The Authors Respond

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We agree with Guarez Garcia et al.1 that alternative ways of testing associations of effort–reward imbalance at work with incident disease (CHD) is justifiable and there is a body of evidence on the strengths and limitations of alternative tests of the effort–reward imbalance model available.2 The decision to restrict our analyses to the widely used effort–reward ratio rather than to perform multiple tests was based on theoretical, methodologic, and empirical arguments:3
First, we consider the effort–reward ratio, an investigator-based algorithm quantifying the mismatch between effort and reward at individual level, consistent with the effort–reward theory on cardiovascular reactions to chronic reward frustration that may bypass conscious trade-off of “costs” and “gains” at work by the working person. Second, we chose a measurement approach—a synthesis of original and proxy measures available in the studies—that is prespecified, validated, and published4 before the data were analyzed to guarantee that we had an exposure definition not affected by post hoc decisions, which can distort evidence. As we note in our article, this conservative approach was considered appropriate in a meta-analysis set up to test a hypothesis rather than to generate new hypotheses. Third, there is empirical support for the clinical significance of the cut-point of 1.0 of the effort–reward ratio, in particular with regard to cardiovascular and metabolic risk.5
Comparison of alternative operationalizations of effort–reward imbalance and its subdimensions in relation to coronary heart disease is a relevant topic for future research. Ideally such investigations should include more cohort studies than the three mentioned by Guarez Garcia et al.
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