10.1136/bmj.310.6987.1122 With the reduction in the number of questions and modification of the wording, comments in round 2 reflected the positive nature to the usability of the tool.I like the fact that it is quite simplenot too overloaded with methodological questions. Does the mode of delivery still allow you to be able to work full time? In round 2, consensus was reached on a further two components, six components were assessed to require modification and it was deemed appropriate to remove two components from the tool. As the need for the inclusion of CSSs in evidence synthesis grows, the importance of understanding the quality of reporting and assessment of bias of CSSs becomes increasingly important. Incidence of lingual nerve damage following surgical extraction of mandibular third molars with lingual flap retraction: A systematic review and meta-analysis. Data were collected from 51 483 participants in Jiangxi province using the multistage stratified random cluster sampling method. After round 2, the tool was further reduced in size and modified to create a fourth draft of the tool with 20 components incorporating 13 components with full consensus and 7 modified components for circulation in round 3 of the Delphi process. Enquiry: unisa.edu.au/international/enquiry, International Centre for Allied Health Evidence, Critical Appraisals - Cardiac Rehabilitation, Critical Appraisals - Chronic Disease Management, Critical Appraisals - Hand Rehabilitation, Critical Appraisals - Neurological Rehabilitation, Critical Appraisals - Nutrition & Dietetics, Critical Appraisals - Musculoskeletal Health, Critical Appraisals - Clinical Supervision, iCAHE PD courses on EBP and Research Methodology, Department of Education and Childhood Development (DECD) Journal Club, For further information please visit unisa.edu.au/study. Critical appraisal is integral to the process of Evidence Based Practice. After the screening process is complete, the systematic review team must assess each article for quality and bias. Some information may be lacking due to poor reporting in studies, making it difficult to assess the risk of biases and the quality of the study design. The Cochrane Collaboration. Using a similar process to other appraisal tools,37 we reviewed the relevant literature to develop a concise background on CA of CSSs and to ensure no other relevant tools existed. Helps understanding the outcomes of research publication Griffith School of Medicine 3. Summary: This CAT from the National Collaborating Centre for Environmental Health focuses on studies investigating effect of environmental issues on public health. HHS Vulnerability Disclosure, Help We could not find any published evaluations of AXIS's psychometric properties nor any comparisons between AXIS and other MQ tools. This is a 20-item appraisal tool developed in response to the increase in cross-sectional studies informing evidence-based medicine and the consequent importance of ensuring that these studies are of high quality and low bias25. These cookies ensure basic functionalities and security features of the website, anonymously. eCollection 2023. A cross-sectional study assesses risk factors and the outcome at the same moment in time. This scoring system assesses Qualitative, Quantitative experimental, Quantitative observational and Mixed Methods at the one time. These evidence evaluation tools ask questions each to help you examine. of General Practice, University of Glasgow, UK, http://cobe.paginas.ufsc.br/files/2014/10/MINORS.pdf. Will an application for an MSc award still be considered if it does not meet the minimum requirement of a First Class or strong Upper Second Class Honours Degree? This has implications for interpretation after using the tool as there will be differences in individuals judgements. 3rd edition. What is the process for applying for a short course or award? m. The cross-sectional dimensions are b = 155 mm, c = 33 mm, d = 72 mm, and t = 8 mm. 0000120034 00000 n Email was used to contact potential participants for enrolment in the Delphi study. In addition, well-developed appraisal tools have been created for readers assessing the quality of cohort and casecontrol studies;12 ,13 however, there is currently a lack of an appraisal tool specifically aimed at CSSs. The Centre for Evidence-based Veterinary Medicine is supported by an unrestrictive grant from Elanco Animal Health and The University of Nottingham. What does it mean? Below, you will find a sample of four popular quality assessment tools and some basic information about each. Phone: +61 8 8302 2376 , Is the effect size practically relevant? Bookshelf 0000121318 00000 n We aimed to conduct a cross-sectional study to assess the relationship between arterial stiffness, depressive and anxiety symptoms, and quality of life. In each round, if a component had 80% consensus, it remained in the tool. the axis tool is a new tool for quality assessment of cross sectional studies and i want to ask about its validity and if any one have used it View What is the best form to assess risk. Join Cochrane. Authors:National Collaborating Centre for Methods and Tools, McMaster University, Canada, http://usir.salford.ac.uk/13070/1/Evaluative_Tool_for_Mixed_Method_Studies.pdf. PDF:Axis Appraisal Tool for Cross Sectional Studies, PDF: JBI checklist for analytical cross sectional studies, https://pdfs.semanticscholar.org/701a/d0df5ae00403b3bd5709d7a68d91db0c3568.pdf. Ball & Giles 1964 Scott & Sommerville Reddy et al. Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection. Objectives To evaluate the risk of bias tool, introduced by the Cochrane Collaboration for assessing the internal validity of randomised trials, for inter-rater agreement, concurrent validity compared with the Jadad scale and Schulz approach to allocation concealment, and the relation between risk of bias and effect estimates. The cookies is used to store the user consent for the cookies in the category "Necessary". 1. a study in which groups of individuals of different types are composed into one large sample and studied at only a single timepoint (for example, a survey in which all members of a given population, regardless of age, religion, gender, or geographic location, are sampled for a given characteristic or finding in one day). , Can the results be applied to my organization and my patient? Summary: A critical appraisal tool that includes the criteria appropriate for criticizing cross-sectional study design developed through a Delphi survey of 15 academics. For example, if one item in the inclusion criteria of your systematic review is to only include randomized controlled trials (RCTs), then you need to pick a quality assessment tool specifically designed for RCTs (for example, the Cochrane Risk of Bias tool). Cross-sectional studies capture a single moment in time, collecting information from a study group at just one point. Evidence based medicine: an approach to clinical problem-solving. Whilst developed to be used for the development of clinical guidelines they are excellent CATs for single study appraisals, PDF: SIGN Checklist 4: Case control studies, PDF: JBI checklist for Case control studies, https://www.cebma.org/wp-content/uploads/Critical-Appraisal-Questions-for-a-Case-Control-Study.pdf. 0000118691 00000 n BMJ 1995;310:11226. It does not store any personal data. UniSA respects the Kaurna, Boandik and Barngarla peoples spiritual relationship with their country. This section contains useful tools and downloads for the critical appraisal of different types of medical evidence. Commonly asked questions about quality assessment using Covidence, Step 6: Assess Quality of Included Studies, Step 7: Extract Data from Included Studies, https://guides.lib.unc.edu/systematic-reviews, CASP- Randomized Controlled Trial Appraisal Tool, Checklist for Randomized Controlled Trials (JBI), Scottish Intercollegiate Guidelines Network (SIGN), The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses, Tool to Assess Risk of Bias in Case Control Studies by the CLARITY Group at McMaster University, Critical Appraisal Checklist for Diagnostic Test Accuracy Studies (JBI), Consensus Health Economic Criteria (CHEC) List, McGill Mixed Methods Appraisal Tool (MMAT) 2018 User Guide, JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses, AHRQ Methods Guide for Effectiveness and Comparative Effectiveness Reviews, National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards (NEATS) Instrument, AGREE-II Appraisal of Guidelines for Research and Evaluation, Quality Assessment on the Covidence Guide, What the quality assessment or risk of bias stage of the review entails, How to choose an appropriate quality assessment tool, Best practices for reporting quality assessment results in your review, Is the research method/study design appropriate for answering the research question?, Are specific inclusion / exclusion criteria used? What's the difference between the Annual Award Fee, the Module/Course Fee, and the Dissertation Fee? If you click 'Reject all non-essential cookies' only necessary cookies providing core functionality such as security, network management, and accessibility will be enabled. This involves consideration of six features: sequence generation, allocation sequence concealment . The authors would also like to thank Michelle Downes for designing the population diagram. Whilst developed to be used for the development of clinical guidelines they are excellent CATs for single study appraisals, Authors:Joanna Briggs Institute, Adelaide, Australia. On the third round of the Delphi process, a draft of the help text for the tool was also included in the questionnaire and consensus was sought as to whether the tool was suitable for the non-expert user, and participants were asked to comment on the text. Did the study use valid methods to address this question? The tool and a guidance on how to use it can be found here. An advantage of using a CAT is that you can apply a level of consistency when reviewing a number of studies. This cross-sectional study was conducted in Ghaem Hospital of Mashhad. The study was cross-sectional, which might have introduced some bias. Review authors should specify important confounding domains and co-interventions of concern in their protocol. Critical appraisal worksheets to help you appraise the reliability, importance and applicability of clinical evidence. High quality and complete reporting of studies is a prerequisite for judging quality.17 ,18 ,35 For this reason, the AXIS tool incorporates some quality of reporting as well as quality of design and risk of biases to overcome these problems. Authors: The University of Auckland, New Zealand This site needs JavaScript to work properly. 0000118764 00000 n 0000118716 00000 n Summary: Assessment of Multiple Systematic Reviews (AMSTAR) is a 37-item assessment tool used to assess the methodological quality of systematic reviews. 0000110879 00000 n The use of a multidisciplinary panel with experience in epidemiology and EBM limits the effect of using a non-representative sample, and the use of the Delphi tool is well recognised for developing consensus in healthcare science.38 The selection of a Delphi group is very important as it effects the results of the process.31 As CSSs are used extensively in human and veterinary research, it was appropriate to use expertise from both of these fields. [9] Critical appraisal may also be an integral part of formalized approaches to turn evidence into recommendations for practice such as GRADE . Critical appraisal is the systematic evaluation of clinical research papers in order to establish: Does this study address a clearly focused question? University of Oxford. It involves identifying a defined population at a particular point in time At the same time measuring outcome of interest e. g. obesity. A number of publications were identified in the review and a number of key epidemiological texts were also identified to assist in the development of the new tool.1 ,11 ,12 ,15 ,17 ,2029 MJD and MLB used these resources to subjectively identify areas that were to be included in the CA tool. The study compared five different algorithms to find the best model, adding to the limited research on stroke risk prediction in China. The initial review of existing tools and texts identified 34 components that were deemed relevant for CA of CSSs and were included in the first draft of the tool (see online supplementary table S2). Authors:The University of Auckland, New Zealand, Summary: This CAT developed by the Scottish Intercollegiate Guidelines Network (SIGN), scores the cohort study over 10 questions and provides an overall assessment of the studies effort to reduce bias. Cross sectional studies Cochrane Mental Health 4.94K subscribers Subscribe 174 Share 18K views 3 years ago Resources: Critical Appraisal Modules 2019 Understanding what they can and can't tell. Colleagues used the tool to assess different research papers of varying quality that used CSS design methodology during journal clubs and research meetings and provided feedback on their experience. Credentialling and Healthcare Industry Professional Courses, Benefits and Career Development for Industry Professionals. - Key areas addressed in the AXIS include - Study Design, Sample Size Justification, Target Population, Sampling Frame, Sample Selection, Measurement Validity & Reliability, and Overall Methods. Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P. Osteoarthritis Cartilage. A CA tool to assess the quality and risk of bias in CSSs (AXIS), along with supporting help text, was successfully developed by an expert panel using Delphi methodology. Authors: Professor Andrew Long, School of Healthcare, University of Leeds, PDF: Evaluation Tool for Mixed Methods Studies, https://www.sciencedirect.com/science/article/pii/S0020748909000145?via%3Dihub. Cross-sectional studies what is new section Key findings We systematically reviewed tools used to assess risk of bias of prevalence studies. Published in The British Medical Journal - 8th December 2016. What is the difference between completing a professional short course 'for credit' or 'not for credit'? BIOCROSS was developed as a tool designed for use by biomedical specialists to assess the quality and reporting of biomarker-based cross-sectional studies. Delphi methods and use of expert groups are increasingly being implemented to develop tools for reporting guidelines and appraisal tools.18 ,19. , Were there enough subjects in the study to establish that the findings did not occur by chance? Were the risk factor and outcome variables measured correctly using instruments/measurements that had been trialled, piloted or published previously? Authors:Dept. The results can be expressed in many ways as shown below. of General Practice, University of Glasgow can be used for diagnostic or screening studies, and is accompanied by a great jargon buster. Introduction 1 Were the aims/objectives of the study clear? The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). PDF:Individually-randomized, parallel-group trials - CAT Guidance sheet, Cluster-randomized, parallel-group trials - CAT Guidance Sheet, Individually-randomized, cross-over trials - CAT Guidance Sheet, Summary: This CAT is based on a combination of other CATs. Access business development opportunities, Set up a collaborative research partnership, Connect with UniSA students and graduates, Excellence in Research for Australia (ERA), http://www.cardiff.ac.uk/insrv/libraries/sure/doc/Project%20Methodology%205.pdf, Individually-randomized, parallel-group trials - CAT, Cluster-randomized, parallel-group trials - CAT, Individually-randomized, cross-over trials - CAT, GATE CAT for Diagnostic Test Accuracy Studies, CAT for an Article on Diagnosis or Screening, Axis Appraisal Tool for Cross Sectional Studies, JBI checklist for analytical cross sectional studies, CEBM Critical Appraisal of a Cross-Sectional Study, National Collaborating Centre for Environmental Health checklist, Specialist Unit for Review Evidence (SURE) 2018 checklist, McMaster Critical Review Form - Quantitative Studies, HCPRDU evaluation tool for quantitative studies, GATE CAT Risk Factor or Prognostic Studies, JBI checklist for Quasi experimental studies, McMaster Critical Review Form - Qualitative Studies, Critical Appraisal Checklist for Qualitative Research Studies, Evaluation Tool for Mixed Methods Studies, A scoring system for appraising mixed methods research, and concomitantly appraising qualitative, quantitative and mixed methods primary studies in Mixed Studies Reviews, Australian University provider number PRV12107. The Appraisal Tool for Cross-Sectional Studies (AXIS) was used to assess the risk of bias of the included studies ( 23 ). Comments voiced included the discussion as part of the CA process being unnecessary and potentially misleading:The interpretation should, in my opinion, come from the methods and the results and not from what the author thinks it means.I dont believe a Discussion section should be part of a critical appraisal. Enquiry: unisa.edu.au/enquiry, Phone: +61 8 9627 4854 This cookie is set by GDPR Cookie Consent plugin. 2001 https://www.fmhs.auckland.ac.nz/assets/fmhs/soph/epi/epiq/docs/GATE%20CAT%20Case%20Control%20Studies%20May%202014%20V3.docx, Summary: This CAT developed by the Scottish Intercollegiate Guidelines Network (SIGN), scores the case control study over 10 questions and provides an overall assessment of the studies effort to reduce bias. Postfeedback modification after the pilot study identified 37 components to be included in the second draft of the CA tool (see online supplementary table S3). Participants. doi: 10.1371/journal.pone.0282185. The development of a novel critical appraisal tool that can be used across disciplines. 0000113169 00000 n Critical Appraisal Skills Programme (CASP) has 25 years of experience and expertise in critical appraisal and offers appraisal checklists for a wide range of study types. The following tutorials provide some information on how to critically appraise the literature, https://casp-uk.net/casp-tools-checklists/. Summary: Critical Appraisal Skills Program (CASP): Qualitative Research is a methodological checklist which provides key criteria relevant to qualitative research studies. Were the results presented for all the analyses described in the methods? reliability testing, the Appraisal tool for Cross-Sectional Studies (AXIS)25 was used. Functional cookies help to perform certain functionalities like sharing the content of the website on social media platforms, collect feedbacks, and other third-party features. The Newcastle-Ottawa Scale (NOS) was selected for cohort studies, and two ROB tools were selected for cross-sectional studies, namely the Agency for Healthcare Research and Quality (AHRQ), and the Effective Public Health Practice Project (EPHPP). MeSH They could be defined as 'studies taking a snapshot of a society'. Read more. BMJ 1998;316:3615. The authors completed a systematic search of the literature for CA tools of CSSs (see online supplementary table S1). A case series is a description of multiple, similar instructive cases; it can be used to study diseases that are rare and unusual in the population. But the results can be less useful. An official website of the United States government. The most important thing to remember when choosing a quality assessment tool is to pick one that was created and validated to assess the study design(s) of your included articles. Fundamentally, the tool developed by Berra et al15 only appraises the quality of reporting of CSSs and does not address risk of bias or other aspects of study quality.16 Good quality of reporting of a study means that all aspects of the methods and the results are presented well and in line with international standards such as STROBE;17 however, this is only one aspect of appraisal as a well-reported study does not necessarily mean that the study is of high quality. Other 19 Were there any funding sources or conflicts of interest that may affect the authors interpretation of the results? Cross sectional studies are quicker and cheaper to do. , Are the measurements/ tools validated by other studies? All blog posts and resources are published under a CC BY 4.0 license. How are Supervisors selected and allocated for the DPhil and can the focus for potential projects be discussed prior to an application? Advertisement cookies are used to provide visitors with relevant ads and marketing campaigns. Central role in the interpretation and dissemination of research for evidence based practice. Participants were given 4weeks to complete their assessment of the tool using the questionnaire. Were the limitations of the study discussed? Analytical cookies are used to understand how visitors interact with the website. 0000001705 00000 n Summary: McMaster Critical Review Form for Qualitative studies contains a generic quantitative appraisal tool, accompanied by detailed guidelines for usage. However, presently, validated instruments to evaluate healthcare professionals' attitude and practices toward implementing EBM are not widely available. PDF: Specialist Unit for Review Evidence (SURE) 2018 checklist, Summary: This CAT developed by the Scottish Intercollegiate Guidelines Network (SIGN), scores the economic study over 10 questions and provides an overall assessment of the studies effort to reduce bias. Epub 2022 Aug 10. The %PDF-1.4 % 70 0 obj <> endobj xref 70 39 0000000016 00000 n [9] Critical appraisal may also be an integral part of formalized approaches to turn evidence into recommendations for practice such as GRADE. BIOCROSS combines 10 items within 5 study evaluation domains ranging from study rationale and design to biomarker assessment and data interpretation scoring for a maximum score of 20 points. Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J. BMC Med Res Methodol. Many of the questions are present in the CASP CAT. Longitudinal studies can offer researchers a cause. We considered it reasonable to initially restrict the recommendations to the three main analytical designs that are used in observational research: cohort, case-control, and cross-sectional studies. However, if consensus was lower than 80% but >50%, the help text was considered for modification. Lunny C, Veroniki AA, Hutton B, White I, Higgins J, Wright JM, Kim JY, Thirugnanasampanthar SS, Siddiqui S, Watt J, Moja L, Taske N, Lorenz RC, Gerrish S, Straus S, Minogue V, Hu F, Lin K, Kapani A, Nagi S, Chen L, Akbar-Nejad M, Tricco AC. Higgins JPT, Green S (eds) (2008). A detailed explanatory document was also developed with the tool, giving expanded explanation of each question and providing simple interpretations and examples of the epidemiological concepts being examined . This is particularly so where the areas of study do not lend themselves to research designs appropriate to intervention studies (i.e. We identified an appraisal tool, developed in Spanish, which specifically examined CSSs.15 Berra et al essentially converted each reporting item identified in the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) reporting guidelines and turned them into questions for their appraisal tool. The https:// ensures that you are connecting to the Covidence includes the Cochrane Risk of Bias 2.0 quality assessment template, but you can also create your own custom quality assessment template. study in which 15% (0.15) of the control group died and 10% (0.10) of the treatment group died after 2 years of treatment. The Methodological Index for Non-Randomized Studies (MINORS) is an excellent tool for assessing non-randomized interventional studies, and the Agency for Healthcare Research and Quality (ARHQ) methodology checklist is applicable for cross-sectional studies. Can the programme be completed entirely online without attending Oxford? Quality Assessment tools are questionnaires created to help you assess the quality of a variety of study designs. What is the measure? The aim was to develop a tool for the critical appraisal of epidemiological cross-sectional studies that can be used to critically appraise research papers or to rate evidence during the elaboration of systematic reviews. Authors: The Centre of Evidence-Based Physiotherapy (CEBP), Sydney, Australia, http://onlinelibrary.wiley.com/doi/10.1002/9780470988343.app1/pdf. If appropriate, was information about non-responders described? The Cochrane Risk of Bias 2.0 tool asks questions about five domains of potential bias for individually randomized trials: The Newcastle-Ottawa scale assesses the quality of nonrandomized studies based on three broad perspectives: These quality assessment checklists ask 11 or 12 questions each to help you identify. Request a systematic or scoping review consultation. A cross-sectional study is conducted over a specified period of time. OARSI recommendations for the management of hip and knee osteoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence. Psychiatric Disorders and Obesity in Childhood and Adolescence-A Systematic Review of Cross-Sectional Studies. the axis tool is a new tool for quality assessment of cross sectional studies and i want to ask about its validity and if any one have used it Cross Sectional Studies Most recent. Two authors independently assessed the quality of the studies. The Delphi panel was based on convenience and may not encompass all eventual users of the tool. Authors: Public Health Resource Unit, NHS, England. These cookies will be stored in your browser only with your consent. 0000043010 00000 n 0000004376 00000 n Event-induced changes of volatility, on the other hand, is a phenomenon common to many event types (e.g., M&A transactions) that becomes problematic when events are clustered. Design: The process was repeated, with a new draft of the CA tool circulated each time based on the findings and consensus of the previous round, until 80% consensus on all components of the tool was achieved. Two contacts felt they were not suitably qualified for the Delphi panel (n=2); one was retired and the other was a lecturer with research and clinical duties. Relative Risk (RR) = risk of the outcome in the treatment group / risk of the outcome in the con-trol group. In some cases, longitudinal studies can last several decades. Association between Cardiovascular Disease Risk Factors and Cardiorespiratory Fitness in Firefighters: A Systematic Review and Meta-Analysis. Is a Healthcare background a requirement for completing the Awards or Short Courses? Thirty-two pregnant women, whose gestational age was 20 weeks or more, were considered as the case group after evaluating blood pressure and confirming proteinuria and pre-eclampsia. Accessibility For round 2 (undertaken in May 2013), 11 components remained the same and did not require testing for consensus as this was established in round 1; 9 components that had previously reached consensus were incorporated with the 13 components that required modification to create 10 new components (see online supplementary table S4). Reformulation of Processed Yogurt and Breakfast Cereals over Time: A Scoping Review. Critical appraisal (or quality assessment) in evidence based medicine, is the use of explicit, transparent methods to assess the data in published research, applying the rules of evidence to factors such as internal validity, adherence to reporting standards, conclusions, generalizability and risk-of-bias. 2023 Feb 1;10(2):285. doi: 10.3390/children10020285. An initial list of 39 components was identified through examination of existing resources. Cross-sectional studies examine the relationship between diseases (or other health-related characteristics) and other variables of interest as they exist in a defined population at a particular point in time (Last 2001). Critical appraisal; Cross sectional studies; Delphi; Evidence-based Healthcare. Some of the tools have been developed to assess specific study topics (e.g. Summary: The Jadad scale assesses the quality of published clinical trials based methods relevant to random assignment, double blinding, and the flow of patients. Design Cross sectional study. Critical appraisal can occur through a non-structured approach where you critically read the study as you read it, or through a structured approach through the use of a Critical Appraisal Tool (CAT). What is the price difference between credit and non-credit bearing modules? sure@cardiff.ac.uk. You should choose a Quality Assessment tool that matches the types of studies you expect to see in your results. When piloted, there was an overall per cent agreement of 88.9%; however, 32.9% of the questions were unanswered. Where can I find information about whether my international qualification and grades are equivalent to what is required for my application to be considered? PGCert in Teaching Evidence-Based Health Care, PGCert in Qualitative Health Research Methods, Introduction to Study Design and Research Methods, Introduction to Statistics for Health Care Research, The History and Philosophy of Evidence-Based Health Care, Developing Online Education and Resources (online only), Statistical Computing with R and Stata (online only), Qualitative and Mixed Methods Systematic Reviews, Fundamentals of Evidence Based Health Care Leadership, Graduate entry/accelerated medical degree, Academic Special Interest Projects (ASIP), Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009), Explanation of the 2011 OCEBM Levels of Evidence, Defining value-based healthcare in the NHS.
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