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Difficulty wise this is pretty much the same as the first book in the series, I didn't notice anything significantly harder or easier.
I'll call out that when I first started this book I didn't really see how the two were connected and thought it was just 'oh, suspense involving hospitals and clowns?' but rest assured this is very much a sequel and you should not read this one without having read the second one unless you're ok with the first book being thoroughly spoiled.
I actually read the