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Michael J Goldacre - One of the best experts on this subject based on the ideXlab platform.
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admission to hospital for bronchiolitis in england trends over five decades Geographical Variation and association with perinatal characteristics and subsequent asthma
Archives of Disease in Childhood, 2016Co-Authors: Christopher A Green, David Yeates, Allie Goldacre, Charles J Sande, Roger Parslow, Philip Mcshane, Andrew J Pollard, Michael J GoldacreAbstract:Background Admission of infants to hospital with bronchiolitis consumes considerable healthcare resources each winter. We report an analysis of hospital admissions in England over five decades. Methods Data were analysed from the Hospital In-Patient Enquiry (HIPE, 1968–1985), Hospital Episode Statistics (HES, 1989–2011), Oxford Record Linkage Study (ORLS, 1963–2011) and Paediatric Intensive Care Audit Network (PICANet, 2003–2012). Cases were identified using International Classification of Diseases (ICD) codes in discharge records. Bronchiolitis was given a separate code in ICD9 (used in England from 1979). Geographical Variation was analysed using Local Authority area boundaries. Maternal and perinatal risk factors associated with bronchiolitis and subsequent admissions for asthma were analysed using record-linkage. Results All-England HIPE and HES data recorded 468 138 episodes of admission for bronchiolitis in infants aged Conclusions Hospital admissions for infants with bronchiolitis have increased substantially in recent years. However, cases requiring intensive care have changed little since 2004.
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time trends over five decades and recent Geographical Variation in rates of childhood squint surgery in england
British Journal of Ophthalmology, 2013Co-Authors: Munazzah Rifat Chou, David Yeates, Aeesha N J Malik, Mehrunisha Suleman, J Muir A Gray, Michael J GoldacreAbstract:Aims To study trends in rates of childhood squint surgery in England over five decades, and to study recent Geographical Variation in England. Methods Use of routine hospital statistics to analyse trends in squint surgery in the Oxford record linkage study area 1963–2010, and England 1968–2010; analysis of Geographical Variation in England 1999–2010. All rates, numerators and population denominators were restricted to people aged under 15 years. Results The study included 519 089 admissions for operations on squint. Annual admission rates for squint surgery in England fell from 188.8 episodes per 100 000 population (95% CI 180.9 to 196.8) in 1968 to 64.1 (62.4 to 65.7) episodes per 100 000 population in 2010. A similar decline was seen in the Oxford region, from 213.2 (181.3 to 245.2) episodes per 100 000 population in 1963 to 61.3 (54.8 to 67.9) episodes in 2010. There was wide Variation across local authorities in annual rates of squint surgery from 28.2 (95% CI 22.7 to 34.8) admissions per 100 000 population to 138.6 (123.0 to 155.7) admissions per 100 000, a 4.9-fold difference between areas with the highest and lowest rates. Conclusions Squint surgery rates have decreased substantially over time. The current wide Geographical Variation in rates raises questions about whether this scale of Variation is clinically warranted, whether it reflects Variation in needs for surgery and patient/parental choice, whether it is a result of inequalities in the availability of ophthalmic services, or whether it results from Variation between clinicians in clinical decision making about the likely benefits of squint surgery.
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trends over time and Geographical Variation in rates of intravitreal injections in england
British Journal of Ophthalmology, 2012Co-Authors: Tiarnan D L Keenan, Clare J Wotton, Michael J GoldacreAbstract:Aims The recent emergence of antivascular endothelial growth factor (anti-VEGF) drugs has led to increased numbers of patients undergoing intravitreal injection for age-related macular degeneration (AMD). The aims of this study were to report on trends over time and Geographical Variation in intravitreal injection rates in England, and consider the implications for publicly funded health services of introducing new and expensive treatments. Methods Hospital episode statistics were analysed for annual treatment rates of intravitreal injection between the NHS financial years of 1989/1990 and 2008/1999. Results Annual injection rates increased from 0.4 episodes (95% CI 0.37 to 0.49) per 100 000 population in 1989/1990 to 10.7 (10.4–11.0) in 2006/2007. Rates then rose exponentially to 59.5 (58.8–60.2) in 2008/2009, with increasing use of multiple injections per person. The largest growth in injection rates was found in older people, and for AMD. Numbers of treatment episodes increased from 203 (1989/1990) to 30 458 (2008/2009). Geographical analysis showed a very wide Variation across local authority areas in injection rates, from 0.9 (0.2–2.2) to 42.2 (38.9–45.7) people per 100 000 population in 2005–2008. Conclusion Rates of intravitreal injection increased exponentially from 2006/2007. This followed the US Food and Drug Association licensing of ranibizumab for the treatment of neovascular AMD (2006), and its recommendation by National Institute for Health and Clinical Excellence (2008). This study demonstrates some of the major issues which arise with the emergence of expensive new treatments, including speed and cost of adoption, Geographical Variation in access, and implications for licensing, commissioning and health financing in an ageing society.
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trends over time and Geographical Variation in admission rates for plastic surgery in england
Journal of Plastic Reconstructive and Aesthetic Surgery, 2010Co-Authors: Aadil A Khan, David Yeates, Timothy E E Goodacre, Michael J GoldacreAbstract:The epidemiology of provision of plastic surgical care is poorly understood. Anecdotally, plastic surgeons in England have reported an increasing volume of work. However, it is unclear how much the workload has increased, and whether there is much Geographical Variation in workload within a publicly funded healthcare system. Data from English national hospital statistics from 1968-2004 and the Oxford Record Linkage Study (ORLS) from 1963-2004 were analysed for plastic surgery to study long-term trends. Linkage enables analyses to be undertaken in which individuals are counted once only each year regardless of how many plastic surgical admissions they had in the year. In addition, linked hospital admission data for plastic surgery in England, available from 2001-2005, were analysed to study Geographical Variation. Admission rates increased very substantially over the last four decades: per 100,000 population, they were 71 per 100,000 in England in 1968 and 408 by 2004. Admission rates in the ORLS area, measured as episodes per 100,000, rose from 73 in 1963 to 452 in 2004; and the corresponding figures for person-based rates rose from 63 to 400. Thus the increase in admission rates was a genuine, substantial increase in numbers of people in receipt of Plastic surgical care and not simply an increase in multiple admissions per patient. Geographical analysis showed 4.6-fold Variation in admission rates for residents of the health authority areas (range 154 (Hampshire and the Isle of Wight) to 716 (County Durham and Tees Valley) admissions per 100,000 population). We discuss implications of the findings for workforce planning and service design in Plastic surgery within the context of the NHS, and how they may be applied to plastic surgical healthcare models globally. Detailed analysis of case-mix in the speciality, aimed at increasing understanding of both trends and Geographical Variation, is warranted.
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Trends in rates of retinal surgery in England from 1968 to 2004: studies of hospital statistics
British Journal of Ophthalmology, 2009Co-Authors: Ahmed N El-amir, David Yeates, Tiarnan D L Keenan, Mohammed Abu-bakra, Vaughan Tanner, Michael J GoldacreAbstract:To describe trends over time and Geographical Variation in rates of vitreo-retinal surgery in England from 1968-2004.
David Yeates - One of the best experts on this subject based on the ideXlab platform.
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admission to hospital for bronchiolitis in england trends over five decades Geographical Variation and association with perinatal characteristics and subsequent asthma
Archives of Disease in Childhood, 2016Co-Authors: Christopher A Green, David Yeates, Allie Goldacre, Charles J Sande, Roger Parslow, Philip Mcshane, Andrew J Pollard, Michael J GoldacreAbstract:Background Admission of infants to hospital with bronchiolitis consumes considerable healthcare resources each winter. We report an analysis of hospital admissions in England over five decades. Methods Data were analysed from the Hospital In-Patient Enquiry (HIPE, 1968–1985), Hospital Episode Statistics (HES, 1989–2011), Oxford Record Linkage Study (ORLS, 1963–2011) and Paediatric Intensive Care Audit Network (PICANet, 2003–2012). Cases were identified using International Classification of Diseases (ICD) codes in discharge records. Bronchiolitis was given a separate code in ICD9 (used in England from 1979). Geographical Variation was analysed using Local Authority area boundaries. Maternal and perinatal risk factors associated with bronchiolitis and subsequent admissions for asthma were analysed using record-linkage. Results All-England HIPE and HES data recorded 468 138 episodes of admission for bronchiolitis in infants aged Conclusions Hospital admissions for infants with bronchiolitis have increased substantially in recent years. However, cases requiring intensive care have changed little since 2004.
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time trends over five decades and recent Geographical Variation in rates of childhood squint surgery in england
British Journal of Ophthalmology, 2013Co-Authors: Munazzah Rifat Chou, David Yeates, Aeesha N J Malik, Mehrunisha Suleman, J Muir A Gray, Michael J GoldacreAbstract:Aims To study trends in rates of childhood squint surgery in England over five decades, and to study recent Geographical Variation in England. Methods Use of routine hospital statistics to analyse trends in squint surgery in the Oxford record linkage study area 1963–2010, and England 1968–2010; analysis of Geographical Variation in England 1999–2010. All rates, numerators and population denominators were restricted to people aged under 15 years. Results The study included 519 089 admissions for operations on squint. Annual admission rates for squint surgery in England fell from 188.8 episodes per 100 000 population (95% CI 180.9 to 196.8) in 1968 to 64.1 (62.4 to 65.7) episodes per 100 000 population in 2010. A similar decline was seen in the Oxford region, from 213.2 (181.3 to 245.2) episodes per 100 000 population in 1963 to 61.3 (54.8 to 67.9) episodes in 2010. There was wide Variation across local authorities in annual rates of squint surgery from 28.2 (95% CI 22.7 to 34.8) admissions per 100 000 population to 138.6 (123.0 to 155.7) admissions per 100 000, a 4.9-fold difference between areas with the highest and lowest rates. Conclusions Squint surgery rates have decreased substantially over time. The current wide Geographical Variation in rates raises questions about whether this scale of Variation is clinically warranted, whether it reflects Variation in needs for surgery and patient/parental choice, whether it is a result of inequalities in the availability of ophthalmic services, or whether it results from Variation between clinicians in clinical decision making about the likely benefits of squint surgery.
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trends over time and Geographical Variation in admission rates for plastic surgery in england
Journal of Plastic Reconstructive and Aesthetic Surgery, 2010Co-Authors: Aadil A Khan, David Yeates, Timothy E E Goodacre, Michael J GoldacreAbstract:The epidemiology of provision of plastic surgical care is poorly understood. Anecdotally, plastic surgeons in England have reported an increasing volume of work. However, it is unclear how much the workload has increased, and whether there is much Geographical Variation in workload within a publicly funded healthcare system. Data from English national hospital statistics from 1968-2004 and the Oxford Record Linkage Study (ORLS) from 1963-2004 were analysed for plastic surgery to study long-term trends. Linkage enables analyses to be undertaken in which individuals are counted once only each year regardless of how many plastic surgical admissions they had in the year. In addition, linked hospital admission data for plastic surgery in England, available from 2001-2005, were analysed to study Geographical Variation. Admission rates increased very substantially over the last four decades: per 100,000 population, they were 71 per 100,000 in England in 1968 and 408 by 2004. Admission rates in the ORLS area, measured as episodes per 100,000, rose from 73 in 1963 to 452 in 2004; and the corresponding figures for person-based rates rose from 63 to 400. Thus the increase in admission rates was a genuine, substantial increase in numbers of people in receipt of Plastic surgical care and not simply an increase in multiple admissions per patient. Geographical analysis showed 4.6-fold Variation in admission rates for residents of the health authority areas (range 154 (Hampshire and the Isle of Wight) to 716 (County Durham and Tees Valley) admissions per 100,000 population). We discuss implications of the findings for workforce planning and service design in Plastic surgery within the context of the NHS, and how they may be applied to plastic surgical healthcare models globally. Detailed analysis of case-mix in the speciality, aimed at increasing understanding of both trends and Geographical Variation, is warranted.
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Trends in rates of retinal surgery in England from 1968 to 2004: studies of hospital statistics
British Journal of Ophthalmology, 2009Co-Authors: Ahmed N El-amir, David Yeates, Tiarnan D L Keenan, Mohammed Abu-bakra, Vaughan Tanner, Michael J GoldacreAbstract:To describe trends over time and Geographical Variation in rates of vitreo-retinal surgery in England from 1968-2004.
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time trends and Geographical Variation in cataract surgery rates in england study of surgical workload
British Journal of Ophthalmology, 2007Co-Authors: Tiarnan D L Keenan, David Yeates, Paul Rosen, Michael J GoldacreAbstract:Aims: Phacoemulsification, day case surgery and Action on Cataracts have increased the national capacity for cataract surgery in England. The aim of this study was to examine time trends and Geographical Variation in rates of cataract surgery, and to determine whether there is evidence of overcapacity in current levels of surgical provision. Methods: Hospital episode statistics (HES), the hospital in-patient enquiry (HIPE) and the Oxford record linkage study (ORLS) were analysed for cataract admissions between the 1960s and 2003. Results: Annual rates of admission for cataract surgery in England rose ten-fold from 1968 to 2003: from 62 episodes per 100 000 population in 1968, through 173 in 1989, to 637 in 2004. The overall increase in cataract surgery was reflected by increases in every age group for both men and women. Geographical analysis showed that there was wide Variation across local authority areas in annual rates of cataract surgery, from 172 to 548 people per 100 000 population in 1998-2003. The rate of surgery by local authority was positively correlated with the index of multiple deprivation (r 2 =0.24). Conclusion: The huge increase in cataract surgery over time and the wide Geographical Variation in rates, raise the question of whether there is now overcapacity for cataract surgery. High levels of social deprivation are associated with high rates of cataract surgery; this may be caused by increased prevalence of cataract or differences in referral patterns.
Tiarnan D L Keenan - One of the best experts on this subject based on the ideXlab platform.
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trends over time and Geographical Variation in rates of intravitreal injections in england
British Journal of Ophthalmology, 2012Co-Authors: Tiarnan D L Keenan, Clare J Wotton, Michael J GoldacreAbstract:Aims The recent emergence of antivascular endothelial growth factor (anti-VEGF) drugs has led to increased numbers of patients undergoing intravitreal injection for age-related macular degeneration (AMD). The aims of this study were to report on trends over time and Geographical Variation in intravitreal injection rates in England, and consider the implications for publicly funded health services of introducing new and expensive treatments. Methods Hospital episode statistics were analysed for annual treatment rates of intravitreal injection between the NHS financial years of 1989/1990 and 2008/1999. Results Annual injection rates increased from 0.4 episodes (95% CI 0.37 to 0.49) per 100 000 population in 1989/1990 to 10.7 (10.4–11.0) in 2006/2007. Rates then rose exponentially to 59.5 (58.8–60.2) in 2008/2009, with increasing use of multiple injections per person. The largest growth in injection rates was found in older people, and for AMD. Numbers of treatment episodes increased from 203 (1989/1990) to 30 458 (2008/2009). Geographical analysis showed a very wide Variation across local authority areas in injection rates, from 0.9 (0.2–2.2) to 42.2 (38.9–45.7) people per 100 000 population in 2005–2008. Conclusion Rates of intravitreal injection increased exponentially from 2006/2007. This followed the US Food and Drug Association licensing of ranibizumab for the treatment of neovascular AMD (2006), and its recommendation by National Institute for Health and Clinical Excellence (2008). This study demonstrates some of the major issues which arise with the emergence of expensive new treatments, including speed and cost of adoption, Geographical Variation in access, and implications for licensing, commissioning and health financing in an ageing society.
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Trends in rates of retinal surgery in England from 1968 to 2004: studies of hospital statistics
British Journal of Ophthalmology, 2009Co-Authors: Ahmed N El-amir, David Yeates, Tiarnan D L Keenan, Mohammed Abu-bakra, Vaughan Tanner, Michael J GoldacreAbstract:To describe trends over time and Geographical Variation in rates of vitreo-retinal surgery in England from 1968-2004.
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time trends and Geographical Variation in cataract surgery rates in england study of surgical workload
British Journal of Ophthalmology, 2007Co-Authors: Tiarnan D L Keenan, David Yeates, Paul Rosen, Michael J GoldacreAbstract:Aims: Phacoemulsification, day case surgery and Action on Cataracts have increased the national capacity for cataract surgery in England. The aim of this study was to examine time trends and Geographical Variation in rates of cataract surgery, and to determine whether there is evidence of overcapacity in current levels of surgical provision. Methods: Hospital episode statistics (HES), the hospital in-patient enquiry (HIPE) and the Oxford record linkage study (ORLS) were analysed for cataract admissions between the 1960s and 2003. Results: Annual rates of admission for cataract surgery in England rose ten-fold from 1968 to 2003: from 62 episodes per 100 000 population in 1968, through 173 in 1989, to 637 in 2004. The overall increase in cataract surgery was reflected by increases in every age group for both men and women. Geographical analysis showed that there was wide Variation across local authority areas in annual rates of cataract surgery, from 172 to 548 people per 100 000 population in 1998-2003. The rate of surgery by local authority was positively correlated with the index of multiple deprivation (r 2 =0.24). Conclusion: The huge increase in cataract surgery over time and the wide Geographical Variation in rates, raise the question of whether there is now overcapacity for cataract surgery. High levels of social deprivation are associated with high rates of cataract surgery; this may be caused by increased prevalence of cataract or differences in referral patterns.
Ben Goldacre - One of the best experts on this subject based on the ideXlab platform.
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opioid prescribing trends and Geographical Variation in england 1998 2018 a retrospective database study
The Lancet Psychiatry, 2019Co-Authors: Helen J Curtis, Alex J Walker, Richard Croker, Georgia C Richards, Jane Quinlan, Ben GoldacreAbstract:© 2019 Elsevier Ltd Background: There is a call for greater monitoring of opioid prescribing in the UK, particularly of strong opioids in chronic pain, for which there is little evidence of clinical benefit. We aimed to comprehensively assess trends and Variation in opioid prescribing in primary care in England, from 1998 to 2018, and to assess factors associated with high-dose opioid prescribing behaviour in general practices. Methods: We did a retrospective database study using open data sources on prescribing for all general practices in England. For all standard opioids we calculated the number of items prescribed, costs, and oral morphine equivalency to account for Variation in strength. We assessed long-term prescribing trends from 1998 to 2017, patterns of Geographical Variation for 2018, and investigated practice factors associated with higher opioid prescribing. We also analysed prescriptions for long-acting opioids at high doses. Findings: Between 1998 and 2016, opioid prescriptions increased by 34% in England (from 568 per 1000 patients to 761 per 1000). After correcting for total oral morphine equivalency, the increase was 127% (from 190 000 mg to 431 000 mg per 1000 population). There was a decline in prescriptions from 2016 to 2017. If every practice prescribed high-dose opioids at the lowest decile rate, 543 000 fewer high-dose prescriptions could have been issued over a period of 6 months. Larger practice list size, ruralness, and deprivation were associated with greater high-dose prescribing rates. The clinical commissioning group to which a practice belongs accounted for 11·7% of the Variation in high-dose prescribing. We have developed a publicly available interactive online tool, OpenPrescribing.net, which displays all primary care opioid prescribing data in England down to the individual practice level. Interpretation: Failing to account for opioid strength would substantially underestimate the true increase in opioid prescribing in the National Health Service (NHS) in England. Our findings support calls for greater action to promote best practice in chronic pain prescribing and to reduce Geographical Variation. This study provides a model for routine monitoring of opioid prescribing to aid targeting of interventions to reduce high-dose prescribing. Funding: National Institute for Health Research (NIHR) School of Primary Care Research, NIHR Biomedical Research Centre Oxford, NHS England.
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time trends and Geographical Variation in prescribing of antibiotics in england 1998 2017
Journal of Antimicrobial Chemotherapy, 2018Co-Authors: Helen J Curtis, Alex J Walker, Kamal R Mahtani, Ben GoldacreAbstract:© 2018. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. Reducing antibiotic overuse is a key NHS priority. The majority of antibiotics are prescribed in primary care. Objectives: To describe antibiotic prescribing trends in NHS England primary care for the years 1998-2017 using various measures. We investigated trends and Variation between practices and Geographical areas, out-of-hours prescribing, and seasonality. Methods: We used publicly available prescribing datasets and calculated antibiotic prescribing rates per 1000 age-sex-adjusted population units, percentage prescribed as broad-spectrum, and course length.We report national time trends for 1998-2016, Geographical Variation across 2017 and Variation trends for 2010-17. We calculated percentiles and ranges, and plotted maps. Results: The overall rate of antibiotic prescribing has reduced by 18% since 2010, with the steepest decline since 2013. The percentage prescribed as broad-spectrum declined since 2006, from 18.0 to 8.4. Between the best and worst Clinical Commissioning Groups (CCGs) there was 2-fold Variation for total antibiotic prescribing, but 7- fold Variation for cephalosporins. Variation across general practices has declined. The CCG to which a practice belongs accounted for 12.6% of current Variation (P,0.0001). Higher antibiotic prescribing was associated with greater practice size, proportion of patients .65 years or ,18 years, ruralness and deprivation. Seasonal increases have been declining for most antibiotics. If every practice prescribed antibiotics at the lowest decile rate in 2017, 10.8 million fewer prescriptions could have been issued (34%). Compared with standard practices, out-of-hours practices prescribed a greater proportion of broad-spectrumantibiotics. Conclusions: Despite a general trend towards more optimal antibiotic prescribing, considerable Geographical Variation persists across England's practices and CCGs.
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time trends and Geographical Variation in prescribing of drugs for diabetes in england from 1998 to 2017
Diabetes Obesity and Metabolism, 2018Co-Authors: Helen J Curtis, John M Dennis, Beverley M Shields, Alex J Walker, Seb Bacon, Andrew T Hattersley, Angus G Jones, Ben GoldacreAbstract:AIMS: To measure the Variation in prescribing of second-line non-insulin diabetes drugs. MATERIALS AND METHODS: We evaluated time trends for the period 1998 to 2016, using England's publicly available prescribing datasets, and stratified these by the order in which they were prescribed to patients using the Clinical Practice Research Datalink. We calculated the proportion of each class of diabetes drug as a percentage of the total per year. We evaluated Geographical Variation in prescribing using general practice-level data for the latest 12 months (to August 2017), with aggregation to Clinical Commissioning Groups. We calculated percentiles and ranges, and plotted maps. RESULTS: Prescribing of therapy after metformin is changing rapidly. Dipeptidyl peptidase-4 (DPP-4) inhibitor use has increased markedly, with DPP-4 inhibitors now the most common second-line drug (43% prescriptions in 2016). The use of sodium-glucose co-transporter-2 (SGLT-2) inhibitors also increased rapidly (14% new second-line, 27% new third-line prescriptions in 2016). There was wide Geographical Variation in choice of therapies and average spend per patient. In contrast, metformin was consistently used as a first-line treatment in accordance with guidelines. CONCLUSIONS: In England there is extensive Geographical Variation in the prescribing of diabetes drugs after metformin, and increasing use of higher-cost DPP-4 inhibitors and SGLT-2 inhibitors compared with low-cost sulphonylureas. Our findings strongly support the case for comparative effectiveness trials of current diabetes drugs.
William Hollingworth - One of the best experts on this subject based on the ideXlab platform.
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a systematic review of Geographical Variation in access to chemotherapy
BMC Cancer, 2016Co-Authors: Charlotte Chamberlain, Amanda Owensmith, Jenny L Donovan, William HollingworthAbstract:Background Rising cancer incidence, the cost of cancer pharmaceuticals and the introduction of the Cancer Drugs Fund in England, but not other United Kingdom(UK) countries means evidence of ‘postcode prescribing’ in cancer is important. There have been no systematic reviews considering access to cancer drugs by Geographical characteristics in the UK.
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A systematic review of Geographical Variation in access to chemotherapy
BMC Cancer, 2015Co-Authors: Charlotte Chamberlain, Amanda Owen-smith, Jenny Donovan, William HollingworthAbstract:Background Rising cancer incidence, the cost of cancer pharmaceuticals and the introduction of the Cancer Drugs Fund in England, but not other United Kingdom(UK) countries means evidence of ‘postcode prescribing’ in cancer is important. There have been no systematic reviews considering access to cancer drugs by Geographical characteristics in the UK. Methods Studies describing receipt of cancer drugs, according to healthcare boundaries (e.g. cancer network [UK]) were identified through a systematic search of electronic databases and grey literature. Due to study heterogeneity a meta-analysis was not possible and a narrative synthesis was performed. Results 8,780 unique studies were identified and twenty-six included following a systematic search last updated in 2015. The majority of papers demonstrated substantial variability in the likelihood of receiving chemotherapy between hospitals, health authorities, cancer networks and UK countries (England and Wales). After case-mix adjustment, there was up to a 4–5 fold difference in chemotherapy utilisation between the highest and lowest prescribing cancer networks. There was no strong evidence that rurality or distance travelled were associated with the likelihood of receiving chemotherapy and conflicting evidence for an effect of travel time. Conclusions Considerable Variation in chemotherapy prescribing between healthcare boundaries has been identified. The absence of associations with natural Geographical characteristics (e.g. rurality) and receipt of chemotherapy suggests that local treatment habits, capacity and policy are more influential.