Re: Effort–Reward Imbalance at Work and Incident Coronary Heart Disease

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We recognize the important contribution of Dragano et al’s1 study: “Effort–Reward Imbalance at Work and Incident Coronary Heart Disease: A Multicohort Study of 90,164 Individuals.” At the same time, we think that the authors’ statement in the study: “The availability of alternative ways of defining effort–reward imbalance can encourage multiple testing and result in bias because of selective reporting” is misleading. Testing alternative ways of defining effort–reward imbalance (ERI) does not result in a bias if all tests are reported. Rather, a bias can occur when researchers select just one method of operationalization, while knowing previously that there are various ways. Dragano et al1 calculated the ERI score as the ratio of an effort scale divided by a reward scale indicating exposure group when values are higher than 1 (>1 criterion). Although this procedure has been the most traditional operationalization of ERI, other operationalizations of ERI exposure exist, but were not analyzed or discussed:
We would like to know whether the association between ERI and coronary heart disease is consistent or not across several alternative operations of ERI in the study.
On the other hand, the authors made the very informative decision of testing the associations of ERI components, effort, and reward (dichotomized at their medians) with coronary heart disease (CHD). Reward, but not effort, was significantly associated with CHD (1.18 hazard ratio). According to the original ERI model, reward is composed of three variables: income, respect, and status. To better develop specific intervention and prevention strategies, we believe it would be even more informative to test the independent associations of the three types of rewards with CHD as well. We think it would be possible at least in the three cohorts–GAZEL (GAZ et Electricité), HNR (Heinz Nixdorf Recall Study), WOLF-F (Work, Lipids, Fibrinogen) study) of the IPD-Work Consortium (Individual-Participant-Data meta-analysis in Working Populations) where the original ERI questionnaire was used.

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