptions, CANCER EPIDEMIOLOGY, Vol: 58, Pages: 44-51, ISSN: 1877-7821
Baier N, Geissler A, Bech M, et al., 2019, Emergency and urgent care systems in Australia, Denmark, England, France, Germany and the Netherlands - Analyzing organization, payment and reforms, HEALTH POLICY, Vol: 123, Pages: 1-10, ISSN: 0168-8510
Hayhoe BWJ, Cowling T, Pillutla V, et al., 2018, Integrating a nationally scaled workforce of community health workers in primary care: a modelling study, Journal of the Royal Society of Medicine, Vol: 111, Pages: 453-461, ISSN: 1758-1095
ObjectiveTo model cost and benefit of a national community health worker workforce.DesignModelling exercise based on all general practices in England.SettingUnited Kingdom National Health Service Primary Care.ParticipantsNot applicable.Data sourcesPublicly available data on general practice demographics, population density, household size, salary scales and screening and immunisation uptake.Main outcome measuresWe estimated numbers of community health workers needed, anticipated workload and likely benefits to patients.ResultsConservative modelling suggests that 110,585 community health workers would be needed to cover the general practice registered population in England, costing £2.22bn annually. Assuming community health workerss could engage with and successfully refer 20% of eligible unscreened or unimmunised individuals, an additional 753,592 cervical cancer screenings, 365,166 breast cancer screenings and 482,924 bowel cancer screenings could be expected within respective review periods. A total of 16,398 additional children annually could receive their MMR1 at 12 months and 24,716 their MMR2 at five years of age. Community health workerss would also provide home-based health promotion and lifestyle support to patients with chronic disease.ConclusionA scaled community health worker workforce integrated into primary care may be a valuable policy alternative. Pilot studies are required to establish feasibility and impact in NHS primary care.
Majeed FA, Harris M, 2018, Importance of accessibility and opening hours to overall patient experience of general practice: analysis of repeated cross-sectional data from a national patient survey in England, British Journal of General Practice, Vol: 68, Pages: e469-e477, ISSN: 0960-1643
Background The UK government aims to improve the accessibility of general practices in England, particularly by extending opening hours in the evenings and at weekends. It is unclear how important these factors are to patients’ overall experiences of general practice.Aim To examine associations between overall experience of general practice and patient experience of making appointments and satisfaction with opening hours.Design and setting Analysis of repeated cross-sectional data from the General Practice Patient Surveys conducted from 2011–2012 until 2013–2014. These covered 8289 general practice surgeries in England.Method Data from a national survey conducted three times over consecutive years were analysed. The outcome measure was overall experience, rated on a five-level interval scale. Associations were estimated as standardised regression coefficients, adjusted for responder characteristics and clustering within practices using multilevel linear regression.Results In total, there were 2 912 535 responders from all practices in England (n = 8289). Experience of making appointments (β 0.24, 95% confidence interval [CI] = 0.24 to 0.25) and satisfaction with opening hours (β 0.15, 95% CI = 0.15 to 0.16) were modestly associated with overall experience. Overall experience was most strongly associated with GP interpersonal quality of care (β 0.34, 95% CI = 0.34 to 0.35) and receptionist helpfulness was positively associated with overall experience (β 0.16, 95% CI = 0.16 to 0.17). Other patient experience measures had minimal associations (β≤0.06). Models explained ≥90% of variation in overall experience between practices.
Ahmad A, Laverty AA, Cowling TE, et al., 2018, Changing nationwide trends in endoscopic, medical and surgical admissions for Inflammatory Bowel Disease: 2003-2013, BMJ Open Gastroenterology, Vol: 5, ISSN: 2054-4774
Background and study aims In the last decade, there have been major advances in inflammatory bowel disease (IBD) management but their impact on hospital admissions requires evaluation. We aim to investigate nationwide trends in IBD surgical/medical elective and emergency admissions, including endoscopy and cytokine inhibitor infusions, between 2003 and 2013.Patients and methods We used Hospital Episode Statistics and population data from the UK Office for National Statistics.Results Age-sex standardised admission rates increased from 76.5 to 202.9/100 000 (p<0.001) and from 69.5 to 149.5/100 000 (p<0.001) for Crohn’s disease (CD) and ulcerative colitis (UC) between 2003–2004 and 2012–2013, respectively. Mean length of stay (days) fell significantly for elective (from 2.6 to 0.7 and from 2.0 to 0.7 for CD and UC, respectively) and emergency admissions (from 9.2 to 6.8 and from 10.8 to 7.6 for CD and UC, respectively). Elective lower gastrointestinal (GI) endoscopy rates decreased from 6.3% to 3.7% (p<0.001) and from 18.4% to 17.6% (p=0.002) for CD and UC, respectively. Elective major abdominal surgery rates decreased from 2.8% to 1.0% (p<0.001) and from 4.9 to 2.4 (p=0.010) for CD and UC, respectively, with emergency rates also decreasing significantly for CD. Between 2006-2007 and 2012-2013, elective admission rates for cytokine-inhibitor infusions increased from 11.1 to 57.2/100 000 and from 1.4 to 12.1/100 000 for CD and UC, respectively.Conclusions Rising IBD hospital admission rates in the past decade have been driven by an increase in the incidence and prevalence of IBD. Lower GI endoscopy and surgery rates have fallen, while cytokine inhibitor infusion rates have risen. There has been a concurrent shift from emergency care to shorter elective hospital stays. These trends indicate a move towards more elective medical management and may reflect improvements in disease control.
Cowling T, Majeed F, Harris M, 2018, Patient experience of general practice and use of emergency hospital services in England: regression analysis of national cross-sectional time series data, BMJ Quality and Safety, Vol: 27, Pages: 643-654, ISSN: 2044-5415
Background The UK Government has introduced several national policies to improve access to primary care. We examined associations between patient experience of general practice and rates of visits to accident and emergency (A&E) departments and emergency hospital admissions in England. Methods The study included 8,124 general practices between 2011-12 and 2013-14. Outcome measures were annual rates of A&E visits and emergency admissions by general practice population, according to administrative hospital records. Explanatory variables included three patient experience measures from the General Practice Patient Survey: practice-level means of experience of making an appointment, satisfaction with opening hours, and overall experience (on 0-100 scales). The main analysis used random-effects Poisson regression for cross-sectional time series. Five sensitivity analyses examined changes in model specification. Results Mean practice-level rates of A&E visits and emergency admissions increased from 2011-12 to 2013-14 (310.3 to 324.4 and 98.8 to 102.9 per 1,000 patients). Each patient experience measure decreased; for example, mean satisfaction with opening hours was 79.4 in 2011-12 and 76.6 in 2013-14. In the adjusted regression analysis, a standard deviation increase in experience of making appointments (equal to nine points) predicted decreases of 1.8% (95% CI: -2.4% to -1.2%) in A&E visit rates and 1.4% (95% CI: -1.9% to -0.9%) in admission rates. This equalled 301,174 fewer A&E visits and 74,610 fewer admissions nationally per year. Satisfaction with opening hours and overall experience were not consistently associated with either outcome measure across the main and sensitivity analyses. Conclusions Associations between patient experience of general practice and use of emergency hospital services were small or inconsistent. In England, realistic short-term improvements in patient experience of general practice may only have modest effects on A&E
Cowling TE, Laverty AA, Harris MJ, et al., 2017, Contract and ownership type of general practices and patient experience in England: multilevel analysis of a national cross-sectional survey, Journal of the Royal Society of Medicine, Vol: 110, Pages: 440-451, ISSN: 1758-1095
Objective: To examine associations between the contractand ownership type of general practices and patient experiencein England.Design: Multilevel linear regression analysis of a nationalcross-sectional patient survey (General Practice PatientSurvey).Setting: All general practices in England in 2013–2014(n ¼ 8017).Participants: 903,357 survey respondents aged 18 years orover and registered with a general practice for six monthsor more (34.3% of 2,631,209 questionnaires sent).Main outcome measures: Patient reports of experienceacross five measures: frequency of consulting a preferreddoctor; ability to get a convenient appointment; rating ofdoctor communication skills; ease of contacting the practiceby telephone; and overall experience (measured onfour- or five-level interval scales from 0 to 100). Modelsadjusted for demographic and socioeconomic characteristicsof respondents and general practice populations and arandom intercept for each general practice.Results: Most practices had a centrally negotiated contractwith the UK government (‘General Medical Services’54.6%; 4337/7949). Few practices were limited companieswith locally negotiated ‘Alternative Provider MedicalServices’ contracts (1.2%; 98/7949); these practices providedworse overall experiences than General MedicalServices practices (adjusted mean difference 3.04, 95%CI 4.15 to 1.94). Associations were consistent in directionacross outcomes and largest in magnitude for frequencyof consulting a preferred doctor (12.78, 95% CI15.17 to 10.39). Results were similar for practicesowned by large organisations (defined as having 20 practices)which were uncommon (2.2%; 176/7949).Conclusions: Patients registered to general practicesowned by limited companies, including large organisations,reported worse experiences of their care than otherpatients in 2013–2014.
Cowling TE, Gunning E, 2016, Access to general practice in England: political, theoretical, and empirical considerations, British Journal of General Practice, Vol: 66, Pages: e680-e682, ISSN: 1478-5242
Access to general practice services in England has been a prominent theme in recent issues of the BJGP. Simpson and colleagues1 outlined the historical context of current policy to extend practice opening hours in the evenings and at weekends. Campbell and Salisbury2 examined the conceptual foundations of access to health care. Ford and colleagues3 reported empirical work on patient preferences for additional opening hours, while Scantlebury and colleagues4 modelled general-practice-level determinants of emergency department visits. We extend this discussion below, focusing on the UK government’s controversial commitment for all patients in England to be offered GP appointments between 8 am and 8 pm, 7 days a week, by 2020.
Cowling T, Harris M, Majeed F, 2016, Extended opening hours and patient experience of general practice in England: multilevel regression analysis of a national patient survey, BMJ Quality & Safety, Vol: 26, Pages: 360-371, ISSN: 2044-5423
Background The UK government plans to extend the opening hours of general practices in England. The ‘extended hours access scheme’ pays practices for providing appointments outside core times (08:00 to 18.30, Monday to Friday) for at least 30 min per 1000 registered patients each week.Objective To determine the association between extended hours access scheme participation and patient experience.Methods Retrospective analysis of a national cross-sectional survey completed by questionnaire (General Practice Patient Survey 2013–2014); 903 357 survey respondents aged ≥18 years old and registered to 8005 general practices formed the study population. Outcome measures were satisfaction with opening hours, experience of making an appointment and overall experience (on five-level interval scales from 0 to 100). Mean differences between scheme participation groups were estimated using multilevel random-effects regression, propensity score matching and instrumental variable analysis.Results Most patients were very (37.2%) or fairly satisfied (42.7%) with the opening hours of their general practices; results were similar for experience of making an appointment and overall experience. Most general practices participated in the extended hours access scheme (73.9%). Mean differences in outcome measures between scheme participants and non-participants were positive but small across estimation methods (mean differences ≤1.79). For example, scheme participation was associated with a 1.25 (95% CI 0.96 to 1.55) increase in satisfaction with opening hours using multilevel regression; this association was slightly greater when patients could not take time off work to see a general practitioner (2.08, 95% CI 1.53 to 2.63).Conclusions Participation in the extended hours access scheme has a limited association with three patient experience measures. This questions expected impacts of current plans to extend opening hours on patient experience.
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