Research highlights – 15 October 2010

“Research highlights” is a weekly round-up of research papers appearing in the print BMJ. We start off with this week’s research questions, before providing more detail on some individual research papers and accompanying articles.

What are the benefits and harms of reboxetine versus placebo or SSRIs in acute major depression, and has the evidence been skewed by publication bias?
How is Apgar score in newborn infants associated with cerebral palsy in childhood?
Do varying responses to surveys of patients on the performance of general practices and doctors reflect differences between practices, doctors, or patients themselves?
How often do doctors in Flanders, Belgium, report cases of euthanasia to the Federal Control and Evaluation Committee?
Can varying rates of caesarean section among English NHS trusts be explained by maternal characteristics and clinical risk factors?

Reboxetine and depression

Reboxetine is the first selective norepinephrine (noradrenaline) reuptake inhibitor approved for the treatment of depression in European countries. The drug works by binding to the norepinephrine transporter and blocking reuptake of extracellular norepinephrine, a catecholamine neurotransmitter. Selective serotonin reuptake inhibitors (SSRIs), the most commonly prescribed class of antidepressant, block the reuptake of the monoamine neurotransmitter serotonin instead.

Although reboxetine has been claimed to be more effective than placebo and similarly effective to other antidepressants, Dirk Eyding and colleagues’ systematic review and meta-analysis of published and unpublished trials has shown that reboxetine is an ineffective and potentially harmful antidepressant.

Reboxetine was no better than placebo and inferior to SSRIs when it came to remission and response rates, whereas the drug was associated with higher rates of harm outcomes than placebo and the selective serotonin reuptake inhibitor fluoxetine.

Writing in an accompanying analysis article, the authors report on the difficulty they had obtaining unpublished studies and recommend “legal obligation for manufacturers to provide all requested data to health technology assessment bodies without commercial restrictions to publication.”

Do we know whether patients are satisfied with English general practice?

Under the Quality and Outcomes Framework in the United Kingdom patients are surveyed after seeing general practitioners, as one measure of practices’ and doctors’ performance. They’re asked, among other things, “How long after your appointment time do you normally wait to be seen?” and “How do you rate your doctor’s caring and concern for you?”

Chris Salisbury and colleagues’ secondary analysis of data from about 4500 patients at 27 English practices in 2005-6 found that reported experiences and satisfaction were related to patient sociodemographics, including age, sex, ethnicity, and employment status.

But adjusting for patients’ characteristics made little difference to the ranking of individual practices, and asking a global question about overall satisfaction wasn’t much use.

Editorialist Jeannie Haggerty agrees with the authors’ view that these measures need refining to include more information on real experiences rather than beliefs, but argues that they are not hopelessly flawed. When they do detect problems, says Professor Haggerty, these are real and important.

Reporting of euthanasia in Flanders, Belgium

The issue of euthanasia divides opinion among health professionals in the UK. Only last week doctors set up a group to campaign for assisted death for terminally ill, mentally competent adults (BMJ 2010; 341:c5498), whereas many professional bodies, including the BMA, have policies against euthanasia.

In Belgium, euthanasia within strict guidelines has been legal since 2002. However, Tinne Smets and colleagues’ research into reporting of cases to federal authorities suggests that doctors in Belgium are likewise not agreed on the issue.

The authors found that only half (549 (52.8%)) of the 1049 cases of euthanasia in 2007 in Flanders, the Dutch speaking part of Belgium, were reported to the Federal Control and Evaluation Committee. Physicians were less likely to report a case if they did not perceive their act as euthanasia or if the time by which life was believed to have been shortened was less than a week.

The authors suggest that the current legal position in Belgium is insufficient and that policy needs strengthening to ensure physicians comply properly with the laws relating to a request for euthanasia, including their obligation to report.

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